Page 2084 - Cote clinical veterinary advisor dogs and cats 4th

Vomiting, Acute 1041

PHYSICAL EXAM FINDINGS important; further workup is determined by • Antiemetics
status and response to treatment.
A thorough physical exam is mandatory. Specific • If the animal is classified as a serious case ○ Should be used only if the possibility of
VetBooks.ir • Hydration status and/or vomiting was nonproductive, further ○ Most useful when vomiting is severe and Diseases and Disorders
GI obstruction has been ruled out
points requiring extra attention:
diagnostic workup is always warranted:
• Mouth inspection (e.g., linear foreign body
animal is at risk for dehydration or devel-
in cats, ulcerations suggesting intoxication
sodium and potassium)
or uremia) ○ CBC, serum chemistry profile (including oping electrolyte/acid-base imbalances or
reflux esophagitis
• Abdominal palpation (e.g., abdominal pain, ○ Urinalysis ○ Maropitant 1 mg/kg q 24h SQ or IV or
abdominal distention, foreign body, mass, ○ Fecal exam 2 mg/kg PO q 24h (selective neurokinin-1
organomegaly, intussusception) ○ Medical imaging receptor antagonist), or
• Rectal exam (e.g., presence of melena, foreign ■ Abdominal radiographs: radiopaque ○ Metoclopramide 0.2-0.5 mg/kg IM or
material) foreign bodies, signs of intestinal obstruc- SQ q 8h or as an IV CRI at 1-2 mg/kg/
tion, ileus, GDV, or loss of abdominal day (dopamine antagonist; central and
Etiology and Pathophysiology detail suggesting pancreatitis or peritonitis peripheral antiemetic agent), or
• Stimulation of humoral (blood-borne sub- ■ Abdominal ultrasound: changes associ- ○ Ondansetron 0.5-1 mg/kg PO or IV q
stances) or neural (especially by receptors ated with organomegaly, identification 12 h (useful in refractory cases)
located throughout the GI tract) pathways of origin and extent of masses, and • Some causes of acute vomiting require surgi-
can lead to activation of the vomiting center. other such findings cal intervention (e.g., GDV, linear foreign
• Certain drugs (e.g., apomorphine [dogs], • With hematemesis: review medication/ body) or endoscopy (e.g., gastric foreign
xylazine [cats]), uremic toxins, electrolyte, drug exposure history, search for cutaneous body)
osmolar, or acid-base disorders can activate nodules (mastocytoma), and if relevant,
the chemoreceptor trigger zone, which trig- consider coagulation profile, adrenocorti- Possible Complications
gers the vomiting center, causing vomiting. cotropic hormone (ACTH) stimulation, • Dehydration
and/or gastroduodenoscopy • Reflux esophagitis
DIAGNOSIS • Aspiration pneumonia
Advanced or Confirmatory Testing • Electrolyte and acid-base imbalances (espe-
Diagnostic Overview • If appropriate, infectious disease testing (e.g., cially hypokalemia and sometimes metabolic
A large proportion of patients presented for parvoviral serology) acidosis)
acute vomiting have benign, self-resolving • If clinically relevant: liver function tests;
illness. The extent of diagnostic testing is ACTH stimulation test to rule out hypoad- Recommended Monitoring
determined by presence or absence of signs renocorticism; toxicologic testing; neurologic Signs of dehydration, body weight, abdominal
of systemic illness; known inciting causes exam; canine or feline pancreatic lipase pain, frequency of vomiting
(e.g., overeating might prompt minimal immunoreactivity or 1,2-O-dilauryl-rac-
investigation, whereas intoxication can warrant glycero-3-glutaric acid-(6′-methylresorufin) PROGNOSIS & OUTCOME
tests to evaluate body systems likely to be ester (DGGR) study to rule out pancreatitis
affected). • In some cases, especially to evaluate motility Excellent with dietary indiscretion; otherwise,
disorders or gastric outflow obstruction, GI depends on underlying cause
Differential Diagnosis contrast studies can be performed.
GI causes: • If vomiting persists for more than 3-4 days or PEARLS & CONSIDERATIONS
• Adverse food reactions (dietary indiscretion, worsens, approach the animal as for chronic
intolerance) vomiting (p. 1042); endoscopy is often war- Comments
• Obstruction (e.g., foreign body, intussuscep- ranted if previous tests fail to identify the cause. • Most cases of acute vomiting are self-limited
tion) and do not require further diagnostics, but
• Gastritis: viral (parvovirus, coronavirus, TREATMENT it is important to not miss the more seri-
distemper), bacterial ously ill animals and to recommend further
• Foreign body Treatment Overview workup and treatment if the vomiting does
• Parasites (Physaloptera spp, Ollulanus tricuspis) • Rehydrate the animal if needed. not subside within a few days.
• Motility disorders • Implement treatment for systemic or life- • Use antiemetics carefully because they can
• GDV (nonproductive) threatening disorders (e.g., GDV, intoxica- mask progressive disease and response to
Extra-GI causes: tions, uremia). primary therapy.
• Extraabdominal disorders • Otherwise, allow the GI tract a short rest
○ Azotemia/uremia by giving nothing per os (NPO). Technician Tips
○ Hypoadrenocorticism Animals should be fed small amounts of bland
○ Diabetic ketoacidosis Acute General Treatment food as soon as it is tolerated.
○ Intoxications Nonserious cases (animals generally treated as
○ Drugs (e.g., NSAIDs, chemotherapy, outpatients): Client Education
glucocorticoids) • NPO for 12-24 hours. If vomiting resolves, Avoid feeding human food scraps and limit
○ Neurologic disorders (especially vestibular) offer a small amount of water or a few ice access to things that may be inappropriate for
• Intraabdominal disorders cubes. Thereafter, initiate feeding with small pets to eat (e.g., dietary indiscretion; garbage,
○ Hepatic failure quantities of a highly digestible, low-fat diet animal carcasses).
○ Pancreatitis for several days. Gradually transition to the
○ Peritonitis regular food. SUGGESTED READING
○ Pyometra Serious cases: hospitalize the animal and perform Tello L, et al: Fluid and electrolyte therapy during
A detailed differential diagnosis is provided further diagnostic steps (see Initial Database and vomiting and diarrhea. Vet Clin North Am Small
on p. 1293. Advanced or Confirmatory Testing above). Anim Pract 47:505-519, 2017.
• NPO, water, and food identical to nonserious AUTHORS: Sylvie Daminet, DVM, PhD, DACVIM,
Initial Database cases DECVIM
• If the animal is classified as a nonserious case: • IV fluid therapy (crystalloids): maintenance EDITOR: Leah A. Cohn, DVM, PhD, DACVIM
history and thorough physical exam are most + replace dehydration + ongoing loss
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