Treatment of I vomit chronic

TREATMENT OF I VOMIT CHRONIC (*)
(*) Memories of XVII PANVET 2000. PANAMA, September 2000.
Michael Willard, Texas To & M University

Differences between the vomit and the regurgitation: In the first place we must distinguish if the animal is vomiting or regurgitating. The expelido flowed moment at which it took place the ingestion and the amount of food or they do not turn out from utility to distinguish the vomit of the regurgitation. The most trustworthy indications of than the patient are truely vomiting are a) obvious prodrómicos signs, b) huélfagos dry and/or vigorous abdominal arches, or c) to find bile (that is to say, a shining yellow fluid or green brilliant) or blood digested (like coffee grains) in the vomit. If these indicators are not present, the possibility of the vomit is not eliminated. In these animals the best decision is to obtain simple x-rays ± resistances torácico.

Once determined that the content of the vomit is of gastric or intestinal origin unlike the content of esofágica regurgitation, the next step will be to determine the presence of blood in the vomit. If there is hematemesis, we will be able to limit the list of causes considerably. The following aspect more important to consider is to determine if the vomit is acute or chronic. Most of the dogs and cats that suffer of acute vomit do not have an acute abdomen (that is to say, they do not have abdominal pain or shock or sepsis) although frequently suffer some form of autolimitada gastroenteritis, although one is due to consider that as much the presence of strange bodies as the intususcepción is possible (the parvovirosis must be considered in younger dogs). The chronic vomit (that is to say, the one that place takes during at least 2-3 weeks) rarely are autolimitado, and it indicates the necessity of a more aggressive diagnosis.

Diagnosis differential for the animals with chronic vomit: Most of the patients with chronic vomit due to a cinetosis it does not have:
a) an obstruction of tracto nourishing,
b) a gastrointestinal or peritoneal inflammation,
c) some of the diverse diseases of tracto extra-nourishing (that is to say, ?sistémicas?).
Occasionally, hipertrofia of the antral gastric mucosa at first (specially through endoscopio) can seem dangerous adenocarcinoma.
Hipertrofia of the antral gastric mucosa appears frequently in old dogs of small size (the same description that suggests a gastric tumor). Nevertheless, hipertrofia of the mucosa has a prognosis far better because the surgery is curativa (that is to say, piloroplastia, not piloromiectomia). It is difficult to differentiate hipertrofia from the antral gastric mucosa from the cancer being based on the great enlarged appearance, although hipertrofia of the mucosa tends to be smoother than the infiltrated cancer (nevertheless, not always it is thus). Therefore, a correct biopsy (the sufficiently deep and extensive thing) always must be indicated before suggesting one eutanasia, does not matter that the diagnosis is obvious.
To remember: not to make a microscopic diagnosis without a microscope, always biopsy and to wait for the results of the cytology or histopatología before suggesting a ?permanent solution?. This is a disease that has an appearance similar to the cancer and that is discovered in old dogs (as it happens with the cancer); nevertheless, he is curable.

Neoplasias gastric is infiltrativas injuries that can be proliferativas and/or ulcerativas. The Chow chows seems to have a showy discharge incidence of these tumors. This injuries frequently have badly a prognosis unless it is made I diagnose early. Unfortunately, in rare occasions these tumors are diagnosed soon because the clinical symptom commonest of gastric tumors (it stops most of the gastric diseases by this subject) is normally the anorexy and not the vomit. The problem is that when an old animal does not want to eat in the form in which it used to do it, it is attributed frequently to that the mascots ?are to him spending the years?. Consequently, nothing is made until the problem is serious or the animal loses weight of significant form or the animal begins to vomit. The ultrasonografía can find injuries that can not be Vista. Therefore, this it is the moment in which we will percutáneamente make a biopsy of the infiltrativas gastric injuries percutáneamente with the ultrasonográfica aid. We have taken biopsies calibrates 18 TRH of each injury without problems for the patient.
To remember: the anorexy usually is the first sign of gastric disease (including the tumor), vomit absence, and some neoplasias (ej. leiomiosarcoma) can be cured with surgery. Therefore, all mass in the stomach is not a tumor, we have observed many polyps, some of which are multiple.

