Diagnosis and Management of the Vomiting Patient David C. Twedt, - - PDF document

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Diagnosis and Management of the Vomiting Patient David C. Twedt, - - PDF document

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June 15 28, 2009 The Vomiting Patient: Four Important Questions. AAHA National Staff Meeting Webcast. The Vomiting Patient: Four Important Questions June 15 - 28, 2009 By David C. Twedt, DVM, Diplomate ACVIM AAHA gratefully

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SLIDE 1

The Vomiting Patient: Four Important

  • Questions. AAHA National Staff

Meeting Webcast. June 15 – 28, 2009 1

The Vomiting Patient: Four Important Questions

June 15 - 28, 2009 By David C. Twedt, DVM, Diplomate ACVIM

AAHA gratefully acknowledges the following for their sponsorship of this Web Conference:

Diagnosis and Management

  • f the Vomiting Patient

David C. Twedt, DVM, Diplomate ACVIM

“Jake” 10 yr C/M WWT

  • Owner’s complaint:

2 years duration of chronic vomiting

  • Referred for a

vomiting work-up

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SLIDE 2

The Vomiting Patient: Four Important

  • Questions. AAHA National Staff

Meeting Webcast. June 15 – 28, 2009 2

The Patient

  • Adopted 2 years ago
  • Little history prior to adoption

except a “reported” episode of pancreatitis

  • On heartworm prevention
  • Since owners obtained Jake he

would vomit

  • Jake has as been treated with a

variety of medications

The Four Important Questions

  • 1. Is the animal really vomiting?
  • 2. What is the vomiting history?
  • 3. How should I direct my work-up?
  • 4. When should I consider antiemetic

therapy, and if so which one?

The Vomiting History

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SLIDE 3

The Vomiting Patient: Four Important

  • Questions. AAHA National Staff

Meeting Webcast. June 15 – 28, 2009 3

  • 1. Is the patient actually vomiting?

The Vomiting History

  • Nausea
  • Salivation
  • Swallowing
  • Retching
  • Expulsion of gastric material
  • 1. Is the patient actually vomiting?
  • 2. Detailed vomiting history

The Vomiting History

  • Determine D’FACTs:

–Duration –Frequency –Association with eating –Character –Treatments

  • 1. Is the patient actually vomiting?
  • 2. Detailed vomiting history
  • 3. Diet and drug history

The Vomiting History

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SLIDE 4

The Vomiting Patient: Four Important

  • Questions. AAHA National Staff

Meeting Webcast. June 15 – 28, 2009 4

  • 1. Is the patient actually vomiting?
  • 2. Detailed vomiting history
  • 3. Diet and drug history
  • 4. Other signs or symptoms

associated with the vomiting

The Vomiting History Jake’s History

  • Vomiting:

–2-3 X a week –Contains predominately bile

  • Occurs almost always during the

night or early morning –Occasionally has a gurgling stomach –Sometimes vomits heartworm pills up to 12-18 hours after given

Jake’s History

  • Additional history:

–Senior premium diet feed

  • nce a day

–Good appetite, no weight loss

  • Past therapy:

–Several specialty GI diets –Antibiotics –Famotidine

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SLIDE 5

The Vomiting Patient: Four Important

  • Questions. AAHA National Staff

Meeting Webcast. June 15 – 28, 2009 5

Physical Examination

  • 9 kg bw, BCS - 5/9
  • Active and responsive
  • T - 100º F, Pulse - 102 bpm
  • GI - normal abdominal palpation
  • Review of other systems - WNL
  • Rectal exam - WNL and normal stool

Would you consider prescribing an antiemetic as part of Jake’s treatment plan?

  • a. Yes
  • b. No
  • c. Need more information

Rational Use of Antiemetics

  • First, always treat primary disease
  • Indications would be…….

–To prevent fluid and electrolyte loss –Patient comfort from nausea and vomiting –Fear of aspiration pneumonia

  • Benefit…..

–Possibly an early return to nutrition

  • Contraindications…..

–GI obstructions

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SLIDE 6

The Vomiting Patient: Four Important

  • Questions. AAHA National Staff

Meeting Webcast. June 15 – 28, 2009 6

Rational Use of Antiemetics

  • Common uses:

–Motion sickness –Uremia –Parvovirus –Pancreatitis –Acute gastroenteritis –Cancer chemotherapy –Undetermined causes and no etiology

What Antiemetic?

