講義教程說明

THERAPEUTICThereasonwearehere我們今天何故聚首在DEFININGTHE

REGURGUsually常 No Usually常 NoBile膽 Sometimes偶 NoDigested

Sometimes偶 NoIfitlookslikevomiting,itisprobablyvomitingIfitlookslikeregurgitation,thenyoudon’treallyknowforsureTAMUSig:4monthFGermanshepherdCC:Febrile主訴：發熱HPI:1monthago:dogfebrile+soft,moistcoughWascuredwithantibiotics3daysagohadsame T=39.7CInspiratorycrackelsinright體格檢查：T= 右肺吸氣階 Sig:10yrM(c)Mixedbreed基本信息：10歲，雄性(已去勢），混種CC:Coughing主訴：咳HPI:Coughingbegan2yearsagoandisnot withanymedications.Dogvomitingforlast2months病史：2年前開始咳嗽，使用任何藥物均無制。近兩個月出 TAMUSig:2yrM(n) “Vomiting”,coughing主訴：“ HPI:Problemsbegan10daysagoNowarningwhenthrowsNobile MajorCausesofAcquiredEsophagealWeaknessMyastheniagravisHypoadrenocorticism(usuallyVariousSpirocerca獲得性食道遲緩的主要原腎上腺皮質機能減退（通常 型TAMUAntibodiestoAcetylcholine0.1nmol/L(<0.1nmol/L(<Localizedandgeneralized局灶性和全身Mostcommonlydiagnosedcauseofacquiredmegaesophagus最常被診斷為獲得性巨食道癥的病因BesttestisAnti-acetylcholinereceptorsMayneedtorepeattestin6monthsSpontaneousremissionsoftenMustkeepaliveuntilTHERAPYFOREnhancemotilityPyridostigmineNOTphysostigmineorTreattheimmunebasisoftheAzathioprine(Imuran)–maybeNOTTAMUCreatinine肌酐=1.9mg/dl(<2.0)Calcium鈣= 11.3mg/dl(9.3-11.8)Glucose136mg/dl60-Sodium=Potassium=Albumin白蛋白=