Partial the gastric expansion or spontaneously solved is difficult to detect since it appears and it disappears spontaneously, which means that it can not detect when we made a x-ray to the patient. This problem appears in the same races affected by the classic gastric expansion-volvulus (Great Danish, Veimaraner, Irish Setter, Ovejero Alemán, etc.). Partial the gastric expansion is diagnosed when the stomach badly is located (what it happens normally during a x-ray, but can happen during a endoscopia or surgery). Simple x-rays are sufficient if the stomach badly is located in the moment in which the x-ray is made. Nevertheless, they are needed to radiograph to the dog more of once observing the stomach badly positioned If with the common x-rays it is not sufficient, are possible to be used x-rays of resistance with barium. One gastropexia prophylactic is indicated to solve the problem and to help to prevent futures episodes with vólvulos the gastric syndrome of expansion/. In University A&M of Texas, we have seen more and more dogs than present/display these partial chronic expansions.
To remember: a normal abdominal simple x-ray does not exclude an intermittent gastric torsion necessarily, spontaneously solved.

The gastric strange bodies are common and frequently responsible for the vomit, and/or abdominal malaise when they are present. Nevertheless, the mere presence of a strange object in the stomach does not guarantee that this one is the cause of the clinical signs in the animal. I have seen dogs that had had strange bodies in their stomachs during months without no problem. If there is some doubt on if a strange body ej is the cause of the vomit (. a piece of weave that is not obstructing píloro or causing to an effect linear strange body, a biopsy of the gastric and duodenal mucosa while the strange body is being removed to obtain a weave sample for histopatología and the case that the animal continued vomiting after the object had been removed. If you decide to extract the strange object with endoscopia, must be sure that she has radiographed to the patient immediately before the procedure because some bodies are based in the stomach (or the intestine) during days and ?decide? to move the night previous to which is made the endoscopia to them. Bones of an incredible size can disappear in 24 hours of exhibition to a gastric acid; deletion marks the possibility of disappearing by its own means instead of cutting them or extracting them.

The linear strange bodies have a similar aspect. Everybody knows that it is necessary to watch underneath the language of the cat that vomits to discover these strange bodies. In individual, those cats that have frenillo lingual painful (because the strange body cuts the area) and those cats that offer resistance to that the internal side of their language is examined to them (what has happened to me to most of the cats with which I have worked) cannot be examined correctly without a chemical tranquilizer. A milligram of ketamina/lb given IV and the use of a hemostatic mosquito will allow him to inspect this area suitably. If you find a strange body linear patch underneath the language in a patient who are been ill only a day or two, you can try to cut the object in the base of the language and to observe if she happens later to the internal without causing no other complication. Monitorear to the patient carefully; if nonimprovement substantially within the 24-36 hours, you probably need to make a surgery. Remember that the linear strange bodies can be lodged in píloro, in which case will be nothing no to see underneath the language. If a linear strange body is endoscópicamente, will be appropriate to try to remove it with endoscopio, if there is there been only during few days. It is made passing the end of endoscopio within the duodeno and trying to take hold the strange body by his end. This way, the object within the stomach will be able to be pushed and later to remove it of there. One is not due to take the object near píloro and to throw. If the strange body has only remained during 2-3 days, would be worth the trouble the attempt, depending of the nature on the linear strange body. If the strange body is relatively wide and seems improbable that it can cut and perforate the intestine, you could try to extract it; nevertheless, he does not remove it abruptly. He is not worth the trouble to run the risk of a perforation. On the other hand, if the strange body has remained there during several days or if the strange body seems relatively thin and could cut the intestine, it does not extract it. The chronic linear strange bodies in dogs are present more frequently of which the clinical ones can realize. We have seen some dogs that had a massive intestinal commitment with linear strange bodies that had vomited minimumly and they even remained normal during few days to weeks before returning to have symptoms again.
To remember: all the strange bodies do not cause clinical symptoms and all the linear strange bodies do not cause to the awaited clinical symptoms (ej. vomit). Second, does not abstain from anestesiar to a cat to watch suitably underneath its language.