Anticholinergic drugs Phenothiazines Antihistamines Metoclopramide Serotonin antagonists Butorphanol NK1 antagonists

Pathophysiology of Vomiting

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SLIDE 7

The Vomiting Patient: Four Important

  • Questions. AAHA National Staff

Meeting Webcast. June 15 – 28, 2009 7

Remember all vomiting is a CNS initiated reflex Emetic Center Vestibular CNS CRTZ CN IX Vagal (X) Sympathetic Peripheral Sensory Receptors

The Pathophysiology of Vomiting

NK1

Emetic Center CRTZ Vagal Afferents

NK1 5-HT1 2- adenergic H1 Histimergic

Vestibular

Dog Cat

NK1

Emetic Center CRTZ Vagal Afferents

NK1 5-HT1A/3 2- adenergic H1 Histimergic

Vestibular

Dog Cat

Phenothiazines Chlorpromazine

2 adenergic (dog?) D2 dopaminergic H1 histiminergic (weak) M1 cholinergic (weak)

Sedation / Hypotension Seizure threshold

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SLIDE 8

The Vomiting Patient: Four Important

  • Questions. AAHA National Staff

Meeting Webcast. June 15 – 28, 2009 8

NK1

Emetic Center CRTZ Vagal Afferents

NK1 5-HT1A/3 2- adenergic H1 Histimergic

Vestibular Antihistamines Diphenhydramine

H1 histiminergic M1 cholinergic

Motion sickness Vestibular disease Sedation / dry mouth Effectiveness?

NK1

Emetic Center CRTZ Vagal Afferents

NK1 5-HT1A/3 2- adenergic H1 Histimergic

Vestibular Anticholinergics Isopropamide

M1 cholinergic Peripheral afferent cholinergics

Generally not indicated Dry mouth  GI secretions  GI motility

NK1

Emetic Center CRTZ Vagal Afferents

NK1 5-HT1A/3 2- adenergic H1 Histimergic

Vestibular

Dog Cat

Dopamine Antagonist Metoclopramide

D2 dopaminergic (cats?) 5HT3 serotonergic ( dose)

Rapid metabolism - CRI CNS excitement,  with phenothiazines  GI motility

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SLIDE 9

The Vomiting Patient: Four Important

  • Questions. AAHA National Staff

Meeting Webcast. June 15 – 28, 2009 9

NK1

Emetic Center CRTZ Vagal Afferents

NK1 5-HT1A/3 2- adenergic H1 Histimergic

Vestibular

Dog Cat

Serotonin Antagonist Ondansetron Dolasetron 5HT3 antagonists Uses: Chemotherapy Severe vomiting

GI motility

NK1

Emetic Center CRTZ Vagal Afferents

NK1 5-HT1A/3 2- adenergic H1 Histimergic

Vestibular

Dog Cat

Maropitant

NK1 Antagonist Vomiting/nausea Chemotherapy Motion sickness ( dose) Hepatic metabolism Dose accumulates > 5 days

Maropitant Mechanism of Action

  • Blocks Substance P (a neuropeptide)

at NK1 receptor

P P MAROPITANT

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SLIDE 10

The Vomiting Patient: Four Important

  • Questions. AAHA National Staff

Meeting Webcast. June 15 – 28, 2009 10

Maropitant

  • Oral (16, 24, 60, 160 mg tabs)

– 2 mg/kg PO q 24 hr - vomiting – 8 mg/kg PO q 24 hr - motion sickness

  • Injectable (10 mg/ml)

– 1 mg/kg SQ q 24 hr

Efficacy - Prevention of Vomiting Central vs. Peripherial

0.5 1 1.5 2 2.5

Ipecac Apomorphine

Pfizer Study No Emetic Events Least Squares Mean Number of Emetic Events

Peripheral Central

Review of Experience At CSU May 14 to July 26, 2007

  • We used 19 bottles in 2 months
  • >85 cases have been treated with

Maropitant

  • A review of first 50 clinical cases

–46 dogs –3 cats –1 ferret

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SLIDE 11

The Vomiting Patient: Four Important

  • Questions. AAHA National Staff

Meeting Webcast. June 15 – 28, 2009 11

First 50 Cases

7 Parvovirus 11 Gastroenteritis 4 Pancreatitis 2 Renal disease 2 Liver disease 17 Oncology

15 chemotherapy 2 tumor related

7 Other conditions: 2 peritonitis 2 neurological disease 1 vestibular disease 1 rattlesnake bite 1 unknown

First 50 Cases

  • Treatment response:

–30/50 had treatment response recorded in record –29/30 cases showed a positive response to therapy –1 case (abdominal cancer) failed to respond with continued vomiting

First 50 Cases

  • Adverse effects - first 50 cases

– 4 clinicians reported stinging at injection site

  • Cases subsequent to first 50

– Bassett hound getting chemotherapy developed gastric dilatation – Pancreatitis case developed gastric atony and required gastric suction

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SLIDE 12

The Vomiting Patient: Four Important

  • Questions. AAHA National Staff

Meeting Webcast. June 15 – 28, 2009 12

Parvovirus: 7 Cases

  • Vomiting & nausea are a major

complication

  • Ability to begin early oral nutrition

improves recovery

  • Maropitant appears to

decrease hospital time by almost one day

Motion Sickness

  • Maropitant had a 84% to 93% efficacy in

dogs with a history of motion sickness

  • Give 2 hours before the trip

Conder GA: Efficacy and safety of maropitant for prevention of vomiting due to motion sickness. J. Vet. Pharmacol Dec 2008

Maropitant Acepromazine

Does Maropitant Effect GI Motility?

  • SmartPill™ evaluation of GI motility in

dogs given placebo vs Maropitant

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SLIDE 13

The Vomiting Patient: Four Important

  • Questions. AAHA National Staff

Meeting Webcast. June 15 – 28, 2009 13 Does Maropitant Effect GI Motility?

  • Maropitant appears to have

no effect on GI motility (ACVIM Forum 2009)

Antiemetics in Cats

  • Antihistamines - poor for

motion sickness

  • Metoclopramide - a poor

choice

  • Maropitant

– Not yet approved for cats – 0.5-1 mg/kg q 24 h SQ or PO – Motion sickness 1 mg/kg PO

Hickman: Safety, pharmacokinetics of maropitant for prevention of vomiting and motion sickness in cats. J Vet Pharmacol Therap 31;220, 2008

QuickT ime™ and a decompressor are needed to see this picture.

Milton

Maropitant

  • Off label use:

–IV in several cases –Dogs under 16 weeks –Dogs for longer than 5 days SQ

  • Cautions:

–Liver disease –Prolonged use

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SLIDE 14

The Vomiting Patient: Four Important

  • Questions. AAHA National Staff

Meeting Webcast. June 15 – 28, 2009 14

When are Antiemetics Contraindicated?

  • Not first performing diagnostics
  • GI obstructions
  • Antiemetic adverse side effects
  • Chronic disease - always pursue

a diagnosis

Back To Jake……

  • No fluid or electrolyte loss
  • No nausea causing anorexia
  • No debilitation due to vomiting
QuickT ime™ and a decompressor are needed to see this picture.

Jake’s First Wave Diagnostics

  • CBC - WNL
  • Biochemical profile - WNL
  • Urinalysis - WNL
  • Fecal flotation - negative
  • Giardia fecal ELISA - negative
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SLIDE 15

The Vomiting Patient: Four Important

  • Questions. AAHA National Staff

Meeting Webcast. June 15 – 28, 2009 15

GI Disorders: Initial Evaluation

Classify the Case Mild Disease Significant Disease

Normal Laboratory Evaluation

Dietary Trials Anthelmintic Therapy Symptomatic Therapy Mild Disease

GI Disorders: Initial Evaluation Parasites and Vomiting

Ascarids Tricuris Giardia Physaloptera

– World wide prevalence – Intermediate host - insects – Fecal flotation - poor – Treatment - febendazole

