{"id":1341,"date":"2013-03-01T17:04:30","date_gmt":"2013-03-01T17:04:30","guid":{"rendered":"http:\/\/phosdev.com\/todaysveterinarypractice\/?p=1341"},"modified":"2022-02-17T19:16:30","modified_gmt":"2022-02-17T19:16:30","slug":"gi-intervention-approach-to-diagnosis-therapy-of-the-vomiting-patient","status":"publish","type":"post","link":"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/gastroenterology\/gi-intervention-approach-to-diagnosis-therapy-of-the-vomiting-patient\/","title":{"rendered":"GI Intervention: Approach to Diagnosis &amp; Therapy of the Vomiting Patient"},"content":{"rendered":"<p class=\"p1\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2016\/09\/T1303F01.pdf\"><img decoding=\"async\" class=\"alignnone size-full wp-image-9886\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2011\/07\/pdf_button.png\" alt=\"pdf_button\" width=\"110\" height=\"27\" \/><\/a><\/p>\n<hr \/>\n<p class=\"p1\"><span class=\"s1\"><em>P. Jane Armstrong, DVM, MS, MBA, Diplomate ACVIM<\/em><\/span><\/p>\n<p class=\"p1\">Vomiting is a common clinical complaint in both dogs and cats and a clinical sign common to diseases of many body systems. Management includes controlling vomiting, addressing underlying causes, and correcting fluid and electrolyte abnormalities.<\/p>\n<hr \/>\n<p class=\"p1\"><span class=\"s1\">Vomiting is a very common clinical complaint in both dogs and cats. It is also a clinical sign seen in diseases of many body systems. Clinicians must avoid assuming vomiting is synonymous with gastrointestinal (GI) disease.<\/span><\/p>\n<blockquote>\n<p class=\"p3\"><span class=\"s1\">In a large national survey, GI signs accounted for 4% of visits at primary care clinics.<\/span><span class=\"s2\"><sup>1<\/sup><\/span><\/p>\n<\/blockquote>\n<h2 class=\"p3\"><span class=\"s1\"><b>DEFINITION<\/b><\/span><\/h2>\n<p><span class=\"s1\">Vomiting is the active expulsion of gastric, sometimes duodenal, contents and is typically preceded by apparent nausea and retching. However, it can often be confused with:<\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\"><strong>Regurgitation<\/strong> associated with esophageal disorders<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\"><strong>Gagging\/coughing<\/strong> associated with respiratory disease<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\"><strong>Oropharyngeal dysphagia<\/strong>.<\/span><\/li>\n<\/ul>\n<h2 class=\"p3\"><span class=\"s1\"><b>CLINICAL SIGNS<\/b><\/span><\/h2>\n<p class=\"p1\"><span class=\"s1\">Key elements of vomiting are: <\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Forceful abdominal contractions (one of the most reliable ways to confirm vomiting)<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Retching and presence of bile.<\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">A thorough history will usually confirm whether the pet is vomiting. If doubt remains, attempt to visualize the behavior by asking the owner to video it or provocatively feeding the patient in the hospital.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Be cautious in overinterpreting the timing of the event in relation to consumption of meals. In some cases, regurgitating animals can passively expel esophageal or gastric contents hours after ingestion of a meal.<\/span><\/p>\n<h2 class=\"p3\"><span class=\"s1\"><b>PATHOPHYSIOLOGY<\/b><\/span><\/h2>\n<p class=\"p1\"><span class=\"s1\">Vomiting is a complex, protective reflex that occurs in carnivores but is not well developed in all species. Although several afferent pathways may be responsible for initiating emesis, it is coordinated by the emetic (or vomiting) center in the medulla (<b>Table<\/b>).<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">An important concept of vomiting is that it occurs through activation of the: <\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Chemoreceptor trigger zone (CRTZ) by blood-borne substances (humoral pathway)<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Emetic center by vagosympathetic, vestibular, or cerebrocortical neurons (neural pathway). <\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">Many spontaneous vomiting disorders of cats and dogs, particularly those due to primary GI disease, are believed to result from activation of the neural pathway. <\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Visceral afferent input to the emetic center arises from receptors located throughout the body.<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Most are distributed in the abdominal viscera, with the largest number in the duodenum. <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Visceral receptors are sensitive to chemical irritation, inflammation, distention, and changes in osmolality.<\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">Several neurotransmitters and their respective receptors stimulate the emetic center; these form the basis for antiemetic classification.<\/span><\/p>\n<p class=\"p1\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/03\/030413-gi-table.png\"><img fetchpriority=\"high\" decoding=\"async\" class=\"alignnone size-medium wp-image-9290\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/03\/030413-gi-table-213x300.png\" alt=\"030413 gi table\" width=\"213\" height=\"300\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/03\/030413-gi-table-213x300.png 213w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/03\/030413-gi-table-729x1024.png 729w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/03\/030413-gi-table-768x1079.png 768w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/03\/030413-gi-table-1093x1536.png 1093w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/03\/030413-gi-table.png 1100w\" sizes=\"(max-width: 213px) 100vw, 213px\" \/><\/a><\/p>\n<h2 class=\"p3\"><span class=\"s1\"><b>CHRONIC VOMITING<\/b><\/span><\/h2>\n<p class=\"p1\"><span class=\"s1\">Chronic vomiting is commonly defined as persistent vomiting of variable frequency and, typically, duration of 3 weeks or longer.