Thoughtful Thursday: Vince Vomits Valiantly (Case 7)

  

Photo of Professor Pocky taken by Dr. Haus

Click For Explanation of Case Flow

 

Click for Test Case Tuesday:  Vince Vomits Valiantly (Case 7)

 Vomiting or Regurgitation?

The MOST important determination to make in a vomiting patient's case is to make sure the patient is actually vomiting.  Vomiting is NOT the same as regurgitation.  Regurgitation is when food/fluid comes out of the mouth from any structure before the stomach (mouth, pharynx (throat), esophagus (food tube), etc.)  Vomiting is when food/fluid come out the mouth from the stomach or upper small intestines.

🤢

This distinction is extremely important because the causes of vomiting and regurgitation are different and the way we work up the two types of cases are completely different.  It is important to remember that an owner can say their pet is vomiting when they are in fact regurgitating food.  The ways you can differentiate vomiting and regurgitation are noted below:

Vomiting

• Abdominal push (abdominal muscles contract to push the vomitus out of the mouth)
  
• Bile present (green substance)
  
• Active process (you can see the whole body put in an effort to vomit)
  

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Regurgitation

• No abdominal push
• No bile present
• Passive process (the mouth opens and the food/fluid comes out, no pushing seen)

 😵

An important aspect of any veterinary professional is to have your acting skills on point as it is common to see us acting out vomiting versus regurgitation.  The things that happen in an exam room are sometimes bananas (ask your vet med friends to act out reverse sneezing, you won't regret it).

 🎭

The owners describe Vince's "vomiting" as him eating his food and then immediately it "falls" back out of his mouth.  The owners do not see Vince actively retching or "pushing" when he has the "vomiting".  It is determined Vince is regurgitating, not vomiting!

 

Diagnostic Testing Results:

 

Radiographs: Severe megaesophagus (enlarged esophagus, food tube), signs of pneumonia 🩻

 

Specific Disease Testing - Acetylcholine Receptor Antibody Test: Positive ➕

 

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Diagnosis:

🦴Myasthenia Gravis🦴

 

Pathophysiological Point:

Myasthenia gravis is a disease where the acetylcholine receptors between nerves and muscles are destroyed or blocked.  Simply, nerves cannot conduct their signals to muscles.  Muscles are unable to contract (move) without the signals from the nerves.

 

 Questions:

Level 1 Questions:

1. Vince's communication between his nerves and muscles is disrupted, how does that affect the muscles of his body?  Why?
   
   
2. What part of Vince's history and physical exam findings support the diagnosis of a disease that affects communication between the nerves and muscles of his body?
   
   
3. Challenge question, why does Vince have megaesophagus?  How does this cause regurgitation after meals?  (HINT:  Think about Vince's disease and how it would affect the muscles of the esophagus)
   

 

Level 2 Questions:

1. How does myasthenia gravis cause disease (i.e., megaesophagus) in a patient?  Be sure to mention the “normal” esophageal physiology in your answer and explain physiologically where the miscommunication is occurring.  (HINT:  Review normal neuromuscular junction physiology)
   
   
2. How does megaesophagus lead to Vince’s major clinical sign (regurgitation)?  (HINT:  Think about what keeps us from floating away into space)
   
   
3. Challenge question, explain why Vince has pneumonia.  Be sure to explain how his underlying disease predisposed him to this condition.  Be sure to mention the anatomy involved.  (HINT:  Think about what structure sits right next to the esophagus) 
   

    
   

Level 3 Questions:

1. Describe the treatment plan you would recommend Vince and why you are recommending each part of your treatment plan.  Please answer this question as if you are speaking to a professional colleague. 
   
   
2. Describe your recommended treatment plan and why you are recommending each part of your treatment plan.  Please answer this question as if you are explaining it to a client/patient without a scientific background.
   
   
3. Please describe the different ways Vince's owners could help manage his condition with environmental changes.
   

  

Day 2 Conclusion

Before Conclusion Caturday think about your...

❓Answers to the above questions

📚 Review Material Related to Vince's case

 

Conclusion Caturday: Vince Vomits Valiantly (link will go live Saturday, 02/17/2024)