2. THERAPEUTIC FAILURE The reason we are here today

9. DEFINING THE PROBLEM VOMITREGURG Prodromal signs usuallyno Retching usuallyno Bile sometimesno Digested blood sometimesno

10. If it looks like vomiting, it is probably vomiting If it looks like regurgitation, then you don’t know for sure

11. If it looks like vomiting, it is probably vomiting If it looks like regurgitation, then you don’t know for sure But it is still more efficient to look for causes of regurgitation first

13. TAMU #79877

14. TAMU #151587

17. TAMU #117587-9/09

18. TAMU #117587-12/09

21. TAMU #156420

23. TAMU #159116 Sig: 4 month F German shepherd CC: Febrile HPI: 1 month ago: dog febrile with soft cough – cured with antibiotics 3 days ago had same signs PE: T = 39.5 C No other abnormalities

27. MSU#167884 Sig: 10 yr M(c) Mixed breed dog CC: Coughing HPI: Coughing began 2 years ago and is not controlled with any medications Dog now vomiting for 2 months

29. Causes of Congenital Esophageal Weakness Idiopathic

30. Causes of Acquired Esophageal Weakness Idiopathic Myasthenia gravis (localized) Hypoadrenocorticism (usually atypical) Various Myopathies/Neuropathies Spirocerca lupi Tetanus/Botulism Distemper Hypothyroidism (?) Trypanosomiasis (??)

33. THERAPY FOR CONGENITAL MEGAESOPHAGUS Dietary modification – Gruel from an elevated platform

34. THERAPY FOR CONGENITAL MEGAESOPHAGUS Dietary modification – Gruel – Meatballs (esp with partial motility) – Canned food – Dry food

37. TAMU #124375 Sig: 2 yr M(c) Dalmatian CC: Vomiting HPI: Present since obtained dog 1 month ago. Dog “inhales” food & immediately vomits food without bile or blood Dog drools constantly Recently has trouble swallowing PE: Not remarkable

41. TAMU#118002 Sig: 5 month F German shorthaired pointer CC: Vomiting HPI: 8 days ago: vomiting clear liquid Next day vomited blood and sticks Laparotomy: inflamed duodenum & blood in stomach Still vomits fluid & blood PE: No significant findings

42. TAMU#118002 CBC: PCV = 20% (35-55) Profile: Albumin = 1.9 gm/dl (2.5-4.4)

43. TAMU#995142/3 Sig: 10 yr F(s) Bichon CC: Vomiting HPI: Started vomiting bile on 1/12 Removed linear foreign object Vomiting continues: surgical pyloromyotomy 3 days later PE: Depressed, tight abdomen

45. ESOPHAGITIS: CAUSES Organisms (especially fungal)

47. ESOPHAGITIS: CAUSES Organisms (fungal) Foreign objects

49. ESOPHAGITIS: CAUSES Organisms (fungal) Foreign objects Caustic agents

51. ESOPHAGITIS: CAUSES Organisms (fungal) Foreign objects Caustic agents doxycycline clindamycin ciprofloxacin NSAIDs

52. ESOPHAGITIS: CAUSES Organisms (fungal) Foreign objects Caustic agents Gastric acid Excessive gastric acidity

53. ESOPHAGITIS: CAUSES Organisms (fungal) Foreign objects Caustic agents Gastric acid Excessive gastric acidity Excessive vomiting

54. ESOPHAGITIS: CAUSES Organisms (fungal) Foreign objects Caustic agents Gastric acid Excessive gastric acidity Excessive vomiting Iatrogenic (post anesthesia)

56. ESOPHAGITIS: CAUSES Organisms (fungal) Foreign objects Caustic agents Gastric acid Excessive gastric acidity Excessive vomiting Iatrogenic (post anesthesia) Spontaneous gastric reflux

59. ESOPHAGITIS: CLINICAL SIGNS Mild disease: “spit up” white phlegm

60. ESOPHAGITIS: CLINICAL SIGNS Mild disease: “spit up” white phlegm Moderate disease: poor appetite, regurgitate food

61. ESOPHAGITIS: CLINICAL SIGNS Mild disease: “spit up” white phlegm Moderate disease: poor appetite, regurgitate food Severe disease: anorexia, drooling, severe pain, regurgitation, vomiting

62. ESOPHAGITIS: DIAGNOSIS History (e.g., repeated vomiting, recent anesthesia)

64. ESOPHAGITIS: DIAGNOSIS History (e.g., repeated vomiting, recent anesthesia) Physical examination (oral lesions)

65. ESOPHAGITIS: DIAGNOSIS History (e.g., repeated vomiting, recent anesthesia) Physical examination (oral lesions) Radiographs (lesions may be subtle)

67. ESOPHAGITIS: DIAGNOSIS History (e.g., repeated vomiting, recent anesthesia) Physical examination (oral lesions) Radiographs (lesions may be subtle) Endoscopy (most sensitive/specific)

69. CHEMICAL CLEARANCE The ulcerated/eroded esophagus is ultra-sensitive to even minute amounts of acid You must “clear” the stomach of acid – the more severe the esophagitis, the more you must eliminate gastric acid secretion

70. ESOPHAGITIS: TREATMENT Antacids – Proton pump inhibitors – H-2 receptor antagonists

71. ANTI-ACID DRUGS: PPI’s Proton pump inhibitors – Irreversibly inhibit H + -K + ATPase Omeprazole (1-2 mg/kg PO q12-24h) Lansoprazole (1 mg/kg IV q24h) Pantoprazole (1 mg/kg IV q24h) Esomeprazole (1 mg/kg IV q24h) – start working immediately, but require 2-5 days to achieve maximal effect – Can cause diarrhea

72. ESOPHAGITIS: TREATMENT Antacids Prokinetics

73. Volume clearance Cisapride (0.1-0.5 mg/kg PO q12- 24h) better than metoclopramide Mosapride available soon? (IV) Erythromycin (1-5 mg/kg PO, IV,q8-12h) Metoclopramide (0.25 mg/kg IV, PO, q8-12 h) more effective on liquids Ranitidine (2.2-4.4 mg/kg PO, IV q8-12h)

74. ESOPHAGITIS: TREATMENT Antacids Prokinetics Analgesics (primarily topicals)

75. ESOPHAGITIS: TREATMENT Antacids Prokinetics Analgesics Gastrostomy tube (rarely needed)

76. ESOPHAGITIS: TREATMENT Antacids Prokinetics Analgesics Gastrostomy tube Carafate ?

77. ESOPHAGITIS: TREATMENT Antacids Prokinetics Analgesics Gastrostomy tube Carafate ? Antibiotics? Steroids?

81. TAMU #178379

86. TAMU #174578

87. TAMU #174578 – with abd pressure

88. TAMU #107138 Sig: 8 yr F(s) Mix 20 kg CC: Vomiting HPI: Started 5 weeks ago Vomits every other day or more often Vomitus often has yellow component Has lost 3.18 kg over the last month Referring vet has dx’ed hiatal hernia and reflux PE:No significant abnormalities

91. TAMU #107138 Sig: 8 yr F(s) Mix 20 kg CC: Vomiting HPI: Started 5 weeks ago Vomits every other day or more often Vomitus often has yellow component Has lost 3.18 kg over the last month Referring vet has dx’ed hiatal hernia and reflux PE:No significant abnormalities