CSAMA-莫道克讲座1-小动物临床中的呕吐、反流和腹泻

希尔思宠物营养-莫道克大学专场讲座 中国畜牧兽医学会小动物分会 第四次研讨会 2009-8 呼和浩特 1 小动物临床中的呕吐、反流和腹泻小动物临床中的呕吐、反流和腹泻 Vomiting, Regurgitation and Vomiting, Regurgitation and Diarrhoea Diarrhoea in Small Animal Practicein Small Animal Practice Peter Irwin 教授 兽医及生物医学系 西澳大利亚，莫道克大学 Division of Veterinary & Biomedical Science Murdoch University, Western Australia 呕吐和呕吐和反反流流 Vomiting and RegurgitationVomiting and Regurgitation 呕吐 Vomiting  常见的问题 Common problem  胃物用力的排出 Forceful expulsion of stomach contents  复杂的神经学通路 Complex neurological pathways 必须和反流相区别 Must be differentiated from regurgitation 反流 Regurgitation  突发和“被动” Sudden and ‘passive’  无恶心 No nausea 呕吐和呕吐和反反流流 Vomiting and RegurgitationVomiting and Regurgitation 暗示胃、肠、腹部或全身性 的疾病 Implies gastric, intestinal, abdominal or systemic disease 暗示食道的疾病 Implies oesophageal disease 呕吐 Vomiting  常见的问题 Common problem  胃内容物用力的排出 Forceful expulsion of stomach contents  复杂的神经学通路 Complex neurological pathways 必须和反流相区别 Must be differentiated from regurgitation 反流 Regurgitation  突发和“被动” Sudden and ‘passive’  无恶心 No nausea 通常有 Often无 No胆汁 Bile 酸性 Acid 碱性 Alkaline 呕吐物的pH 值 pH of contents 任何时候 Any 任何时候，通常在饲喂后立即 Usually immediate, but any time 饲喂后时间 Time after eating 食物、胆汁、消化的食 物 Food, bile, digested blood 泡沫、唾液、未消化的食物 Froth, saliva, undigested food 排出内容物 Contents of ejection 腹部主动收缩 Active abdominal contractions 被动的 Passive ‘splash’ 喷射力 Force of ejection 有 Yes 无 No 前兆（恶心、不适） Preceding signs (nausea, discomfort) 呕吐 Vomiting 反流 Regurgitation 症状 Sign 反流和呕吐的鉴别诊断 Differentiation of Regurgitation and Vomiting 为什么区别呕吐和反流是如此重要？为什么区别呕吐和反流是如此重要？ Why is it important to differentiate betweenWhy is it important to differentiate between Vomiting and Regurgitation?Vomiting and Regurgitation? 因为你会错过食道的疾病，关注错误的部位因为你会错过食道的疾病，关注错误的部位 Because you will miss oesophageal diseaseBecause you will miss oesophageal disease And look in the wrong place!And look in the wrong place! 希尔思宠物营养-莫道克大学专场讲座 中国畜牧兽医学会小动物分会 第四次研讨会 2009-8 呼和浩特 2 反流的原因反流的原因 Causes of RegurgitationCauses of Regurgitation  食道阻塞 Oesophageal obstruction  骨头、或其他异物 Bone, or other foreign body  旋尾线虫 感染 – 肉芽肿 Spirocerca lupi infection - granuloma  食道炎 Oesophagitis  胃反流 Gastric reflux  最近进行过麻醉？ Recent anaesthetic?  呕吐 Vomiting  食道肌肉无力 （巨食道症） Oesophageal muscle weakness (megaoesophagus)  很多原因 Many causes  在老年犬为特发性 Idiopathic in old dogs 反流的诊断反流的诊断 Diagnostic Evaluation of RegurgitationDiagnostic Evaluation of Regurgitation  拍摄胸部x-光片 Thoracic radiographs  异物？ Foreign body?  组织密度（液体，异物）？ Tissue density (fluid, FB)?  鼓气 （=巨食道症）？ Gas distension (= megaoesophagus)?  食物积聚 ？ Food accumulation?  肺部病理 – 显示肺炎？ Lung pathology – evidence of pneumonia?  粪便检查看有无旋尾线虫感染 Faecal tests for Spirocerca lupi infection  内窥镜检查 Endoscopy 你的诊断？ What is your diagnosis? Bone FB inBone FB in OesophagusOesophagus 异物带有射线可透过性“晕环” FB with radiolucent ‘halo’ 在我们医院，骨头是引起反流最常见的原因 Bones are the most common cause of regurgitation in our Hospital 病例病例 Case Case -- TammyTammy  突发性反流 Sudden onset regurgitation  小孩扔树枝让狗去叼回来 Children throwing sticks for the dog to fetch 进行钡餐之后进行钡餐之后--你看到什么？