Intususcepción is not a common cause so that an animal vomits. These animals can indeed vomit, but the diarrea is a more obvious symptom. If acute and diarrea vomit with blood exists, or if a thickened intestinal handle is observed that it pretends to be a possible intususcepción, then the abdominal ultrasenografía will be the best test to detect the injury.
To remember: it is very easy not to feel a íleo-cólica intususcepción.

The idiopática gastric hipomotilidad is an exclusion diagnosis. It seems infrequent, but nobody imagines the common thing that it is. There is no an anatomical obstruction of the flow of tracto gastric, but these patients typically vomit food nondigested after hours it to have ingested. The x-rays of resistance with barium document the absence of gastric emptiness. The surgery and/or the endoscopia do not reveal an obstruction of the gastric flow. It is necessary to remember that any inflammation anywhere of the abdomen can produce gastroparesis; therefore, it has well-taken care of when it makes east diagnosis so that an inflammatory injury is not ignored. The metoclopramida one is used often to help to drain the stomach and to prevent the vomit, but some patients are refractory to the treatment. The cisaprida one (0.25-0.5 mg/gk I.A.D.B. to tid) can be effective when stimulating the gastric motilidad when the therapy with metoclopramida fault. The eritromicina is also an excellent proquinético agent for the stomach. Nevertheless, the proquinética dose of eritromicina is 1 mg/kg, around 1/5 to 1/10 of antimicrobial dose.
To remember: he is crucial to eliminate totally those causes of gastric hipomotilidad, like inflammatory diseases and partial obstruction.

The syndrome of the bilious vomit is a situation in which of another way the normal animals vomit bile, usually in the morning, shortly after awaking. It seems to be some luck of syndrome of gastrointestinal ebb tide. To feed the animal before one is going away to sleep, or some times to give him to a proquinético (ej. metoclopramida or cisaprida or eritromicina) normally it solves the problem.

The diseases of tracto extra-nourishing (that is to say, ?sistémico?) that must specially be considered in dogs and cats that are vomiting are:
1) renal insufficiency,
2) adrenal hypofunction,
3) hipercalcemina,
4) diabetic cetoacidosis,
5) acute pancreatitis,
6) hypofunction/hepática inflammation,
7) feline hipertiroidismo,
8) feline filariosis (congestiva cardiac insufficiency),
9) piómetra.
With respect to the renal insufficiency and the hipoadrenocorticismo: the sérica creatinina is more trustworthy to accurately value the renal state of the animal that the BUN, unless the animal is emaciado (in which case there is no muscle that produces creatinina and the sérica concentration underestimates the deficiency). The adrenal hypofunction can cause exactly changes in BUN, creatinina, phosphorus, and specific gravity observed in the primary renal insufficiency such. An stimulation-ACTH test is obligatory because many diseases simulate the electrolytic changes that are ?classic? in the adrenal hypofunction and some dogs with hipoadrenocorticismo do not have electrolytic changes. This lack of electrolytic changes frequently must to a previous fluidoterapia and some times to a glucocorticoid deficiency. Therefore, it is important to always consider the hipoadrenocorticismo since it is ?good? a disease to discover (that is to say, is one of those diseases that when they do not treat will kill the patient; nevertheless, it is very easy to treat and it has an excellent prognosis).

Hipercalcemia causes a renal disfunción but it can also cause nonazotémicos animal vomit. The sérico calcium concentration in dogs must always adjust to the amount of albumen in blood using the following formula: Right calcium (mg/dl) = Measured Calcium (mg/dl) - Albumen Concentration Sérica (mg/dl) + 3.5. You can also measure the ionized calcium that must be increased in animals with clinical signs due to hipercalcemia. Any persistent hipercalcemina in a mature animal requires to be investigated. The same formula in cats cannot be applied, but the idea is the same one.

