The Acutely Vomiting Dog

So what are we going to ask Ellie's owners?

Ellie did not have any diarrhoea – just vomiting and depression. There hadn't been any changes in her diet.

Here are the results of her physical exam:

Let's come up with some differential diagnoses.

http://twitter.com/czaydner/status/723228020610347010

Think we got most of the ones on Nick's list!

Any comments on these?

http://twitter.com/czaydner/status/723230101731725312

Nick cleared a couple of things up for us…

What shall we do next to determine the cause of Ellie's vomiting?

http://twitter.com/czaydner/status/723230615139717121

Yes, haematology and biochemistry are definitely sensible first-line tests – they help rule in and out several of our DDx. Here are the results:

Thoughts?

Yes, the hypokalaemia is likely the result of vomiting and anorexia – this needs correcting when we address fluid therapy. The mildly raised albumin is due to dehydration. The elevated liver enzymes indicate hepatocellular damage (ALT, AST) and biliary stasis (ALP).

Let's remind ourselves about the different liver enzymes:

So we know Ellie's liver is unhappy 😦 Does this mean she has liver disease as a cause of her acute vomiting and anorexia?

http://twitter.com/czaydner/status/723234855128014848

It's important to remember that elevated liver enzymes are common in many conditions 'outside the liver' – these are called secondary or 'reactive' hepatopathies. Common ones include:

We don't have an answer from the bloods we've done so far…What shall we do next?

http://twitter.com/czaydner/status/723236737590398980

Yes, diagnostic imaging is a sensible choice. Checking for pancreatitis is a common theme too!

Here's a lateral radiograph of Ellie's abdomen – great to assess for foreign bodies:

Thoughts?

Both good points. The serosal detail definitely looks poor, especially in the cranial abdomen.

Next we moved onto ultrasonography – great for looking at abdominal organs and assessing for free fluid etc.

So the ultrasound findings are suggestive of acute pancreatitis, which fits with Ellie's clinical signs and was one of our original DDx!

How would we confirm our suspicion of pancreatitis?

What about DGGR-lipase?

So cPLI is the way forwards! It's true that a pancreatic biopsy is probably the gold standard but it would be very difficult via tru-cut biopsy and would likely make the disease worse too.

Here are Ellie's results:

Nick then reminded us of the importance of ruling out surgical disease (e.g. foreign body/pyometra/peritonitis) before treating a dog or cat for pancreatitis.

Are we happy that pancreatitis is the diagnosis in Ellie's case? Does everything fit (clinical signs, clinical exam, biochemistry, imaging)?

So how are we going to treat Ellie?

Good suggestions!

Are maropitant and a lidocaine CRI enough to encourage intestinal motility? Or is there a need for metoclopramide as well?

Any thoughts on which opioid we should use to provide analgesia?

Here's what Nick recommends in terms of treatment:

So how did Ellie get on?

A fantastic outcome 🙂 !

Thanks for another brilliant #VetFinals session Nick!