你看到什么？ After barium After barium –– what can you see?what can you see? 希尔思宠物营养-莫道克大学专场讲座 中国畜牧兽医学会小动物分会 第四次研讨会 2009-8 呼和浩特 3 Oesophageal Oesophageal stick FBstick FB 棍状异物 – 在他跑向树枝 时，树枝插入到食道中。 Stick foreign body – The stick had passed into the oesophagus as the ran onto it. 通过内窥镜诊断食道炎通过内窥镜诊断食道炎 OesophagitisOesophagitis is diagnosed by endoscopyis diagnosed by endoscopy  食道炎 Oesophagitis  伴随着异物阻塞 Following FB obstruction  继发于呕吐 Secondary to vomiting  胃液反流 Gastric reflux  先天性 Congenital  麻醉并发症 Anaesthetic complication  治疗 Treatment  泼尼松龙 Prednisolone (0.5mg/kg q12h)  雷尼替丁 或者 Ranitidine, or  奥美拉唑 Omeprazole  硫糖铝 Sucralfate (0.5-1g per dog q8- 12h PO in slurry) 通过内窥镜诊断食道狭窄通过内窥镜诊断食道狭窄 Oesophageal stricture by endoscopyOesophageal stricture by endoscopy  狭窄 Stricture  食道炎的结果 Consequence of oesophagitis  治疗 Treatment  探针扩张术 Bougienage 先天性巨食道症先天性巨食道症 Congenital megaoesophagusCongenital megaoesophagus 病例病例Jack Jack 的病史的病史 JackJack–– Case HistoryCase History  2岁绝育的公犬 2 Yr.o. MN Tenterfield Terrier  6个星期的病史 6 week history of:  呕吐 （严重且治疗很棘手） Vomiting (severe, intractable)  干呕和流涎 Retching & hypersialism (流口 水drooling)  没有食欲 5 天 Anorexia (5 days)  以前的资料是 Previous work-up:  血液化验正常 Blood screens (normal)  腹部X光正常 Abdominal radiographs (normal)  X光造影 Contrast radiographs (normal)  治疗 Treatment:  止吐，H2受体阻断剂，硫糖铝，抗生素和泼 尼松龙 Anti-emetics, H2-blockers, sucralfate, antibiotics & prednisolone 侧位X光片－注意在食道的后端有软组织密度增加 Lateral radiograph of Jack’s thorax – note soft tissue density in caudal oesophagus 希尔思宠物营养-莫道克大学专场讲座 中国畜牧兽医学会小动物分会 第四次研讨会 2009-8 呼和浩特 4 病变诊断为食道线虫肉芽瘤病变诊断为食道线虫肉芽瘤 The lesion is diagnosed as The lesion is diagnosed as SpirocercaSpirocerca granulomagranuloma  食道内窥镜 Oesophageal endoscopy  食道肉芽瘤 Oesophageal granuloma  粪便中有卵 Eggs in faeces instruction.cvhs.okstate.edu/lst41_50.htm 4个食道肉芽瘤 Image of 4 oesophageal granulomas www.proteaanimalclinic.co.za/kobus/spiro_eng.html 食道线虫的治疗食道线虫的治疗 Treatment of SpirocercosisTreatment of Spirocercosis  治疗 Treatment for the spirocercosis:  依维菌素，2次。间隔14天 Ivermectin 2 doses 14 days apart  600μg/kg SC (test dose 125μg/kg first, unregistered use)  (DNA test for mdr-1 gene readily available)  泼尼松 Prednisolone (0.5mg/kg q12h PO)  可能发生的并发症 Possible Complications  肉芽瘤癌变 Neoplastic transformation of granuloma  肺脏骨质增生 Hypertrophic pulmonary osteopathy  主动脉破裂和致命血胸 Aortic rupture and fatal haemothorax 病例病例JackJack的结果的结果 Jack Jack -- OutcomeOutcome 伴发吸入性肺炎的获得性巨食道症伴发吸入性肺炎的获得性巨食道症 Acquired Megaoesophagus with Acquired Megaoesophagus with Aspiration PneumoniaAspiration Pneumonia 伴发吸入性肺炎的伴发吸入性肺炎的 获得性巨食道症获得性巨食道症 Acquired Acquired Megaoesophagus Megaoesophagus with with Aspiration Aspiration PneumoniaPneumonia 获得性巨食道症的治疗获得性巨食道症的治疗 Management of Acquired MegaoesophagusManagement of Acquired Megaoesophagus  治疗吸入性肺炎 Treat the aspiration pneumonia  治疗潜在的疾病 Search for a treat any underlying disease  特发性 Idiopathic  肾上腺皮质机能减退 Hypoadrenocorticism  毒素，神经疾病… Toxins, neurological disease…  试用不同粘稠度的食物 Try foods of different consistencies  抬高头部进行饲喂 Feed from an elevated position  考虑使用胃管饲喂 Consider G-tube feeding  棘手而且预后不良 Frustrating and a poor prognosis 希尔思宠物营养-莫道克大学专场讲座 中国畜牧兽医学会小动物分会 第四次研讨会 2009-8 呼和浩特 5 呕吐呕吐 VomitingVomiting 呕吐呕吐 VomitingVomiting  非常常见的问题 Very common problem  首先决定 – 犬是否需要住院？ First decision – does the dog require hospitalization?  如果不需要，你希望犬在家能够好转 If not, you expect the dog to recover at home  哪些是“危兆”，明必须住院？ What are the “warning signs” that indicate admission is necessary?  第二个决定 – 诊断？ Second decision – what is the diagnosis?  第三个决定 – 你如何治疗？ Third decision – how should you treat? 呕吐犬的危兆呕吐犬的危兆 Warning Signs in the Vomiting DogWarning Signs in the Vomiting Dog  全身疾病症状 Evidence of systemic illness  脱水、没精神、发烧 Dehydration, lethargy, fever…  大量的呕吐物 Large volumes of vomitus  可能是胃肠道阻塞 Suggests intestinal obstruction  持续的呕吐，尽管进行了对症治疗 Persistent vomiting despite treatment  呕吐物中带有鲜血 Vomitus contains blood  严重的腹痛 Severe abdominal pain  显著的体重减轻 Marked weight loss 让病患住院！ Admit the patient to your clinic! 便血便血 –– 需要调查需要调查 HaematocheziaHaematochezia –– needs investigationneeds investigation 溃疡性胃癌 Ulcerated gastric carcinoma 腹痛腹痛 -- 需要调查需要调查 Abdominal pain Abdominal pain –– needs investigationneeds investigation 急性胰腺炎 Acute pancreatitis 体重减轻和中枢神经系统症状体重减轻和中枢神经系统症状––需要调查需要调查 Weight loss and CNS signs Weight loss and CNS signs –– needs investigationneeds investigation 伴有肝脑症的肝衰竭 Liver failure with hepatic encephalopathy 希尔思宠物营养-莫道克大学专场讲座 中国畜牧兽医学会小动物分会 第四次研讨会 2009-8 呼和浩特 6 严重的体重减轻严重的体重减轻 -- 需要调查需要调查 Severe weight loss Severe weight loss –– needs investigationneeds investigation 慢性异物和肠套叠 Chronic foreign body and intussusception 引起呕吐的原因引起呕吐的原因 Causes of VomitingCauses of Vomiting  胃肠道的原因 Gastrointestinal (GI) causes  在胃肠道内的疾病 Diseases arising within the GI tract  可能没有其他症状 May have no other signs  通常为胃病 或者 Usually gastric disease; or  非阻塞性肠道疾病 Non-obstructive intestinal disease  腹腔疾病 Abdominal disease  通常有腹痛 Usually have abdominal pain  胃肠道外的原因（全身性疾病） “Extra” GI causes (systemic disease)  通常还有其他临床症状 Usually have other clinical signs  中枢神经系统疾病 CNS disease  通常还有其他神经症状 Usually have other neurological signs 1.1.胃肠道的原因胃肠道的原因 Gastrointestinal CausesGastrointestinal Causes  食物问题 Dietary indiscretion  传染病 Infectious disease  犬细小病毒、犬瘟热、肠道寄生虫 Canine parvovirus, distemper, intestinal parasites  肠道阻塞 Intestinal obstruction  异物、肿瘤 Foreign body, neoplasia  胃溃疡、胃炎 Gastric ulcers, gastritis  胃扩张 – 扭转 Gastric dilation-volvulus (GDV)  胃肿瘤 Gastric cancer 2. 2. 腹腔原因腹腔原因 Abdominal CausesAbdominal Causes  炎症性疾病 Inflammatory disease  胰腺炎 Pancreatitis  腹膜炎 Peritonitis  肝炎.. Hepatitis…  尿道阻塞 Urinary tract obstruction  扭转 Torsions  疝气 Hernias  脾 Splenic  睾丸 Testicular 3. 3. 全身性疾病全身性疾病 Systemic DiseasesSystemic Diseases  糖尿病酮酸中毒 Diabetic ketoacidosis (DKA)  尿毒症（肾衰竭）Uraemia (kidney failure)  急性肝病和肝衰竭 Acute hepatopathy and liver failure  肾上腺皮质机能减退 Hypoadrenocorticism  中毒（毒物）Toxicity (poisons)  败血症 Sepsis 4. 4. 