The feline hipertiroidismo also cause vomits. It can be confused to diagnose since often they accompany to this disease SAP increased and/or values by ALT, that suggest a hepática disease. The normal values cannot be taken only from sérica tiroxina, can be had normal values and nevertheless to have hipertiroidismo, also values below the normal thing of sérica tiroxina can be had and of having a cat with hipertiroidismo symptoms. In general the measurement of a free T4 seems to be more appropriate than the determination of total T4.
To remember: to find tiroideo a nodule concrete is very useful. If you discover this nodule, would have to look for the hipertiroidismo with the test of suppression of T3 or with the test of simulation TRH or the nuclear gammagrafía or the therapeutic tests with tapazol, without considering the T4 total.

The inflammation of tracto nourishing can be one of the three main categories more difficult to diagnose. One is not due to trust hemograma or in the x-rays or ultrasonografías, an appropriate biopsy is needed to make the diagnosis. Espiroquetas gastric has recently received much attention like cause of the gastric inflammation. Firstly they were discovered in the gastric mucosa of animals and people to the arrival of this century. Then a newness was considered nonpatogénica and were redescubiertas in apparently normal dogs in 1960. Nevertheless, one decade ago, in Australia investigators suggested a causal relation between these bacteria and the gastritis/human ulceraciones. Today, a strong evidence for which the Helicobacter pylori is responsible for most of the diagnosed peptic ulcers in humans, as well as of dispepsia exists nonulcerosa. Pylori has also been indicated to the Helicobacter as a factor of predisposition of the gastric carcinoma and exist multiple studies of biopsy that prove the complete regression of linfosarcoma gastric after to have eliminated the resident Helicobacter with antibiotic therapy.
The veterinarians have much interest in the works on this bacterium due to two main questions: a) The dogs and cats also develop the disease due to this bacterium? and b) This bacterium can be transmitted by dogs and cats to humans.
The diagnosis of gastric infection by Helicobacter is obtained by means of cytology, test of ureasa of the gastric mucosa, and/or histopatología of the biopsy of the gastric mucosa. I consider that the histopatología more than is adapted when the pathologist looks for the organisms.
The cytology (which is at the moment a little more sensible than the biopsy) is made on the samples of the biopsy of the gastric mucosa or on the obtained cytological samples by means of the endoscópico sweeping. The plates can be dyed with a new blue methylene or Diff Quick or with diverse techniques. The made cytological preparations from the techniques of sweeping carried out endoscópicamente tend to be less sensible than the preparations made in the biopsies of the mucosa. The histopatología is reasonably sensible. At the moment, the dyes of plasta are used or (ej. Warthin-Starry) or the Giemsa dyes, nevertheless, pathologists experienced routinely find the organisms in sections dyed with H&E. The test of ureasa is made placing the biopsy of the gastric mucosa on an appropriate one to agar. They are possible to be obtained to equipment (ej. test CLO, Trimed Inc. Specialties Lenexa, KS) in which when it is placed a sample of the gastric mucosa on he himself will indicate the presence of ureasa (and by implication, the Helicobacter Pylori) in 2-3 hours. In human beings, one has inquired who have a sensitivity of 90-98% and one specificity near the 100%. Tubes of agar can be used less expensive designed to detect ureasa in other species of bacterium for he himself intention. Although at the moment a serológico test for the infection by Helicobacter in people exists, a valid similar test for dogs or cats does not exist.
In human beings the treatment has implied a variety of combinations with drugs. Because the bacterium lives under the layer of the mucus, in vitro sensitivities not always are translated in effectiveness in alive. In general, the Helicobacter pylori tends to develop resistance quickly when an only drug is used. At the moment, approximately 30% of the stocks are resistant to metronidazol. Some factors (that is to say, a period of short treatment, bad fulfillment, previous therapy with omeprazol), seem to be associate to the increase of the therapeutic failure.
The classic triple therapy (metronidazol, subsalicato of bismuth, and tetracycline during two weeks) has reached percentage of success of 90% (understood the success when the eradication of the organism is obtained) Nevertheless, until 30% of the patients that receives the triple therapy they have adverse effects that lead to the breach. The macrólidos ones can be antibiotic more cash for this type of infection. According to some studies the eritromicina works like unique agent in some cats and dogs well. Recently, the claritromicina and the acitromicina (new macrolidas) have been used with apparent good result in infected people.
The dose of acitromicina at the moment recommended seems to be of 5 mg/kg sid for cats and 10-40 mg/kg sid for dogs. The acitromicina seems to have less indirect effect (specially vomits) that the eritromicina, but probably is equal or more effective.
The use of omeprazol to eliminate the gastric acidity seems that it does to the most effective antibiotics. Omeprazol is, at least in people, singularly more cash to eliminate the infections by Helicobacter that the cimetidina or the famotidina. The combinations of omeprazol, acitromicina, and metronidazol according to it only seems need to be provided during 7-12 days to have a curativo effect in people which makes suppose (although nontest) that the dogs and cats in the same way require a treatment of smaller duration. Since many dogs and cats become infected with species of Helicobacter different from the H. pylori, it is possible that a much less aggressive therapy could be satisfactory in dogs and cats.