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">In cases of chronic vomiting, relatively extensive diagnostic evaluation is almost always warranted in order to determine a cause rather than solely providing supportive and symptomatic care. See <b>Determining Reasons for Vomiting &amp; Appropriate Diagnostics<\/b>, for further information. The remainder of this overview will focus on acute vomiting.<\/span><\/p>\n<h2 class=\"p3\"><span class=\"s1\"><b>ACUTE VOMITING: DIAGNOSTICS<\/b><\/span><\/h2>\n<p class=\"p1\"><span class=\"s1\">Acute vomiting is commonly defined as vomiting of variable frequency over a period of less than 7 days, although, in practical terms, acute vomiting is usually of 1 to 3 days&#8217; duration since owners will commonly seek medical attention within this interval. <\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">From the signalment, history, and physical examination, the clinician should be able to:<\/span><\/p>\n<ol class=\"ol1\">\n<li class=\"li1\"><span class=\"s1\">Categorize the patient as: <\/span>\n<ul class=\"ul2\">\n<li class=\"li1\"><span class=\"s1\">Stable, with no criteria for further immediate assessment or treatment<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Unstable, with 1 or more criteria for intervention.<\/span><\/li>\n<\/ul>\n<\/li>\n<li class=\"li1\"><span class=\"s1\">Establish a differential list.<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Identify appropriate diagnostic interventions and therapy. <\/span><\/li>\n<\/ol>\n<h3 class=\"p4\"><span class=\"s1\"><b>Mild Acute Vomiting<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">Pets with a history of mild, acute vomiting (with or without concurrent diarrhea) that have a normal physical examination and no other concurrent signs usually have self-limiting signs and can be treated symptomatically or simply monitored. In such cases, signs resolve after 1 to 2 days, with or without supportive therapy.<\/span><span class=\"s3\"><sup>2<\/sup><\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">The suggested minimum diagnostic evaluation of a healthy vomiting animal includes:<\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Packed cell volume and total protein (provides a crude assessment of hydration status) <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Fecal flotation.<\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">Even with more extensive diagnostic evaluation, a diagnosis may not be reached unless the history suggests a likely cause, such as dietary indiscretion. <\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Cats appear to be less likely than dogs to present with acute, self-limiting vomiting (&#8220;acute gastritis&#8221;) and are relatively more likely than dogs to require diagnostic investigation and treatment.<\/span><span class=\"s3\"><sup>3<\/sup><\/span><span class=\"s1\"> Feline acute hemorrhagic vomiting syndrome has been reported in the UK.<\/span><span class=\"s3\"><sup>3<\/sup><\/span><span class=\"s1\"> This self-limiting syndrome occurs in cats in rescue shelters and catteries; etiology has yet to be determined.<\/span><\/p>\n<h3 class=\"p4\"><span class=\"s1\"><b>Severe Acute Vomiting<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">Some characteristics of acute vomiting may indicate serious, even potentially life-threatening, diseases and warrant immediate diagnostic investigation and treatment. This category includes patients with:<\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Hematemesis (vomiting blood) or melena<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Frequent vomiting (8\u201310 times in 1 day)<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Concurrent signs (such as anorexia; lethargy; fever; apparent abdominal pain; or pale, &#8220;muddy,&#8221; congested, or jaundiced mucous membranes). <\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">Diagnostic evaluation is mandatory to attempt to determine the underlying cause and guide therapy, and includes:<\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Survey abdominal radiographs<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">CBC, serum biochemical profile, urinalysis<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">SNAP Parvo Test (idexx.com) (puppies or kittens), regardless of vaccination history. <\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">Additional diagnostic studies may include further laboratory testing, such as: <\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Canine or feline pancreatic lipase (Spec cPL or fPL Tests, idexx.com)<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Resting cortisol and\/or adrenocorticotropic hormone (ACTH) stimulation testing<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Abdominal ultrasonography<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Upper GI endoscopy and\/or barium contrast series<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Surgical exploration of abdomen.<\/span><\/li>\n<\/ul>\n<h2 class=\"p3\"><span class=\"s1\"><b>ACUTE VOMITING: MEDICAL THERAPY<\/b><\/span><\/h2>\n<p class=\"p1\"><span class=\"s1\">The goals of symptomatic or supportive therapy for acute vomiting are: <\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Treating or removing the underlying cause<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Controlling the vomiting episodes<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Addressing abdominal pain, if present<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Correcting the fluid, electrolyte, and acid\u2013base abnormalities that may occur as a consequence of frequent vomiting.<\/span><\/li>\n<\/ul>\n<h3 class=\"p4\"><span class=\"s1\"><b>Antiemetic Therapy<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">Antiemetic therapy is warranted when: <\/span><\/p>\n<ol class=\"ol1\">\n<li class=\"li1\"><span class=\"s1\">Vomiting is frequent or severe, making the animal uncomfortable<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Persistent vomiting puts the animal at risk for aspiration pneumonia or acid\u2013base and electrolyte disturbances<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">The animal is <em>not<\/em> suffering from GI obstruction or toxicity.