Thank you very much and thank you very much for a very kind introduction. So, this evening we're talking about vomiting and diarrhoea, which is a very common presentation in general practise, and one that we also see some more complicated cases of referral. But we're gonna start at the beginning of that and have a think this evening about how animals present to us of vomiting and diarrhoea, what the causes of that might be.

And trying to stratify that from really simple things that we can do from history taking, from clinical exam findings, from thinking then about whether we make treatment decisions and what treatments might be helpful, or whether we take more of a diagnostic path and want to do some tests. And with vomiting and diarrhoea, that very much is a pathway through thinking about treatment options to try and see if things respond and lots of acute vomiting and acute diarrhoea will respond very nicely to symptomatic treatment. Thinks of performing and diarrhoea can be a symptom of something a lot more serious, so GDV or a foreign body obstruction or torsion, that we want to try and evaluate a lot more thoroughly.

So picking these cases where we want to do our investigations is going to be really important. And that sort of diagnostic approach versus the treatment approach will hopefully help us to, to get to the answer. So we'll talk about the causes of diarrhoea, we'll talk about the causes of vomiting.

How we approach these cases both from evaluation and treatment and very happy to answer questions. We'll we'll answer as long as it's needed to be able to do that. I, I'm sorry to interrupt you.

We are losing some of your sound. It looks like that gremlin is back again. I wonder if you wouldn't mind phoning in just before we get into the meat of the presentation.

I'm really sorry. That's right. So we're just talking about.

The the first consultation and vomiting and diarrhoea being a very prominent cause of general practise presentations and talking about how we would take a diagnostic and a therapeutic approach. Very happy to answer questions at the end. You can do that with the Q&A box, or if there are questions later, if you're listening at a later point, very welcome to to email me and my email address is there, and there will be some notes, which will also have that in at a later point as well.

So we're going to start off thinking about vomiting, and then we'll come back to diarrhoea, and then we'll think about the treatment pathways we take and how we might think about investigative pathways for both of these things as well. And I guess one of the things that we think about with vomiting is that, that, that it happens and it happens as a reflex, and it's a reflex of a lot of the body's ability. Expel things forcibly from the body.

So it's a very useful reflex to have if you eat something that isn't going to agree with you and there's toxic changes. Expelling it from the body is going to be very useful. So it's a reflex that involves contraction of the abdominal muscles, the diaphragm, opening of the gastri cardia, and then very explosive removal of material from the mouth.

Well it's really important that we understand that animals are vomiting because one of the common things that confuses people is when we see cases where we see either nausea, where animals are are sort of unsettled and have the urge to try and vomit and feel sick as a result of that, or have evidence of regurgitation and differentiating regurgitation from vomiting is quite important because we spend a lot of time looking. Causes of vomiting, which will be from a gastric cause and a forcible expulsion of food from the stomach rather than a regurgitation cause where we've got a problem maybe within the oesophagus, where we've got dilation or esophageal inflammation, which tends to be much more passive and doesn't involve the full reflex of abdominal movement when we have vomiting and forceful contraction. So differentiating the two is important and making sure that we understand whether we have vomiting or regurgitation is really useful.

And on that point, I think it's really important that we understand that owners don't use these words correctly. And so when an owner comes in and says, Oh, my dog is regurgitating or my dog's got chronic diarrhoea, that they won't mean exactly what we mean by that, by the technical definition. So vomiting is this, this coordinated activity where we know there's.

Be a prodrome and they're going to be sick and they have for expulsion, regurgitation tends to be much more passive, and questioning what they're actually doing is really important. So not just taking their word that the dog is vomiting, getting them to describe how the dog brings up the material will be really useful to try and understand that. And some owners get a little bit cross with you because they, oh, my dog is definitely vomiting, but it's really important that we understand that, otherwise we will be misled with our investigation.

So vomiting has this reflex action. Usually the vomit will contain some bilious material. It can be acidic, not always, because it's only there's only an acid pH in the stomach certain times during the digestive cycle usually associated with when food is about to be taken in, so not acidic the rest of the time.

And the regurgitation is this very passive expulsion of material from the oesophagus. It can be quite sudden. Usually it's after eating, but it can be a while later and it may just be frothy material.

So saliva is produced all of the time and it can be really kind of sticky, and the material that comes up with regurgitation from the oesophagus, often described by owners as kind of frothy egg yolk egg white type material, that's thick saliva that's quite tricky to get rid of and pick up on kitchen towel when it's on the kitchen floor on the carpet. And we'll usually have a normal pH. It doesn't, it doesn't have an acidic material.

It doesn't come from the stomach. This is helpful because it will help us to look for regurgitation being a cause of esophageal disease, and there are several causes of esophageal disease that are quite commonly seen as causes of regurgitation, so obstruction, usually associated with a foreign body, so a toy or a meat knuckle or a bone or something that's been eaten. Stretch of formation where we find that the oesophagus is narrowed and that usually happens as a consequence of either getting something stuck, so foreign body that is present, or regurgitation of acidic material under GA.

So it's quite common with quite lengthy orthopaedic position positional procedures with regurgitation material, or we can see. Things like hiatal hernias, which are often overdiagnosed, but this is an endoscopic image looking down towards the stomach. You've got quite a lot of the hiatus coming back into the oesophagus, which obviously stops material from going down into the stomach, and those can be quite tricky things to manage medically and need surgery, but we can often see them as causes of regurgitation.

And then inflammatory causes, so esophagitis, usually associated with lots of vomiting and and changes. So vomiting and regurgitation can come together in those instances. We'll make your oesophagus where we've got dilation of the oesophagus, and taking conscious chest X-rays in those cases, so there isn't an effect of sedation on the oesophagus and dilation would be definitely the way forward.

So this is esophagitis and and really inflamed esophageal mucosa, and this is a dog with a very obvious megaesophagus just taken under sedation. So, dorsal border of the oesophagus up here, the ventral border down here, so a very wide change. Now this would be something that if the dog was sedated, we'd be really suspicious this dog had a mega oesophagus, but if it's less obvious and there's just a little bit of gaps in the esophageal area under sedation, then it's very hard to prove that, definitively.

But often if there is a history of of vomiting, but actually on description, it sounds more regurgitated and a lot of investigations have been done in the abdomen, then you can miss where the cause of the problem is. The other potential benefit of the X-ray is looking for aspiration, and in this area here you can see this sort of patchy alveolar change around the hilar area, and this is because material has been aspirated and gone down the wrong way, as a result of the dog having micro oesophagus and very frequent aspiration. So we're going to leave regurgitation for the rest of this.

I don't want to get confused or spend too much time talking about regurgitation, but think about why animals vomit and what things trigger off that reflex action for bringing up material and expelling it from the body. So it's a very coordinated reflex which is controlled by the nucleus tus solitaris, which is part of the brain that triggers vomiting, that triggers this reflex action of bringing material up from the stomach, and there are lots of things that feed into this centre in the brain, so sensory vagal inputs from the gut, cortical inputs, so sensations and emotions. The area postrema, the chemotactic trigger zone, which is at the base of the skull, which monitors things in the serum, so triggers from the bloodstream that can cause problems, and then vestibular inputs as well.