156mEq/L(138-3.0mEq/L(3.8-3.2gm/dl(2.5-ALT98IU/lTAMURestingcortisol

0.90.9PostACTHcortisol= 0.9ug/dlACTH刺激后可的松濃度=0.9ug/dlInfrequentlycausesmegaesophagus,espcommoninpoodles(espblackseldomcauses↓Naor↑Kwhenitproducesmegaesophagus(atypical) restingcortisolisgoodscreeningeasyandrewardingtodon’tusesteroidsastherapeutictrialunless經常引起巨食道癥，但是restingcortisolisgoodscreening刺激前可的松檢測時很好的排查檢easyandrewardingto治療簡單且見效don’tusesteroidsastherapeutictrialunlessyouareSUREdoghas經常引起巨食道癥，但是don’tusesteroidsastherapeutictrialunlessyouareSUREdoghasMajorCauseofCongenitalEsophagealWeaknessTHERAPYFORCONGENITALDietarymodificationGruelfromanelevatedTHERAPYFORCONGENITALDietarymodificationGruelMeatballs(espwithpartialCannedfoodDryfoodMSUSig:5yrF(s)CC:“Vomiting”主訴 HPI:Vomitingbegan1weekago.Noprodromalsigns;producesfoodbutnobileorblood PE:Obese,“...manydoctorsinthisspeciality[radiology]relyheavilyonfirstimpression–gestalt–rapidlydistinguishingnormalfromabnormal,drawingconclusionswithinsecondsofviewinganimage.”page179,J.Thenextthreedogsallhavethesamedisease–whatisit?—TAMUSig:2yrM(c)CC:“Vomiting”主訴 HPI:Presentsincegotdog1month ago.Dogeatsravenously,thenvomitsfoodwithin3-4minutesofeating.Nobileorbloodseen.Dogdroolsconstantly.Recentlyhastroubleswallowing NotSig:5monthFGermanshorthairedCC:“Vomiting”主訴 HPI:Startedvomiting8daysago.Startedvomitingclearliquid.Nextdayvomitedbloodandsticks.Laparotomyshowedinflamedduodenum&bloodinstomach.Appetitebetter,nowvomitsfluid&blood. PCV=20%(35-紅細胞壓積=20%（35-Profile:Albumin=1.9gm/dl(2.5-白蛋白=1.9mg/dl（2.5- Sig:10yrF(s) HPI:Beganvomitingbile21daysago.Surgery–removedlinearforeignobjecton12daysago.Vomitingcontinues:2ndsurgery9daysago–find Depressed,tightWhichdiseasedothesedogsMegaesophagusEsophagealforeignbodyHiatalherniaEsophagealtumorEsophagitisEsophagealstrictureSpirocercalupiE-ESOPHAGITIS:Organisms(especiallyESOPHAGITIS:Organisms ForeignobjectsESOPHAGITIS:Organisms ForeignobjectsESOPHAGITIS:Organisms Foreignobjectsdoxycycline多西環素clindamycin克林霉素NSAIDs非甾體類抗炎藥ESOPHAGITIS:Organisms Foreignobjects異物Causticagents刺激性物質Gastricacid胃酸ExcessivegastricacidityESOPHAGITIS:Organisms Foreignobjects異物Causticagents刺激性物質Gastricacid胃酸ExcessivegastricacidityExcessive ESOPHAGITIS:Organisms 源（真菌Foreignobjects異物Causticagents刺激性物質Gastricacid胃酸ExcessivegastricacidityExcessive 過Iatrogenic(postanesthesia醫源性（麻醉后ESOPHAGITIS:Organisms 源（真菌Foreignobjects異物Causticagents刺激性物質Gastricacid胃酸ExcessivegastricacidityExcessive 過Iatrogenicpostanesthesia醫源性（麻醉后Spontaneousgastric自發性胃酸反ESOPHAGITIS:CLINICALMilddisease:“spitup”whiteESOPHAGITIS:CLINICALMilddisease:“spitup”whiteModeratedisease:poorappetite,regurgitatefoodESOPHAGITIS:CLINICALMilddisease:“spitup”whiteModeratedisease:poorappetite,regurgitatefoodSeveredisease:anorexia,drooling,severepain,regurgitation,vomitingESOPHAGITIS:History(e.g.,repeatedvomiting,prior病史（如：術前反 ESOPHAGITIS:History(e.g.,repeatedvomiting,prior病史（如：術前反 Physicalexamination(oral體格檢查（口腔病變ESOPHAGITIS:History(e.g.,repeatedvomiting,prior病史（如：術前反 Physicalexamination(oral體格檢查（口腔病變Radiographs(lesionsmaybeX線檢查（病變可能很輕微ESOPHAGITIS:History(e.g.,repeatedvomiting,prior病史（如：術前反 Physicalexamination(oral體格檢查（口腔病變Radiographs(lesionsmaybeX線檢查（病變可能很輕微Endoscopy(mostsensitive&內窺鏡檢查（敏感性和特異性均最佳TheesophagusisNOTsensitiveTheulcerated/erodedesophagusisULTRA-SENSITIVEtoevenminuteamountsofacidYoumusttrytocomple y“clear”thestomachofacidESOPHAGITIS:AntacidsProtonpumpH-2receptorANTI-ACIDDRUGS:Protonpumpinhibitors質子泵抑制IrreversiblyinhibitH+-K+Omeprazole(1-2mg/kgPOq12-奧美拉唑（1-2mg/kgPOq12-Lansoprazole(1mg/kgIV蘭索拉唑（1mg/kgIVPantoprazole(1mg/kgIV泮托拉唑（1mg/kgIV艾美拉唑（1mg/kgIV艾美拉唑（1mg/kgIVANTI-ACIDDRUGS:Startworkingimmedia y,butrequire2-5daystoachieve aleffectCancause可能引起腹ESOPHAGITIS:Reflux:thetwo-edgedsword反流：雙向Gastroesophageal

ESOPHAGITIS:Reflux:thetwo-edgedsword反流：雙向Gastroesophageal

GastroesophagealESOPHAGITIS:Reflux:thetwo-edgedsword反流：雙向Gastroesophageal

GastroesophagealESOPHAGITIS:PROKINETICSCisapride(0.1-0.5mg/kgPOq12-24h)betterthanmetoclopramideMosaprideavailablesoon?Erythromycin(1-5mg/kgPO,IV,q8-Metoclopramide(0.25mg/kgIV,PO,q8-12h)moreeffectiveonliquidsRanitidine(2.2-4.4mg/kgPO,IVq8- (0.1-0.5mg/kgq12-24h)比甲氧氯普胺(0.25mg/kgIVPOq8-12h)注射劑更雷尼替丁(2.2-4.4mg/kgPO,IVq8-ESOPHAGITIS:PROKINETICSgesics(espESOPHAGITIS:PROKINETICSgesicsGastrostomytuberarelyneeded)胃管（ESOPHAGITIS:PROKINETICSgesicsGastrostomytuberarelyneeded)胃管（Carafate胃潰寧（硫糖鋁ESOPHAGITIS:PROKI