The Three Ralphs
Vomit isn't always straight forward...
IWantToBecomeAVet.com
“Ralph has been sick!”
IWantToBecomeAVet.com
Ralph 1- History
• Signalment- golden retriever, MN, 9yo
• Bringing up food over the past 3 weeks
• ...
IWantToBecomeAVet.com
Ralph 1- Physical Exam
• Respiratory- tachypnea, mild dyspnea, increased noses, nasal discharge
• BC...
IWantToBecomeAVet.com
Ralph 1- DDx
Problem List DDX Diagnostic Approach
Regurgitation
Oesphagitis- trauma, GA, reflux, irr...
IWantToBecomeAVet.com
Ralph 1- Diagnostics
• CBC/BIOCHEM:
elevated CK
• Survey Thoracic Rx:
cranial mediastnal mass
(thymo...
IWantToBecomeAVet.com
Ralph-1 Diagnosis
• Thymoma with Myasthenia Gravis
causing
• Megaoesphagus
• Secondary aspiration pn...
IWantToBecomeAVet.com
Ralph 1- Treatment
Condition Tx
Myathenia Gravis: Anticholinesterase pyridostgmine bromide syrup
Cor...
IWantToBecomeAVet.com
Ralph 1- Prognosis
• Poor prognosis
• 50% of MG cases
respond to
therapy
• up t0 248 days
Uh-oh Spag...
IWantToBecomeAVet.com
Ralph 2- History
• Signlament: Great Dane, 5 yo, FE
• After walk yesterday afternoon
• unproductive ...
IWantToBecomeAVet.com
Ralph 2- Physical Exam
• Tachycardia
• Tachypnea
• Poor peripheral pulses
• Pale mucous membranes
• ...
IWantToBecomeAVet.com
WHAT’S COMMON IS
COMMON
If it looks like GDV, it
probably is GDV.
If it looks like GDV, it
probably ...
IWantToBecomeAVet.com
Ralph 2 - Stablization
• Hypovolameic shock
• 2 IV catheters into cephalic veins
• Fluid therapy- Ha...
IWantToBecomeAVet.com
Ralph 2- Diagnostics
• Radiographs
• RIGHT LATERAL
• GDV: large gas-filled
gastric shadow
occupying ...
IWantToBecomeAVet.com
Ralph 2- Diagnostics
• Bloods: stress leukogram,
hemoconcentration, metaboloic
acidosis, hypercapnea...
IWantToBecomeAVet.com
Ralph 2- Treatment
• Surgical intervention once patient is stable, three goals:
• anatomical reposit...
IWantToBecomeAVet.com
Ralph 2- Prognosis
• Prognosis is good
• Partial gastrectomy- 70% survival rate
IWantToBecomeAVet.com
Ralph 3- History
• Signalment- 14 yo, FN, DSH
• 3 week History of vomiting
• dark brown coffee granu...
IWantToBecomeAVet.com
Ralph 3- Physical Exam
• Pale mucous membranes
• Weight loss- BCS 3/9
• Tachycardia
IWantToBecomeAVet.com
Problem List DDX Diagnostic Approach
Vomiting
Dietary-indiscretion, intolerance
Infection- parasites...
IWantToBecomeAVet.com
Ralph 3- Diagnostics
• CBC/BIOCHEM/UA:
• Regenerative anemia (macrocytic, reticulocytes) PCV 30
• BU...
IWantToBecomeAVet.com
Ralph 3- Treatment
• Owner advised to stop Meloxicam Tx, until revisit in 1 week, and to
not change ...
IWantToBecomeAVet.com
Ralph 3- Prognosis
• Excellent! ...
• As long as Owner doesn’t try to kill
her cat again.
IWantToBecomeAVet.com
THE END
Ok. Thank you.
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GIT - Gastrointestinal Disease in Animals

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Three clinical cases focusing on the topic of gastrointestinal disease. The cases aim to highlight commonly presenting gastrointestinal concerns and how the similar presenting complaints can represent very different disease processes. The cases are presented in a fashion so that they can be worked through in the same approach a working vet would. The level is intended for pre-veterinary students and veterinary students.

