1. Practical Internal Medicine Don’t Throw Your Hands Up! Keep It All Down Managing the Vomiting Companion Animal Wendy Blount, DVM Nacogdoches, TX

2. Housekeeping Handouts other than PowerPoint slides are already in your notebook You will get copies of the PowerPoint slides after each section Course materials are also downloadable at http://wendyblount.com http://wendyblount.com Click on “Presentation Notes” Click on the link for this seminar

3. Housekeeping Proceedings –TOC, Abbreviations, Evaluation –Promotional Literature – GCVS, Henry-Schein –Put each PowerPoint handout behind the colored tab for that section and in front of the first blue subdivider –Then you will find client handouts, diagnostic and treatment aids, lab submission forms, etc. CE certificates in your notebook –I will sign at the end of the seminar –Please complete evaluation

4. Housekeeping Breakfast, coffee and registration 7:30-8am Morning Session 8am-12noon Afternoon session 1:30-5pm We’ll break the last 10 minutes of every hour Lunch break 12-12:30pm Dry Lab 12:30-1:30pm –Small groups for the dry lab –Dry lab group assignments and schedule are in your Proceedings PLEASE PARTICIPATE!! But take private conversations out in the hall

5. Practical Medicine Philosophy As referral medicine becomes more advanced, it by default becomes more expensive Growing gap between general practice and specialty practices These seminars help us fill those gaps Everything we talk about this weekend can be done in a rural mixed animal practice

6. Practical Medicine Philosophy Some are already doing these things –Feeding tubes, managing DKA, liver aspirates Some will be ready to begin Some will need some hand holding, at least at first –TexasVets – Yahoogroups –Moderator Rosemary Lindsey rosemarylindsey@sbcglobal.net rosemarylindsey@sbcglobal.net Some will be happy to be better referring vets

7. Agenda Saturday – 8am-12noon, 12:30-5pm Vomiting Regurgitation Dry Lab – Liver Aspiration Cytologies Elevated Liver Ezymes Liver Failure (Sign CE Certificates)

8. Agenda Sunday – 8am-12noon, 12:30-5pm Diarrhea Pancreatitis Dry Lab Time if needed Managing Feeding Tubes The Acute Abdomen Diagnostic Surgery Sign CE Certificates

9. Why do Dogs & Cats Vomit? A protective mechanism of removing toxins from the body Endogenous and exogenous 43% gave GI disease 27% systemic illness 16% abdominal disease Neurologic 1-2% Miscellaneous 5-6%

10. Causes of Vomiting Vomiting is the most common sign of gastric disease But not all vomiting dogs have gastric disease Not all dogs with gastric disease vomit

11. Causes of Vomiting – GI Disease Distal Esophagus Stomach Small Intestine Large intestine Pancreas Liver & Biliary Tract

12. Causes of Vomiting – ExtraGI Abdominal Dz – Acute or Chronic Obstruction/Irritation from outside GI Tract Foreign Substance in GI Lumen Neurologic Disease Systemic Disease Toxicity Environmental/Behavioral

13. Causes of Vomiting That’s about a jillion causes How do you find the cause in a particular patient? Acute or Chronic? 2 weeks Mild, Moderate or Severe? 1. Treat mild disease empirically 2. Diagnose and Treat Severe Dz ASAP 3. Proceed after discussion with chronic & mod-severe acute vomiting. Compartmentalize, then DAMNIT-V

14. Compartmentalization Is vomiting from GI disease or secondary to something else? Is the dog relatively well and vomiting, or very sick and also vomiting? Are there other symptoms not attributed to the GI tract? Systemic Diagnostics for Systemic Disease Minimum database, imaging diagnostic surgery GI diagnostics fro GI Disease GI Lab Tests, endoscopy diagnostic surgery

15. DAMNIT-V D – Degenerative A – Anomalous M – Metabolic N – Neoplastic, Nutritional I – Infectious, Inflammatory, Immune Mediated, Idiopathic T – Toxic, Traumatic V - Vascular

16. Distal Esophageal Disease chronic vomiting and regurgitation DAMNIT-V A – hiatal hernia N – neoplasia – leiomyoma/leiomyosarcoma I – GERD and distal esophagitis, Spirocerca lupi GERD – GastroEsophageal Reflux Disease

17. Gastric Disease DAMNIT-V D - Degenerative – chronic »gastric hypomotility »gastric dysrhythmia stomach motility seems normal when the stomach is empty, but is incoordinated in response to solid food »Dysautonomia A – Anomalous - chronic pyloric outflow obstruction (mucosal or muscular)

18. Gastric Disease DAMNIT-V N – Nutrition - acute »Eating spoiled food »Abrupt dietary change, when diet is uniform »Gastric foreign body/material »Eating too rapidly Nutrition - chronic »Dietary intolerance Gluten in Irish Setters »Food allergy

