THERAPEUTIC FAILURE
The reason we are here today
Therapeutic failure
Wrong diagnosis
Right diagnosis
Wrong treatment
Right diagnosis
Right treatment
Wrong client
Therapeutic failure
Wrong diagnosis
Right diagnosis
Wrong treatment
Right diagnosis
Right treatment
Wrong client
Therapeutic failure
Wrong diagnosis
Right diagnosis
Wrong treatment
Right diagnosis
Right treatment
Wrong client
Therapeutic failure
Wrong
diagnosis
Right diagnosis
Wrong treatment
Right diagnosis
Right treatment
Wrong client
Patient is "spitting up"
Regurgitation
Vomiting
Expectoration
DEFINING THE PROBLEM
VOMIT
REGURG
Prodromal
signs
usually
no
Retching
usually
no
Bile
sometimes
no
Digested blood
sometimes
no
If it looks like vomiting, it
is probably vomiting
If it looks like
regurgitation, then you
don’t know for sure
If it looks like vomiting, it
is probably vomiting
If it looks like
regurgitation, then you
don’t know for sure
But it is still more efficient to look for causes of
regurgitation first
TAMU #79877
TAMU #151587
TAMU #151587
TAMU #117587-9/09
TAMU #117587-12/09
TAMU #156420
TAMU #156420
TAMU #159116
Sig: 4 month F German shepherd
CC: Febrile
HPI: 1 month ago: dog febrile with soft
cough – cured with antibiotics
3 days ago had same signs
PE:
T = 39.5 C
No other abnormalities
MSU #167884
Sig: 10 yr M(c) Mixed breed dog
CC: Coughing
HPI: Coughing began 2 years ago and
is not controlled with any
medications
Dog now vomiting for 2 months
Causes of Congenital Esophageal
Weakness
• Idiopathic
Causes of Acquired Esophageal
Weakness
• Idiopathic
• Myasthenia gravis (localized)
• Hypoadrenocorticism (usually atypical)
•
Various Myopathies/Neuropathies
•
Spirocerca lupi
•
Tetanus/Botulism
•
Distemper
•
Hypothyroidism (?)
•
Trypanosomiasis (??)
Acquired
Weakness
Congenital
Weakness
Look for
cause
Idiopathic
Cause found
Treat cause
Idiopathic
Supportive
therapy
Acquired
Weakness
Congenital
Weakness
Look for
cause
Idiopathic
Cause found
Treat cause
Idiopathic
Supportive
therapy
THERAPY FOR CONGENITAL
MEGAESOPHAGUS
• Dietary modification
– Gruel from an elevated platform
THERAPY FOR CONGENITAL
MEGAESOPHAGUS
• Dietary modification
– Gruel
– Meatballs (esp with partial motility)
– Canned food
– Dry food
TAMU #124375
Sig: 2 yr M(c) Dalmatian
CC: Vomiting
HPI: Present since obtained dog 1 month
ago. Dog “inhales” food & immediately
vomits food without bile or blood
Dog drools constantly
Recently has trouble swallowing
PE: Not remarkable
TAMU #118002
Sig: 5 month F German shorthaired pointer
CC: Vomiting
HPI: 8 days ago: vomiting clear liquid
Next day vomited blood and sticks
Laparotomy: inflamed duodenum &
blood in stomach
Still vomits fluid & blood
PE: No significant findings
TAMU #118002
CBC:
PCV = 20% (35-55)
Profile: Albumin = 1.9 gm/dl (2.5-4.4)
TAMU #99514
2/3
Sig: 10 yr F(s) Bichon
CC: Vomiting
HPI: Started vomiting bile on 1/12
Removed linear foreign object
Vomiting continues: surgical
pyloromyotomy 3 days later
PE: Depressed, tight abdomen
ESOPHAGITIS: CAUSES
Organisms (especially fungal)
ESOPHAGITIS: CAUSES
Organisms (fungal)
Foreign objects
ESOPHAGITIS: CAUSES
Organisms (fungal)
Foreign objects
Caustic agents
ESOPHAGITIS: CAUSES
Organisms (fungal)
Foreign objects
Caustic agents
doxycycline
clindamycin
ciprofloxacin
NSAIDs
ESOPHAGITIS: CAUSES
Organisms (fungal)
Foreign objects
Caustic agents
Gastric acid
Excessive gastric acidity
ESOPHAGITIS: CAUSES
Organisms (fungal)
Foreign objects
Caustic agents
Gastric acid
Excessive gastric acidity
Excessive vomiting
ESOPHAGITIS: CAUSES
Organisms (fungal)
Foreign objects
Caustic agents
Gastric acid
Excessive gastric acidity
