Page 279 - Cote clinical veterinary advisor dogs and cats 4th

120 Bilious Vomiting Syndrome

patient is unwell or severely affected, other • Fecal flotation ○ Cisapride 0.1-0.5 mg/kg q 8-24h has
limited availability, or
underlying disease should be suspected first. • Abdominal radiographs: usually unremark- ○ Erythromycin 0.5-1 mg/kg PO q 8-12h
VetBooks.ir HISTORY, CHIEF COMPLAINT and other pathology. Gastric outflow obstruc- ○ Ranitidine 1-2 mg/kg PO or SQ q 8-12h
able. Evaluate for evidence of obstruction
between meals, or
tion or hypomotility is likely if gastric
• Intermittent vomiting of bile (85%), often
in the morning (60%)
• Abdominal pain, nausea, hyporexia/anorexia, contents are retained in the stomach for • Gastroprotectants
longer than 8 hours and especially beyond
○ Omeprazole 1 mg/kg PO q 12-24h
and weight loss may also be seen. 12-16 hours postprandially preferred, or
○ Famotidine 0.5-1 mg/kg SQ or PO q
PHYSICAL EXAM FINDINGS Advanced or Confirmatory Testing 12-24h
• Often unremarkable • Abdominal ultrasound: evaluation of gastric/
• Some dogs may have ptyalism, borborygmus, intestinal wall thickness, wall layering and Nutrition/Diet
and cranial abdominal pain. discrete masses. Intraluminal masses/foreign • Frequent meals: 3-6 times daily to minimize
bodies can be difficult to assess. the time with an empty stomach; feed right
Etiology and Pathophysiology • Contrast radiography (barium study): can before bedtime and first thing in the
Bilious vomiting syndrome is caused by evaluate gastric emptying, gastrointestinal morning.
abnormal gastroduodenal motility and reflux obstructions, and mural lesions. Gastric • To facilitate gastric emptying, a semiliquid,
of bile into the gastric lumen, resulting in gastric emptying time varies with different food low-fat, and low-fiber diet can be used (e.g.,
mucosal irritation and vomiting. Decreased consistencies and between dogs (p. 1172). commercial intestinal diets blended with
gastric motility may result in decreased intra- • Fluoroscopy: usually unremarkable water and equal volume of rice)
gastric pressure, leading to gastroduodenal • Scintigraphy: considered the most accurate • Some dogs may benefit from a hypoallergenic
reflux. There may also be changes to the determination of gastric emptying but or novel protein diet trial. These dogs may
gastrointestinal “housekeeping complex”/migra- requires radioactive isotopes and has limited have food hypersensitivity/intolerance.
tory motor complex secondary to overnight availability outside a referral setting. Gastric
fasting. emptying time is 100-180 minutes. PROGNOSIS & OUTCOME
• Gastroduodenoscopy and biopsies (p. 1098):
DIAGNOSIS rule out inflammatory diseases, parasites, Good to excellent with dietary +/− medical
foreign bodies, and structural abnormalities therapy
Diagnostic Overview in the stomach and proximal duodenum.
Bilious vomiting syndrome is a diagnosis of Motility cannot be reliably assessed during PEARLS & CONSIDERATIONS
exclusion and diagnostics are aimed at ruling anesthesia. Barium or sucralfate administra-
out underlying diseases. tion interferes with endoscopic visualization. Comments
• Wireless motility capsule: measures pH, If the patient is severely affected (weight loss,
Differential Diagnosis temperature, and pressure as capsules traverse electrolyte abnormalities, marked lethargy or
• Gastric outflow obstruction: foreign body, the gastrointestinal tract. Gastric emptying abdominal pain, or signs of hypovolemia) or
pyloric stenosis, neoplasia, polyp, intus- time: 6-15 hours does not improve with medical management,
susception, motility disorder • ACTH stimulation test: rule out hypoadre- further diagnostics should be pursued to rule
• Parasitism nocorticism (p. 512) out underlying disease.
• Gastrointestinal inflammation: gastritis,
gastroenteritis, pancreatitis, colitis, others TREATMENT Technician Tips
• Dietary hypersensitivity or intolerance Weigh the patient frequently because weight
• Metabolic disease: renal disease, hepatobili- Treatment Overview loss can indicate another underlying disease.
ary disease, hypokalemia, hypocalcemia, Nutritional and medical management are
hypoadrenocorticism mainstays of therapy. Client Education
• Drugs/toxicity: anticholinergics, narcot- Trials with different drugs or diets may be
ics, nonsteroidal antiinflammatory drugs Acute General Treatment necessary to resolve clinical signs in some dogs,
(NSAIDs), other drugs Treat underlying diseases, dehydration, or and patience and perseverance may be needed
• Nervous inhibition: trauma, pain, stress metabolic derangements if identified. during the initial treatment period.
Initial Database Chronic Treatment SUGGESTED READING
• CBC, serum biochemistry, and urinalysis: • Altered feeding schedule (see Nutrition/Diet) Ferguson L, et al: Bilious vomiting syndrome in dogs:
usually unremarkable. Hypokalemia, hypo- • Prokinetics: if anatomic/structural disease retrospective study of 20 cases (2002-2012). J Am
chloremia, and metabolic alkalosis with or has been ruled out, prokinetics can be Anim Hosp Assoc 52:3, 2016.
without aciduria would suggest gastric or instituted. Treatment trials of at least 7-10 AUTHOR: Janne G. Lyngby, DVM, DACVIM
proximal duodenal obstruction. days are recommended before trying another EDITOR: Rance K. Sellon DVM, PhD, DACVIM
• Total T 4 and feline immunodeficiency virus prokinetic.
(FIV)/feline leukemia virus (FeLV) testing ○ Metoclopramide 0.2-0.5 mg/kg PO or
should be considered for the initial database SQ q 8h was associated with the best
in appropriate cats outcome in a retrospective study, or

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