19. Gastric Disease DAMNIT-V N – Nutrition - acute »Eating spoiled food »Abrupt dietary change, when diet is uniform »Gastric foreign body/material »Eating too rapidly Nutrition - chronic »Dietary intolerance Gluten in Irish Setters »Food allergy

20. Gastric Disease DAMNIT-V N – Nutrition - acute »Eating spoiled food »Abrupt dietary change, when diet is uniform »Gastric foreign body/material »Eating too rapidly Nutrition - chronic »Dietary intolerance Gluten in Irish Setters »Food allergy Buster Maze Bowl

21. Gastric Disease DAMNIT-V N – Nutrition - acute »Eating spoiled food »Abrupt dietary change, when diet is uniform »Gastric foreign body/material »Eating too rapidly Nutrition - chronic »Dietary intolerance Gluten in Irish Setters »Food allergy Buster Maze Bowl

22. Gastric Disease DAMNIT-V N – Nutrition - acute »Eating spoiled food »Abrupt dietary change, when diet is uniform »Gastric foreign body/material »Eating too rapidly Nutrition - chronic »Dietary intolerance Gluten in Irish Setters »Food allergy Stephen Garner Nacogdoches, TX

23. Gastric Disease DAMNIT-V N – Nutrition - acute »Eating spoiled food »Abrupt dietary change, when diet is uniform »Gastric foreign body/material »Eating too rapidly Nutrition - chronic »Dietary intolerance Gluten in Irish Setters »Food allergy Kyjen “Hills” Slo-Bowl

24. Gastric Disease DAMNIT-V N – Nutrition - acute »Eating spoiled food »Abrupt dietary change, when diet is uniform »Gastric foreign body/material »Eating too rapidly Nutrition - chronic »Dietary intolerance Gluten in Irish Setters »Food allergy Kyjen “Coral” Slo-Bowl

25. Gastric Disease DAMNIT-V N – Nutrition - acute »Eating spoiled food »Abrupt dietary change, when diet is uniform »Gastric foreign body/material »Eating too rapidly Nutrition - chronic »Dietary intolerance Gluten in Irish Setters »Food allergy Kyjen “Drop” Slo-Bowl

26. Gastric Disease DAMNIT-V N – Nutrition - acute »Eating spoiled food »Abrupt dietary change, when diet is uniform »Gastric foreign body/material »Eating too rapidly Nutrition - chronic »Dietary intolerance Gluten in Irish Setters »Food allergy Kyjen “Flower” Slo-Bowl

27. Gastric Disease DAMNIT-V N – Nutrition - acute »Eating spoiled food »Abrupt dietary change, when diet is uniform »Gastric foreign body/material »Eating too rapidly Nutrition - chronic »Dietary intolerance Gluten in Irish Setters »Food allergy Buster Cubes

28. Gastric Disease DAMNIT-V N – Nutrition - acute »Eating spoiled food »Abrupt dietary change, when diet is uniform »Gastric foreign body/material »Eating too rapidly Nutrition - chronic »Dietary intolerance Gluten in Irish Setters »Food allergy Green Bowl

29. Gastric Disease DAMNIT-V N – Neoplasia – usually chronic Lymphoma (LSA) »most common gastric neoplasia in the cat »2 nd most common gastric neoplasia in the dog adenocarcinoma »most common gastric neoplasia in the dog »Most commonly in the pylorus Leiomyoma - GIST »Most commonly in the cardia »Usually asymptomatic unless pyloric outflow obstruction Schirrhous adenocarcinoma, Fibroma/FSA SCC, plasma cell tumor, MCT Gastric Polyp – symptomatic if pyloric obstruction

30. Gastric Disease DAMNIT-V I – Infectious, Inflammatory – acute or chronic Bacterial - Helicobacter gastritis - chronic Fungal – phycomycosis, Histoplasma - chronic Parasitic »Ascarids – puppies »Physaloptera spp – acute »Ollulanus spp »Giardia spp – acute or chronic »Neorickettsia spp (salmon poisoning) - acute Chronic Gastritis superficial, atrophic, hypertrophic Gastric Ulcer – acute or chronic

31. Gastric Disease DAMNIT-V I – Idiopathic – chronic Chronic gastric dilatation »Anaerobic bacteria »aerophagia »Hypomotility Acquired mucosal hypertrophy Acquired muscularis hypertrophy Duodenogastric reflux (bilious vomiting) Immune Mediated – chronic Inflammatory bowel disease

32. Gastric Disease DAMNIT-V T – Toxic, Traumatic Drugs – acute or chronic Antibiotics, NSAIDs, immunosuppressives, cardiac glycosides, anticholinergics, emetics Toxins »caustic substances – usually acute pot pourri oil, cleaning supplies, fertilizers petroleum distillates, organophosphates, toxic plants »Heavy metals - chronic lead, zinc »Ethylene glycol - acute Trauma – GDV, Diaphragmatic Hernia usually acute, but can be chronic

