Chronic vomiting in cats Student: G2荊蕙, G1黃柏堯 Table of content • Introduction • The mechanism of vomiting • Regurgitation v.s. vomiting • Clinical presentation and initial assessment • Diagnostic approach • Treatment • Conclusions Introduction • Active elimination of stomach contents through the mouth • ± Preceded by nausea, pacing, and salivation. • Usually digested food or liquid with acidic or neutral pH. • ≥ 2 weeks duration. The mechanism of vomiting • A complex reflex involving the gastro-intestinal system, respiratory and abdominal muscles, and changes in posture. 1. Start with nausea, and cats may exhibit signs of lip-licking behavior, hypersalivation, and food aversion. 2. Retching, which consists of powerful contractions of the abdominal muscles and diaphragm. 3. Gastric contents are forcefully expelled by the contraction of the abdominal muscles, stomach, and the diaphragm, with concurrent relaxation of esophageal sphincter. The mechanism of vomiting • Emetic center (wide distribution of neurons) is stimulated • Humoral pathway • conditions affecting the blood or cerebrospinal fluid （uremic toxins, drugs, and metabolic derangements ） • Activation of neural receptors and pathways • Peripheral sensory receptors (afferent, vagal, sympathetic, and glossopharyngeal pathways) • Vestibular • Cerebrocortical pathways The mechanism of vomiting • Neurotransmitter • dopamine, norepinephrine, 5-hydroxytryptamine, histamine, substance P, opioid, and acetylcholine Regurgitation v.s. vomiting • Pathology • In the cat, distal 1/3~1/2 of the esophagus is composed of smooth muscle. • Disease that result in inflammation, obstruction, or hypomotility in the esophagus interrupt the normal swallowing process, can result in regurgitation. Regurgitation v.s. vomiting Most important: History!!! nausea • Salivation • Lip-smacking Retching • Sound • Stomach movement Diagnostic approach • History • Physical examination IV fluid if need (dehydration, shock or hypothermia) • • • • • • Thoracic radiographs • Abdomen imagine • X-ray • Ultrasound Haematological examination Biochemistry profile Tt4(cat>6yrs) Urinalysis Faecal analyses History Physical examination Diagnostic approach • Advance test • ACTH stimulation test • Heartworm (Dirofilaria immitis) testing • Gastrin • Biopsy collection and examination • • • • Endoscopic aspiration of intestinal contents Immunohistochemistry PCR or Warthin-Starry staining on gastric mucosa Fluorescence in situ hybridization(FISH) in tissue biopsy Diagnostic approach Diagnostic approach Reference 1. Batchelor, Daniel J., et al. "Mechanisms, causes, investigation and management of vomiting disorders in cats: a literature review." Journal of feline medicine and surgery 15.4 (2013): 237-265. 2. Hauck, Shannon Ryan, et al. "Chronic Vomiting in Cats: Etiology and Diagnostic Testing." Journal of the American Animal Hospital Association 52.5 (2016): 269-276. Clinical presentation and initial assessment • The severity of the disease process should be determined at first. • Assessment starts with the signalment, including the age, breed and gender. • A complete history is strongly essential. • Distinguish vomiting from regurgitation • Onset and progression of signs: sudden, chronic/recurrent, persistent or chronic intermittent • Color and odor of vomitus • Relationship to eating • Concurrent constipation and tenesmus • Presence of diarrhea, or even bloody diarrhea, melena • A complete history is strongly essential. (cont.) • Appetite, nutritional status and weight loss • Fluid intake (increased, normal or decreased) and micturition behavior (dysuria, anuria) • Presence of abdominal pain • Diet changes (past and now), recent drug therapy, access to toxins or FBs • Other clinical signs: dermatology signs, vaginal bleeding or vulvar discharge, ptyalism or depression • Concurrent treatments (e.g. hormonal treatment) • Physical examination is important and should be done carefully. • Heart rate, respiratory rate, body temperature, blood pressure • Abdominal palpation: pain, fluid • Oral examination: color of mucus membrane, FBs • Hydration status • Peripheral lymph nodes palpation • Cervical area palpation for thyroid glands • Skin condition/fragility • Nasal discharge • Vaginal discharge • Neurological examination • After we have all the information above, the patient could be categorized in to 2 groups: • Systemically well patients with no criteria for further assessment or treatment. • Unwell patients with 1 or more criteria for intervention Criteria Nature of the vomiting Frequent acute vomiting, large volume of vomitus, hematemesis GI signs Melena, abdominal pain, abdominal swelling/fluid, weight loss, Other signs Pyrexia, severe dehydration/hypovolemic, hypothermia, PU/PD, bradycardia, etc Time frame Chronicity (>2 weeks), failure of symptomatic therapy Diagnostic approach • Hematological examination • Biochemistry profile: TT4, GI function tests • Urinalysis • Thoracic radiographs • Diagnostic imaging of abdomen: ultrasonography, contrast radiography, endoscopy • Exploratory coeliotomy or laparoscopys 個論 Base on 統計 好發年紀種別特徵等等 造成嘔吐的機制 症狀不用講太多（focus on vomit） 確診方法 治療，預後 Causes Foreign bodies Inflammatory bowel disease (IBD) • Etiology usually includes multiple causes. • The GI signs are usually persistent. • Diagnosis depends on histopathology. Specific findings include inflammation of mucus membrane layer, and the structural change of villous epithelium. • Therapy • Immunosuppression: prednisolone or methylprednisolone (1-2mg/kg q12h PO), chlorambucil, cyclosporine • Antibiotics: metronidazole (5-10mg/kg q12h PO), tylosine • Synbiotics: fortiflora/purina • Diet containing low-carbohydrate and digestible protein is beneficial to cats with IBD. Food intolerance and food allergy • Food intolerance is a non-immunologic, abnormal physiologic response to the diet. • Food allergy is an adverse reactions to the diet with a proven immunologic basis. Food intolerance Non-immunologic, abnormal physiologic response to the diet Vomiting, dairrhea Food allergy Immunologic reaction to the diet 7-14 days to see the improvement 8-12 weeks to see the improvement Vomiting, dermatologic signs • Dietary elimination trial • A variety of commercially available and homemade elimination formulations can be used. Pancreatitis • Lymphoplasmocytic pancreatitis is the most common type. • Unlike dogs, high-fat diet is not a risk factor for cats to get pancreatitits.