Gastrointestinal problems in pediatric patients require careful assessment

Gastrointestinal problems in pediatric patients require careful assessment

Gastrointestinal problems in puppies and kittens after birth to adulthood are extremely common. In the last 10 years, there actually have been no new or unique gastrointestinal problems noted in puppies and kittens. However, the practical principles of diagnosing and managing common gastrointestinal problems are still warranted.

Gastric disorders Vomiting is the primary sign of gastric disorders and as an event first appears in puppies and kittens with a full stomach at 3 days and 10 days of age, respectively. The vomiting is usually preceded by a short period of nausea with licking, hypersalivation or multiple attempts at swallowing. This is followed by retching or several forceful, simultaneous diaphragmatic and abdominal contractions and, with the head lowered, expulsion of gastric contents. Observation of the amount, color and consistency of vomitus is useful for obtaining insight into the origin of a gastric disorder and the degree of mucosal damage. If the vomitus consists of food, the degree of digestion indicates the length of time food has remained in the stomach. Vomitus can contain varying amounts of mucus and fluid from gastric and swallowed salivary secretions. Yellow-stained or green-stained vomitus indicates intestinal reflux of bile into the stomach. Vomitus containing feces usually indicates intestinal stasis or possibly intestinal obstruction. Fresh blood from gastric bleeding may be present as small red flecks or as large blood clots. Blood that has been retained in the stomach soon becomes partially digested and has a brown "coffee grounds" appearance. The presence of blood in vomitus usually signifies a more serious gastric disorder. Other signs associated with gastric disorders may include nausea, belching, inappetence, polydipsia and pica. Black tarry stools are seen with upper gastrointestinal bleeding and may imply gastric mucosal damage.

Gastritis can be associated with a multitude of causes but more commonly results from dietary indiscretions, infectious diseases and possibly endoparasites. Ingestion of foreign material such as bones, pins, needles, plastic objects, food wrappings, rocks and small toys mechanically irritates the gastric mucosa and thereby causes gastritis. The incidence of ingested foreign material is much higher in young dogs and cats, possibly owing to their developmental chewing habits and curious natures. Trichobezoars (hairballs) are frequently seen in the vomitus of long-haired cats and some dogs. Many drugs (antimicrobial agents, nonsteroidal anti-inflammatory drugs, anthelmintics and corticosteroids) and chemicals (heavy metals, cleaning agents, fertilizers and herbicides) may also contribute to gastritis in the young animal. Bacterial-induced gastritis is extremely uncommon because the acidic gastric lumen does not favor the growth and colonization of bacteria. Helicobacter spp. are commonly present but non-contributory to gastric disease. Viruses, most commonly canine herpesvirus and parvoviruses, may cause gastric lesions and vomiting as a part of a more extensive disease condition. Endoparasites seldom produce gastric lesions or signs. Physaloptera spp., Ollulanus tricuspis (cats), ascarids, and, occasionally, tapeworms are endoparasites that may be associated with gastric irritation and vomiting. Other conditions, including renal failure, liver disease, neurologic disease, shock, sepsis and possibly altered behavior, may also play a role in the cause of gastritis in the young dog and cat.

Management of vomiting Symptomatic treatment of most cases of gastritis and vomiting begins without extensive diagnostic procedures. Most young animals show improvement within 12-24 hours following little or no therapy and usually are treated on an outpatient basis. Those young animals with persistent vomiting; evidence of dehydration, abdominal pain, organomegaly or palpable abdominal mass; or failure to respond to previous symptomatic treatment require further medical and laboratory evaluation. The general principles in the treatment of gastric disorders include removing the inciting cause; providing proper conditions to promote mucosal repair; correcting fluid, electrolyte and acid-base abnormalities; and alleviating secondary complications of gastritis, such as abdominal pain and diarrhea.

Table 1: Antiemetics and Dosages
Dietary restriction is the initial management for gastritis. A young animal with gastritis should be withheld food for 24-48 hours and water for 12-24 hours. If no vomiting occurs during this period of management, over the next two to five days the animal is gradually returned to full feed and water. Water is offered initially in small, frequent amounts or provided in ice cubes, enough to keep the mouth moist and to supply a modest fluid replacement. Until vomiting is well controlled, feed small amounts frequently (three to six times daily) of a highly digestible, low-fiber diet. One can expect most cases of vomiting in young dogs and cats will respond to just dietary and water intake management.

Administration of parenteral fluids, antiemetics (Table 1, p. 24), and secretory H2-receptor antagonists (Table 2, p. 25) drugs may be given to control refractory vomiting in puppies and kittens and when a gastric foreign object has been ruled out. antiemetic drugs inhibit vomiting but do little for primary treatment of gastritis. Anticholinergic drugs reduce gastric motility and smooth muscle spasms. Overuse of the anticholinergic drugs can cause gastric atony and a pharmacologic gastric outflow obstruction, resulting in further vomiting. Oral protectants and antimicrobial agents are usually not indicated in the treatment of gastritis. Severe gastric hemorrhage should be treated as an emergency. Whole blood and parenteral fluids should be given to replace blood and fluid lost. Attempts at controlling bleeding are generally made with the use of gastric lavages with ice water or surgical gastrectomy.

Table 2: Summary of Therapeutic Products for Management of Gastrointestinal Disorders
Gastric retention problems Gastric retention and paresis are most often associated with pyloric dysfunction, motility disturbances of the stomach, or both. Pyloric dysfunction in the young dog or cat usually results from congenital pyloric stenosis or from an intraluminal foreign object obstructing the gastric outflow area. Traumatic injury and inflammatory bowel disease can reduce motility throughout the gastrointestinal tract, resulting in the retention of gastric contents and recurrent episodes of mild bloating. Management should then be directed toward control of the underlying condition and possibly stimulating gastric motility.