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GI Part 3 - Chronic Vomiting, Pancreatitis

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sihirlifil's version from 2018-02-05 11:23

Chronic Vomiting

Question Answer
Bilious vomiting syndrome: often in who?Young dogs, often small breed
Bilious vomiting syndrome: whats happening?Chronic vomiting, usually bile
Occurs most often when stomach empty for prolonged period
Bilious vomiting syndrome: tx"Snack" before bed
+/- Metaclopramide (prokinetic), PPI
Bilious vomiting syndrome: dxResponse to treatment & r/o other causes
2 categories of delayed gastric emptyingMechanical or functional
Delayed gastric emptying dx: 4 steps1: Radiographs +/- contrast
2: Abd ultrasound
3: Endoscopy
4: Fxnl studies (Barium, scintigraphy, wireless capsule camera)
**Whats this thing? why is it awesome?
ALICAM (wireless capsule camera)! Capsule that you give & watch whole GI tract. Gives motility time
Pyloric hypertrophy akaChronic hypertrophic gastropathy
Why does pyloric hypertrophy occur?Unknown! genetic suspected (middle/older Westies, Shih Tzus, Maltese)
Dx of pyloric hypertrophy?Chronic vomiting workup, rule out other diseases
Ultrasound & endoscopy
What are these ultrasound & endoscopy images giving you the dx for?
Pyloric hypertrophy
(muscularis = hypoechoic which is normal, just super thick!)
How to treat pyloric hypertrophy?Surgery: V-Y pyloroplasty has high success rate
Describe functional motility disordersRare, poorly understood, poor prognosis. could be smooth musc dz? (biopsy) or neuromusc (myenteric plexus)
May get dx by ruling out everything else
Look like mechanical obstruction
Tx: Prokinetics, small frequent low-fat meals
(Chart of motility disorders & prokinetic drugs)
Most common ddx of chronic vomiting, normal motliltyInflam: IBD, Food-responsive enteropathy, polyps
Infectious: parasites, fungal
Neoplasia
Dx plan for chronic vomiting: what tests r/o extra-GI causes?Bloodwork: CBC, Chem, UA
T4 in cats
Baseline cortisol (+/- ACTH stim)
What's the overal diagnostic plan for chronic vomiting?Rule out extra-GI causes of GI signs
Fecal testing (min float), empiric deworming
Abdominal rads (+/- thoracic rads = **noninvasive way to ddx neoplasia, met)
Abdominal US
Ultrasound: can tell you what?Mass
Thick layer
Big LN
If other organs are normal
Ulcer
FB
Ultrasound: can NOT tell you what?Reasons for mass, thick layer, big LN, other organs normal or not
Can not rule out ulcers or FB (not seen =/= ruled out)
Ultrasound: what snag do you run into with a mass or thickening?Can't ddx inflammatory, infectious, or neoplastic (**esp small cell lymphoma)
Ultrasound: why is it useful?R/o other causes, ESPECIALLY IF EXTRA-GI
ID the location of the abnormality
Helps know WHERE to biopsy
Endoscopic vs full-thickness biopsy: which is less invasive?Endoscopic
Endoscopic vs full-thickness biopsy: can you assess the jejunum?Endoscopic: nope
Surgical: YES!
Endoscopic vs full-thickness biopsy: which layers can be assessed?Endoscopic: Just mucosa & submucosa
Surgical: All 4 layers!
(inflam) Food-responsive enteropathy: common in who? what is it?Food "allergy", protein antigen (not usually wheat, grain etc), possibly microflora disturbance (chicken or egg? other dz disturbs natural flora)
Most common in young adult dogs & cats
(inflam) Food-responsive enteropathy: dx?EXCLUDE other dzs
Improvement with hypoallergenic or novel protein diet
(inflam) Food-responsive enteropathy: what's the difference between novel protein & hydrolyzed protein?Novel: no antigenic response
Hydrolyed (hypoallergenic): Protein particles hydrolyzed into particles not recognized as antigens (too small)
(inflam) Food-responsive enteropathy: how do you do a diet trial?Cut out all other proteins, including heartwork & flea/tick flavored pills, rawhides, chew toys, etc for 4-6 weeks
(inflam) IBD: characterized by what? (5)Chronic GI signs >3 weeks
Histopath evidence of mucosal inflammation
Inability to document underlying cause of inflammation by thorough investigation
Inadequate response to therapeutic trials: deworming, antibx, diet
Clinical response to anti-inflammatory or immunosuppressive therapy
(inflam) How is IBD diagnosed?R/o extra-GI causes of GI signs
R/o infectious causes (test & deworm)
R/o food allregies, microbial imbalance: hypoallergenic diet trials 4-8 weeks, antibiotic & probiotic trials
Biopsies
Decrease in CS with anti-inflam or immunosupp tx
(inflam) CS of gastric polyp?Chronic vomiting, may be intermittent
What is this? underlying cause?