So motion sickness type events that can trigger our vomiting as well. So lots of things that potentially happen in people, but also the same mechanisms that happen very frequently in dogs as. Well, the nucleus tractor to get to the point where we have a vomiting episode and it wants to expel material from the body, uses the vagal complex to dispel and disseminate information to the gut, to cause the abdominal muscles to contract, the diaphragm to move up, and then the gut to expel material from the body.

So that reflex action happens very, very rapidly. So what causes this sort of thing, we talked about some of the sensory and emotional stimuli from from the brain. I guess that happens perhaps more so with people than we perhaps predict and they're able to document in in our patients, but I mean people we well know that things like pain, sight, smell will trigger off nausea and potentially vomiting in in some individuals, and emotional things, so memory, anticipation, fear will cause vomiting as well and potentially there are components of that in our patients as well.

The chemotactic trigger zone, the floor of the fourth ventricle is bathed in blood, and so it is outside of the CSF and can react to changes that occur in the circulation. And so the chemotactic trigger zone will pick up on drugs and substances that are metogenic that will trigger a vomiting. So certain drugs that we give some toxins.

The present, ammonia, uremia, things that will trigger off vomiting in individual patients, and that works through various receptors, dopamine receptors and 5H3 receptors that will trigger off vomiting, and we can antagonise those using epomorphine, which is why it's such a good emetic substance will trigger off vomiting in our patients when we need them to. Something up, we can antagonise the dopamine receptors with metoclopramide. So it's a very good way of stopping nausea, and metoclopmide is a very good anti-nausea drug both in people and in animals, although it's a bit more hard to recognise nausea in our patients than it is because they can't tell you that they feel sick.

So it's a perception of things sometimes. So we also have input from the sensory, vagal nerves, the afferences that come from the GI tract, so from the GI tract itself, looking for the stomach and the small intestine, distention or compression within the GI tract will lead to vomiting, and irritation and inflammation within the mucosal surface of both the stomach or the small intestine can also cause problems. Uogenital inflammation from the GI tract from the urogenital tract will will also trigger our problems, and any stimulation around the oropharynx can trigger off vomiting as well.

So, mass lesions or inflammation in the throat, can also cause problems. And then lastly we have the vestibular inputs. So, essentially motion type sickness, it comes from the labyrinth and organs within the year.

If there's motion changes, so car sickness essentially in, in, in dogs and cats, which will trigger a vomiting, and the receptors as a histaminegic and cholinergic, we can treat those with specific anti-sickness medications, not usually something that we associate with GI based disease. So when we're thinking about GI based disease, we we try to classify things into lots of different groups. So anatomical presentations, thinking about disease processes that might be present, the portion of the GI tract that is, is affected.

And and in result of when we have vomiting, we'll have stimulation of the gastrointestinal tract, and vomiting is a sign of both gastric disease but also potentially small intestinal disease as well. And we can have small intestinal disease with vomiting as the primary presenting sign because of reflux of material back into the stomach and then. The bile and bilious material being very irritant to the mucosa of the stomach, and it gets forcibly expelled from the body, whereas if we have diarrhoea as a presenting sign, that must be an intestinal-based problem.

So vomiting we will think about is more diffuse GI type change, whereas diarrhoea will be more of an intestinalbas problem. So we'll see vomiting for lots of reasons, stimulation of the GI tract itself, the part and the visceral para organs and surfaces, stimulation to other abdominal organs will also trigger our vomiting, cheat to trigger zones through systemic causes, so, hepatic encephalopathy with pneumonia and uremia, and stimulation of the vomiting centre directly. We also think about clinical classifications, and this is really important when we're thinking about sort of acute versus chronic vomiting, acute vomiting, we'll perhaps treat more symptomatically as long as there isn't a very spectacular cause, whereas chronic vomiting, we might want to make some more treatment decisions or potentially think about workup.

And the differentiation between acute and chronic is is tricky because they vary in different places. But normally vomiting that's occurring for more than 5 to 7 days would be classified as, as chronic. Animals that are well or unwell, going to take much more attention to those that are unwell rather than those that are well and have just vomited once because they've eaten something when they were out on a walk, and the type of material that's brought up food and bilious material versus sort of hematosis, this dog here has identified toxicity.

Blood is incredibly emitogenic, so once it's in the stomach, it often does get brought up as a result of that, regardless of where it's come from. And the type of vomitter is interesting. It's often not something that helps us as a diagnostic process, and you often get owners that come in with pictures of their dogs vomit and their diarrhoea and have a diary of what's been produced, and that sometimes it is helpful.

You sort of watch and listen and look at them because it makes the owners feel involved. But working out exactly what they brought up can be tricky. The sorts of circumstances, I guess, where it comes into play would be where we do just have sort of billiards vomiting syndrome, the small white fluffy dogs.

We see, vomiting first thing in the morning where there's been bilious reflux back into the stomach overnight, and then they wake up in the morning and the first things that they do is because there's bile in the stomach, they bring that up and feeding them last thing in the evening to absorb the bile usually works quite well at stopping that from happening. But understanding what it is, sometimes isn't that helpful in understanding so and this will give you lots of lengthy discussions about colour and material, but it isn't that useful in terms of working out what's going on. So you're going to have to think of a diagnostic approach, and we always start by listening to the history, and it's important that we that we listen and then we ask our questions and try and differentiate between vomiting and regurgitation, as we said, working out what they're bringing up.

So is it food, is it saliva, the bile, there's blood there, because it will take us in slightly different directions if we've got hematosis, we're going to be much more concerned about understanding why there's bleeding compared with if the dog's just brought up food material or eat in the park earlier on. Timing after feeding is helpful if we're thinking about obstruction. So if the dog is vomiting very, very soon after eating, it's going to make us think about obstructive change potentially in the oesophagus or the stomach or something within the stomach that's very painful, like an ulcer, sometimes we get immediate vomiting or eating as a result of that, or if there's a problem with gastric empty.

Then the vomiting can be anything up to 24, 48 hours later, so a long time afterwards. And when we're thinking about vomiting and diarrhoea, concurrent diarrhoea can be a useful thing. It helps us think about having more diffuse intestinal disease, and if there's bleeding or if there's blood loss, that melena sort of indicates that we might have more of a systemiculopathy.

And then signs that sort of point us in more of a direction of intestinal disease, and we'll talk more about this when we think about diarrhoea in just a second. But weight loss is either because of loss of food through the vomiting or poor digestion in the small intestines. So thinking about the amount of food that's actually brought up as to whether that would be responsible or whether it is a digestive problem would be, would be useful.

And then flatulence and borg arrhythy, both are actually small intestinal signs. Flat and you think about a large intestinal component, but it's a sign of small intestinal disease, and borg arrhythmia, that kind of gurgling abdominal noise again, signs that there's abdominal change as a result of small intestinal problems, and that helps us to localise where to look for the problem. So you want to do a very thorough clinical exam with the patient, and I'm sure everyone's very happy to do that, but the things that we're very keen on looking at will be the abdominal palpation, really searching to see if there's any area where there's focal pain or anything where there feels to be an abnormal area where there's a lump or a bump or there's a thickening within the abdomen.

So we start just behind the ribs cage with the sharps of our fingers and move back, and then Often we'll go back to repeatedly try and see if an area is uncomfortable. So usually don't like animals being restrained too much when we're doing abdominal palpation unless they're being very difficult, because just a subtle head turn or a movement can give away that something isn't particularly comfortable when they're when they're being palpated. So having them in a sort of freely and relaxed position will be useful for that.