<\/span><\/li>\n<\/ol>\n<p class=\"p1\"><span class=\"s1\">Antiemetics control emesis by either central or peripheral blockade of neurotransmission at receptor sites (see <a href=\"https:\/\/todaysveterinarypractice.com\/medications-for-vomiting-dogs-cats\/\" target=\"_blank\" rel=\"noopener noreferrer\"><b>Medications for Vomiting: Dogs &amp; Cats<\/b><\/a>). <\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\"><strong>In the emetic center<\/strong>, neurokinin (NK)1 receptors and alpha-2 adrenergic receptors are the most clinically important. Selective NK1 receptor antagonists (ie, maropitant) act by blocking the binding of substance P within the emetic center and CRTZ; therefore, they uniquely inhibit vomiting through both the humoral and neural pathways.<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\"><strong>In the CRTZ in dogs<\/strong>, dopamine and histamine are significant neurotransmitters, making dopaminergic and histaminergic receptor antagonists important antiemetic classes.<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\"><strong>In the CRTZ in cats<\/strong>, alpha-2 adrenergic and 5-HT3 serotonergic receptors are the significant neurotransmitters.<\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\"><strong>Specific Notes<\/strong>. An antiemetic is commonly administered concurrently with a prokinetic agent. In addition, antiemetics with different modes of action may be combined in patients with refractory vomiting.<\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Maropitant, ondansetron, and dolasetron are very effective antiemetics for cats.<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">In dogs with uremia, the central component of vomiting can be treated with antiemetics; the peripheral component is best treated with gastroprotectants.<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Chemotherapy drugs induce vomiting by stimulating 5-HT3 serotonergic receptors; effective antiemetics include dolasetron, maropitant, and ondansetron. Metoclopramide is less effective but less expensive; if administered to dogs, it should be used at high doses (1 mg\/kg).<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Metoclopramide is considered a weak prokinetic agent. Higher doses (up to 4 mg\/kg\/day CRI or 1 mg\/kg PO Q 8 H) are occasionally used in dogs but patients must be carefully monitored for extrapyramidal side effects.<\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\"><strong>Side Effects<\/strong>. The main side effects of antiemetics include: <\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\"><strong>Systemic hypotension<\/strong>: Chlorpromazine and prochlorperazine<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\"><strong>Sedation<\/strong>: Phenothiazines (chlorpromazine and prochlorperazine), antihistamines, and yohimbine<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\"><strong>Behavioral changes<\/strong> (eg, dose-related excitation): Metoclopramide<\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">Only administer chlorpromazine or prochlorperazine if the patient is normotensive or is receiving adequate IV fluid support. These drugs were thought to reduce the seizure threshold but clinical experience suggests they can be used in patients with seizure disorder histories.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Patients with GI obstruction should not receive prokinetic agents, including metoclopramide. However, many experienced clinicians report that serious adverse effects have not been seen when these agents have been inadvertently given to such patients, with the exception of those with linear foreign bodies.<\/span><\/p>\n<div class=\"orange-box\">\n<h2 class=\"p3\"><span class=\"s1\"><b>Maropitant: A Multimodal Antiemetic<\/b><\/span><\/h2>\n<p class=\"p1\"><span class=\"s1\">Maropitant citrate (Cerenia, zoetis.com), a potent selective NK1 receptor antagonist, plays an important role in managing vomiting, mediated via both the vomiting center and CRTZ (ie, humoral and neural pathways).<\/span><span class=\"s3\"><sup>3-5<\/sup><\/span><span class=\"s1\"> The drug is effective for:<\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Prevention of motion sickness in dogs<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Chemotherapy-induced nausea and vomiting<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Management of vomiting due to other causes.<\/span><\/li>\n<\/ul>\n<h3 class=\"p4\"><span class=\"s1\"><b>Nausea<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">Nausea cannot be reliably assessed in animals, but signs interpreted as nausea include salivation, increased frequency of or exaggerated swallowing motions, and licking of lips. A recent study evaluating maropitant as an antiemetic for dogs premedicated with hydromorphone found that maropitant effectively prevented vomiting, retching, and nausea associated with hydromorphone administration.<\/span><span class=\"s3\"><sup>6<\/sup><\/span><\/p>\n<h3 class=\"p4\"><span class=\"s1\"><b>Analgesia<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">Two recent studies indicate that maropitant also provides visceral analgesia in dogs and cats.<\/span><span class=\"s3\"><sup>7,8<\/sup><\/span><span class=\"s1\"> During visceral ovarian and ovarian ligament stimulation, maropitant decreased anesthetic requirements. This analgesic property makes maropitant especially suitable for managing vomiting caused by painful intra-abdominal conditions, such as pancreatitis and cholangitis, and painful gastric or intestinal disorders. <em>Note: At this time, this use of maropitant should only be considered adjunctive to other methods of pain control.<\/em><\/span><\/p>\n<h3 class=\"p3\"><b>Administration<\/b><\/h3>\n<p class=\"p1\"><span class=\"s1\">Common doses for maropitant are given in <strong>Medications for Vomiting: Dogs &amp; Cats<\/strong>. Maropitant is commonly administered off label in both dogs and cats. Hickman and colleagues reported on the pharmacokinetics of PO, SC, and IV use in cats.