HomeChronic Gastric Diseases
Definition: Chronic Vomiting - Acute vomiting that fails to respond to appropriate symptomatic therapy - Untreated vomiting that persists longer than two weeks – Consistent – Intermittent or episodic
Approach to Vomiting - Primary GI – Gastric – Small intestinal – Colonic - Secondary GI – Systemic illness that affects GI function
Secondary GI Causes of Vomiting SYSTEM - Kidneys - Liver - Exocrine pancreas - Endocrine pancreas - Adrenals - Peritoneum - CNS
- Thyroid - Uterus - Systemic infection
Disease: - Renal failure - Hepatic disease - Pancreatitis - DKA - Addison's - Peritonitis - Cerebral or vestibular disease - Hyperthyroidism - Pyometra - Sepsis
Overview: Gastric Causes of Chronic Vomiting - Chronic gastritis – Lymphocytic/plasmacytic – Eosinophilic – Associated with GHLOs – Parasitic – Reflux gastritis - Gastric foreign body - Gastric ulceration - Gastric motility disorders - Gastric neoplasia
Overview: Intestinal Causes of Chronic Vomiting - Inflammatory bowel disease (IBD) - Intestinal neoplasia - Duodenal ulcers - Fungal enteritis - Chronic intussusception - Foreign bodies - Colitis
Chronic Vomiting: History - Characterize vomiting – Onset – Duration – Frequency – Progression – Relationship to eating – Specific features (blood, foreign material, undigested food, projectile, etc.) – Response to changes in diet or feeding schedule, medication, other changes
Associated clinical signs- – Appetite changes – Weight loss – Diarrhea – Changes in attitude (lethargy) – PU/PD – Cough, tachypnea, dyspnea – Other
- Potential exposures prior to onset: – Medications – Plants – Toxins – Garbage – Potential foreign bodies – Other sick animals
- Dietary history - Deworming history - Vaccination status - Past medical history - Past surgical history
Approach to Vomiting: - Primary GI – Gastric – Small intestinal – Colonic - Secondary GI – Systemic illness that affects GI function
Chronic Vomiting: Diagnostic Steps - CBC, biochemistry profile, UA - Fecal - Survey abdominal radiographs - Cats: – T4 if over 6 yrs, FeLV, FIV – occult heartworm test - Elimination diet - Endoscopy - Abdominal ultrasound - Barium series - Laparatomy
Approach to Chronic Vomiting CBC, biochemistry profile, UA, fecal Survey abdominal radiographs Cats: T4 if over 6 yrs, FeLV, FIV (occult heartworm test)
Mild Signs: - Elimination diet
Significant Clinical Signs: - Endoscopy - Abdominal ultrasound - Barium series - Laparotomy
Overview: Gastric Causes of Chronic Vomiting - Chronic gastritis – Lymphocytic/plasmacytic – Eosinophilic – Associated with GHLOs – Parasitic – Reflux gastritis
- Gastric foreign body - Gastric ulceration - Gastric motility disorders - Gastric neoplasia
Chronic Gastritis Classified by etiology, breed, and/or histopathology Types of Chronic Gastritis
– Lymphocytic/plasmacytic gastritis (Chronic non-specific gastritis, IBD) – Eosinophilic gastritis – Granulomatous gastritis – Atrophic gastritis – Gastritis associated with GHLOs – Parasitic gastritis – Reflux gastritis
Etiopathogenesis of Chronic Lymphocytic/Plasmacytic Gastritis
- Non-specific reaction to many insults - Either wall defects allow antigen absorption from stomach stimulating immune response OR breakdown in immune tolerance (auto-immune gastritis) - Mucosal damage allows back-diffusion of acid - Gastric inflammation compromises motility, secretions and plasma proteins lost into lumen
Chronic Lymphocytic/Plasmacytic Gastritis: Clinical Features - Persistent intermittent vomiting exacerbated by eating - Diarrhea occurs if animal has concurrent IBD of intestines - PE, CBC, chemistries, UA, fecal, and survey radiographs – typically NAF
Chronic Lymphocytic/Plasmacytic Gastritis: Diagnosis - Obtain endoscopic biopsies or full-thickness biopsies by laparotomy - Infiltration of the gastric mucosa predominantly with lymphocytes and plasma cells - Mucosa may be normal thickness (simple gastritis), increased (hypertrophic), or decreased (atrophic) Note: Mucosal hypertrophy can cause outflow obstruction
Chronic Lymphocytic/Plasmacytic Gastritis: Treatment PRIMARY THERAPY - +/- NPO or "no food" for 24-48 hours - Multiple small daily meals – Easily digested diet (i/d) – Novel protein diet (e.g. venison and rice) – Hydrolyzed protein diet (z/d, HA) - Gastric protectant (Sucralfate) - Treat for ulceration if indicated
SECONDARY THERAPY - Prednisolone 1-2 mg/kg PO q12 hr, tapered - Usually reserve antiemetics for acute exacerbations
Eosinophilic Gastritis - Clinical signs like L/P gastritis - Inflammatory infiltrate dominated by eosinophils - May have peripheral eosinophilia - May be associated with: – Generalized eosinophilic gastroenteritis (dogs and cats) – Eosinophilic granulomas (dogs) – Hypereosinophilic syndrome (cats)
Eosinophilic Gastritis - Suspected etiologies – Parasites – Dietary hypersensitivity – Hypereosinophilic syndrome (cats) – neoplastic-
Eosinophilic Gastritis: Treatment - Therapeutic deworming - Treat as for L/P gastritis except use prednisolone as part of primary therapy - Cats usually require higher doses of steroids for control (2-3 mg/kg q12 hr) - If refractory, add azathioprine - Resect granulomatous masses
Eosinophilic Gastritis: Prognosis - Eosinophilic gastritis +/- enteritis: Good prognosis for control of clinical signs - Hypereosinophilic syndrome in cats: Very guarded prognosis