Thinking about feeling for intestinal thickening is useful. If intestines become thicker, they often feel a bit more sort of hose pipe-like or or rounded, which will indicate that there's potential thickening. And they're looking for signs of systemic disease, so other disease processes that might be perpetuating to vomiting.

So thinking about other toxic processes, other systemic diseases, like renal failure or hepatic encephalosophy where we might have neurological signs would point us in that direction. So what causes acute vomiting, so vomiting that happens very suddenly, and we generally have a sort of nauseous and, and to some extent unwell patient as a result of that. Well, there's a huge long list, and this is just some of those changes, but by far and away the most likely would be some sort of garbage gastritis, so a dietary indiscretion whether it'll be.

And something and it brings it up. Cats don't tend to do that very often, but we do occasionally see cats bring up unusual things that they've eaten, toads that they've come into contact with, that they've become very nauseous and hyper salivate as a result of all these kind of things that they find in the garden that dogs various states of digestion that are causing a problem. Can see foreign bodies, so either gastric or intestinal things, again, more common in dogs, but we occasionally see them in, in cats, some sort of obstructive change, so dilation, we've got a GTV or an interception which is causing obstruction.

Intestinal ululus like this on on the picture here is uncommon but not not a good sign if intestines are that are later than that are blackened, we're not going to have a good outcome, but we don't see those very often. Motility disorders, we sometimes see ileus as a result of things like pancreatitis or other inflammatory diseases within the abdomen.patic encephalopathy, usually not acutely causing vomiting, but.

It can do and then toxic things that have been ingested or things that we've given us as drugs. So sort of classic example of that would be erythromycin, we're trying to treat something like Campylobacter. It is quite a metogenic and it will cause problems with things.

So just being aware of that would be really important. And then there's a massive list of infections that can cause problems and the things that we kind of identify very. In dogs, so things like canine parvovirus through things that we don't see very often like distemper, but it's coming back because the vaccine breakdown and lots of dogs being imported legally and otherwise from Eastern Europe.

And then in cats sorts of things like feline leukopenia, some of the retroviruses, coronaviruses, and then a swathe of bacterial things that we'll talk through a bit more when we're talking about diarrhoea, but some of them have a vomiting propensity and some of them we we sort of see as normal commensals, so some of them are definitely pathogenic but canylo back a big spectrum from normal commensals through to things that have a pathogenic appearance. And then lots of protocell and parasitic conditions that can cause problems. So having an idea of of worming history would be really important in that regard.

So some of the things that we would perhaps be a little bit more concerned about would be things like acute pancreatitis. Pancreatitis will cause vomiting because the pancreas is lying right next to the stomach, and along the, transverse colon. So, vomiting and many clitic signs would be, quite common in terms of things that are coming, being expelled from the body in terms of vomiting and diarrhoea.

Acute hepatitis obviously will cause the encephalopathy signs, acute eugenic tract disease, if we've got obstructive disease with uremia, then that can manifest as as vomiting and peritonitis with sepsis or with biliary tract rupture, causing irritation to the surface of the peritone will trigger a vomiting, quite easily as well. There are also some systemic causes, so the sort of endocrine diseases, hypoadrenal corticism and and diabetic idosis, really serious endocrine conditions, hopefully a reasonably easy to spot with basic blood work from the point of view of having hypoglycemic and and potentially ketoic patients with DKA. We can use the urine dipsticks to look for ketones on urine, urine and on serum, which is something that is quite handy to exclude that.

And hypoadrea corticism, looking at electrolytes, electrolytes is quite tricky. To diagnose hyperadrenal corticism, but, obviously you have a very high potassium and a low sodium and looking at sodium potassium ratios can be useful as a guide to that, bearing in mind that the other thing that changes potassium, sodium potassium ratios like that is renal failure, which is the other main differential. So a basal corolla or ACH stimulation test, if you can get the synthetic ACH would be the way forward.

And then things like hyperthyroidism, hyperemia, hypercalcemia occasionally trigger our vomiting, in our patients as well. And there are lots of ways that this work, they feed into the vomiting centres, into the chematachic trigger zones, into the vestibular changes depending on what we, what we see and and the mechanisms and the causes that happens, it depends on theology and the underlying pathophysiology of the disease process that's present. So if we identify an animal that is is relatively well, that has acute vomiting, the on clinical exam is, is relatively bright and doesn't have signs of dehydration, of abdominal discomfort, of any sickening that is present, then we would usually try to, to treat in a symptomatic manner.

If we can establish a diagnosis, then we would need to treat it specifically. So if it's uncomfortable in abdominal palpation, we usually suggest we do some imaging. If there's.

Any evidence of any lumps or bumps in the abdomen or any thickening with the intestinal tract, then again, we would usually do some imaging in that regard. Well if the animal is in appetence or there are any other problems, then usually we would want to do a little bit more investigation. But if the animal is well, it's a fairly acute history, so maybe 12 to 24 hours, then we would want to try and treat for acute vomiting, and we would think about replacing fluids and electrolytes and glucose.

There are lots of electrolytes and glucose. Fluids, usually they contain some glutamine, which is really helpful for the intestinal recovery, conditional amino acid that allows androcytes to recover. It's really important in young animals that we think about that.

There's usually a discussion about starving animals for 24 hours or giving small amounts of food to give micro nutrition. Historically, the older textbooks have suggested we starve animals for 24 hours to let everything settle down and then introduce small amounts of food. More recently that hasn't really been shown to hold water in terms of reducing the speed of recovery in these patients.

I, I guess the only concern the the the place where we might think about withholding food for some period of time is in animals that are vomiting and regurgitating so much, especially if they've got a reduced state of consciousness that puts them at risk of aspiration, that giving medication to try and control vomiting before we start thinking about introducing food would be sensible, but we'll see if that, if there is reduced mentation probably not gonna be wanting to eat in that regard. And then thinking about bland diets, so, usually chicken and rice-based diet, things that are quite bland would be a reasonable starting point. Small amounts are often tempting them to get to eat, and there are lots of recovery diets that are available in, in that regard, in terms of trying to get animals to take food on board.

And then we would think about effective parasitic control to make sure that they haven't got tapes around when things that might be causing a problem, treating any concurrent diarrhoea that might be present, and we'll mention that again in a second when we're talking about diarrhoea, and thinking about symptomatic treatment with antiemetics. And treating antiemetics is important because usually we're thinking about not giving any antiemetics until we've got to the point where we've ruled out that there's obstructive disease. If animals are vomiting through antiemetics, then they definitely need to have a further investigation, so.

Giving a single dose of antiemetic to a dog that is well and otherwise, comes from an abnormal palpation is very reasonable, but if they vomit through that first dose of potent or metoclopromide or whatever you give them, then we probably should investigate further at that stage. Now, antibiotics in acute gastroenteritis is hugely controversial. I know a lot of people give them, but there are actually very few indications for giving them.

So we tend to avoid giving antibiotics in acute gastroenteritis unless there's a specific indication because they suppress the normal flora and that changes the population of commensals, leads us open to potential colonisation of things that are pathogenic. Like salmonella, roto difficile, those sorts of things that cause a problem, and they suppress normal clonic metabolism, and that's really important for normal gut function and normal gut motility. So trying to avoid antibiotics would be a very good way forward, and owners will often demand them.