<\/span><span class=\"s3\"><sup>5<\/sup><\/span><span class=\"s1\"> Because maropitant is metabolized by the liver, a lower dosage of 0.5 mg\/kg IV is sometimes used for treatment or prevention of vomiting in both species, if there is concern about liver function.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">The label states that using Cerenia for treatment or prevention of acute emesis should not last longer than 5 consecutive days.<\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Maropitant has nonlinear pharmacokinetics in dogs. Pharmacokinetic studies conducted since the approval of Cerenia have shown that a steady state is reached in dogs in 4 days (at 2 mg\/kg daily). A steady state is reached in cats in 7 days. <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Another reason for this concern is that, if vomiting persists longer than 5 days, the underlying cause needs to be thoroughly reinvestigated. <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">In dogs, the injectable solution and tablets may be used interchangeably for once daily dosing to prevent acute vomiting.<\/span><\/li>\n<\/ul>\n<h3 class=\"p4\"><span class=\"s1\"><b>Safety<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">Cerenia has been tested for safety in both dogs and cats at 1\u00d7, 3\u00d7, and 5\u00d7 the label dose for 15 days (3\u00d7 the duration of treatment recommended on the label) as required by the FDA.<\/span><\/p>\n<\/div>\n<h3 class=\"p4\"><strong><span style=\"line-height: 1.5\">Gastroprotective or Cytoprotective Agents<\/span><\/strong><\/h3>\n<p class=\"p4\"><span style=\"line-height: 1.5\">Peripheral pathways are mediated through irritation and inflammation of the GI mucosa. Therefore, another common approach to therapy is administration of gastroprotective agents, such as drugs that:<\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Inhibit gastric acid production: H2 histaminergic receptor antagonists and proton pump inhibitors <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Act locally on the gastric mucosa: Sucralfate.<\/span><\/li>\n<\/ul>\n<h3 class=\"p4\"><span class=\"s1\"><b>Histamine H2 Receptor Antagonists<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">Histamine H2-receptor antagonists are the most commonly used drugs to manage gastric ulceration or severe gastritis. These agents competitively block the H2 receptor on the parietal cell, reducing gastric acid secretion.<\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\"><strong>Cimetidine<\/strong> is the least potent of the H2 receptor antagonists and also inhibits the cytochrome P-450 enzyme system, potentially altering metabolism of co-administered drugs that are metabolized by the same enzyme system. <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\"><strong>Ranitidine<\/strong> also inhibits the cytochrome P-450 enzyme system, but much less so than cimetidine. <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\"><strong>Famotidine<\/strong> and <strong>nizatidine<\/strong> are more potent than cimetidine and famotidine and do not inhibit the cytochrome P-450 enzyme system. In addition, they might stimulate gastric emptying in the cat and dog by inhibiting acetylcholinesterase activity.<\/span><\/li>\n<\/ul>\n<h3 class=\"p4\"><span class=\"s1\"><b>Proton Pump Inhibitors<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">Proton pump inhibitors (PPIs) are currently the most potent inhibitors of gastric acid secretion. They irreversibly block the gastric proton pump (hydrogen-potassium ATPase), causing a marked decrease in gastric acid secretion.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">PPIs are recommended for use in small animals diagnosed with severe reflux esophagitis or gastric ulceration.<\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\"><strong>Omeprazole<\/strong> (<strong>0.7 mg\/kg PO Q 24 H<\/strong>, dogs and cats) is now available over the counter, markedly reducing its cost and increasing its availability and usage in small animals. It has come into common use (perhaps overuse) in vomiting animals without hematemesis.<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\"><strong>Pantoprazole<\/strong> (<strong>0.7\u20131 mg\/kg PO or IV PO Q 24 H<\/strong>, dogs and cats) is a newer PPI available for oral or IV use.<\/span><\/li>\n<\/ul>\n<h3 class=\"p4\"><span class=\"s1\"><b>Sucralfate<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">Sucralfate (<strong>0.25\u20131 g PO Q 8\u201312 H<\/strong>, dogs and cats) is a basic aluminum salt of a sulfated disaccharide that selectively binds to proteins at sites of ulceration.<\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">This drug has a sustained local protective effect against acid, pepsin, and bile at the ulcer site, forming a protective barrier. <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">It also increases the luminal concentration of prostaglandin E2, which protects against ulcerogenic factors.<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Because sucralfate is not absorbed from the GI tract, it has virtually no systemic toxicity. <\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">Constipation is a rare side effect that occurs because of the aluminum moiety. Sucralfate may also inhibit the absorption of other drugs, including doxycycline and, potentially, H2 receptor antagonists.<\/span><\/p>\n<h3 class=\"p4\"><span class=\"s1\"><b>Prokinetic Agents<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">Agents that enhance gastrointestinal motility may be indicated for: <\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Vomiting associated with delayed gastric emptying<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Vomiting caused by gastritis, metabolic derangements, and postoperative gastric dilatation volvulus<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Dogs that vomit bile in the morning prior to eating (bilious vomiting syndrome). <\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">Therapeutic choices for prokinetics include: <\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">5-HT4 serotonergic agonists: Cisapride, metoclopramide <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">D2 dopaminergic antagonist\/5-HT3 serotonergic antagonist: Metoclopramide<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Cholinesterase inhibitors: Ranitidine, nizatidine<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Motilin agonists: Low-dose erythromycin (dogs only).