Insert video N Duodenum

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SLIDE 16

The Vomiting Patient: Four Important

  • Questions. AAHA National Staff

Meeting Webcast. June 15 – 28, 2009 16

Adverse Food Reactions

  • Food allergies
  • Immune reaction to

dietary protein

  • Food intolerance
  • pharmacologic to a

dietary substance

  • Chronic nonspecific GI

disease ~50% responded to diet change

–Dogs: Gaschen; JVIM 2006 –Cats: Guilford; JVIM 2001

Dietary Trials

Novel protein diets Gluten free diets Hydrolyzed diets Gastrointestinal diets Other commercial diets * Diets should be fed for ~ 2 weeks to determine response

Jake: First Wave Treatment

  • Trial therapies:

–Febendazole 50 mg/kg X 3 da –Hydrolyzed protein diet X 3 weeks

  • Day 10 days later:

–Vomited 3 X –Owner started famotidine and bland diet

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SLIDE 17

The Vomiting Patient: Four Important

  • Questions. AAHA National Staff

Meeting Webcast. June 15 – 28, 2009 17

Jake: Second Wave

  • Jake was re-admitted for further

diagnostics

  • Now possible causes of chronic

vomiting? –Chronic pancreatitis? –Atypical Addison’s disease? –Primary GI disease

Jake’s Results

  • Spec cPL: 36 µg/L (normal < 200 µg/

L)

  • Abdominal ultrasound : normal
  • ACTH Stimulation test : normal

3 6 9 12 15 18 Zero 1 Hour Cortisol µg/dl

Zero = 3.1 µg/dl 1 hr. = 13.2 µg/dl A baseline cortisol > 2 µg/dl is unlikely hypoadrenocorticism

Clinical Assessment of GI Disorders Possibly Causing Vomiting

Diagnostic Evaluation Obstructive Inflammatory Motility disorder Radiology Endoscopy Surgical biopsy

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SLIDE 18

The Vomiting Patient: Four Important

  • Questions. AAHA National Staff

Meeting Webcast. June 15 – 28, 2009 18

Likely Differentials for Jake

  • Inflammatory disease:

–Gastritis/IBD –Helicobacter

  • Obstructive disorders

–Mucosal hypertrophy

  • Motility disorders

–Bilious vomiting disorder

Insert video N Duodenum

Jake: Second Wave Results

  • Gastric biopsy

–Normal

  • Helicobacter culture

–Negative

  • Intestinal biopsy

–Normal

QuickTime™ and a Sorenson Video 3 decompressor are needed to see this picture.

Insert video Gastric reflux

  • Etiology:

–Idiopathic

  • Gastric motility disorder?

–Secondary

  • IBD
  • Giardia

Enterogastric Reflux Syndrome

Bilious Vomiting Syndrome

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SLIDE 19

The Vomiting Patient: Four Important

  • Questions. AAHA National Staff

Meeting Webcast. June 15 – 28, 2009 19

  • Clinical syndrome

–Older dogs –Chronic bilious vomiting

  • Early morning
  • Empty stomach
  • Endoscopy

–Antral inflammation

Enterogastric Reflux Syndrome Enterogastric Reflux Treatment

  • Dietary management

–Late evening meals

  • Gastric protectants

–Antiacids –Sucralfate

  • Prokinetic agents

–Metoclopramide - poor –Cisapride - better –Erythromycin - good?

  • Dose: 0.5- 1.0 mg/kg BW

Jake: Follow Up

  • Treatment

–Diet

  • 3 meals/day
  • Last meal late in the

evening –Cisapride

  • 0.25 mg/kg
  • 30 min before last meal
  • Outcome

–Resolved > 1 year

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SLIDE 20

The Vomiting Patient: Four Important

  • Questions. AAHA National Staff

Meeting Webcast. June 15 – 28, 2009 20

Vomiting: Final Thoughts

  • First rule out:

–Common conditions –Non-GI disease

  • Treat primary disease
  • Use antiemetics with

acute or severe signs

  • r when nausea and

vomiting effect nutrition

  • r clinical status of

patient

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SLIDE 21

The Vomiting Patient: Four Important

  • Questions. AAHA National Staff

Meeting Webcast. June 15 – 28, 2009 21

AAHA gratefully acknowledges the following for their sponsorship of this Web Conference.

Questions to the Speaker Please email your questions to webconference@aahanet.org by Sunday, July 5, 2009.

  • Dr. Twedt will provide written responses to all of the questions and they

will be posted on AAHA’s website by Wednesday, July 15, 2009.