Gastic polyp
Underlying inflammatory dz condition
(inflam) how to tx gastric polypResection curative, but may recur
**Good idea to do what when dx gastric polyp?Biopsy surrounding area to find underlying cause
(inflam) CS of gastric fungal infectionChronic vomiting, weight loss, diarrhea
+/- other sites of infection (BELLS)
**Tipoff for fungal infxnMORE THAN 1 KIND OF CS (Bone, eye, lungs, LN, skin). WITH mass-like lesion (granuloma)
(inflam) Fungi that can cause GI infxnsHistoplasma
Blastomyces
Pythium
Prototheca (algae-like organism)
(inflam) Definitive Dx of fungal infxnRectal scraping cytology (if in colon) (see organism in macrophages etc)
Urine antigen (Histo, blasto)
Gastric biopsies
FNA of LN if enlarged
(inflam) Unique diagnostic test for Histoplamsa & Blastomyces?Urine antigen (highly sensitive!)
If you see this on histopath, what are you thinking?
Fungal infection
(inflam) what does bloodwork look like when working up a fungal infection?CBC: usually marked neutrophilia
Chem: Hypoalbuminemia WITH hyperglobulinemia, hypocholesterolemia
UA: nothing specific unless organisms are in kidneys
(inflam) what do rads look like when working up fungal infxn?Possible lung involvement
Lymphadenopathy
Splenomegaly
Intestinal mass
(inflam) what does abdominal US look like when working up fungal infxn?May appear like mass, or diffuse inflam dz
Lymphadenopathy common
(inflam) Tx of fungal infxnSurgical resection of as much infected tissue as possible
Tx with antifungals often lifelong
(General prognosis poor to grave)
(Neopl) Most common gastric neoplasias in DOGS?Adenocarcinoma
Leiomyo(sarco)ma
Gastrointestinal stromal tumor (GIST)
Lymphoma (large cell)
(Neopl) Most common gastric neoplasias in Lymphoma (Large & small cell)
MCT
Adenocarcinoma
(Neopl) CS of gastric neoplasiaAcute or chonic vomiting, usually older pets
(Neopl) How does bloodwork look like on gastric neopl workup?CBC, Chem, UA look like other inflam causes unless other organs involved
(Neopl) Special thing you might see on chem on ~leiomyo(sarco)ma?Paraneoplastic hypoglycemia
(Neopl) **Besides bloodwork, how else would you work up?Chest radiographs: check metastases (& ddx fungal)
Abdominal US: Mass or diffuse infiltration, guide FNA or biopsy
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Pancreatitis

Question Answer
CS of pancreatitis in DOGS?Anorexia (91%)
Vomiting (90%)
Lethargy (79%)
Diarrhea (33%)
Icterus
CS of pancreatitis in CATS?Lethargy (100%)
Anorexia (97%)
Vomiting (only 35%)
Dyspnea (20%)
Icterus (20%)
Diarrhea (15%)
In CATS, icterus is a sign of what?Common bile duct obstruction! Becomes surgical disease
Is this dog religious or is something wrong?
Prayer position = common sign of pancreatitis
Defenses against autodigestion (5)Physical separation- manufacturing & storage
Zymogens = inactive
Activation peptide in small intestine
Pancreatic secretory trypsin inhibitor
Plasma anti-trypsin alpha-macroglobulins in circulation
What happens when autodigestion defenses fail? (4)Activation of zymogens within pacreas
Autodigestion
Local inflammation
Systemic inflam --> DIC, SIRS
Some triggers of pancreatitisHigh fat meals
Different food than norm
Metabolic: obesity, diabetes, hypertriglyceridemia, Cushings
Medications
Vomiting
(breed predisp Yorkies, Schnauzers)
How can vomiting be a trigger of pancreatitis?Stomach acid forcefully pushed into pancreatic duct, ESPECIALLY IN CATS! they have no sphincter there
How does a pt with pancreatitis present?Wide array of severities, either stable or unstable
What do you have to tell the owner at the hospital, day 1?Stability can change DURING hospitalization WITH TX!
Snowball effect of inflam, can progress to need outpatient --> inpatient --> ICU lvl care
Can occur 2ry to other problems
No specific treatment and may get worse before better
Dx: how do you work up a pancreatitis case?Work up for vomiting
CBC looks like?Neutrophilia with left shift (Bands)
Chem looks like?Hypoalbuminemia: vasculitis, edema
Azotemia: pre-renal (dehyd) or renal (AKI from inflammation)
Elevated liver enzymes & Tbili (inflammatory or cholestatic)
Hypocalcemia
High cholesterol, triglycerides
Why would you see hypoCa?Fat of pancreas being saponified
Poor prognostic indicator
Why would you see high cholesterol/triglyc?Pancreas not doing its job of lipid metabolism
UA looks like?+/- ketones, without being a diabetic (altered metabolism)
Radiographic signsDecreased serosal detail- ground glass
Wide gastroduodenal angle
Useful to r/o other causes of vomiting
How does pancreatitis look with abdominal ultrasound?(not best test!)