The BSAVA Protect me poster that was released recently that A nice nonprescription pad that comes with that sort of explains to the owner's wife we don't prescribe antibiotics in the case of acute gastroenteritis. Having something like that that we can give to the owners or your own practise set up to do that is really helpful to explain why we haven't given antibiotics in these instances where perhaps owners expect them to have something. So one antiemetics we use, well, there's two licenced metoclopramide and ripotent.

Metoclopramide has some other actions potentially, other than an antiemetic, it's quite a useful antiemetic, but also has some, pro-kinetic actions, which is, useful if we've got signs of bilius suggested that we might have small intestinal inflammation. It's only going to have a pro-kinetic effect on the small intestine, not going to affect gastric emptying or gastric. We need something like ranitidine to be able to do that.

The metalopmite would be useful in that regard and has quite a short duration of action, which I guess is one of the downsides that it needs to be given more frequently, so 2 or 3 times a day, or is most effective as a concentrate infusion. We tend to use it as a concentrating fusion if we're giving metholmide at about 0.5 to a milligramme per kilogramme for 24 hours per day, and that tends to work very nicely.

At higher doses, we potentially can sometimes see extra paranoidal effects, so muscle folliculation and tremors and augmentation as a result of that, and that can be problematic. And there are reports of melopromide causing interception through increased gut ertility, but it's rare for that to occur. So we have licenced products with names like men who would hope that the drug is saying it will end from.

Would, would work and it is a very effective antiemetic. The other licenced product is Marriottant works through inhibiting NK one receptors, so it's a substances in that regard, licenced product for for treatment in dogs, and not for very young puppies, but it is effective in those regards and there needs to be care given with animals that are very hypermic or safe to Do that and it's very effective in stopping vomiting. They use a model to get the licence through cisplatin, which is a very potent and mutagenic drug.

We don't tend to use it very much as an oncotic oncotic treatment in the sense of we use more carboplatin for treating things like osteosarcomas, but it induces vomiting very easily, and, was very, yeah, good at stopping that from happening. So it's a very good safety profile can be given once a day, but it's very highly protein bound. So if we've got patients that are very, hyperinemic, adjusting the dose is, is sometimes needed or, giving animals a break once you get to the end of that 5 day licence period, having a day off before you.

Reintroduce it, and it is sensible in those sorts of circumstances, but it's a very, very good antimetic and can be used in combination with metoclopramide. So, depending on the circumstance and clinical signs that are present, we would choose one or the other, but we can use them together, if we want to. So treatment of vomiting is obviously going to depend on what's happening with the patient, and we need to think a bit about when we treat and when we don't, and think about whether symptomatic therapy is appropriate.

So when to treat, if we well, when not to treat, in fact, in some instances, won't treat things at all if there's a potential intoxication. Usually we'll just let things settle and we want to get the animal to bring up anything that's there, think about side effects and drug interactions and if symptomatic therapy is appropriate or not, we want to try and rule out obstructive disease or anything that might be more serious in that respect, and we'll have a think about the diagnostic workup towards the end of the talk when we're talking about diarrhoea. So I was thinking about the causes of vomiting and, and how we might treat sort of acute cases and how we might look for causes of acute cases.

Just gonna have a think through the causes and description of diarrhoea for 15 minutes or so and then come back to the diagnostic process and the tests that we might use in terms of evaluating GI disease. So diarrhoea is a main sign of intestinal disease. Vomiting, as you said, is an important sign of small intestinal disease, so don't don't exclude small intestinal disease if we have animals that are vomiting, and we can see quite significant small intestinal disease without without diarrhoea.

So obviously we're talking about diarrhoea as a presenting sign, but we can. Significant weight loss and significant malabsorption without any problems being reported in normal faeces being produced. And there are lots and lots of different ways of classifying diarrhoea from the colour and the description from the atomical place where we might find it being produced and the changes in the disease processes that might be causing the problem.

And some of these are helpful and some of these aren't helpful in terms of how we would address the problem and how we might think about trying to to treat the problem that's presented. So the descriptions of diarrhoea vary and and one of the things that we sometimes think about is by the sort of mechanism. So whether it's an osmotic diarrhoea, which would be associated with feeding or food changes, changes in permeability of the GI tract if we've got inflammation and.

As a result of that, and just motility, where we've got poor absorption through the intestinum being, very static, so an ileus situation, a secretory diarrhoea, usually seen with bacterial infection, or mix it can be lots of those components that would cause a problem. Anatomical site is useful. So if we're thinking about small intestinal signs versus large intestinal signs, we know some of the treatments for small intestinal diarrhoea don't work as well for large intestinal diarrhoea.

So colitis versus the sort of large volume small intestinal diarrhoea that we see, diffuse changes so small and large intestinal diarrhoea and and extra and extra GI disease, so sort of things like pancreatitis or or liver disease that can unsettle the gut and cause problems. The pathophysiology, so the exact mechanism by which it's caused, so allergic, neoplastic, inflammatory, and the ecology, so whether it's dietary, bacterial, viral, parasitic, lots of different ways of looking at things. Classifications we tend to use though tend to be sort of based on whether it's acute or chronic.

And similar to vomiting, it's it's a bit tricky to actually put a time point in place as to when acute diarrhoea becomes chronic diarrhoea. Generally, we're starting to worry about diarrhoea being more chronic after 2 or 3 weeks. Some people use a shorter period of time, some people use a longer period of time, but it depends on the situation with the animal as to when you would intervene to think about trying to, to investigate and rather than putting a time point on saying we only invest.

Get the acute ones and the chronic ones at this time point and thinking about the global picture and the whole presenting animal and the financial constraints and then what's available and what you can do in your practise would be much more important. And then think about the anatomical site, whether it's small or large intestinal, and then think about physiological things. So what the causes might be and think about differential diagnosis and how we might go through a problem solving approach to look to see what might be causing the problem.

So how do we tell the difference between small and large intestinal diarrhoea? Well, with small intestinal diarrhoea, we said that vomiting is quite common. Weight loss is quite common through malabsorption and maldigestion.

Polydipsia can be quite common as well. Animals feel thirsty, tends to affect their perception of thirst, so animals drink quite a lot of water, which is, sometimes a presenting sign if the owners. They like the dog peeing overnight and having to to tidy up, where they will tolerate the dog just going out a couple of times a day with with slightly softer than normal faeces.

Appetite is often altered, so they feel nauseous in appetite, very watery and often quite voluminous faeces, so an increased volume of what they're passing, and a normal sort of defecation rate, so 1 to 3 times a day. Large intestinal disease, vomiting is uncommon, but we do see it in about 30% of cases, and that could be because inflammation within the, colon the transverse colon part is very close to the stomach which can unsettle the stomach, and we can have systemic causes of of nausea. Weight loss tends to be quite rare because we have the absorptive part of the small intestine and then the large intestine, which is more of a a storage area rather than absorptive, a lot of water, but it doesn't absorb the nutritional contents of the of the of the food.

Polydipsia is rare, so it's uncommon for us to see that appetite is often very normal. And the faecal type often varies a lot. So colitis usually associated with mucus, a little bit of fresh blood, and those are signs from irritation within within the colon, and, and normally we have a normal volume of faeces as a result of that, but an increased urge to defecate, so a lot of straining and an increase in frequency and the animals are going out very, very often to try and pass faeces.