中枢神经系统疾病中枢神经系统疾病 CNS DiseasesCNS Diseases  前庭疾病 Vestibular disease  晕动症 Motion sickness  颅内压增加 Increased intracranial pressure  炎症性脑病 Inflammatory brain disease  肿瘤 Neoplasia 希尔思宠物营养-莫道克大学专场讲座 中国畜牧兽医学会小动物分会 第四次研讨会 2009-8 呼和浩特 7 对呕吐原因的诊断对呕吐原因的诊断 Diagnosis of the Cause of VomitingDiagnosis of the Cause of Vomiting  病史 History  身体检查 Physical examination  血检 Blood screens  血清生化 Serum biochemistry  全血检 CBC (haematology)  尿液 Urinalysis  影像 Imaging  腹部x-光片 Abdominal radiographs  超声波 Ultrasound  内窥镜 Endoscopy  开腹探查 Exploratory laparotomy 你的诊断？ What is your Diagnosis? L5 如何知道是否有阻塞？How do you tell if there is obstruction? 正常情况下 SI/L5 比例 < 1.6 Normal SI/L5 ratio < 1.6 比例>1.6 说明可能有阻塞 Ratio > 1.6 suggests obstruction SI 希尔思宠物营养-莫道克大学专场讲座 中国畜牧兽医学会小动物分会 第四次研讨会 2009-8 呼和浩特 8 手术取出异物手术取出异物 Surgical Removal of FBSurgical Removal of FB 内窥镜内窥镜 –– 取出异物的有用工具取出异物的有用工具 Endoscopy Endoscopy –– a useful tool for FB removala useful tool for FB removal 血检的价值血检的价值 The Value of Blood ScreensThe Value of Blood Screens  电解质 Electrolytes  给出关于电解质紊乱的信息 Give you information about electrolyte disturbances  肾上腺皮质机能减退？ Hypoadrenocorticism?  尿素、肌酐和尿比重 Urea, creatinine and USG  肝功能 – 肾衰竭是原因？ Renal function – renal failure as a cause?  白细胞计数 WBCC  胰腺炎，腹膜炎 Pancreatitis, peritonitis  丙氨酸氨基转换酶、碱性磷酸酶 ALT, AP  肝病是引起呕吐的原因? Hepatic disease as the cause of vomiting? 呕吐的饮食管理呕吐的饮食管理 Dietary Management of VomitingDietary Management of Vomiting  让胃休息 Gastric rest  12-24小时禁食 Nothing to eat for 12-24 hours  饲喂高消化性、低-中等水平脂肪的饮食 Introduce a highly digestible, low-moderate fat diet  补充钾 Potassium supplemented  补充维生素B B vitamin supplemented 呕吐的对症治疗呕吐的对症治疗 Symptomatic Management of VomitingSymptomatic Management of Vomiting  止吐剂 Anti-emetics  胃复安 Metoclopramide – 0.5mg/kg q8-12h IV, CRI, SC, PO  决不能用于胃肠道阻塞的病例 NEVER in obstruction  多巴胺拮抗剂，中枢和局部作用（肠促动剂 ） Dopamine antagonist, central and local effects (prokinetic)  吩噻嗪类 Phenothiazines:  乙酰丙嗪 Acepromazine  氯丙嗪 Prochlorperazine  阻断 CTZ Blocks CTZ  镇静 Sedative  罗马匹坦 Maropitant – 1mg/kg q24h SC or PO  神经激肽 （NK1）拮抗剂 Neurokinin (NK-1) antagonist 呕吐的对症治疗呕吐的对症治疗 Symptomatic Management of VomitingSymptomatic Management of Vomiting  胃保护剂 Gastric protectants  硫糖铝 Sucralfate - 0.5-1g per dose q12h PO  聚合需要酸性 Requires acidity to polymerase  与溃疡面暴露的胶原蛋白结合？Binds to exposed collages (ulcers)  H2 受体拮抗剂 H2-antagonists  雷尼替丁 Ranitidine  法莫替丁 Famotidine  奥美拉唑 Omeprazole  胃酸的有效抑制剂 Potent inhibitor of gastric acid 希尔思宠物营养-莫道克大学专场讲座 中国畜牧兽医学会小动物分会 第四次研讨会 2009-8 呼和浩特 9 治疗中的治疗中的““要要””与与““不要不要”” Some Treatment Do’s and Don’tsSome Treatment Do’s and Don’ts  一定要鉴别诊断反流还是呕吐 Do differentiate regurgitation from vomiting  如果可能一定要做出明确的诊断 Do make a specific diagnosis is possible  如果有阻塞，不要使用止吐剂 Do not use anti-emetics if there is an obstruction  没有诊断前不要使用止吐剂 Do not use anti-emetics without a diagnosis 谢谢谢谢 Thank you!Thank you! 致谢 Acknowledgements 林德贵教授 Prof Lin Degui CSAMA 戴庶 兽医师 Dr Shu Dai 张莹 兽医师 Dr Joyce Zhang Dr Mark O’Byrne 希尔思宠物营养 Hill’s Pet Nutrition 任何问题？ Any Questions?