THERAPEUTIC FAILURE The reason we are here today

THERAPEUTIC FAILUREThe reason we are here today

W rong diagnosis Right diagnosisW rong treatm ent

R ight diagnosisRight treatm ent

W rong client

Therapeutic failure

W rong diagnosis Right diagnosisW rong treatm ent

R ight diagnosisRight treatm ent

W rong client

Therapeutic failure

W rong diagnosis Right diagnosisW rong treatm ent

R ight diagnosisRight treatm ent

W rong client

Therapeutic failure

W rongdiagnosis

R ig ht d iag no s isW ron g trea tm ent Right diagnosis

Right treatm entW rong client

Therapeutic failure

Regurgitation Vom iting Expectoration

Patient is "spitting up"

DEFINING THE PROBLEM

VOMIT REGURGProdromalsigns usually no

Retching usually no

Bile sometimes no

Digested blood sometimes no

If it looks like vomiting, it

is probably vomiting

If it looks like

regurgitation, then you

don’t know for sure

If it looks like vomiting, it

is probably vomiting

If it looks like

regurgitation, then you

don’t know for sureBut it is still more efficient to look for causes of

regurgitation first

TAMU #79877

TAMU #151587

TAMU #151587

TAMU #117587-9/09

TAMU #117587-12/09

TAMU #156420

TAMU #156420

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

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

Causes of Congenital Esophageal Weakness

• Idiopathic

Causes of Acquired Esophageal Weakness

• Idiopathic• Myasthenia gravis (localized)• Hypoadrenocorticism (usually atypical)• Various Myopathies/Neuropathies

• Spirocerca lupi• Tetanus/Botulism

• Distemper

• Hypothyroidism (?)

• Trypanosomiasis (??)

Treat cause

C ause found Id iopath ic

Look forcause

A cquiredW eakness

Supportivetherapy

Id iopath ic

C ongenitalW eakness

R EG U R G ITA TIO N

Treat cause

C ause found Id iopath ic

Look forcause

A cquiredW eakness

Supportivetherapy

Id iopath ic

C ongenitalW eakness

R EG U R G ITA TIO N

THERAPY FOR CONGENITAL MEGAESOPHAGUS

• Dietary modification

– Gruel from an elevated platform

THERAPY FOR CONGENITAL MEGAESOPHAGUS

• Dietary modification

– Gruel

– Meatballs (esp with partial motility)

– Canned food

– Dry food

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

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

TAMU #118002

CBC: PCV = 20% (35-55)

Profile: Albumin = 1.9 gm/dl (2.5-4.4)

TAMU #99514 2/3

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

ESOPHAGITIS: CAUSES

Organisms (especially fungal)

ESOPHAGITIS: CAUSES

Organisms (fungal)

Foreign objects

ESOPHAGITIS: CAUSES

Organisms (fungal)

Foreign objects

Caustic agents

ESOPHAGITIS: CAUSES

Organisms (fungal)

Foreign objects

Caustic agentsdoxycycline

clindamycin

ciprofloxacin

NSAIDs

ESOPHAGITIS: CAUSES

Organisms (fungal)

Foreign objects

Caustic agents

Gastric acid

Excessive gastric acidity

ESOPHAGITIS: CAUSES

Organisms (fungal)

Foreign objects

Caustic agents

Gastric acid

Excessive gastric acidity

Excessive vomiting

ESOPHAGITIS: CAUSES

Organisms (fungal)

Foreign objects

Caustic agents

Gastric acid

Excessive gastric acidity

Excessive vomiting

Iatrogenic (post anesthesia)

ESOPHAGITIS: CAUSES

Organisms (fungal)

Foreign objects

Caustic agents

Gastric acid

Excessive gastric acidity

Excessive vomiting

Iatrogenic (post anesthesia)

Spontaneous gastric reflux

ESOPHAGITIS: CLINICAL SIGNS

Mild disease: “spit up” white phlegm

ESOPHAGITIS: CLINICAL SIGNS

Mild disease: “spit up” white phlegm

Moderate disease: poor appetite,

regurgitate food

ESOPHAGITIS: CLINICAL SIGNS

Mild disease: “spit up” white phlegm

Moderate disease: poor appetite,

regurgitate food

Severe disease: anorexia, drooling,

severe pain, regurgitation,

vomiting

ESOPHAGITIS: DIAGNOSIS

History (e.g., repeated vomiting,

recent anesthesia)

ESOPHAGITIS: DIAGNOSIS

History (e.g., repeated vomiting,

recent anesthesia)

Physical examination (oral lesions)

ESOPHAGITIS: DIAGNOSIS

History (e.g., repeated vomiting,

recent anesthesia)

Physical examination (oral lesions)

Radiographs (lesions may be subtle)

ESOPHAGITIS: DIAGNOSIS

History (e.g., repeated vomiting,

recent anesthesia)

Physical examination (oral lesions)

Radiographs (lesions may be subtle)

Endoscopy (most sensitive/specific)

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

ESOPHAGITIS: TREATMENT

• Antacids

– Proton pump inhibitors– H-2 receptor antagonists

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

ESOPHAGITIS: TREATMENT

• Antacids

• Prokinetics

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)

ESOPHAGITIS: TREATMENT

• Antacids

• Prokinetics

• Analgesics (primarily topicals)

ESOPHAGITIS: TREATMENT

• Antacids

• Prokinetics

• Analgesics

• Gastrostomy tube (rarely needed)

ESOPHAGITIS: TREATMENT

• Antacids

• Prokinetics

• Analgesics

• Gastrostomy tube

• Carafate ?

ESOPHAGITIS: TREATMENT

• Antacids

• Prokinetics

• Analgesics

• Gastrostomy tube

• Carafate ?• Antibiotics?

• Steroids?

TAMU #178379

TAMU #174578

TAMU #174578 – with abd pressure

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

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

Surgery m aybe appropriate

Sym ptom s m ay bedue to hiatal hernia

Young

M edical therapym ight be best

Sym ptom s possiblydue to other disease

O ld

Sym ptom atic Asym ptom atic

H IATAL HERNIA

Surgery m aybe appropriate

Sym ptom s m ay bedue to hiatal hernia

Young

M edical therapym ight be best

Sym ptom s possiblydue to other disease

O ld

Sym ptom atic Asym ptom atic

H IATAL HERNIA

Surgery m aybe appropriate

Sym ptom s m ay bedue to hiatal hernia

Young

M edical therapym ight be best

Sym ptom s possiblydue to other disease

O ld

Sym ptom atic Asym ptom atic

H IATAL HERNIA