<\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\"><strong>Cisapride<\/strong> is superior to metoclopramide for treating gastric emptying disorders in cats and dogs. Cisapride stimulates GI motility from the lower esophageal sphincter to the colon (through stimulation of 5-HT4 serotonergic receptors), with minimal direct antiemetic effects. <\/span><\/p>\n<p class=\"p1\"><span class=\"s1\"><strong>Metoclopramide<\/strong> is used to increase gastroesophageal sphincter tone, and as a prokinetic for treating gastric emptying disorders and enhancing the coordination of antropyloroduodenal contractions. The prokinetic effects of metoclopramide are not readily or exclusively explained by dopamine receptor antagonism. However, metoclopramide has other pharmacologic properties, including stimulation of 5-HT4 receptors, which may better explain some of its effects on the GI tract.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\"><strong>Erythromycin<\/strong> stimulates phase III migrating myoelectric complex activity in the dog, but the physiologic regulation of migrating spike complex activity in the cat is different; therefore, erythromycin is not used as a prokinetic in cats.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">When these drugs are used for delayed gastric emptying, they should be administered 30 minutes prior to feeding. Metoclopramide has a short half-life (60\u201390 min) in dogs, and is best given as a CRI for maximal effect.<\/span><\/p>\n<h3 class=\"p4\"><span class=\"s1\"><b>Antibiotics<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">Antibiotics are not routinely used for empirical therapy in acute vomiting unless the patient is febrile or has an abnormal CBC that suggests systemic infection.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">When indicated, broad-spectrum antibiotics, such as amoxicillin combined with enrofloxacin, provide excellent coverage against most bacteria associated with infection following breakdown of the GI mucosal barrier. <\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Probiotics or an antibiotic (metronidazole, tylosin) may be useful for controlling acute diarrhea accompanying vomiting.<\/span><\/p>\n<div class=\"orange-box\">\n<h2 class=\"p3\"><span class=\"s1\"><b>Determining Reasons for Vomiting &amp; Appropriate Diagnostics<\/b><\/span><\/h2>\n<p class=\"p1\"><span class=\"s1\">Vomiting can be caused by a wide variety of GI, intra-abdominal, metabolic, systemic, and neurologic diseases. An efficient clinical approach is to determine whether vomiting results from a: <\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Primary GI problem<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Metabolic problem secondarily causing GI signs.<\/span><\/li>\n<\/ul>\n<h2 class=\"p4\"><span class=\"s1\"><b>CLINICAL APPROACH<\/b><\/span><\/h2>\n<p class=\"p1\"><span class=\"s1\">Primary disease is most likely when:<\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">An abnormality is palpable in the gut (eg, foreign body, intussusception).<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Vomiting is associated with significant diarrhea. <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">If the animal is otherwise historically and clinically normal. <\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">In the case of an animal with acute vomiting, it is important to rule out obstructions or other disorders that might require emergency surgical intervention.<\/span><\/p>\n<h3 class=\"p3\"><span class=\"s1\"><b>Primary GI Disease Diagnostics<\/b><\/span><\/h3>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Survey and contrast radiographs<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Abdominal ultrasonography<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Endoscopy<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Exploratory laparotomy<\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">In chronic vomiting, emergency surgical procedures are usually not needed. In that case, it is less invasive, less expensive and usually faster to first investigate whether a metabolic problem is causing secondary GI signs with appropriate laboratory tests; then investigate primary GI disease if clinical pathology results are normal.<\/span><\/p>\n<h2 class=\"p1\"><span class=\"s1\"><b>CAUSES &amp; DIAGNOSTICS\u00a0<\/b><\/span><\/h2>\n<p class=\"p1\"><span class=\"s1\">The many causes of vomiting pose a challenge when determining the degree of diagnostic evaluation warranted. This clinical decision is largely based on:<\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Chronicity and frequency of vomiting<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Presence or absence of other historical and\/or physical examination abnormalities.<\/span><\/li>\n<\/ul>\n<h3 class=\"p3\"><span class=\"s1\"><b>Dogs<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\"><b>Ros\u00e9 &amp; colleagues.<\/b> In a recent publication, 213 dogs that had vomiting as the main, or one of the main, signs were evaluated at a referral institution to determine which diagnostic tests were of greatest value.<\/span><span class=\"s3\"><sup>10<\/sup><\/span><span class=\"s1\"> A diagnosis was reached in 203 dogs (95.3%). See <strong>Tables 1 and 2<\/strong> for study results. Overall, there was a high incidence of nongastrointestinal diseases, especially renal, which emphasizes the need to perform a urinalysis in association with a serum biochemical profile in most animals with vomiting as the major complaint.