Hypoechoic pancreas with hyperechoic surrounding mesentery
+/- common bile duct obstruction
2 surgical pancreatitis casesBile duct obstruction, abscess
GOLD STANDARD test for pancreatitisBiopsy (which isnt a great test, CS =/= results)
What's the problem with biopsy?Histopath =/= CS
What are some dx tests we can do?Gold Std: Biopsy
Lipase: Sens 30-71%, Spec 43-55%
Amylase: Sens 7-40%, Spec 78-100%
Abd US: Sens 60-84%, Spec 75-88% **better at detecting ACUTE!
Most sensitive test for pancreatitisUltrasound (60-84%) (acute)
Most specific test for pancreatitisAmylase (78-100%)
What is PLI?Pancreatic lipase immunoassay (Snap or quantitative PL)
Feline Sens 67%, Spec 90%
Canine Sens 20-80%, Spec 80-97.5%
What can cause false + on PLI?Acute abdomen
HAC
What does a - PLI result mean?Pancreatitis is unlikely! (b/c high spec)
(Criteria for dx of acute pancreatitis in dogs)
Cornerstones of acute pancreatitis txIV fluids
Anti-emetics
Analgesia!!!! (Fentanyl or Lidocaine CRI, bupivicaine)
Nutrition (eneral = faster recovery, less risk bask translocation)
How is enteral nutrition helpful?Promotes GI motility = decrease V+/Regurg
Gut barrier
Decreases time spent in hospital
Nasoesophageal tube: pros? cons?Pros: Easy to place, only need sedation
Cons: Easy to rip out, can only do liquid diet
Esophagostomy tube: pros? cons?Pros: can feed actual food & give medications
Cons: need ANX to place, $$$
**Which feeding tube for pancreatitis patients?Nasoesophageal. only need for few days)
Clinical nutrition: whats the protocol for enteral nutrition?Day 1: Feed 1/3 RER (resting energy req), divided, into 4-6 small feedings
Day 2: Feed 2/3 RER
Day 3: Feed full RER
(RER =)(weight in kg x 30 + 70)
**What happens with refeeding syndrome?Endogenous insulin release K+, Mg++, P, blood glc crash
Clinical nutrition: how to avoid food aversion?No force feeding!
No syringe feeding in nauseous (turn away from food)
Don't leave food in with patient if nauseous
Low fat diet: via NE tubeClinicare (high in fat, so mix with vanilla Ensure 50/50)
Low fat diet: problem with feeding via E-tube (& for life)Predisposed to another episode of pancreatitis
**T/F Cats with pancreatits should not be given low fat diet for pancreatitisIt doesnt help them, can actually be detrimental
Possible tx for acute pancreatitis? (& controversies)Antibiotics
Anti-inflam (NSAIDs, steroids) (affect blood flow to pancreas :/)
Plasma (colloid for hypoalb/more circ anti-trypsin alpha globulins, but $$$ and risk xfusion reactions)
Surgery (abscesses, bile duct obstx)
Fatal complications of pancreatitisDIC
SIRS
PTE
AKI
(rarely leads to DM, EPI)
Poor prog indicators: CATSHypocalcemia (saponification)
Dyspnea
Hyperkalemia
Serum fPLI concentration >20 ug/L when admitted
Poor prog indicators: DOGSAKI (or devlp during hospitalization)
SIRS
DIC
Chronic pancreatitis looks like what? More common in who?IBD of the pancreas. Idiopathic inflammatory. More common in Cats (triaditis)
Chronic inflam can lead to fibrosis --> EPI, DM
Chronic: CSCats>>>dogs, small breed dogs>large
Waxing & waning decr appetitie, v+, d+, lethargy
GOLD STANDARD dx of chronic pancreatitisBiopsy
Concurrent GI & liver biopsy ESPECIALLY IN CATS! (triaditis)
Besides biopsy, what other dx tests are useful for chronic pancreatitis?US & quantitative fPLI
Useful for long-term care, monitoring, recognizing flare-ups
Chronic panc: TxTx concurrent dz (IBD, cholangitis)
Cats: Prednisolone may be useful (prevent flare-ups from other concurrent dz), but LOW-FAT DIET IS NOT INDICATED!
Even if tx chronic pancreatitis, what do you have to tell the O?Recurrent episodes still likely- support with anti-emetics, appetite stimulants (**if incr dose of pred, can increase until flare-up over)
Chronic panc: during tx, what else should you monitor for?Development of DM or EPI
memorize