33. Gastric Disease Helicobacter Gastritis Associated with chronic gastritis, gastric and duodenal ulcers, gastric carcinoma, gastric LSA Infection is often asymptomatic Treatment – triple therapy x 14 days 1. antibiotic 1 – metronidazole 2. Antibiotic 2 – amoxicillin or tetracycline 3. Antacids – bismuth or proton pump blocker BTM – bismuth, tetracycline, metronidazole OAM – omeprazole, amoxicillin, metronidazole

34. Small Intestine Bile in vomit indicates duodenogastric reflux DDx similar to gastric vomiting DAMNIT-V N – Neoplasia – acute or chronic Strangulation by a pedunculated tumor causing volvulus (lipoma) Intussusception of tumor Obstruction by tumor or fungal mass I – Infectious, Inflammatory Antibiotic responsive diarrhea – chronic Hemorrhagic gastroenteritis (HGE) - acute

35. Small Intestine DAMNIT-V I – Infectious – viral Parvovirus, coronavirus Rotavirus Canine distemper virus I – Idiopathic Reverse intestinal peristalsis T – Traumatic - acute Mesenteric volvulus Intussusception most commonly secondary to severe diarrhea

36. Large Intestine Acute or chronic DAMNIT-V M – Metabolic - chronic Hypothryoidism can predispose to megacolon I – Inflammatory HGE – acute or relapsing Colitis – acute or chronic IBS - irritable bowel syndrome T– Traumatic Constipation – acute or chronic

37. Pancreas Acute Pancreatitis Chronic Pancreatitis

38. Liver & Biliary Tract Vomiting more common when there is cholestasis Most icteric dogs vomit Why do dogs with non-icteric liver disease vomit? »Decreased gastric mucus, due to abnormal protein synthesis. »Decreased gastric epithelial cell renewal due to abnormal protein synthesis. »Decreased gastric blood flow, due to altered vasoactive factors.

39. Liver & Biliary Tract DAMNIT-V M – Metabolic - chronic Biliary sludging and/or mucocoele Gall stone obstruction N – Neoplasia - chronic Hepatic carcinoma Biliary carcinoma LSA Hepatoma

40. Liver & Biliary Tract DAMNIT-V I – Infectious – acute or chronic Acute or chronic bacterial cholangiohepatitis Viral hepatitis – chronic Heterobilharzia spp – chronic Fungal hepatitis I – Inflammatory, Immune mediated – acute or chronic Acute hepatic necrosis Chronic active hepatitis T - Trauma – acute Biliary tract rupture

41. Liver & Biliary Tract DAMNIT-V I – Infectious – acute or chronic Acute or chronic bacterial cholangiohepatitis Viral hepatitis – chronic Heterobilharzia spp – chronic Fungal hepatitis I – Inflammatory, Immune mediated – acute or chronic Acute hepatic necrosis Chronic active hepatitis T - Trauma – acute Biliary tract rupture Loretta Ehrlund, DVM San Antonio, TX

42. Abdominal Disease Peritonitis (ascitic exudate) and resulting ileus Abdominal pain Impingement on the biliary and/or GI tracts by mass DDx Peritonitis Septic – perforated bowel or abscess, or localized infection Bile – ruptured biliary tract Uroabdomen – ruptured urinary tract chyloabdomen Generalized enteritis Pancreatitis Viral - FIP

43. Abdominal Disease DDx Abdominal pain – acute abdomen Passing a kidney stone pancreatitis Biliary obstruction GI obstruction Rapidly growing mass in an encapsulated organ (kidney, liver, spleen) Abdominal abscess Pyelonephritis Splenic torsion Cryptorchid testicular torsion

44. Abdominal Disease DDx Impingement on the biliary and/or GI tracts by mass Neoplasia Cyst Pancreatic cyst Perirenal cyst Choledochal cyst Hepatic cyst Abscess Granuloma

45. Abdominal Disease DDx Impingement on the biliary and/or GI tracts by mass DDx Granuloma I – Infectious - chronic L-form bacteria Ureaplasma, Mycoplasma spp Mycobacterium spp Bartonella spp FIP Many fungal infections

46. Abdominal Disease DDx Impingement on the biliary and/or GI tracts by mass DDx Granuloma I – Inflammatory – necrosis or saponification of fat Pancreatitis Pansteatitis Pancreatic adenocarcinoma lymphangiectasia I - rarely immune mediated Idiopathic Post rabies vaccine steatitis

47. Neurologic Limbic Epilepsy Seizure locus at the vomiting center Responds to anticonvulsants (don’t use bromide) Vestibular Disease Neoplasia Vomiting center or CRTZ Increased CSF pressure Many things that increase CSF

