scott@vtx-cpd.com
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Thanks for sharing this.
This is really interesting but so sad.
I hate seeing things like this.
Scott 🙂
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:
Hope this helps.
Scott 🙂
Great question!
And quite a long answer! I will pop on a couple of posts about the different drugs!
Scott x
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 🙂
No problem!
Hope that helps!
Scott 🙂
Hello.
The tablet sizes are challenging. One option would be to use a company to reformulate to smaller sizes:
The other option would be to consider mycophenolate as an alternative that BOVA makes in smaller sizes:
Mycophenolate also comes as an oral suspension for humans that would suit smaller doses.
Hope that helps.
Scott 🙂
Hello.
Hope you are safe and well. This is an interesting one. I think that a shunt would still have to be on the list of differentials. If I sent this case to one of my neurology collegues, they would ask me to do a bile cid stimulation before they saw it!
Dogs can definately present later in life with shunts. I must admit, the signs with this dog are a wee bit odd. You would definatley want to keep other neurological differential into consideration too. The best way to move forward would be to do a bile acid stimulation test and then you can more confidently rule it out. The rise in ALP could be non specific and not related as we know.
Hope that helps and keep me posted with the case!
Scott 🙂
So sorry!
Hopefully all sorted now! Let us know if still an issue!
Veterinary medicine is our friend… technology is clearly not!
Hope you are safe and well.
Scott x
Also…
We will provide all the Powerpoint slides as PDF files at the end of the course. This might mean you have to less frantically take notes.
Hope that helps.
Scott 🙂
Hello.
I hope you are safe and well. Great question. Most of the initial studies in Greyhounds used the night of surgery and it was still effective:
https://pubmed.ncbi.nlm.nih.gov/22712787/
https://pubmed.ncbi.nlm.nih.gov/22612729/Most of the time in humans it is used at the time. It would seem it is best used at the time of the trauma/surgery. I would not use it more than the night before.
Hope that helps.
Scott 🙂
Hello!
Is it a wee bit sad that I am very excited for you!
Would be interesting to know how the dog gets on. What did you decide diagnostics wise?
Scott 🙂
Hello.
Hope you are well. Thanks so much for the question. The post prandial bile acids of 50 is a bit of a grey zone. I would still be suspicious of a shunt at this level if clinical signs fit, which they seem to. It is slightly weird that the neurological signs have not shown themselves until now. Normally the shunts that we find in older dogs present with GI or urogenital signs.
I would definitely consider CT or ultrasound to look for a shunt in this case.
Scott 🙂
Hello!
What a great case! I would love to see some images! Would you be able to upload them?
this might be worth publishing!
I would treat like emphysematous cholecystitis. Anaerobes are most commonly isolated and include E. coli and Clostridium perfringens.48 Fluoroquinolones, metronidazole, and chloramphenicol are commonly used as they achieve high concentrations in bile and have strong anaerobic activity.
Hope that helps.
Scott 🙂
Hey.
I think they are definitely referring to the level of consciousness. I am not able to find anything in the literature that talks about this being specifically validated.
I think there is obviously a sliding scale between totally conscious and totally unconscious under the influence of drugs… I think this is what they must be referring to.
I agree with Sara, I would definitely be checking for a gag reflex in any patient where emesis is a consideration.
Scott 🙂
This is an interesting question that much better developed in human medicine:
The most common functional disorder of the biliary tract and pancreas relates to the activity of the Sphincter of Oddi. The Sphincter of Oddi is a small smooth muscle sphincter strategically placed at the junction of the bile duct, pancreatic duct, and duodenum. The sphincter controls flow of bile and pancreatic juices into the duodenum and prevents reflux of duodenal content into the ducts. Disorder in its motility is called Sphincter of Oddi dysfunction. Clinically this presents either with recurrent abdominal biliary type pain or episodes of recurrent pancreatitis. Most of these patients present with abdominal pain. Symptomatic treatment comprises treatment of abdominal pain. In patients with a severe episode of either biliary or pancreatic Sphincter of Oddi dysfunction the most appropriate pain medication is parenteral opiates. This is despite the known observation that opiates produce sphincter of Oddi contraction. The rational for their use is that the contraction has already occurred and the opiate is unlikely to aggravate matters further. However, on the other hand opiates are the most effective therapy for pain relief. In order to prevent future episodes in patients who have identified opiates such as codeine to provoke pain avoidance of these medications is recommended. There is no effective pharmaceutical therapy for these patients.
Reflecting on that, I would not withhold methadone/full opioids in cases of abdominal pain. If the rationale is that we are preventing Sphincter of Oddi contraction, it has probably already happened in these cases. In cases of known pancreatitis we would still use opioids, as further contraction will not worsen signs.
The only thing that we may have to be cautious of is long term opioid use, which is not really a thing for our patients:
https://www.gastrojournal.org/article/S0016-5085(13)00507-6/pdf
Hope that helps!
Scott x
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