<\/span><\/p>\n<p class=\"p1\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/03\/030413-gi-table-1.png\"><img decoding=\"async\" class=\"alignnone size-medium wp-image-9291\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/03\/030413-gi-table-1-300x116.png\" alt=\"030413 gi table 1\" width=\"300\" height=\"116\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/03\/030413-gi-table-1-300x116.png 300w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/03\/030413-gi-table-1-768x297.png 768w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/03\/030413-gi-table-1.png 834w\" sizes=\"(max-width: 300px) 100vw, 300px\" \/><\/a><\/p>\n<p class=\"p1\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/03\/030413-gi-table-2.png\"><img loading=\"lazy\" decoding=\"async\" class=\"alignnone wp-image-9292 size-medium\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/03\/030413-gi-table-2-e1457102922185-300x181.png\" alt=\"030413 gi table 2\" width=\"300\" height=\"181\" \/><\/a><\/p>\n<p class=\"p1\"><span class=\"s1\"><b>Leib &amp; colleagues.<\/b> In another study, the diagnostic utility of abdominal ultrasound was evaluated in 89 dogs with chronic vomiting.<\/span><span class=\"s3\"><sup>11<\/sup><\/span><span class=\"s1\"> Ultrasound examination was considered to be vital or beneficial to diagnosis in 22.5% of dogs. Increasing age and a final diagnosis of gastric adenocarcinoma or GI lymphoma were associated with increased diagnostic utility.<\/span><\/p>\n<h3 class=\"p3\"><span class=\"s1\"><b>Cats<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\"><b>Batchelor &amp; colleagues.<\/b> A recent evidence-based review of mechanisms, causes, diagnostic investigation, and management of vomiting in cats evaluated the most common causes (<strong>Table 3<\/strong>).<\/span><span class=\"s3\"><sup>2<\/sup><\/span><\/p>\n<p class=\"p1\"><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/03\/030413-gi-table-3-copy.png\"><img loading=\"lazy\" decoding=\"async\" class=\"alignnone size-medium wp-image-9293\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/03\/030413-gi-table-3-copy-300x232.png\" alt=\"030413 gi table 3 copy\" width=\"300\" height=\"232\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/03\/030413-gi-table-3-copy-300x232.png 300w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/03\/030413-gi-table-3-copy-768x594.png 768w, https:\/\/navc.sitepreview.app\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2013\/03\/030413-gi-table-3-copy.png 952w\" sizes=\"(max-width: 300px) 100vw, 300px\" \/><\/a><\/p>\n<p class=\"p1\"><span class=\"s1\">Most notable is the fact that vomiting in cats might be associated with a wide range of diseases originating outside of the GI tract, such as neoplasia, splenic disease, infectious disorders, chronic nasal disease, pyothorax, aortic thromboembolism, and bronchial disease. However, the authors noted that further exploration was needed and vomiting may have been incidental.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\"><b>Additional causes.<\/b> Cats frequently vomit trichobezoars (hairballs) and also vomit after administration of alpha-2 adrenergic drugs, such as xylazine and dexmedetomidine, reflecting the importance of these receptors in the brainstem areas that control vomiting.<\/span><span class=\"s3\"><sup>12,13<\/sup><\/span><\/p>\n<\/div>\n<h2 class=\"p3\"><span class=\"s1\"><b>ACUTE VOMITING: ADDITIONAL THERAPY<\/b><\/span><\/h2>\n<h3 class=\"p4\"><span class=\"s1\"><b>Dietary Management<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">Dogs or cats presenting with acute vomiting are commonly held NPO (<em>nothing per os<\/em>) for 12 to 24 hours until the vomiting ceases. While a period of NPO has not been evaluated in an evidence-based manner, its prevention of aspiration pneumonia, additional fluid losses, and discomfort of the patient are excellent reasons to use this approach.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">After vomiting has been controlled or has ceased for several hours, a small volume of a digestible intestinal formula or elimination diet (containing a novel, single protein source or hydrolyzed peptides) should be fed. <\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">A highly digestible,<strong> low-fat diet<\/strong> is usually selected for dogs, but dietary fat content appears to play a smaller role in gastric emptying in cats. <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\"><strong>Cats<\/strong> do not need a carbohydrate source and are sometimes best managed with a <strong>single-protein<\/strong> source, such as cooked chicken breast.<\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">Feeding small meals frequently will minimize gastric distention and gastric acid secretion. A gradual transition to the pet&#8217;s usual diet is made over 2 to 3 days, providing that signs have resolved.<\/span><\/p>\n<h3 class=\"p4\"><span class=\"s1\"><b>Fluid Therapy<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">Vomiting of gastric and intestinal contents usually involves:<\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Loss of fluid containing chloride, potassium, sodium, and bicarbonate<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Dehydration accompanied to a variable extent by hypochloremia, hypokalemia, and hyponatremia. <\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">Subcutaneous fluids are useful for mild dehydration. <\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\"><strong>Isotonic fluids<\/strong> should be used, with no more than <strong>10 to 20 mL\/kg<\/strong> administered at each injection site. The rate of SC fluid flow usually is governed by patient comfort. <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Acetated polyionic solutions, such as Normosol-R and Plasmalyte, should not be administered SC due to discomfort associated with administration.<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Generally, all SC fluids are absorbed within 6 to 8 hours. If pockets of SC fluid are still present after this time, use of IV fluids to reestablish peripheral perfusion should be considered. <\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">Fluids should be administered IV to animals that are moderately to severely dehydrated (&gt;= 7%).<\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\"><strong>Potassium<\/strong> supplementation to replace that lost in vomitus is usually necessary, since whole body depletion of potassium can cause GI hypomotility.