You also see lots of sort of straining and urgency. We said, mucus, with the large intestinal disease, flatulence is the way in this slide, so apologies for that should be flatulence associated with small intestinal disease, but large intestinal disease usually isn't. It's a small intestinal sign.

If there's bleeding into the GI tract, then usually we have blood, which is, which is fresh if it's present in the large intestine, whereas we'll have digestive blood present from the small intestines, so all the. That sort of black, dark, sticky, often tarry faeces that are being produced. Obviously you have to be careful with the owners feeding charcoal biscuits and sometimes they're very similar, but, the stickiness is, is one of the telltale signs.

If we look, we can see faecal fat and starch and small intestinal diarrhoea which we won't find that in large intestinal diarrhoea, but that tends to be a test which is largely superseded by the other tests of small intestinal digestion. So looking at pancreatic function with TLIs, for example. So what are the causes of acute diarrhoea?

Well, it's very similar in terms of the list to what we see with acute diarrhoea, acute vomiting, dietary things, hypersensitivities, intolerances, things that have been eaten that have of course an upset as they go through, so dietary indiscretion, lots of infectious causes, so cardinal sign with with parvovirus causing, enteritis, lots of other viral infections, lots of other bacterial infections that can cause issues, parasitic diseases, and then the thing. That become sort of more, more worrisome in the sense of sort of acute emergencies in sense of interceptions, seeing that sort of oversocking type effect of the small intestine with interceptions in young animals or obstructions with foreign bodies, acute pancreatitis, metabolic disease like Addison's and the hypoadrenal corticism would all be on the list and usually we can screen for those with blood tests and have a specific type of presentations that we would think about. So if we have acute diarrhoea in a, in a well patient, there's often very little need to investigate.

A lot of these are self-limiting. A lot of them we can use supportive things that will be helpful to enable the gut to maybe recover a little bit more quickly and owners will feel that they're helping their pet to improve. But we should really investigate if the animal is obviously unwell, so systemically when we're doing our clinical exam, much the same as we would do for the vomiting patient to make sure that there isn't something that suggests that there's abnormal pain or.

A mass or a lump or a bump that's causing an issue. If there's Melina, so same as if we have hematosis, or if there's very frequent vomiting associated with the diarrhoea, so by frequent vomiting, more than 2 or 3 times a day, would definitely make us, worried depending on what's happening with the patient. And if we find obvious clinical exam or systemic findings, then we would definitely want to go forward with those investigations.

And we'll talk a bit more about how we can investigate as, as we go through, but at this point we would think about symptomatic things that might be useful. And food would be important because the more we feed feed the animal, the more will come through. And similarly with vomiting with holding food used to be recommended, mainly from the result of trying to reduce the amount of diarrhoea that was being produced while things were improving, rather than it had any impact on the disease process itself.

And now we probably wouldn't withhold food for animals that just have acute diarrhoea that are well in that we know. That the gut recovers better if glutamine, conditional amino acid is present to allow those ancytes to recover, so reduce the volume maybe small amounts and often, but don't starve for the sort of 24, 48 hours that sometimes suggested in old textbooks that that that won't necessarily help the progression, speedy recovery from the diarrhoea, and hopefully by just reducing the volume we'll reduce the amount of diarrhoea that's produced. Rehydration solutions or fluids as necessary, if they're well, and then you can take fluid and not vomiting, then that will work quite well.

Usually if, if they're dehydrated and to the point where we can pick that up on exam, they will be systemically unwell enough to, to require hospitalisation or treatment. And antibiotics aren't really indicated in, in acute diarrhoea, in the sense of the same way they are with, with acute vomiting, that there are very few bacterial diseases that will cause acute vomiting that don't cause the animal, cause acute diarrhoea that require antibiotics. Yes, if there are signs.

The animal is pyrexic or if there are other disease processes and we've evaluated, we've looked to see that there are problems, then yes, there may be an indication to give antibiosis, but just the basis of having acute onset diarrhoea in a well patient doesn't make us think about giving antibacterial medication. So can we help to settle the bacterial population if there is diarrhoea, can we help to support it to recover? Well, the answer to that is we don't really know and there's a lot of debate about it and there are some products that are available that would help to allegedly repopulate the intestinal populations or to rebalance the intestinal population if we have a dysbiosis that is present.

That how well they work is is tricky. There, there aren't good studies looking at evidence in acute diarrhoea and vomiting, suggesting using pre and probiotics helps to settle things, but there's certainly things that don't seem to, seems to be quite popular with owners and most of the time don't cause any problems. There are some case reports in people of probiotics causing problems, mainly they're lactobaci, so they're not normal bacterial population or flora within the gut.

And there are a few case reports of people with probiotics and finding those lacto cili in unusual places on the heart valves, for example, with endocarditis, but they're rarely associated with any systemic disease that causes the problem. So they're relatively safe things for us to be more so than antibiotics. So giving those for a few days may help to, to feel that we're improving things and there will be evidence there are studies that are ongoing looking at the effectiveness of those in those sorts of circumstances.

So usually the diarrhoea will settle and usually the diarrhoea settles over a few days with dietary changes, feeding blender food, easily digestible food, reducing the bulk of material that's coming through to the large intestines. So, a recovery-based diet, usually chicken or rice based in that. Regard but white fish and potato usually a good alternative to that.

If, if things aren't improving or if the animal is unwell or if these bouts of diarrhoea start to come back very frequently, or associated with vomiting, then we would want to try and investigate a bit further at that stage. This is where we have to balance that sort of investigative versus treatment type approach as to how we go forward, and we'll talk about the investigations first, and then we'll talk a little bit about the treatments as to how we might use those in combination to try to get to the bottom of what's causing a problem and improve the situation for that patient. So starting with the history and clinical exam, very useful starting point.

If we've got diarrhoea, faecal evaluation is very useful, lots of pros and cons of that, but it helps us to exclude pathogenic causes of, of, of infectious diarrhoea and so not the things that we need to worry about. As medics who always do blood tests, so haematology and biochemistry, with a biotic stimulation tests when needed, using a basal cortisol to exclude, atypical Addison's is very helpful. All looking at gut function, so TLI like a pancreatic function, B12 and folate, give us a rough idea about absorption, although there are some changes that sometimes don't give us changes in B12 and folate, but it tells us whether we need to supplement of those B vitamins and having a very low B12.

So carbalamine means that the gut androcytes aren't able to recover. So if we document a low B12, supplementing the B12 would be the way forward. Historically.

That's been done by injection. So once weekly injection for about 4 or 5 weeks. More recently, there's some evidence that suggests that giving high doses of all B12 will also overcome a carbalamine deficiency as well, and that may be something that is considered as well.

And again, have to pick the compliance potentially is an issue, remembering to do something and someone will prefer a more injectable form. And then thinking about imaging and and if we're finding. Obstructive changes in acute diarrhoea, then they'll take us in a specific direction with the more chronic ones thinking about endoscopy, taking biopsies, we will perhaps potentially be useful, but there's a lot more to do before we get to that stage and usually we'd want to have a really good diet trial in place before we think about going anywhere near endoscope or or surgical biopsies unless there's thickening or a mass lesion or something that suggests that we need to investigate that a little bit further.

