Delayed

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Delayed

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Delayed

• Gastric Emptying

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What is delayed gastric emptying?

• Food retained in stomach for longer than normal
• Pet vomits food gt12 hours after ingestion
• Due to a functional or structural abnormality

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Approach to Delayed Gastric Emptying

• Gastric Outflow Obstruction

• Gastric Motility Disorder

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Approach to Delayed Gastric Emptying

• Gastric Outflow Obstruction
• FB
• Neoplasia
• Pyloric stenosis
• Chronic hypertrophic gastritis
• Granuloma (eosinophilic, other)
• Antral polyps
• External compression

• Gastric Motility Disorder
• Acute and chronic causes
• Primary GI and Secondary GI causes

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Causes of Acute Gastric Motility Disturbances

• Acute gastroenteritis
• Gastric overdistension (gluttony)
• Electrolyte alterations (Ca, K)
• Acute pancreatitis
• Pain, stress
• Peritonitis
• Trauma or surgery to abdomen or spine
• Drugs (atropine, narcotics)

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Causes of Chronic Gastric Motility Disturbances

• Gastric ulceration
• Chronic gastritis/IBD
• Gastric neoplasia
• GDV
• Addisons
• Liver failure
• Uremia
• Endocrine disorders (DM, hypothyroidism)?

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Clinical Signs of Delayed Gastric Emptying

• Vomiting large amounts of undigested food gt12
  hours after eating
• Stomach normally empties by 8-10 hrs
• If due to outflow obstruction
• No bile in vomitus
• Projectile vomiting
• Abdominal distension, discomfort, tympany,
  belching

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Diagnosis of Delayed Gastric Emptying

• Identifying the syndrome
• Pathognomonic history
• /- barium series and/or gastrogram
• Identifying the cause
• Ultrasonography
• Electrolyte or acid-base disturbances
• Anemia/hematemesis/melena
• Endoscopy

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Treatment of Delayed Gastric Emptying

• Treat underlying cause if possible
• Medical
• surgical
• Nutritional management
• Prokinetic drugs

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Nutritional Management of Delayed Gastric
Emptying

• The stomach expels
• Liquids faster than solids
• CHO faster than protein
• Protein faster than fat
• Feed frequent small meals of a
  low fat, low-moderate protein diet

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Medical Management of Delayed Gastric Emptying

• Metoclopramide (Reglan)
• Ranitidine (Zantac)
• Nizatidine (Axid)
• Erythromycin
• Cisapride (Propulsid)

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Metoclopramide (Reglan)

• Antiemetic and prokinetic
• Increases LES tone, increases gastric
  contractions, relaxes pylorus
• Give Q8 hr PO, SC, or IV or give continuous IV
  infusion

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Ranitidine (Zantac)

• Antiulcer and prokinetic
• Stimulates smooth muscle by inhibiting
  acetylcholinesterase activity increases LES tone
• Give Q12 hr PO
• Good choice for dogs with delayed gastric
  emptying due to ulcer disease

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Nizatidine (Axid)

• Antiulcer and prokinetic
• Stimulates gastric contractions
• Give Q24 hr PO
• Note Prokinetic activity is NOT a property of
  cimetidine or famoditine

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Low Dose Erythromycin

• Low dose erythromycin mimics the effects of
  motilin
• Stimulates gastric, pyloric, and duodenal
  contractions
• Dose related effect Standard antimicrobial dose
  commonly induces vomiting

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Cisapride (Propulsid)

• Promotes Ach release increased pyloric and
  duodenal contractions, enhanced contraction
  coordination, increased LES tone, and increased
  colonic motility
• Withdrawn from market due to human deaths from
  arrythmias

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Gastric Motility Disorder

• Idiopathic or primary motility disorder
• Diagnosis of exclusion
• No outflow obstruction
• No secondary cause of impaired gastric motility

• Secondary to other diseases
• Presumptive diagnosis
• No outflow obstruction
• Compatible historical or laboratory finding

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Hairballs in Cats
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Hairballs (Trichobezoars)

• Chronic hairball formation may be related to
  abnormal migrating motor complexes that interrupt
  the housekeeping waves of motility
• Housekeeping waves function to move
  indigestible material out of the stomach between
  meals

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Pylorospasm

• An idiopathic gastric motility disorder
• Diagnosis now in question
• Vomiting appears to result from poorly
  coordinated contraction of antrum, pylorus, and
  duodenum NOT abnormal contraction of pylorus
• Rx Prokinetics atropine?
• Must differentiate from pyloric stenosis (APHS)

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Pyloric stenosis (APHS)

• Antral pyloric hypertrophy syndrome
• Brachycephalic breeds
• Bostons, Boxers Congenital
• Pekingese, Lhaso apso, Shih Tzu Adult onset
• Chronic intermittent vomiting in an otherwise
  healthy dog
• Projectile vomiting in 25 of cases

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Pathogenesis of Pyloric Stenosis

• Excessive gastrin secretion?
• Gastrin is trophic to pyloric muscles and gastric
  mucosa
• 25 of pups born to bitches given gastrin
  injections were affected
• Abnormal pyloric innervation -gt insufficient
  relaxation (children)
• Mild congenital stenosis -gt hypergastrinemia -gt
  trophic effect

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Diagnosis of Pyloric Stenosis

• Contrast radiographs
• Beak sign
• Fluoroscopy
• Commonly hypermotile
• Endoscopy
• Protuberant pylorus makes scope passage difficult
• Hyperplasic pyloric mucosa /- scattered erosions
• Histopathology on gastric biopsies

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Treatment of Pyloric Stenosis

• Surgery
• Pyloromyotomy
• Pyloroplasty
• Gastroduodenal anastamosis

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Gastric Neoplasia

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Clinical signs of gastric neoplasia

• Insidious onset, progressive course
• Vomiting, hyporexia/anorexia, weight loss
• Often see hematemesis and/or melena
• Often anemia from severe bleed or chronic blood
  loss
• May cause gastric outflow obstruction

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Gastric Neoplasia in Dogs

• lt1 of all canine tumors
• Mean age 8-10 years
• 1 is adenocarcinoma
• Chow chows predisposed
• Usually arise in pyloric antrum
• Raised plaque/mass or diffuse infiltration
• Commonly ulcerate and can be obstructive
• Leiomyoma, lymphosarcoma, leiomyosarcoma, polyps,
  other types

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Gastric Neoplasia in Cats

• Mean age lower than for dogs
• 1 is lymphosarcoma
• Usually FeLV negative
• Multiple white raised masses OR diffuse
  infiltration of gastric wall
• Commonly ulcerate
• Can be obstructive
• Adenocarcinomas are rare

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Treatment of Gastric Neoplasia

• Most gastric neoplasm are malignant (70)
• Spread early to regional LN followed by liver and
  lungs
• Gastric carcinoma
• Surgical resection H2 blocker
• Lymphosarcoma
• Chemotherapy
• Can resect large solitary masses
• Poor prognosis if diffuse infiltrate

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