Chronic Gastric Diseases - By: Dr. D.S. Merchant

Definition: Chronic Vomiting
- Acute vomiting that fails to respond to appropriate symptomatic therapy
- Untreated vomiting that persists longer than two weeks
– Consistent
– Intermittent or episodic

Approach to Vomiting
- Primary GI
– Gastric
– Small intestinal
– Colonic
- Secondary GI
– Systemic illness that affects GI function

Secondary GI Causes of Vomiting
SYSTEM
- Kidneys
- Liver
- Exocrine pancreas
- Endocrine pancreas
- Adrenals
- Peritoneum
- CNS

- Thyroid
- Uterus
- Systemic infection

Disease:
- Renal failure
- Hepatic disease
- Pancreatitis
- DKA
- Addison’s
- Peritonitis
- Cerebral or vestibular disease
- Hyperthyroidism
- Pyometra
- Sepsis

Overview:
Gastric Causes of Chronic Vomiting
- Chronic gastritis
– Lymphocytic/plasmacytic
– Eosinophilic
– Associated with GHLOs
– Parasitic
– Reflux gastritis
- Gastric foreign body
- Gastric ulceration
- Gastric motility disorders
- Gastric neoplasia

Overview:
Intestinal Causes of Chronic Vomiting
- Inflammatory bowel disease (IBD)
- Intestinal neoplasia
- Duodenal ulcers
- Fungal enteritis
- Chronic intussusception
- Foreign bodies
- Colitis

Chronic Vomiting: History
- Characterize vomiting
– Onset
– Duration
– Frequency
– Progression
– Relationship to eating
– Specific features (blood, foreign material, undigested food, projectile, etc.)
– Response to changes in diet or feeding schedule, medication, other changes

Associated clinical signs-
– Appetite changes
– Weight loss
– Diarrhea
– Changes in attitude (lethargy)
– PU/PD
– Cough, tachypnea, dyspnea
– Other

- Potential exposures prior to onset:
– Medications
– Plants
– Toxins
– Garbage
– Potential foreign bodies
– Other sick animals

- Dietary history
- Deworming history
- Vaccination status
- Past medical history
- Past surgical history

Approach to Vomiting:
- Primary GI
– Gastric
– Small intestinal
– Colonic
- Secondary GI
– Systemic illness that affects GI function

Chronic Vomiting:
Diagnostic Steps
- CBC, biochemistry profile, UA
- Fecal
- Survey abdominal radiographs
- Cats:
– T4 if over 6 yrs, FeLV, FIV
– occult heartworm test
- Elimination diet
- Endoscopy
- Abdominal ultrasound
- Barium series
- Laparatomy

Approach to Chronic Vomiting
CBC, biochemistry profile, UA, fecal
Survey abdominal radiographs
Cats: T4 if over 6 yrs, FeLV, FIV (occult heartworm test)

Mild Signs:
- Elimination diet

Significant Clinical Signs:
- Endoscopy
- Abdominal ultrasound
- Barium series
- Laparotomy

Overview:
Gastric Causes of Chronic Vomiting
- Chronic gastritis
– Lymphocytic/plasmacytic
– Eosinophilic
– Associated with GHLOs
– Parasitic
– Reflux gastritis

- Gastric foreign body
- Gastric ulceration
- Gastric motility disorders
- Gastric neoplasia

Chronic Gastritis
Classified by etiology, breed, and/or histopathology
Types of Chronic Gastritis

– Lymphocytic/plasmacytic gastritis (Chronic non-specific gastritis, IBD)
– Eosinophilic gastritis
– Granulomatous gastritis
– Atrophic gastritis
– Gastritis associated with GHLOs
– Parasitic gastritis
– Reflux gastritis

Etiopathogenesis of Chronic Lymphocytic/Plasmacytic Gastritis

- Non-specific reaction to many insults
- Either wall defects allow antigen absorption from stomach stimulating immune response OR breakdown in immune tolerance (auto-immune gastritis)
- Mucosal damage allows back-diffusion of acid
- Gastric inflammation compromises motility, secretions and plasma proteins lost into lumen

Chronic Lymphocytic/Plasmacytic Gastritis: Clinical Features
- Persistent intermittent vomiting exacerbated by eating
- Diarrhea occurs if animal has concurrent IBD of intestines
- PE, CBC, chemistries, UA, fecal, and survey radiographs – typically NAF

Chronic Lymphocytic/Plasmacytic Gastritis: Diagnosis
- Obtain endoscopic biopsies or full-thickness biopsies by laparotomy
- Infiltration of the gastric mucosa predominantly with lymphocytes and plasma cells
- Mucosa may be normal thickness (simple gastritis), increased (hypertrophic), or decreased (atrophic)
Note: Mucosal hypertrophy can cause outflow obstruction

Chronic Lymphocytic/Plasmacytic Gastritis: Treatment
PRIMARY THERAPY
- +/- NPO or “no food” for 24-48 hours
- Multiple small daily meals
– Easily digested diet (i/d)
– Novel protein diet (e.g. venison and rice)
– Hydrolyzed protein diet (z/d, HA)
- Gastric protectant (Sucralfate)
- Treat for ulceration if indicated

SECONDARY THERAPY
- Prednisolone 1-2 mg/kg PO q12 hr, tapered
- Usually reserve antiemetics for acute exacerbations

Eosinophilic Gastritis
- Clinical signs like L/P gastritis
- Inflammatory infiltrate dominated by eosinophils
- May have peripheral eosinophilia
- May be associated with:
– Generalized eosinophilic gastroenteritis (dogs and cats)
– Eosinophilic granulomas (dogs)
– Hypereosinophilic syndrome (cats)

Eosinophilic Gastritis
- Suspected etiologies
– Parasites
– Dietary hypersensitivity
– Hypereosinophilic syndrome (cats) – neoplastic-

Eosinophilic Gastritis: Treatment
- Therapeutic deworming
- Treat as for L/P gastritis except use prednisolone as part of primary therapy
- Cats usually require higher doses of steroids for control (2-3 mg/kg q12 hr)
- If refractory, add azathioprine
- Resect granulomatous masses

Eosinophilic Gastritis: Prognosis
- Eosinophilic gastritis +/- enteritis: Good prognosis for control of clinical signs
- Hypereosinophilic syndrome in cats: Very guarded prognosis

About the Author

Dr. D.S. Merchant is a Gold Medalist in (Anatomy & Histology), Resident AKUH, Pakistan. For more information on Gastroenterology or visit http://www.update.pk is a popular website that offers information on Endoscopy, Pulmonary Disease and VHF Medications.

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