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.
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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
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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
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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
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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
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Ralph 2- Physical Exam
• Tachycardia
• Tachypnea
• Poor peripheral pulses
• Pale mucous membranes
• Abdominal distension
• Depressed mentation
• Retching in consult
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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
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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.
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Ralph 2- Diagnostics
• Bloods: stress leukogram,
hemoconcentration, metaboloic
acidosis, hypercapnea
• Lactate- 3.3mmol/L (better prognosis
and less tissue necrosis)
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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
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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
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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
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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
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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!