serious primary or secondary GI disease.
A logical approach to assessing the patient that presents with the problem of vomiting is important to ensure that the problem and system are defined correctly so that diagnostic and treatment plans are rational and justifiable.
Clinical pathology will often progress understanding of secondary GI disorders but is not usually particularly helpful in primary GI disorders where imaging of the GI tract is often more diagnostically useful.
Key points
As a result of reading this chapter you should be able to:
Appreciate the importance of differentiating regurgitating, reflux and vomiting
Understand what initiates vomiting and, hence, how different disorders cause vomiting
Appreciate the importance of determining whether vomiting is due to primary or secondary gastrointestinal disease
Develop a rational diagnostic approach to the vomiting patient and to appreciate when a diagnostic work‐up vs. symptomatic therapy is appropriate
Understand the secondary gastrointestinal causes of vomiting and the most appropriate methods of diagnosis
Review primary gastrointestinal disease processes that cause vomiting
Understand the causes and consequences of disorders of the oesophagus
Recognise the patient at risk of reflux and its consequences.
Questions for review
When is a fuller work‐up of a vomiting patient indicated as opposed to symptomatic treatment?
What clinical features of a patient would strongly suggest to you that it was vomiting because of primary gastrointestinal disease?
What clinical features of a patient would strongly suggest to you that it was vomiting because of secondary gastrointestinal disease?
Case example
‘Muriel’ is a 7‐year‐old Labrador (neutered) dog who presented with a 3–4‐week history of reduced appetite and depression. She started to intermittently vomit bile‐stained material about 2 weeks ago, and the vomiting has become much more frequent over the past week. The vomiting occurs unrelated to eating, and abdominal effort is obvious when she vomits. Prior to vomiting she appears restless and frequently licks her lips. No diarrhoea has been noted. Water intake is normal.
On physical examination she is thin (body condition score 3/9). There is no evidence of abdominal discomfort. Rectal temperature is normal. Heart rate and respiratory rate are within normal limits, pulses are strong and synchronous.
Define the problem
Is Muriel vomiting or regurgitating or refluxing?
She is vomiting as evidenced by abdominal effort observed, lip licking indicating hypersalivation and bile in the vomitus.
Define the system
Does Muriel have primary or secondary GI disease?
Most indicators in this case suggest that the vomiting is due to secondary GI disease because:
The vomiting was preceded by 1–2 weeks of depression and reduced appetite.
The vomiting is usually intermittent and unrelated to feeding (although of
increasing frequency latterly).
This does not preclude primary GI disease but is more typical of secondary GI disease. Primary GI disease is less likely (although it cannot be completely excluded just yet).
Define the location
Where is the problem in the secondary GI system?
Secondary GI causes of vomiting of most relevance for Muriel include:
Hepatic disease
Hypoadrenocorticism
Chronic (but not acute) pancreatitis
Electrolyte perturbations due to various disorders (calcium, potassium).
Because polyuria and polydipsia are not features in this case (assuming the owner’s history is correct), other conditions, which are less likely (but not excluded yet), would be:
Renal disease
Diabetic ketoacidosis.
Primary GI disease is less likely (although it cannot be completely excluded just yet) and will be investigated if there is no evidence for secondary GI disease. GI neoplasia or inflammatory bowel disease would be the most likely differentials if primary GI disease is present.
Define the lesion
This will be determined when the location is identified.
Case outcome
The diagnostics planned assessed the differentials considered for secondary GI disease (define the location +/‐ lesion). Biochemistry results were consistent with presence of a significant hepatopathy, ultrasound examination supported diffuse parenchymal disease and histopathology on an ultrasound‐guided biopsy confirmed hepatocellular carcinoma.
CHAPTER 4 Diarrhoea
Jill E. Maddison1 and Lucy McMahon2
1 Department of Clinical Science and Services, The Royal Veterinary College, London, UK
2 Anderson Moores Veterinary Specialists, Winchester, UK
The why
Veterinarians frequently assess animals with diarrhoea in general veterinary practice.
Many cases will be transient and respond to symptomatic management.
Those cases that are chronic can be a source of great frustration for all concerned.
A structured approach to diarrhoea, including classification of the type of diarrhoea, and a judicious mix of diagnostic tests and therapeutic trials can greatly improve the outcome.