So those are the investigative things. The other things that we think about in terms of treatments would be would be sort of treatment trials, and usually I'd much prefer to spend money on treatment than on investigations, but there are some investigations that are really handy that will help to take you in different directions with treatment. So you have to sort of balance these things up, and it's one of these things to discuss with an owner and in a 10 minute consultation that can be obviously really tricky and we're lucky enough to spend a lot longer being able to talk to owners, but there are some times where treatment trials will give you a.

Of information about what might be wrong with the patient after you've done some baseline investigations. And one of the things that's very useful is recurrent chronic diarrhoea will just be to do a diet trial. We'll talk about different types of diets as we as we go on.

And we sometimes think about antibiotics, although there is some difficulty ethically about some of the antibiotic trials we might do. So we know metroniso, y tetracycline Tylasin will help with chronic diarrhoea, but whether we should be using them these instances is is tricky because we may be encouraging antimicrobial resistance. Using fambendazole as a treatment trial for things like Jardia, it can be really hard to find Jardia, so we can do Jardia snap tests and we can pull samples and we can repeat the sample, but sometimes it's just easier to spend the money on treatment and to try and exclude it.

Very little bendazole resistance has been documented, so it's a very effective treatment. So as long as we can give it once a day. For 3 days, we should be able to charge you as the cause of the infection of the of the diarrhoea.

Given B12, usually we would measure it, but sometimes we can just give it. It's quite cheap. It's quite easy.

It's very safe. It's water soluble vitamins that's not going to cause a problem. And then we can think about immunosuppression, but generally we're only doing that when we've documented that when we have inflammatory change in the gut.

Or animals have failed treatment with all other options, and we're left with a choice between this being things like inflammatory bowel disease or lymphoma or lymphantassis's causing a problem and then treatment trial with steroids might be, might be something to consider, but it's not something we would do in the first instance and comes at the end of a very long evaluative and treatment protocol. So what sort of clues might we have as to the cause of diarrhoea? Well, age is going to take us in different directions, younger dogs, infectious things, dietary causes, older dogs are going to think about, neoplastic conditions, middle age is generally where we'll see signs of inflammatory bowel disease starting to develop, and there are various genetic predispositions for for lots of these diseases, but genetic predisposition.

Is always difficult because there's a temptation when the animal comes in through the through the waiting if it's a and that we say, oh, they've definitely got protein losing enteropathy and lymphantatasia, but actually when we do the workup, there's something completely different going on. So, tend to ignore a sort of geneticists in that regard as long as you make sure you're sort of testing for the thing that might be most common in that breed. And then taking a detailed history is really important, especially thinking about diet, so what sorts of things that they had, what sorts of things make a difference, thinking about the appetite, thinking about the type of diarrhoea, we've gone through all of those, categorizations of that, so it's their bulk arrhythmia, is a flat.

Evidence of any abdominal pain, so stretching, getting into unusual positions, pacing after eating and, and just being uncomfortable, signs of weight loss and and concurrent vomiting, and that would be helpful to help localise where the disease process might be present. Scoring systems are useful. I, I guess they use a lot in studies.

We tend to use them a little bit to try and gauge whether there's been improvement with patients who are in the hospital, and I'm not sure they're that useful at home, but people like talking through them. And then we would obviously want to try and examine our patients and just do a full clinical exam, making sure we do a detailed body condition score using the 9 point scale which WSAP. You've just issued some guidelines on recently, it makes it much easier to tell about obesity patients, and that's probably the other end of what we're talking about today, but that 9 point scale is really useful.

And again, the abdominal palpation is the key part of what we're doing with our clinical exam, feeling the small intestinal loops, feeling for any lymph nodes that might be present, any pain that might be uncomfortable, and doing a rectal exam is is really important. We have large intestinal signs, any lumps or bumps or anything that feels uncomfortable will be really useful, and that's something that's often, often forgotten, but partly because it's not a very nice thing to do. It's not very nice thing for owners to watch being done.

But if there are signs of straining to Nesmus and hemapocasia, where we've got fresh faecal blood, being expelled, especially on the early parts of of defecation, and the rectal exam is going to be absolutely essential. So what about these tests. Well, faecal tests are invariably done, and they're invariably useful or not.

If we find something that we know has pathogenic potential, then great, we can treat it. So, the nematodes around worms, tapeworms, coccidia, Sardia, all very treatable things and, and useful things to try and rule out. They are intermittently shared, so doing a poor faecal sample can be really helpful for Chardie.

A 3 day period quite robust, so we still find them on the lighter tests. Ri chickenmonness would be similar to Shay, very similar approaches our organism generally causes really kind of liquid foul smelling diarrhoea in young pedigree cats, but we can see it in other animals as well, other other ages, or other breeds, and PCR is a very good way of looking for that. So don't, don't forget about Trichomonas when we're thinking about faecal samples.

Cultures are much more tricky and much more controversial in terms of the usefulness, and we tend to do faecal cultures, but we're looking for fewer things than perhaps have been looked for historically, and we tend to be looking for salmonella, for Campylobacter and for E. Coli. We know some others have pathogenic potential.

We know some of the E. Colis have pathogenic potential, but, telling the difference between the pathogenic E. Coli and the pathogenic Campylobacters can be really tricky.

So things like, Campylobacterjuni would be pathogenic, butalis is, is not, it's a, it's a non-pathogenic form, which is very commonly found in normal cats and dogs. So if we find a Campylobacter speciating, it's going to be really important to know whether we treat it or not. And if you're not going to speciate it, you shouldn't be treated just from finding Campylobacter because you'll find them in almost all animals if you look hard enough.

Simily with E. Coli, we'll grow E. Coli from faeces all the time.

In a normal animal, about half the faecal bulk is back. Bacteria, the normal commensal bacteria that are present in the gut. So we will grow stuff, and it's whether that stuff is important and it's relevant to what's causing the diarrhoea that is important, and we can do PCR tests looking for pathogenic, so EEC, pathogenic bacteria that can have adhesion protocols, and invasive protocols that can then cause secretion diarrhoea.

So looking for E. Coli, we tend not to, on faecal samples, mainly salmonella and Campylobacter and speciating them to the level that we know that they're pathogenic causes. Haematology biochemistry talks about it when we're thinking about vomiting, looking at signs associated with the vomiting.

It's very unusual to find causes of vomiting, from, from a complete blood count from haematology, but we might be finding supportive evidence of things like parasites or hyperdrinic course finding large numbers of sinophils. Simily with biochemistry, it's telling us about other things that are happening, so other changes that are present in the body. Just give us a little bit of information about potentially the gut if we've got low albumin, then we'd be thinking about liver function, potentially thinking about renal loss, but having a a low abdomen with a low globulin, makes us worry about a protein using enteropathy, kidneys tend to lose globulins, so, ummin is usually low in globulins usually.

More normal with with liver disease as well. But we're looking for other things in the body that can cause problems that might trigger off vomiting or diarrhoea and unsettle the gut function. Also looking for things like pancreatitis, and lipase, DTL lipase, very accurate way of trying to assess for pancreatitis.

Standard lipase, less so PLI test would be a good way a CPL or an FPL on a snap or a quantitative if you've got them in-house. And then thinking about ways of ruling out more substantial disease based cortisol will help us to rule out atypical hydrogenic corticism, looking for a cortisol over about 60, 65 to be able to do that, which is, you know, a low level in a stressed animal, we should be able to do that, but these atypical dogs just have a glucocortico deficiency. They don't have.