48. Systemic Disease Why do dogs with systemic disease vomit? Chemical stimulation of the vomiting center & chemoreceptor trigger zone. Drugs that suppress this center work best Cerenia®

49. Systemic Disease DAMNIT-V M- Metabolic (ileus) »Hypercalcemia »Acute hypocalcemia Eclampsia »Hypokalemia »hypomagnesemia »hypothyroidism »hypoadrenocorticism »Hyperadrenocorticism

50. Systemic Disease DAMNIT-V M- Metabolic (toxic) »Uremia »Jaundice »Sepsis »Acidosis (lactate, ketones, necrosis, etc.) Metabolic (idiopathic) »Hyperthyroidism Metabolic (shock)

51. Systemic Disease DAMNIT-V N – Neoplasia (paraneoplastic effects) High gastrin levels Gastrinoma MCT Hypercalcemia Systemic inflammation I – Infectious (unknown mechanism) »Feline heartworm disease »Systemic fungal infection

52. Systemic Disease DAMNIT-V T - Toxicity »Hypercalcemia Cholecalciferol rodenticide Eczema cream (calcipotriol – Dovonex®) toxicity »NSAIDs »corticosteroids »Acidosis – ethylene glycol

53. Systemic Disease Why do dogs with renal failure vomit? Direct toxicity to the gastric mucosa my renal toxins Decreased renal metabolism of gastrin by the kidneys, leading to elevated gastrin levels, and increased HCl secretion in the stomach. Drugs that protect the GI tract and stop gastric acid secretion work best sucralfate Proton pump blockers >> H2 blockers

54. Systemic Disease Why do dogs with NSAID toxicity vomit? Direct toxicity to the gastric mucosa Inhibition of gastroprotective prostaglandins »Piroxicam, ibuprofen and naproxen undergo more complete enterophepatic circulation, and thus have prolonged half life in the dog and cat. »COX2 selective are not as GI toxic as COX non- selective, but both can cause problems. Prostaglandin analogs work best misoprostol ( Cytotec® ) BID works as well as TID

55. Systemic Disease Why do dogs with corticosteroid toxicity vomit? Decreased mucosal cell growth and mucus production Increased gastric acid secretion High doses required for acute toxicity Chronic toxicity when other risk factors present: NSAIDs, hypotension, bile acid reflux, spinal cord disease, liver disease, renal disease, Addison’s disease, mast cell tumor degranulation, gastrinoma. H2 blockers/proton pump blockers & sucralfate work best

56. Systemic Disease Can low dose aspirin be given with immunosuppressive prednisone? Graham and Lee, 2009 – IMHA dogs –study on healthy dogs –No GI ulcers with pred alone or pred + ultra low dose aspirin (0.5 mg/kg SID) –Combination dose cause diarrhea Nelger et al, 2000 & Rohrer, 1999 – Corticosteriods did cause gastric erosions in dogs with IVDD at high doses – No protection from omeprazole, H2 blocker or misoprostyl

57. Environmental/Behavioral Motion sickness Heat Stroke Pain Fear Excitement

58. Dozens of Causes of Vomiting Did that help us diagnose and treat our vomiting patients? Not a Lot!

59. Dozens of Causes of Vomiting Did That Help? Not a Lot!

60. Working Up the Vomiting Patient Empirical Treatment first if indicated Pattern Recognition Step Wise Work-Up

61. Step 1 – Empirical Treatment 1. Cerenia PO SID x 1-4 days 2. Metronidazole 10-15 mg/kg PO BID x 7 days 250 mg tab – ¼ tab per 10 lbs 500 mg tab – ¼ tab per 20 lbs Max dose 500mg 3. Deworm pyrantel or Profender for cats fenbendazole for dogs

62. Step 1 – Empirical Treatment 1. Cerenia PO SID x 1-4 days 2. Metronidazole 10-15 mg/kg PO BID x 7 days 250 mg tab – ¼ tab per 10 lbs 500 mg tab – ¼ tab per 20 lbs Max dose 500mg 3. Deworm pyrantel or Profender for cats fenbendazole for dogs Kim Hendrick, DVM Kurten, TX

63. Physaloptera spp. Always deworm vomiting animals Presentation: acute or chronic onset of profuse vomiting weight loss is usual Sometimes anorectic, sometimes not Diagnosis: Almost never see the eggs on fecal Deworming empirically prevents the need for diagnosis by endoscopy

64. Physaloptera spp.

66. Clues in the Signalment Deep chested breeds - GDV Poodles – hypoadrenocorticism Brachycephalic breeds - GERD, hiatal hernia, pyloric mucosal hypertrophy GSD – antibiotic responsive diarrhea

