Veterinary Medicine - February 2008 - (Page MV13) rather than waiting to feed as the gut deteriorates. Leib: So let’s say you have a patient in the hospital that has moderate to severe vomiting and you may or may not have a diagnosis. You are treating it with an antiemetic that seems to be working appropriately. Should these animals be receiving a histamine-2 blocker or sucralfate? Jergens: I tend not to be a polypharmaceutical clinician, and I direct my drug therapy as specically as I can. So, if I am able to control it with an antiemetic and I have no concern about disrupted gastric or intestinal barrier integrity, then I won’t use a histamine-2 blocker. Twedt: I agree. It’s uncommon to see gastric ulcers in our patients. We do see some animals that have erosions and possibly hematemesis. In those cases, I would use an acid-blocking drug. But I don’t routinely use them. For example, I wouldn’t routinely put a parvovirus patient on a histamine blocker. Simpson: In general, I tend to avoid nonspeci c antisecretory therapy unless I have a speci c indication. Maybe there’s a case for combined use of histamine blockers and an antiemetic in prophylactically treating esophagitis and animals at high risk for aspiration. Leib: Does the same philosophy exist with proton pump inhibitors even though they are more potent acid suppressors? Twedt: In those acute cases it takes a while for them to work. Williams: I recommend proton pump inhibitors in chronic vomiting cases with underlying chronic gastritis. Leib: What about speci c prokinetic therapies like cisapride? Simpson: I would almost always reserve cisapride for suspected motility problems rather than vomiting (e.g., a patient with delayed gastric emptying associated with vomiting and bloating). Leib: Are there other adjunctive drugs? What about using ranitidine as a promotility agent? Are people prescribing it for small intestinal and colonic motility disorders? Maybe in some cats with megacolon? Williams: There is evidence that available alternative promotility drugs are more e ective. Simpson: My impression is ranitidine is not as e ective as cisapride or erythromycin. Twedt: I agree. I also believe metoclopramide is a potent prokinetic agent. So cisapride or erythromycin would be my choices as a prokinetic agent. I probably use cisapride more than any other, especially in cats with megacolon. Leib: But, once again, we wouldn’t use a prokinetic agent in an animal with nonspeci c acute vomiting that doesn’t have signs of delayed gastric emptying. Williams: On what basis does the group diagnose the delayed gastric emptying? I don’t think it is that common, and I would diagnose it primarily when I do an endoscopic examination and the stomach is full of food after what I know is an overnight fast. Do you make that diagnosis frequently? Take note • Histamine-2 receptor blockers, such as famotidine, can also be used to treat vomiting in animals. • Proton pump inhibitors may be useful in chronic vomiting cases with underlying chronic gastritis. • Practitioners can diagnose delayed gastric emptying when they perform an endoscopic examination and the stomach is full of food after an overnight fast. Twedt: I sometimes see it secondary to in ammatory bowel disease. Occasionally we see animals that have altered gastrointestinal motility, but we have rst ruled out in ammatory and infectious etiologies. In those patients, I try a prokinetic agent. Another example is the gastric dilatation volvulus case that had a surgical gastropexy but postoperatively still had a huge stomach with delayed gastric emptying. Simpson: That’s the group I see. Twedt: Those animals de nitely bene t from prokinetics and not antiemetics. Leib: I think abnormal motility in some cases is a component of gastritis with or without in ammatory bowel disease, and I’m not sure whether it needs to be treated speci cally. Nutrition and diet Leib: Let’s talk about nutrition and diet in the vomiting pet. If we have trouble controlling the vomiting and the animal is being held NPO, how long do we withhold food and what parameters do we evaluate? What 13
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