For more information please go to my website at http://www.IWantToBecomeAVet.com

GIT - Gastrointestinal Disease in Animals

  1. 1. The Three Ralphs Vomit isn't always straight forward...
  2. 2. IWantToBecomeAVet.com “Ralph has been sick!”
  3. 3. IWantToBecomeAVet.com Ralph 1- History • Signalment- golden retriever, MN, 9yo • Bringing up food over the past 3 weeks • passive event, no retching • no prodromal nausea • undigested food, with saliva and froth but without bile • Increased appetite • Weight loss • Exercise intolerance • Sleeps with eyes open • Voice change • Cough and nasal discharge of one week duration
  4. 4. IWantToBecomeAVet.com Ralph 1- Physical Exam • Respiratory- tachypnea, mild dyspnea, increased noses, nasal discharge • BCS 2/9 • Excessive drooling and repeated swallowing • Neurological exam: • absent palpebral reflex • fatigue after walking • fatigue-able spinal reflexes • Temperature- 40
  5. 5. IWantToBecomeAVet.com Ralph 1- DDx Problem List DDX Diagnostic Approach Regurgitation Oesphagitis- trauma, GA, reflux, irritation Anatomic- vascular ring anomaly, hiatal hernia, cricopharyngeal dz Obstruction- mural, luminal, extraluminal Motility Disorders- megaoesphagus, neurpathy, myopathy BIOCHEM+CBC Survey Rx Contrast Rx Endoscopy Weight loss with Increased Appetite (without diarrhoea) CHF HAC Renal Dz Megaoesphagus DM Neoplasia BIOCHEM+CBC+UA Survey Rx Contrast Rx LDDST Neurological Concerns (exercise intolerance, fatigue and lack of reflexes) Myasthenia Gravis Spinal cord lesion Survey Rx BIOCHEM+CBC Endrophonium chloride test Respiratory Concerns (tachypnea, dyspnea, increased lung sounds, discharge, cough) Pneuomoia Metastatic Neoplasia CHF BIOCHEM+CBC+UA Survey Rx BAL TTW
  6. 6. IWantToBecomeAVet.com Ralph 1- Diagnostics • CBC/BIOCHEM: elevated CK • Survey Thoracic Rx: cranial mediastnal mass (thymoma), bronchoalveolar pattern in right cranial, and middle and left cranial (aspiration pneumonia), megaoesphagus • Endrophonium chloride test- postive result increase in muscle strength
  7. 7. IWantToBecomeAVet.com Ralph-1 Diagnosis • Thymoma with Myasthenia Gravis causing • Megaoesphagus • Secondary aspiration pnuemonia
  8. 8. IWantToBecomeAVet.com Ralph 1- Treatment Condition Tx Myathenia Gravis: Anticholinesterase pyridostgmine bromide syrup Corticosteroids if non responsive Aspiration Pneumonia: Ampicillin + flouroquinilone Oxygen Megaoesphagus Metochlorpamide-pro-kinetic Ranitidine- reflux Elevated feeding Thymoma Non-resectable Radiotherapy
  9. 9. IWantToBecomeAVet.com Ralph 1- Prognosis • Poor prognosis • 50% of MG cases respond to therapy • up t0 248 days Uh-oh Spaghetti-O
  10. 10. IWantToBecomeAVet.com Ralph 2- History • Signlament: Great Dane, 5 yo, FE • After walk yesterday afternoon • unproductive retching • agitated/restless • progressive abdominal distension • One episode of collapse this morning • Always been a voracious eater
  11. 11. IWantToBecomeAVet.com Ralph 2- Physical Exam • Tachycardia • Tachypnea • Poor peripheral pulses • Pale mucous membranes • Abdominal distension • Depressed mentation • Retching in consult
  12. 12. IWantToBecomeAVet.com WHAT’S COMMON IS COMMON If it looks like GDV, it probably is GDV. If it looks like GDV, it probably is GDV.
  13. 13. IWantToBecomeAVet.com Ralph 2 - Stablization • Hypovolameic shock • 2 IV catheters into cephalic veins • Fluid therapy- Hartman’s proportion of shock dose (90ml/kg) • Serum electrolytes + PCV +TS • Analgesia- • morphine or methadone IM, fentanyl IV • ECG-VPCs most likely • Gastric Decompression • Orogastric tube (may need diazepam IV sedation) • If not possible- percutaneous gastrocentresis