67. Clues in the History If weight loss associated with increased appetite - diabetes, hyperthyroidism & IBD Most common clinic sign of gastric neoplasia – anorexia, then weight loss, then vomiting

68. Step-Wise Plan for Diagnosing Vomiting 1.Minimum Database 2.GI Diagnostics - Imaging, GI Lab, ACTH Stim (26%) –radiographs (15%) + contrast, US (34%, FN 52%) 3.Flexible Endoscopy 4.Surgery with biopsies (85%) 5.Fluoroscopy 6.Empirical Tx for limbic epilepsy & motility disorders

69. Step-Wise Plan for Diagnosing Vomiting 1.Minimum Database CBC, Profile (38%) Electrolytes/blood gases Urinalysis Fecal flotation and direct smear (28%) FeLV/FIV for all cats T4/free T4 for older cats HW Test for dogs Coagulation panel if hematemesis (Rose et al, 2010) – 200+ GI cases

70. Clues in the MDB Polycythemia- HGE, neoplasia Albumin normal with HGE, high with dehydration, globulins high with neoplasia Low albumin and globulin – protein losing enteropathy, GI blood loss HCT normal with PLE, low with GI blood loss Low albumin, normal globulin – liver disease, protein losing nephropathy, vasculitis

71. Clues in the MDB Azotemia High BUN with normal creat and phos - GI blood or high protein diet High BUN, high creat, high phos - Check urine specific gravity to confirm renal disease Liver Disease Pattern High liver enzymes High bili with normal PCV Low albumin, glucose Abnormal cholesterol, triglycerides

72. Clues in the MDB Cat – icterus w/normal PCV and normal liver enzymes Pancreatitis FIP Lymphoma Diagnostic Trifecta for FIP Lymphopenia <1500/ul Titer 1:160 or greater Globulins >5.1 g/dl Positive predictive value 89% Negative predictive value 99% Histopath and fluid analysis supportive Fluid analysis chart – pancreatitis sectionFluid analysis chart

73. Clues in the MDB Pancreatitis pattern icterus hypocalcemia Acidosis Hyperglycemia Elevated fPL or cPL >>TLI Elevated lipase lipemia Amylase not helpful if azotemic Abdominal pain Whacked out insulin response if diabetic Ketonuria if diabetic

74. Clues in the MDB Ethylene glycol toxicity pattern Period of ataxia at onset Increased anion gap Calcium oxalate crystals in the urine Neoplasia pattern Really sick with pretty boring bloodwork Intermittent low grade fever Hypercalcemia Increased globulins Increased white count

75. Clues in the MDB Addison’s Disease pattern Signs wax and wane Hematemesis, hematochezia Azotemia with moderately concentrated urine (1.020’s) Hypoalbuminemia Hypercalcemia High potassium and/or low sodium Remember whipworms can cause hyperkalemia and hyponatremia, as can repeated abdominocentesis

76. TAMU GI Lab Tests TLI/PLI – do you have significant pancreatic disease? B12/folate – do you have significant intestinal disease? Bile acids – do you have significant liver disease? Tritrichomonas PCR – chronic diarrhea in cats

77. Gastrin Made by gastric mucosa, pancreas Eliminated by the kidneys Increased with MCT, CRF, chronic proton pump administration, gastrinoma Stimulates the gastric mucosa to make HCl Causes problems: GERD Distal esophagitis and regurgitation Ulcers in esophagus, stomach, duodenum Chronic gastritis, duodenitis

78. When to do a barium study? NOT just prior to an abdominal US NOT just prior to a scope NOT if perforation is suspected If evidence of mural GI disease – to check for obstruction If you suspect a foreign body If you suspect a motility disorder Abdominal contents are malpositioned If you suspect a diaphragmatic hernia

79. Barium study for vomiting Avoid drugs that inhibit GI motility Opiates beta agonists (bronchodilators) Anticholintergics (atropine, aminopentamide) 1.Shoot scout films 2.Give barium –4-6 ml/lb small dogs and cats –2-4 ml/lb large dogs 3.Immediate for esophagram 4.Within 5 minutes for gastrogram 5.30 minutes, and every hour until barium is gone from stomach and enters the colon

80. Barium study for vomiting Thumb Rules for GI Transit Times Barium should be in duodenum within 20 minutes Stomach should be empty of liquid barium within 3-4 hours in the dog and 1 hour in the cat Barium coated food can remain in the stomach for 12-15 hours in the dog and 4-5 hours in the cat

81. When to recommend endoscopy? No evidence of systemic disease outside the GI tract Not suspecting lymphoma, which is more often in the muscularis Low albumin – poor surgical risk Abnormal B12/folate indicate significant intestinal disease Owner wants low morbidity procedure

