scott@vtx-cpd.com

Thank you so much for this feedback.

I have a few more cases in the last lesson.

Thanks again.

Scott 🙂

Thanks so much for sharing the images.

This is an interesting case.

How has the patient done?

Scott 🙂

From my imaging specialist pal…

“If it is emphysematous gastritis then they would see gas in the gastric wall on ultrasound, which would appear as hyperechoic foci with reverberation artefacts, this can be difficult to appreciate when there is gas in the lumen, so usually takes several goes at looking through the gastric wall carefully and possibly from different sides/angles (pic below from that paper). Usually, the gastric wall looks thickened and abnormal as well. They may also see it on radiographs (see pic below again from paper).

It appears from that paper if the patient does not have systemic signs then they tend to do ok and the diagnosis would be more of a benign gastric emphysema and treatment wise just standard gastritis treatment. If patient not doing well, then more towards emphysematous gastritis and then they do not do very well (all patients in that paper were PTS). I specifically remember one of the cases from that paper as I scanned it, which was a case that did well and the gastric emphysema was presumed clinically insignificant in that case…. I have not had any further cases since.

If the dog in question is doing well not sure how useful any more imaging/follow-up ultrasound images of stomach would be tbh.”

Turns out she was involved with some of the cases in the paper!

Hope that helps!

Scott 🙂

This is really interesting!

Do you have any images? Definitely not associated with gastric ulcers? Ulceration of the gastric wall can sometimes cause some gas appearance?

I can only find the same case series that you have mentioned. I have contacted a surgical and imaging specialist to get some more input. I will let you know what they say!

I would be interested to hear the input of others!

Scott 🙂

Hello.

Thank you so much as always for your questions.

Sorry about the delay in getting back to you.

– Are there any major side effects that you worry about when adding this drug in?

Based on preliminary data, rivaroxaban appears safe and well-tolerated in dogs. The main concerns would be related to inappropriate bleeding.

– Would you stop both clopidogrel and rivaroxaban at the same time or do you stagger/taper the end of the course?

It is probably a good idea to consider weaning direct oral Xa inhibitor therapies. No relevant veterinary studies were identified and 3 studies from human medicine were extrapolated to generate this guideline. Overall, there is insufficient evidence to confirm or refute a rebound effect following the discontinuation of the direct Xa inhibitors. Several human case reports describe thrombotic events following discontinuation of rivaroxaban. There are no data in dogs or cats on rivaroxaban withdrawal to provide guidance. Until more data are available, weaning of these therapies is reasonable. I would probably stop rivaroxaban first by going down to every other day for 2 weeks then do the same with the clopidogrel.

– Do you also use Rivaroxaban in PLE cases alongside clopidogrel?

There is insufficient evidence to make strong recommendations for or against the use of combination antiplatelet and anticoagulant therapy in dogs with PLE or PLN. I would suggest that combination antiplatelet and anticoagulant therapy can be considered when the risk of thrombosis is felt to outweigh the increased risk of bleeding
resulting from combination therapy. I would routinely just use clopidogrel in these cases.

– You mentioned monitoring for rivaroxaban briefly: in practical terms if this product is used do we need to do any additional monitoring when reviewing our IMHA cases?

Practically you can use rivaroxaban without significant monitoring.

Hope that helps.

These guidelines are really useful:

CURATIVE 1
CURATIVE 2
CURATIVE 3

Scott :)https://vtx-cpd.com/events/

Hello again!

I have popped on a couple of posts about the different prokinetic options. Treatment of dysmotility is multimodal and should be implemented by taking individual patient factors into account. Early enteral nutrition appears to stimulate the return of normal bowel function and exerts a prokinetic effect. Adequate hydration and electrolyte balance should be maintained, but gut edema should be avoided at all times when implementing a fluid resuscitation plan. Alternative modes of analgesia, including local anesthesia, should be utilized, especially when attempting to decrease opioid use in postoperative patients. Prokinetic therapy in patients with dysmotility of critical illness is recommended; however, due to the lack of evidence for a single prokinetic, a multimodal approach should be utilized. Human and animal studies have suggested that early judicious nutritional support in addition to a combination of prokinetic drugs based on GI localization of clinical signs is superior to delayed EN and monotherapy with prokinetic agents.

It is likely that the cisapride/erythromycin combination is the best choice.

The following is a really good review:

Prokinetic Review

Hope this helps.

Scott 🙂

Hello.

Sorry for the delay in getting back to you.

On the basis of one study, postprandial bile acids (PPBA) greater than 20 mmol/L indicated histopathologic abnormalities of the hepatobiliary system or portosystemic vascular anastomosis.

In another study, he specificity of PPBA for the diagnosis of liver disease exceeded 90% at values greater than or equal to 30 mmol/L and reached 100% at greater than or equal to 50 mmol/L.

Basically the higher the PPBA the more likely the shunt is! I would follow up anything above 20 mmol/l with imaging (CT or ultrasound).

If the bile acids are consistent then there would be no need to follow up with ammonia. An ultrasound would be the next step.

I have trialled treatment before when SUPER suspicious of shunt and no money for imaging. This case is maybe not so obvious, so maybe not in this case. If there were no other options, then it would not be a ridiculous thing to do.

Hope that helps.

Scott 🙂