Excessive vomiting
Iatrogenic (post anesthesia)
ESOPHAGITIS: CAUSES
Organisms (fungal)
Foreign objects
Caustic agents
Gastric acid
Excessive gastric acidity
Excessive vomiting
Iatrogenic (post anesthesia)
Spontaneous gastric reflux
ESOPHAGITIS: CLINICAL SIGNS
Mild disease: “spit up” white phlegm
ESOPHAGITIS: CLINICAL SIGNS
Mild disease: “spit up” white phlegm
Moderate disease: poor appetite,
regurgitate food
ESOPHAGITIS: CLINICAL SIGNS
Mild disease: “spit up” white phlegm
Moderate disease: poor appetite,
regurgitate food
Severe disease: anorexia, drooling,
severe pain, regurgitation, vomiting
ESOPHAGITIS: DIAGNOSIS
History (e.g., repeated vomiting,
recent anesthesia)
ESOPHAGITIS: DIAGNOSIS
History (e.g., repeated vomiting,
recent anesthesia)
Physical examination (oral lesions)
ESOPHAGITIS: DIAGNOSIS
History (e.g., repeated vomiting,
recent anesthesia)
Physical examination (oral lesions)
Radiographs (lesions may be subtle)
ESOPHAGITIS: DIAGNOSIS
History (e.g., repeated vomiting,
recent anesthesia)
Physical examination (oral lesions)
Radiographs (lesions may be subtle)
Endoscopy (most sensitive/specific)
CHEMICAL CLEARANCE
• The ulcerated/eroded esophagus is
ultra-sensitive to even minute
amounts of acid
• You must “clear” the stomach of acid
– the more severe the esophagitis,
the more you must eliminate gastric
acid secretion
ESOPHAGITIS: TREATMENT
• Antacids
–
–
Proton pump inhibitors
H-2 receptor antagonists
ANTI-ACID DRUGS: PPI’s
• Proton pump inhibitors
– Irreversibly inhibit H+-K+ ATPase
• Omeprazole (1-2 mg/kg PO q12-24h)
• Lansoprazole (1 mg/kg IV q24h)
• Pantoprazole (1 mg/kg IV q24h)
• Esomeprazole (1 mg/kg IV q24h)
– start working immediately, but require
2-5 days to achieve maximal effect
– Can cause diarrhea
ESOPHAGITIS: TREATMENT
• Antacids
• Prokinetics
Volume clearance
• Cisapride (0.1-0.5 mg/kg PO q1224h) better than metoclopramide
• Mosapride available soon? (IV)
• Erythromycin (1-5 mg/kg PO, IV,q8-12h)
• Metoclopramide (0.25 mg/kg IV, PO, q8-12 h) more
effective on liquids
•
Ranitidine (2.2-4.4 mg/kg PO, IV q8-12h)
ESOPHAGITIS: TREATMENT
• Antacids
• Prokinetics
• Analgesics (primarily topicals)
ESOPHAGITIS: TREATMENT
• Antacids
• Prokinetics
• Analgesics
•
Gastrostomy tube (rarely needed)
ESOPHAGITIS: TREATMENT
• Antacids
• Prokinetics
• Analgesics
•
Gastrostomy tube
•
Carafate ?
ESOPHAGITIS: TREATMENT
• Antacids
• Prokinetics
• Analgesics
•
Gastrostomy tube
•
Carafate ?
•
Antibiotics?
•
Steroids?
TAMU #178379
TAMU #174578
TAMU #174578 – with abd pressure
TAMU #107138
Sig: 8 yr F(s) Mix
20 kg
CC: Vomiting
HPI: Started 5 weeks ago
Vomits every other day or more often
Vomitus often has yellow component
Has lost 3.18 kg over the last month
Referring vet has dx’ed hiatal hernia
and reflux
PE: No significant abnormalities
TAMU #107138
Sig: 8 yr F(s) Mix
20 kg
CC: Vomiting
HPI: Started 5 weeks ago
Vomits every other day or more often
Vomitus often has yellow component
Has lost 3.18 kg over the last month
Referring vet has dx’ed hiatal hernia
and reflux
PE: No significant abnormalities
HIATAL HERNIA
Symptomatic
Asymptomatic
Young
Old
Symptoms may be
due to hiatal hernia
Symptoms possibly
due to other disease
Surgery may
be appropriate
Medical therapy
might be best
HIATAL HERNIA
Symptomatic
Asymptomatic
Young
Old
Symptoms may be
due to hiatal hernia
Symptoms possibly
due to other disease
Surgery may
be appropriate
Medical therapy
might be best
HIATAL HERNIA
Symptomatic
Asymptomatic
Young
Old
Symptoms may be
due to hiatal hernia
Symptoms possibly
due to other disease
Surgery may
be appropriate
Medical therapy
might be best