82. When to recommend endoscopy? No evidence of systemic disease outside the GI tract Not suspecting lymphoma, which is more often in the muscularis Low albumin – poor surgical risk Abnormal B12/folate indicate significant intestinal disease Owner wants low morbidity procedure Melanie Enger, DVM - Lufkin TX

83. Preparation for endoscopy Withhold water the morning of scope Upper GI: Withhold food and barium for 24 hours Withhold food for 48 hours for lower GI Lower GI: Withhold food and barium for 48 hours Biscodyl 5 mg PO 24 hours before Enemas 24, 12 and 1-2 hours before Or use GoLytely

84. When do you suspect a Motility Disorder? Minimum database and imaging NSAF Prolonged GI transit on contrast study without obstruction Regurgitation without an identifiable cause Other signs of peripheral neuropathy –Laryngeal paralysis –Spinal or cranial nerve deficits (LMN) –constipation Other signs of dysautonomia Presence of hypothyroidism, Cushing’s Disease, Addison’s Disease, Myasthenia Gravis, spinal cord disease, uremia, hypercalcemia, hypocalcemia, etc.

85. Delayed Gastric Emptying Criteria –Vomit undigested food > 8-12 hours after eating –Food still in the stomach 8-12 hours after eating –Liquid barium in stomach > 4 hours –US – gastric contractions 4-5/minute DDx –outflow obstruction Foreign body, infiltrative disease, stricture, hypertrophy –Hypomotility Pancreatitis GI infiltrative disease Opiates Hypokalemia Post surgery parvovirus

86. Delayed Gastric Emptying Diet –Liquid food –Low fat –Low protein –Low fiber Prokinetics –Metoclopramide works only on the stomach –Cisapride may also work on the esophagus and colon, at least somewhat –Erythromycin and ranitidine have prokinetic characteristics –Erythromycin lower dose 0.25-0.5 mg/kg PO TID –Worsened by aminopentamide (Centrine®), opiates, beta agonists –Effective in beagles but not Labradors

87. DDx Hematemesis Blood swallowed Blood coming from the erosive disease in the stomach Blood coming from erosive disease in the duodenum and refluxed into the stomach Trauma Coagulopathy

88. DDx Hematemesis Blood swallowed and then vomited and/or produces melena –Trauma or coagulopathy can result in bleeding from any of these areas 1.Respiratory tract »Neoplasia »Pulmonary thromboembolism 2.Caudal nasopharynx (rostral nasal cavity bleeding usually results in epistaxis) »Neoplasia »Fungal infection 3.Oral cavity »Dental disease »Neoplasia

89. DDx Hematemesis Causes of erosive gastritis – erosion more superficial than an ulcer »Liver failure. »Kidney failure. »Hypoadrenocorticism. »Gastric neoplasia – see chronic vomiting. »MCT »Pancreatic neoplasia – gastrinoma. »Toxicity – NSAIDs > glucocorticoids, lead »Toxicity – caustic substances »cleaning supplies »pot pourri oil

90. DDx Hematemesis Causes of erosive gastritis – erosion more superficial than an ulcer »Trauma to the gut. »Shock – anaphylaxis, hypovolemia, septic, HGE. »Anesthesia (hypovolemia). »Spinal trauma. »Athletic exertion

91. DDx Hematemesis Bleeding from the duodenum, refluxed into the stomach. –Ulcerative/erosive duodenal disease – see differentials for gastric ulcerative/erosive disease. –Parasites – Coccidia, hookworms. –See also Melena in the Diarrhea Section.

92. DDx Hematemisis Coagulopathy 1.Factor deficiency »Liver failure »Anti-vitamin K rodenticide toxicity »congenital 2.Platelet problem »Thrombocytopenia »Platelet function defect 3.Blood vessel problem – vasculitis, hypertension, hyperviscosity 4.Combination - DIC

93. DDx Hematemisis Recurring Hematemisis and Hematochezia are special indications for ACTH Stim Even if electrolytes are normal

94. Tx Hematemisis Treat underlying cause Continue sucralfate for 5-7 days after hematemesis resolves Continue proton pump or H2 blockers for 10-14 days after hematemesis resolves Somatostatins inhibit HCl secretion octreotide

95. H2 Blockers Cimetidine (Tagamet®) 2.5-5 mg/lb PO IM IV TID-QID. –Inhibits hepatic microsomal enzymes. –May increase half life of drugs that are metabolized in the liver – theophylline, warfarin, phenobarbital. –Can cause mental depression. Ranitidine (Zantac®) 1 mg/lb PO SQ IM IV BID- TID –5x as potent as cimetidine. –Also a prokinetic, by inhibiting acetylcholinesterase. –Inhibits hepatic microsomal enzymes as cimetidine, but to a lesser extent.