<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Metabolic acidosis is the most common acid\u2013base alteration in dogs with GI disease and is usually corrected by appropriate fluid therapy with <strong>lactated Ringer&#8217;s solution<\/strong> or 0.9% <strong>saline<\/strong>. <\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Foreign bodies causing GI obstruction that involves the stomach or proximal duodenum can result in metabolic alkalosis, but such patients can also have metabolic acidosis or normal acid\u2013base status, so no presumption should be made without laboratory evaluation.<\/span><span class=\"s3\"><sup>9<\/sup><\/span><\/li>\n<\/ul>\n<blockquote>\n<h2 align=\"LEFT\">BILIOUS VOMITING SYNDROME<\/h2>\n<p align=\"LEFT\">Dogs that suffer from this syndrome can be treated with prokinetic agents. other therapeutic approaches, alone or in combination, include:<\/p>\n<ul>\n<li>Dividing the total daily food amount into an extra meal that can be given late in the evening<\/li>\n<li>Using an acid inhibitor (h2 receptor antagonist) once daily in the evening<\/li>\n<li>administering a calcium-containing antacid (such as Tums [gsk.com]) late in the evening.<\/li>\n<\/ul>\n<\/blockquote>\n<div class=\"orange-box\">\n<h2 class=\"p3\"><span class=\"s1\"><b>Motion Sickness: Helping Pets &amp; Their Owners<\/b><\/span><\/h2>\n<p class=\"p1\"><span class=\"s1\">With warmer weather quickly approaching, many pet owners will be eager to head outside\u2014and, for many, back on the road\u2014with their pets. However, motion sickness in pets creates an unpleasant situation that often results in the pet being left out of the fun. It may even deter owners from bringing their pets to the clinic for veterinary care.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Natalie Marks, DVM, of Blum Animal Hospital in Chicago, has worked with families that have pets with motion sickness. &#8220;As veterinarians, we want to do all we can to enhance the human\u2013animal bond for our clients,&#8221; Marks says. &#8220;For many pet owners, companionship\u2014both off and on the road\u2014is central to the relationships with their pets. Having a pet that doesn&#8217;t enjoy those experiences can leave the owner and pet&#8217;s bond unfulfilled.&#8221;<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">These 3 steps outline a therapeutic approach to motion sickness in pets:<\/span><\/p>\n<h3 class=\"p3\"><b style=\"line-height: 1.5\">1. Start the Motion Sickness Conversation<\/b><\/h3>\n<p class=\"p1\"><span class=\"s1\">&#8220;Many times, motion sickness is brought up to us as veterinarians. Pet owners are generally very in tune with their pets and, unfortunately, may see the problem immediately in their cars,&#8221; Marks explains. However, while owners of severely stressed pets are well aware when their pets exhibit the main sign of motion sickness\u2014vomiting\u2014others may not recognize the less obvious signs, such as drooling, panting, licking lips, or yawning.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Veterinarians can begin a pet&#8217;s appointment by asking the owner about the ride to the clinic. This simple question may lead to discovery of motion sickness in the pet.<\/span><\/p>\n<h3 class=\"p3\"><span class=\"s1\"><b>2. Make Travel a Positive Experience<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">Marks says that many cases of motion sickness can be addressed through simple training methods and adjustments to the travel process, such as making sure the pet does not eat 30 minutes prior to any trip.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">&#8220;In these cases, I encourage pet owners to start slowly and remove any fear the pet may have of the car itself. This may begin by (1) showing the pet the car without going anywhere, (2) letting the pet take in the sights and smells, and (3) rewarding the pet with a treat. This process can evolve to a short trip to the post office, again offering a reward after completing the trip,&#8221; Marks explains. <\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">She also encourages pet owners to make sure the car is welcoming to the pet by setting a lower temperature, cracking open a window for air circulation and, of course, making sure the pet is properly restrained facing forward in either a seat harness or carrier.<\/span><\/p>\n<h3 class=\"p3\"><span class=\"s1\"><b>3. Consider Treatment Options<\/b><\/span><\/h3>\n<p class=\"p1\"><span class=\"s1\">If motion sickness is chronic or cannot be resolved with behavioral methods, Marks recommends a prescribed treatment program to pet owners. &#8220;I like to discuss all the options with pet owners to find treatments that best fit their pets&#8217; needs and the family&#8217;s lifestyle.&#8221;<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Marks says. &#8220;There are excellent options available. For example, veterinarians recognize that antiemetics are excellent for GI cases, but I&#8217;m not sure everyone realizes that some are FDA-approved, and very effective, for motion sickness.&#8221;<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">Marks sums up the motion sickness discussion with, &#8220;The most important element of our work is building trust with our clients and letting them know we are there for them completely\u2014not just for wellness, illness, or injury\u2014but for their overall lifestyle experiences with their pets. Helping manage motion sickness can be an important part of ensuring the human\u2013animal bond is developed to the fullest.&#8221;<\/span><\/p>\n<\/div>\n<h2><\/h2>\n<h2 class=\"p3\"><span class=\"s1\"><b>IN SUMMARY<\/b><\/span><\/h2>\n<p class=\"p1\"><span class=\"s1\">There are many causes of vomiting and evaluation of the vomiting dog or cat requires consideration of the whole animal, not just the GI tract.