Telemedicine: Is endoscopy needed when dog presents with vomiting, anorexia?
May 01, 2001
Clinical history: The dog presents with a recent history of vomiting and anorexia for the last two weeks. There has been a weight loss of about 5 lbs. When the dog eats for the owner, she will vomit the food soon after. At home, the dog is lethargic and quiet, but in the examination room today the dog is active and alert.
Ultrasound examination: Thorough abdominal ultrasonography is performed with the dog positioned in dorsal recumbency. The ultrasonographic image provided hereafter is of the duodenum and pancreatic region.
My comments: The liver shows uniform, slightly increased echogenicity in all liver lobes. There is some periportal infiltrate or fibrosis that makes some of the portal vessels appear slightly more prominent then normal. The gallbladder is mildly distended, and its walls are not thickened or hyperechoic. The spleen has uniform, slightly increased echogenicity - no masses noted. The left and right kidneys are similar in size, shape and echotexture. No masses or calculi were noted in either kidney. The urinary bladder is distended with urine and contains some urine sediment material - no masses or calculi noted. The stomach wall may be slightly thickened. The pancreas is seen but has uniform echogenicity. I did not visualize the walls of the duodenum and remaining intestinal loops well.
Case management: In this case, chronic inflammatory bowel disease is the clinical diagnosis. This is the type of case in which it is always good to pass an endoscope into the stomach and duodenum for direct visualization and collection of appropriate surface biopsies, especially if supportive care does not resolve the vomiting and anorexia.
I do not believe that lymphoma or chronic pancreatitis is a concern in this case.
Follow-up report: Two days following the initial diagnostic evaluation, the dog returned with acute cranial abdominal pain, generalized weakness to almost the point of collapse, and more vomiting. An exploratory laparotomy was performed and multiple duodenal ulcers and one perforated duodenal ulcer were found. The following is state-of-the-art information on duodenal ulceration and its clinical management in older dogs.
Review on duodenal ulceration Duodenal erosions are superficial mucosal defects that do not penetrate the lamina muscularis mucosae. Duodenal ulcers penetrate deeper into the muscular mucosae layer.
Duodenal ulcers are less commonly observed than duodenal erosions and diagnosed more commonly in adult dogs than in adult cats.
Duodenal ulceration or erosions may result from any of the agents that cause acute or chronic gastritis and acute or chronic duodenitis. The most important causes include drugs (NSAIDs, corticosteroids), primary gastric or duodenal diseases (inflammatory bowel disease, gastric dilatation-volvulus, neoplasia, chemical toxins), stress factors (hypotension, severe illness, environmental stress), neurologic disease, metabolic disorders (renal disease, liver disease, hypoadrenocorticism), gastric hyperacidity conditions (systemic mastocytosis, neoplasia), and miscellaneous disorders (pancreatitis, shock, foreign objects).
The most common causes of duodenal ulceration in older dogs include drugs, liver disease, renal disease, pancreatic disease, neoplasia and shock. Drugs (especially NSAIDs), chronic inflammatory bowel disease and neoplasia are more commonly ulcerative, whereas other causes more commonly result in erosions.