96. H2 Blockers Famotidine (Pepcid®) 0.25-0.5 mg/lb PO IV SID- BID. –Inhibits hepatic microsomal enzymes as cimetidine, but to a lesser extent. –20x as potent as cimetidine. Nizatidine (Axid®) 1.25-2.5 mg/lb PO SID. –5x as potent as cimetidine. –Also a prokinetic.

97. Proton Pump Blockers –More effective than H2 blockers for mast cell degranulation. –Stronger suppressors of gastric acid secretion than H2 blockers. –Diminishes proteolytic effect of pepsin. –Maximum effect at the 5 th dose (may need to use with H2 blockers for the first 3-4 days). –Prolonged use (greater than 4 weeks) can cause reversible gastric mucosal hypertrophy. –Rebound hypersecretion of HCl can occur if stopped abruptly (high gastrin levels due to lack of feedback).

98. Proton Pump Blockers –Omeprazole (Prilosec®) – 0.7-1 mg/kg PO SID »5 mg (1/2 capsule) PO SID, for dogs <11 lbs. »10 mg PO SID, for dogs 11-45 lbs. »20 mg PO SID, for dogs greater than 45 lbs. –Lansoprazole (Prevacid®) »15 mg PO SID for small dogs »30 mg PO SID for large dogs. –Esomeprazole (Nexium®) »0.7 mg/kg PO SID for dogs. »Granules in capsule inactivated if sprinkled on food. –Pantoprazole (Protonix®) – 10-40 mg PO SID; 1 mg/kg IV SID. –Rabeprazole (Aciphex®) – 5-20 mg PO SID.

99. Antiemetics Central Antiemetics Phenothiazines - Act at both the CRTZ and the vomiting center. –Use only in well hydrated patients, without low blood pressure, as they are hypotensives. –Prochlorperazine (Compazine®) 0.25 mg/lb SQ IM TID –Chlorpromazine (Thorazine®) 0.15-0.25 mg/lb SQ TID. Antihistamines - Act at the CRTZ –Diphenhydramine (Benadryl®) 05-2 mg/lb PO IM or SLOWLY IV. –Dimenhydrinate (Dramamine®) 2-4 mg/lb PO TID. –Meclizine (Antivert®) 12.5 mg PO SID for small dogs and cats; 25 mg PO SID for medium to large dogs.

100. Antiemetics Central Antiemetics Central Anticholinergics –Scopolamine (Hyoscine®) 0.02 mg/lb SQ IM QID. –Acts at vestibular center and CRTZ. –Side effects ileus, dry mouth, sedation. Yohimbine (Yobine®) –Acts at the CRTZ and the vomiting center. –0.15-0.25 mg/lb SQ IM BID.

101. Antiemetics Peripheral Antiemetics Cisapride (Propulsid®) –Antiemetic and prokinetic. –Acts peripherally on the GI tissue – does not cross the blood brain barrier, so no associated extrapyramidal side effects. –0.05-0.25 mg/lb PO TID. Anticholinergics –Aminopentamide (Centrine®) 0.1-0.4 mg IM SQ BID- TID. –Side effect – ileus (undesirable when there is ileus or motility disorder).

102. Antiemetics Peripheral and Central Antiemetics*** Metoclopramide (Reglan®) - Antidopaminergic and antihistaminic, acts at the CRTZ –Antiemetic as well as prokinetic –0.2-0.4 mg/kg PO, SQ, IV TID-QID. –CRI – 0.5-1 mg/lb/day IV (works better as CRI) –Reduce dose by 50% in pets with renal failure –Side effects hyperactivity and constipation (extrapyramidal signs) - more common in the cat –For severe metoclopramide side effects, give Benadryl. –Because serotonin receptors dominate in the feline CRTZ rather than dopamine, metoclopramide may not work as well as an antiemetic in cats, when compared to dogs.

103. Antiemetics Peripheral and Central Antiemetics*** Block vagal afferent neurons, act at the CRTZ & vomiting center NK antagonists – inhibit substance P (analgesic) –Maropitant (Cerenia®) 1 mg/kg SC SID, 2 mg/kg PO SID for acute vomiting, no more than 5 days in a row (skip 1-2 days); daily up to 14 days in beagle study –8 mg/kg PO 2 hours prior to travel for motion sickness, for no more than 2 days in a row (skip 3 days) –Aprepitant – human drug 5HT antagonists –Ondansetron (Zofran®) 0.5-1 mg/kg PO or 0.1-0.5 mg/kg IV over 15 minutes SID-TID. –Dolasetron (Anzemet®) 0.6 mg IV SID-BID. –Side effects sedation and head shaking.