  14. 14. IWantToBecomeAVet.com Ralph 2- Diagnostics • Radiographs • RIGHT LATERAL • GDV: large gas-filled gastric shadow occupying most of cranial abdomen, divided into two compartments • “double bubble” • DV: abnormal location of pylorus in left cranial abdomen The gas-filled pylorus is located dorsal and slightly cranial to the gas- filled gastric fundus. A compartmentalization line between the pylorus and fundus that represents folding of the pyloric antral wall back onto the fundic wall is frequently seen.
  15. 15. IWantToBecomeAVet.com Ralph 2- Diagnostics • Bloods: stress leukogram, hemoconcentration, metaboloic acidosis, hypercapnea • Lactate- 3.3mmol/L (better prognosis and less tissue necrosis)
  16. 16. IWantToBecomeAVet.com Ralph 2- Treatment • Surgical intervention once patient is stable, three goals: • anatomical reposition of stomach and spleen • assessment of organ viability- partial resection of fundic region • prevention of recurrence-inscional gastropexy
  17. 17. IWantToBecomeAVet.com Ralph 2- Prognosis • Prognosis is good • Partial gastrectomy- 70% survival rate
  18. 18. IWantToBecomeAVet.com Ralph 3- History • Signalment- 14 yo, FN, DSH • 3 week History of vomiting • dark brown coffee granules and fresh blood 4 x day • Hyper-salivation • appears nauseous beforehand • abdominal effort • Lays in praying position and doesnt like being picked up • Reduced appetite • Bilateral OA of coxofemoral joints, long term use of oral meloxicam to control • Owner considered Ralph was especially stiff recently so doubled his dose
  19. 19. IWantToBecomeAVet.com Ralph 3- Physical Exam • Pale mucous membranes • Weight loss- BCS 3/9 • Tachycardia
  20. 20. IWantToBecomeAVet.com Problem List DDX Diagnostic Approach Vomiting Dietary-indiscretion, intolerance Infection- parasites Inflammatory disease- gastritis, IBD, ulceration Neoplasia-lymphoma Obstruction- neoplasia, FB Secondary- renal, hepatic, pancreatitis, drug Tx CBC +Biochem +UA US Endoscopy Weight loss with Decreased Appetite (without diarrhoea) Mastication difficulties Hepatic disease Dysphagia Pyrexia Swallowing (oesophageal concerns) Loss of smell Pychic factors neoplasia Electrolyte disturbances CBC +Biochem +UA US Oral examination Feeding test Smell test Abdominal Rx CVS Concerns (elevated HR, pale MM) Anaemia Hypolvolemia PCV +TS CBC +Biochem +UA Cranial Abdominal Pain Pancreatitis Gastroduodenal ulcer Gastritis Obstruction CBC +Biochem +UA US Endoscopy
  21. 21. IWantToBecomeAVet.com Ralph 3- Diagnostics • CBC/BIOCHEM/UA: • Regenerative anemia (macrocytic, reticulocytes) PCV 30 • BUN elevated • Hypokalemia and hypochloraemia • TS 89 • Fecal Float- negative • Survey Rx- nomal • Contrast Rx and US- gastroduodenal ulcer
  22. 22. IWantToBecomeAVet.com Ralph 3- Treatment • Owner advised to stop Meloxicam Tx, until revisit in 1 week, and to not change dosages without consulting the vet (placed on tramadol) • Fluid Therapy for dehydration • Ranitidine- H2 receptor antagonist • Sulcralfate- protects ulcerated tissue (given first and before food) • Omeprazole- inhibits gastric acid secretion • Antiemetic- chlorpromazine • Possible use of Misoprostol synthetic PG analogue if NSAIF Tx continued 6-8 week treatment!
  23. 23. IWantToBecomeAVet.com Ralph 3- Prognosis • Excellent! ... • As long as Owner doesn’t try to kill her cat again.
  24. 24. IWantToBecomeAVet.com THE END Ok. Thank you.

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