<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">An assessment as to whether the dog or cat has a self-limiting or potentially serious cause of vomiting is crucial and depends on a: <\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Thorough history and careful physical examination<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Sound understanding of the differential diagnoses for acute vomiting<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Clinical judgment.<\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">If in doubt, especially in cats, err on the side of caution and evaluate the animal more extensively to assess for potentially serious problems. <\/span><\/p>\n<p class=\"p1\"><span class=\"s1\">When treating a patient symptomatically for acute vomiting, further evaluation is indicated if: <\/span><\/p>\n<ul class=\"ul1\">\n<li class=\"li1\"><span class=\"s1\">Signs do not resolve in 2 to 3 days<\/span><\/li>\n<li class=\"li1\"><span class=\"s1\">Additional clinical signs develop.<\/span><\/li>\n<\/ul>\n<p class=\"p1\"><span class=\"s1\">ACTH = adrenocorticotropic hormone; CRTZ = chemoreceptor trigger zone; GI = gastrointestinal; PPI = proton pump inhibitor<\/span><\/p>\n<h3 class=\"p8\"><strong>References<\/strong><\/h3>\n<ol>\n<li class=\"p8\"><span class=\"s1\">Lund EM, Armstrong PJ, Kirk CA, et al. Health status and population characteristics of dogs and cats examined at private veterinary practices in the United States. JAVMA 1999; 214:1336-1341.<\/span><\/li>\n<li class=\"p8\"><span class=\"s1\">Batchelor DJ, Devauchelle P, Elliott J, et al. Mechanisms, causes, investigation and management of vomiting disorders in cats: A literature review. J Feline Med Surg 2013; Feb 12 (Epub ahead of print).<\/span><\/li>\n<li class=\"p8\"><span class=\"s1\">Sedlacek HS, Ramsey DS, Boucher JF, et al. Comparative efficacy of maropitant and selected drugs in preventing emesis induced by centrally or peripherally acting emetogens in dogs. J Vet Pharmacol Ther 2008; 31:533-537.<\/span><\/li>\n<li class=\"p8\"><span class=\"s1\">de la Puente-Redondo VA, Siedek EM, Benchaoui HA, et al. Anti-emetic efficacy of maropitant in the treatment of ongoing emesis caused by a wide range of underlying clinical aetiologies in canine patients in Europe. J Small Anim Pract 2007; 48:93-98.<\/span><\/li>\n<li class=\"p8\"><span class=\"s1\">Hickman MA, Cox SR, Mahabir S, et al. Safety, pharmacokinetics and use of the novel NK-1 receptor antagonist maropitant (Cerenia) for the prevention of emesis and motion sickness in cats. J Vet Pharmacol Ther 2008; 31:220-229.<\/span><\/li>\n<li class=\"p8\"><span class=\"s1\">Hay Kraus BL. Efficacy of maropitant in preventing vomiting in dogs premedicated with hydromorphone. Vet Anaesth Analg 2013; 40:28-34.<\/span><\/li>\n<li class=\"p8\"><span class=\"s1\">Boscan P, Monnet E, Mama K, et al. Effect of maropitant, a neurokinin-1 receptor antagonist, on anesthetic requirements during noxious visceral stimulation of the ovary in dogs. Am J Vet Res 2011; 72:1576-1579.<\/span><\/li>\n<li class=\"p8\"><span class=\"s1\">Niyom S, Boscan P, Twedt DC, et al. Effect of maropitant, a neurokinin-1 receptor antagonist, on the minimum alveolar concentration of sevoflurane during stimulation of the ovarian ligament in cats. Vet Anaesth Analg 2013; doi: 10.1111\/vaa.12017 (Epub ahead of print).<\/span><\/li>\n<li class=\"p8\"><span class=\"s1\">Boag AK, Coe RJ, Martinez TA, Hughes D. Acid\u2013base and electrolyte abnormalities in dogs with gastrointestinal foreign bodies. J Vet Intern Med 2005; 19:816-821.<\/span><\/li>\n<li class=\"p8\"><span class=\"s1\">Ros\u00e9 A, Neiger R. Causes of vomiting in dogs and usefulness of clinical investigations. Tierarztl Prax Ausg K Kleintiere Heimtiere 2013; 41:16-22.<\/span><\/li>\n<li class=\"p8\"><span class=\"s1\">Leib MS, Larson MM, Panciera DL, et al. Diagnostic utility of abdominal ultrasonography in dogs with chronic vomiting. J Vet Intern Med 2010; 24:803-808.<\/span><\/li>\n<li class=\"p8\"><span class=\"s1\">Trepanier L. Acute vomiting in cats: Rational treatment selection. J Feline Med Surg 2010; 12:225-230.<\/span><\/li>\n<li class=\"p8\"><span class=\"s1\">Cannon M. Hair balls in cats: A normal nuisance or a sign that something is wrong? J Feline Med Surg 2013; 15:21-29.<\/span><\/li>\n<\/ol>\n<p class=\"p8\"><span class=\"author-bio\"><strong><a href=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/02\/P.-Jane-Armstrong.png\"><img loading=\"lazy\" decoding=\"async\" class=\"size-full wp-image-8128 alignleft\" src=\"https:\/\/todaysveterinarypractice.com\/wp-content\/uploads\/sites\/4\/2015\/02\/P.-Jane-Armstrong.png\" alt=\"P. Jane Armstrong\" width=\"100\" height=\"133\" \/><\/a>P. Jane Armstrong<\/strong><\/span>, DVM, MS, MBA, Diplomate ACVIM (Small Animal Internal Medicine), is a professor in the Department of Veterinary Clinical Sciences at University of Minnesota College of Veterinary Medicine. She is also a member of the World Small Animal Veterinary Association (WSAVA) Liver Standardization Group. Her clinical and research interests include gastrointestinal disease, feline medicine, integrative medicine, clinical nutrition, and canine genetics. Dr. Armstrong is a past president of the American College of Veterinary Internal Medicine (Small Animal) and Comparative Gastroenterology Society and an Editorial Advisory Board member for Today&#8217;s Veterinary Practice. She received her DVM from Ontario Veterinary College, University of Guelph; then completed an internship at University of Illinois and residency and Master&#8217;s degree at Michigan State University<i>.<\/i><\/p>\n","protected":false},"excerpt":{"rendered":"<p>P.<\/p>\n","protected":false},"author":1,"featured_media":2741,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"iawp_total_views":7479,"footnotes":""},"categories":[375],"tags":[13],"class_list":["post-1341","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-march-april-2013","tag-peer-reviewed","column-features","clinical_topics-gastroenterology"],"acf":{"hide_sidebar":false,"hide_sidebar_ad":false,"hide_all_ads":false},"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v24.7 (Yoast SEO v27.3) - https:\/\/yoast.com\/product\/yoast-seo-premium-wordpress\/ -->\n<title>GI Intervention: Approach to Diagnosis &amp; 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