104. Antiemetics Peripheral and Central Antiemetics*** Block vagal afferent neurons, and act at the CRTZ NK antagonists – inhibit substance P –Maropitant (Cerenia®) 1 mg/kg SC SID, 2 mg/kg PO SID for acute vomiting, no more than 5 days in a row (skip 1-2 days) –8 mg/kg PO 2 hours prior to travel for motion sickness, for no more than 2 days in a row (skip 3 days) 5HT antagonists –Ondansetron (Zofran®) 0.05-0.15 mg/lb PO or slowly IV SID-TID. –Dolasetron (Anzemet®) 0.4-0.6 mg IV SID-BID. –Side effects sedation and head shaking. Lisa Lowenstein Houston, TX

105. Antiemetics Which is better? Sedlacek et al, 2008; Conder et al, 2008 Syrup of ipecac induced (peripheral) vomiting –Cerenia and Ondansetron worked best –both better than chlorpromazine, metoclopramide Apomorphine induced (CRTZ) vomiting –Cerenia, metoclopramide, chlorpromaizine best –All 3 better than Ondansetron Presurgical –Eliminated vomiting due to opiates –Decreased anesthesia gas needed

106. Prokinetics –Reduce gastroesophageal reflux (increased LES tone). –Help control vomiting by accelerating gastric emptying. –Improve coordination of antrum, pylorus and duodenum. –Increases propagation distance of peristaltic waves. –Contraindicated in cases with obstruction (can precipitate perforation). –Can usually wean prokinetics to the lowest effective dose.

107. Cytoprotective Agents Bind to the ulcer/erosion to create a physical protective barrier. Inactivate pepsin. Adsorb bile acids, which can be inflammatory. Sucralfate (Carafate®) 0.5 g/15 lb PO BID-QID – max 1 g Barium sulfate 2-6 ml/lb PO (same as for upper GI series). Side effect constipation.

108. Mucosal Protective Agents Increase mucosal mucus and bicarbonate production. Decrease mucosal acid production. Promote mucosal blood flow. Indicated for NSAID gastritis. Misoprostyl (Cytotec®) 2-5 ug/lb PO BID- TID. Side effects include: –Abdominal cramping. –Vomiting, diarrhea. –Abortion.

109. Dysautonomia First cases in Scottish horses in the 19 century First reported in the cat in 1982, first dog in 1983 Degeneration of autonomic ganglia and failure of autonomic function History: Vomiting, regurgitation, diarrhea Anorexia weight loss, lethargy Dyspnea, coughing Photophobia Dysphagia, dysphonia dysuria Onset over 1-2 weeks

110. Dysautonomia Exam: Decreased anal tone Absent PLR, moderate mydriasis Third eyelid prolapse Dry mucous membranes and eyes Crusty nose, nasal discharge Dyspnea, pulmonary crackles, fever Cachexia, weakness Global LMN weakness and CP deficits on neuro exam Large urinary bladder that is easy to express Heart rate and blood pressure relatively low

111. Dysautonomia Diagnosis: Thoracic rads may show megaesophagus and/or aspiration pneumonia Other neurologic deficits are absent Ileus, bladder distension on abdominal imaging Schirmer Tear Test less than 10mm OU CBC, panel, CSF tap may be normal if no systemic complications

112. Dysautonomia Diagnosis: Pilocarpine test Place 1-2 drops 0.05% pilocarpine in one eye Check PLR every 15 minutes for one hour Normal dogs show minimal response If dysautonomia, miosis due to denervation hypersensitivity Can be false negatives Chronic OP toxicity can produce similar results Adding atropine will reverse the miosis in OP toxicity but not dysautonomia No tachycardia in response to atropine injection

113. Dysautonomia Treatment: Bethanechol 1.25-5 mg PO BID or 0.05 mg/kg SC BID SC seems to work better Can help with urination and secretion Can gradually increase to effect Side effect – can increase vomiting and aspiration pneumonia Pilocarpine eye drops Can assist tear production and photophobia Artificial tears OU PRN, Genteel, Soothe XP Elevated feedings, prokinetics, permanent Gtube

114. Dysautonomia Prognosis: Grave Mortality 70-90% Those who survive have significant disability and progressively debilitate

115. Dysautonomia Pathology: 50% have megaesophagus 20% have aspiration pneumonia Can diagnose with histopath on necropsy Widespread degeneration of the autonomic nerves and ganglia More than 50% are rural, outdoor dogs Exposure to Clostridium toxins and/or paraneoplastic disease may play a role in pathogenesis

116. Handouts.pdf of this PowerPoint – behind the red tabpdf of this PowerPoint TAMU GI Lab Submission Form Client Drug Handouts –Amoxicillin –Oral antacids –Bethanechol –Bisacodyl –Bismuth subsalicylate –Cimetidine –Cisapride –Erythromycin –Famotidine –Fenbendazole –Maropitant –Metoclopramide –Metronidazole –Omeprazole –Praziquantel –Pyrantel pamoate –Ranitidine –Sucralfate

117. Handouts Client Handouts –Diaphragmatic hernia –Endoscopy –Hemorrhagic gastroenteritis