A fundamental question is, ? When we must treat to the animals with symptoms in tracto gastrointestinal superior of infections by Helicobacter? The present experience suggests is not due to trust only the gastric presence or absence of infiltrated inflammatory to determine the clinical relevance of the presence of the Helicobacter. A study showed that those cats that did not vomit was probable that they had espiroquetas and gastric inflammation like the cats that were vomiting. Dr Guyer discovered that approximately 30% of the cats that vomited and 30% of the normal cats they had both infiltrated gastric inflammatory and Helicobacter. Also, approximately 30% of the cats that vomited and 30% of the normal cats had neither inflammation nor Helicobacter in their stomachs.
To remember: the simple finding of espiroquetas in the stomach does not mean that they are the cause of a disease (many normal dogs and cats have espiroquetas - some times in great number and some times with inflammation - in the gastric mucosa); you probably must treat the infection and observe as she responds the mascot. Finally, when the mascot even responds, we cannot still be sure that the Helicobacter sp is the cause of the problem.
Assuming inclusively which outside this one the problem, is necessary to consider that well is documented that these bacteria can ?return? and re-infect the patient, so and as it has been observed in cats.
The rare Physaloptera is a parasite to which, until recently time, more like a national phenomenon has been considered him that like a clinical organization. Nevertheless, we have seen many cases of vomit that were intratables in dogs that cured themselves removing. the only parasite that was adhered of its gastric mucosa pyrantel and the ivermectina is two drugs that seem to be effective to eliminate this parasite. It is very difficult to find eggs of this nematodo in an examination of fecal flotation. Unfortunately, it can also be very difficult to find the parasite in some dogs that vomit. Some dogs have been put under a surgical exploration to find the cause of the vomit when later endoscopía was discovered by means of one that the solution to the problem was in the gastric mucosa.
To remember: he is reasonable, depending on the severity of the clinical symptoms, to treat a dog that is vomiting (and perhaps to a cat) with ivermectina or Pyrantel before making one endoscopía.

Antieméticos is indicated a) when the patient due to the vomit is losing much liquid what makes difficult its treatment, b) when she is needed to provide lightening to an animal that shows much malaise, c) if the patient suffers a car-limited acute cause of the vomit that can be solved with time and that what we want it is to diminish the symptoms while it improves. My antivomiting one preferred is the clorpromacina. If he is not available, the procloperacina is also very useful. It is necessary to have much taken care of with these drugs because they cause dehydration in the animals because their vasodilator properties can cause that the perfusión is worse. Also the metoclopramida one is used like antivomiting; nevertheless, it tends to be less effective than the derivatives of the promacina. Ondansetron is a receiving antagonist of 5-HT3 (ej. serotonin) that is effective when the clorpromacina and the metroclorpromacina fail. It will not solve to all the problems (ej. it does not stop the vomit due to associated obstruction or to feline hepática lipidosis), but it manages to frequently stop the vomit due to inflammatory parvovirosis and other states. The dose seems to be around 0.1-0.2 mg/kg, sid to tid.
To remember: the Ondansetron can be very expensive and must be reserved for patient the particularly ill one that does not respond to other medicines.