Mirra corticoid changes, so they don't have the electrolyte changes. So we can just see these dogs that just have a corticoid deficiency. Some of them go on to develop classic caterins, but some of them don't, and they're a bit odd, so looking for them is really important because they respond really nicely to just a basal dose of prednisolone and a supplementation dose and they do really well as a result.

TLI helps us to exclude X pancreatic insufficiency. Really good test to be able to do that. Usually dogs with EPI are very classic.

They have stratoric faeces and it's very sort of greasy because they're not digesting fat effectively, similarly with cats, but occasionally you find animals where that that's not the case at all and they're producing quite normal type, . Faecal material and usually they respond very well to pancreatic enzyme supplementation and we can find TLA is supportive of pancreatitis, but it's, it's not a very sensitive test. We don't find it in all cases tests got up very early in the disease course and come back down again and not be persistently elevated in the way that a CPL test would be.

Follet and balaine, we said a good markers of gut functions. They tell us about absorptive function. Usually we associate folate with a marker of proximal GI change.

We don't tend to supplement it that much in dogs, but it is important in cats when it's very low, and there are good ways of doing that orally. Similarly, as we've talked through in in animals that have low B12 in hypercarbamia, usually associated with distal small intestinal function, important that we exclude EPI. If we do find the B12 is low, and usually we use cyanobalamine, which is what's licences in dogs as a weekly injection, but usually 4 doses and if the animal is doing well, then it's reasonable not to remeasure, but if they're not, we would remeasure and potentially give a further 4 doses of 2 weekly intervals depending on how the animal is doing.

But because it's water soluble and relatively cheap supplementation is is also another option. There were really rare hypersensitivity reactions reported to the phenol, which is the preservative that's present, and it's, yeah, it's not something that we get overly hung up on. I mean, human medicine they use hydroxobalamine, which means it can just be given as a single injection and last for 6 weeks.

We don't yet have that available as a licenced product, but it would be really nice if we could, because then we could, we could give it and not need to see the animal back, for that reason, if the animal is doing relatively well. So finishing thinking about investigations by thinking about how we would do imaging and how we want to try and investigate, looking for causes of small intestinal disease by imaging is tricky. We'd want to look for evidence of obstructive disease and looking on plane films can be difficult, gives us a good information about the stomach size and position, and then thinking about looking at for obstruction, so looking for foreign bodies or dilation as a result of that.

Tend to use contrast that much in in imaging with radiographs anymore because we've sort of talked so much is much more sensitive and specific. So X-rays tend to be used when we're worried about sort of foreign bodies and obstructive disease. So, this still has a very obvious foreign body which is causing small.

Distension proximal to where the foreign body is, so we can see that there are loops of small intestine here which are very obvious to see. But sometimes we, we find that it's really hard to see where the foreign body is if it was really opaque, for example, we wouldn't necessarily see the foreign body itself, we just see the distension. I mean you're looking at the radiographs I think, you know, is that within the realms of normal if it's just really gaseously distended because of ileus rather than a foreign body, you can use this ratio of the depth of the width of L5 compared with the small intestinal width, and anything greater that ratio greater than 1.6 is really strongly suggestive of intestinal obstructions.

It's a nice sort of in the middle of the night rough ballpark test to see whether you might need to think about surgery. But ultrasound would help back that up and loads of information that we can get from, ultrasound from the investigation of both vomiting and diarrhoea, much more than we can talk about, just in the context of the talk this evening, but using it to try and look for evidence of any obstruction, looking for intestinal layering, any thickening changes, any associated disease that might be present associated with the lymph nodes, and changes in the abdominal organs. If there is thickening and if there are changes that are present, then we would think about endoscopy to have a look down into the garden and to potentially take biopsies.

But we always do that after we've thought about a diet trial to try and exclude causes of intestinal hypersensitivity or abnormal thickening that might be causing a problem. There's also a sort of a discussion to have between full fitness and the scopic biopsies if you've got changes in the deeper layers or potentially thinking about lymphendotasia, then surgical biopsies would be beneficial, but there's obviously a risk of taking full fitness biopsies with we breakdown, and then that's probably something that's going to cause a problem. So how do we treat recurrent diarrhoea or chronic diarrhoea?

Well we sort of think about progressing logically or on the knee depending on how the animal is doing, making some dietary changes, potentially thinking about exclusion diet, so novel protein, no carbohydrate diet, excluding Jardia by using a fMbendazole trial, considering an antibiotic trial with metroyo, 10. Twice a day wouldn't go higher than that in terms of those. I mean usually using a short course, so 3 or 4 weeks.

Metronizezo is useful for damping down bacterial populations in the guts, but also has an immunomodulator reaction, which is helpful in terms of limiting intestinal inflammation, which can be really useful and then thinking about supplementation with BP12 and with folate when necessary. And I mean Suppression if we've documented inflammatory changes. If we really struggled, then it wouldn't be unreasonable to give steroids.

But doing the basic parts of this before we reach for steroids is really important. Having a good dietary trial, having the owners being completely on board with that trial and only feeding the diet on its own and giving that a chance to work, it usually takes 2 or 3 weeks for that to happen would be really important. So what sort of diets would be used to do that sort of dietary testing?

Well, we have a number of different groups. We have sort of sensitive diets, we have sort of exclusion diets, and then we have hydrolyzed diets. And there are loads of sensitive diets which are sort of marketed at the pet pet shop as being hypoallergenic, and they are to some degree limited in their context, but I wouldn't necessarily use them in dogs with current GI signs unless there was finances that were limited in that respect.

What we want is a completely different protein and a completely different carb. Hydrate. So really keen on fish and potato-based diets.

duck, is quite a useful source for venison, as a, as a source with, with cats as well. And the venison and pea-based diets, which are really hard to get hold of at the moment, really nice. The lamb and barley diets tend to work quite nicely.

Duck and potato in in dogs is, is useful if they, if they've already had a fish-based diet. So using a single carbohydrate and a single protein is usually the first choice in the management of these recurrent cases. If they're not improving, then we would think about hydrolyzed diet.

There's been massive improvement with the hydrolyzed diets that are available on the vest market, both for cats and for dogs, palatability and the way that they don't unsettle the gatorically when ZD was first brought out, it caused a lot of osmotic diarrhoea, but there's a lot of improvements that have. As a result, so you have your own favourite hydrolyzed diet. There are some subtle differences between them in terms of taste and where they come from, but all in all, they, they invariably do the same thing.

And if we're not seeing an improvement with a single carbohydrate, a single protein diet, we would potentially think about using a hydroly diet to be able to move forward. Low fat diets are important as well for pancreatitis cases, but also if we've got any signs of delayed gastric motility, fat will limit gastric emptying and using a low fat diet is really helpful in supporting gastric emptying and improving gastric fertility. Again, there are lots of of veterinary available low fat diets, but things like chappy have very Low fat contents and there are a number of more natural and rule-based diets, not that I'm suggesting that we really ever want to give a raw diet to a dog that has an intestinal disease, but owners will sometimes go off on their own direction.

There are lots of things where there are low fat contents that would be potentially useful in those sorts of circumstances. Talked about antibiotics and we want to try and limit their use wherever possible, but there are some specific indications for some of the diseases, so things like granulomatous colitis in boxes where we need to use fluocriolone to clear the E. Coli that causes the problem.

And sometimes we will use metrozole, or ylasin where we have a bacterial overgrowth. Now documenting a bacterial overgrowth is very difficult because It's more dysbiosis. It's more of a population shift in the bacteria and using antibiotics to try and reduce the population, have a repopulation effect is often helpful, but we should really be limiting our use of antibiotics, the cases that haven't responded to dietary management rather than using them to cure everything and fix problems without sort of tinkering with the diet and making sure we've got everything on the right plate.

The steroids and the immunosuppressors are only really useful and we've documented that we've got, inflammatory bowel disease and changes as a result of that. So we tend not to use that less of a problem. So a lot of that sort of workup for for more chronic diarrhoea is, is completely applicable to the workup for more chronic vomiting as well.

A lot of the tests and a lot of the diagnostic problems will affect the stomach in the same way as these things affect the small intestine. So usually with the same vomiting and diarrhoea mixed together, then we will have done a lot of the workup that we've described here. So we'll think about doing haematology, we'll think about doing a biochemistry, looking for evidence of more systemic disease.

There are some blood gas changes that we'll see, but they're not really specific and that sometimes isn't that helpful. The imaging is really useful, as we said, to rule out masses and obstructions that are causing a problem and, and similarly looking at imaging to look at the wall thickness and the structure of the smaller the the stomach would be really important when we're thinking about vomiting, but also to look at the small intestine as well. And then there are lots of causes of chronic vomiting.

We have a very long list and I could talk through all of them and bring you to death this evening in terms of the causes, but just trying to work out whether they're intestinal or other abdominal causes if they're chronic. Inflammatory changes of the gut itself, whether there are other endocrine or systemic diseases causing a problem, a GI based food allergy or intolerance, very common cause, and then moving on to more inflammatory causes and in older animals intestinal neoplasias, either within the stomach or intestine and specific breeds as well. For example, Belgian shepherd dogs, staff or terriers very common to have gastric applasia and we perhaps want to weed those out and to look at them perhaps a bit more carefully, if that was the case.

So with a chronic vomiting patient, how do we look and, and, and see what's happening, what, what sort of treatment-based approach would we take? Well, very similar to the, the sort of chronic diarrhoea patient trying to treat infections and and parasitic disease, so nonspecifically treating withardia, thinking about faecal culture, probably less important for vomiting than it is with diarrhoea, looking for extra and pancreatic iniciency, looking for evidence of pancreatitis, so, DGR lipase, looking at CPLI or SPLI, supplementing B12. So late stopping scavenging.

Sometimes you just have to muzzle these dogs from vomiting, which is, which is awful, but it's really difficult to get them from picking up things they're causing a problem. And then when their treatment things would be helpful. So antacids and antiemetics, antacids hugely controversial.

The ACAM consensus statement on antacids really suggests that there's very limited indication for their use, but I think anecdotally a lot of us would. Find that there are situations where they're helpful, but probably guilty, myself included of overusing them in all circumstances. And if we are using antacids omeprazolele, used twice a day at the k would be the way forward because there's a lot of evidence that that is an effective dose, whereas the H2 antagonists, for example, are much less effective in that regard.

And then sometimes using long term antiemetics can be helpful, not very long term, but if we're starting a diet trial. Using Metoclop provided once we've excluded that there's an obstructive cause or a functional cause, to help enable the data trial to be effective over the 1st 2 or 3 weeks, can be really useful in those sorts of. And if there's no response to that sort of symptomatic treatment, then we need to think about other causes and thinking about inflammatory bowel disease and dietary intolerances would definitely be where we go forward and that's where we think about our strict diet trials as we're talking through in terms of single proteins, and carbohydrate sources, very similar diets for both intestinal and gastric causes, so both vomiting and diarrhoea, wouldn't really treat, treat the diet too much in that regard, and that makes it.

Simple because different companies have very similar diets for both indications and then thinking about biopsies if there's no improvement in regard of how the animal is doing on a very strict artery trial when we've excluded the causes, having a look down the stomach and taking biopsies would be that forward and there are gastricically focused forms of inflammatory bowel disease, as we all because we usually associate that with intestinal disease that we pick up on biopsies and are able to treat as a result of that. An endoscopy would be the best way to do that visualise the whole stomach and then take biopsies, allows us to retrieve our bodies and allows us to have a very good look around, which is a good way forward. Occasionally we consider doing surgical biopsies for, for, for the stomach, but we don't usually like making a hole in the stomach because there are potential risks of, of any intestinal surgery that we do, and, and not rushing to take gastric biopsies or, or.

Biopsies would be a good plan because unless we've done a really strict eye trial, it's really difficult for us to to try and diagnose those problems and there is a non not unsubstantial risk of having we breakdown and problems as a result of taking for scalp biopsies around about 10% would breakdown, which is a problem because if a wind breaks down, we would have potential peritonitis and that can cause a problem. So there's a lot to think about with vomiting and diarrhoea, and we've we've talked a lot in a lot of different directions about how these animals present, and having a good discussion as to what the animal is actually doing to really understand whether they're vomiting, regurgitating, whether the diarrhoea is a small intestine, large intestinal will really help you to make decisions. And if it's acute in a in a well animal, then we can hopefully use supportive treatment and we talk through what might be good options for that.

If the animal is unwell, then doing some imaging, some blood tests is usually a good starting point. And if things aren't improving, then a good dietary trial is is usually the way forward. Seeing whether the animal improves that, doing a bit more investigation, so being a little bit more elusive of faecal testing, maybe thinking more advanced blood tests, maybe some more detailed imaging with ultrasound looking at the GI tract, and if that doesn't help, then, endoscopy or full biopsies would be the way forward or trial treatment with immunosuppressors, which would be a last resort but potentially as indicated if there isn't improvement with supportive or symptomatic treatment.

Perfect. Thank you for listening. I'm very happy to answer any questions.

Simon, can you hear me? I can indeed. Oh, excellent.

OK, sorry, I thought I'd lost you there. Thank you Simon for your time and folks here, as I promised you an absolutely fascinating talk. Simon has brought a a nice logical perspective to approaching diarrhoea cases.

Simon, we have got one question through from Jill. And she wants to know, do any of the lymphoma blood tests demonstrate bowel lymphoma accurately? So there are a variety of of blood tests that are marketed to try and diagnose lymphoma, so thymodine kinase and the blood test that was marketed by a factor looking at acute phase proteins, so .

Recently actually, not been marketed anymore, but no, they, well, they do support there being lymphoma, so, thymodine kinase is shown to be elevated in intestinal lymphoma, but it's also increased in inflammatory diseases as well. So whilst they might give you an indication that there is potential for lymphoma, they don't differentiate from inflammatory bowel disease, so no, we wouldn't really use them in those instances. Excellent.

Catherine wants to know in a needle shy cats, can you use oralmiropotents? Obviously off licence. So we have used tablets, tablets in, in cats.

It is off licence, but yes, we will use that occasionally for cats that have had chemotherapy, for example, and the nauseous as a result. So yes, you can, but yes, it is off licence. Excellent.

Simon, I, I cannot thank you once again, as always, it's been great to listen to you and you make everything sound so simple until you've got that case in front of you. But thank you so much for your time.