The hematemesis requires a different approach slightly since causes become more probable that others. Three important reasons so that exist an animal vomits blood: coagulopatía, that swallows blood of another place, and an erosion/gastrointestinal ulceración (GUE). The most frequent causes of GUE, that are at the same time easiest to detect, are: mastocitoma, the drug administration and ?stress?.
The drugs represent an important cause of GUE in the dog. Although some controversy on if all the corticoesteroides they are ulcerogénicos, most of the clinical ones exists agree in which a high dose of dexametasona has the potential to cause significant a gastric erosion. Prednisolona by itself is not ulcerogénica unless ej is used in very high doses (. >2-3 mg/lb/día), and then is not even particularly bad. Nevertheless, doubt does not exist about the danger of nonesteroidales antiinflammatory drugs in dogs.
All the AINES (including they carprofen) can potentially cause a devastating GUE, and some of nonesteroidales drugs are known by their poisonous effects (that is to say, indometacina and they naproxen). The ibuprofeno is also particularly ulcerogénico in the dog because it happens to the enterohepática circulation. Some of the new AINES (they carprofen) have less capacity to cause GUE that other medicines; nevertheless, you can cause GUE if she uses an overdose or she uses a drug at the mistaken moment (ej. when the patient experiences a shock or a bad perfusión in tracto nourishing).
Flunixin is particularly dangerous like GUE cause. He is extremely powerful and it can be devastating when it is combined with steroids like dexametasona. Although by themselves they are able to cause a significant ulceración and bled, the ulcerogénico potential of the AINES is seen particularly increased with other factors, specially the administration synchronizes of another AINES or a corticoesteroide, and a hipoperfusión of tracto nourishing.
To remember: The AINES must are due to consider in any dog that suffers of GUE that not must to some other cause obvious.
When we talked about to stress like a cause of ulcers, we are specifically talking about the hipovolémico or séptico shock (that usually is obvious, although not always, of history and/or the physical examination).
The neurogénico shock also can be the person in charge. The bad perfusión is often more severe in the intestine, doing it particularly susceptible to the ulceración. Mastocitomas can have the appearance of any injury of skin. In particular, they can perfectly simulate the appearance of lipomas, the only form to be able to distinguish them of lipomas is by means of a aspirativa cytology. When these tumors desgranulan they release histamina which it specially inside causes the hypersecretion of gastric acid, that can lead to a severe ulceración, or outside píloro.
Other causes of GUE exist that are a little more implied in the diagnosis. An important cause of GUE in the dogs seems to be the hepática insufficiency. A good example of this disease is the hepática cirrhosis. Whenever I have had to take care of a dog with a hepática disease that of sudden form gets worse clinically (specially in case of encefalopatía), I look for GUE. The blood within the intestine would turn out to be as a rich protein food and prearranges to the hepática encefalopatía in these patients.
The hepática disease can cause scattered intravascular coagulopatía what darkens the panorama when we are trying to determine the cause of the hematemesis.
The cimetidina (5-10 mg/kg) is due to provide 3-4 times per day if we really want to diminish the gastric acid secretion. Nevertheless, the famotidina (0,5 mg/kg) is only necessary to twice provide it one or per day. In most of the patients, the cimetidina is more than adapted to cure the gastric ulcers. The ranitidina (2,2 mg/kg) is effective if it is provided to the day twice and is my favorite injectable H-2 antagonist; nevertheless, it can produce vomits if a skittle occurs IV. The indirect effect of the H-2 antagonist are rare although they can produce diarrea, medicamentosa eruption, hiperpirexia, trombocitopenia, granulocitopenia, and problems of the SNC including convulsions. The main function of the H-2 antagonist is the treatment of the erosions and existing ulcers, can be useful to prevent some types with ulcers, but this is not certain for all the types of ulcers.
Omeprazol and lanosprazol is the most effective inhibiting inhibitors of the gastric acid secretion and of the proton pump (PPI). The dose of omeprazol is of 0.7-1.5 mg/kg sid, although I have used up to 2 mg/kg I.A.D.B. in patients with gastrinomas or severe esofágico ebb tide.
The sucralfato seems very effective to protect those zones that already are ulceradas helping to cure them. The only indirect effect is the constipation.
To remember: avoid to at the same time provide this drug that others. Although, normally it is well admitted, some times prevents the absorption of another drug.
Translation: Lic. Ana Bretón

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