OrganizationChartTherapeuticTherapeutic治療失Wrong誤OrganizationChartTherapeuticTherapeutic治療失Wrong誤Rightdiagnosis治療錯(cuò)Wrong誤

OrganizationChartTherapeutic治療失Rightdiagnosis治療錯(cuò)

Rightdiagnosis診斷正確Righttreatment治療正確

RihtdianosisWrongDEFININGTHE癥狀辨前驅(qū)癥

Usually常 No Usually常 NoBile膽 NoDigested便

NoIfitlookslikevomiting,itisprobablyvomitingIfitlookslikeregurgitation,thenyoudon’treallyknowforsure如果它看起來是那八成它就是如果它看起來像在反那我們確實(shí)無法確定它在干 TAMUSig:4monthFGermanshepherdCC:Febrile主訴：發(fā)熱HPI:1monthago:dogfebrile+soft,moistcoughWascuredwithantibiotics3daysagohadsame病史：1個(gè)月前：發(fā)熱，咳嗽弱，帶痰；曾使用抗生素治 T=39.7CInspiratorycrackelsinright 右肺吸氣階TAMU TAMUTAMU TAMU Sig10yrM(c)Mixedbreed基本信息：10歲，雄性(已去勢），混種CC:Coughing主訴：咳HPI:Coughingbegan2yearsagoandisnotcontrolledwithanymedications.Dogvomitingforlast2 TAMU 2yrM(n)基本信息：2歲，雄性（已去勢），柯利 “Vomiting”,coughing主訴 ”，咳HPI:Problemsbean10dasaNowarningwhenthrowsupNobilenoted Otherwisenormal體格檢查未見其他異MajorCausesofAcquiredEsophagealWeakness?MyastheniagravisHypoadrenocorticism(usuallyVariousSpirocerca獲得性食道遲緩的主要原特發(fā)重癥肌無力（局部腎上腺皮質(zhì)機(jī)能減退（通常 型多種肌病和神經(jīng)病狼旋尾線TAMUAntibodiestoAcetylcholine0.1nmol/L(<抗乙酰膽堿受體抗體濃0.1nmol/L(<MYASTHENIA肌無Localizedandgeneralized局灶性和全身MostcommonlydiagnosedcauseofacquiredBesttestisAnti-acetylcholinereceptors最好的檢測是抗乙酰膽堿受體（AchR）抗體檢Mayneedtorepeattestin6monthsSpontaneousremissionsoften常見自Mustkeepaliveuntil癥狀緩解之前都需要警THERAPYFOR肌無力的治Localizedandgeneralized局灶性和全身Pridostimine吡斯的NOTphysostigmineorTreattheimmunebasisofthe治療免疫失AzathiorineImuran–mabe咪唑硫嘌呤（依木蘭）-可能NOT禁用類固醇類藥TAMUCreatinine肌酐=1.9mg/dl(<2.0)Calcium鈣= 11.3mg/dl(9.3-11.8)Glucose葡萄糖=136m/dl60-120)Sodium=Potassium=Albumin白蛋白=

156mEq/L(138-3.0mEq/L(3.8-3.2gm/dl(2.5-ALT谷丙轉(zhuǎn)氨98IU/lTAMURestingcortisol刺激前可的松濃度

0.90.9PostACTHcortisol= 0.9ug/dlACTH刺激后可的松濃度=0.9腎上腺皮質(zhì)機(jī)能減Infre causesmeaesohaus經(jīng)常引起巨食道癥，但是espcommoninpoodles(espblack尤其在貴賓犬中常見（尤其是黑色貴賓犬seldomcauses↓Naor↑Kwhenitproducesmegaesophagus(atypical)當(dāng)期引起 型）巨食道癥時(shí)，很少造成低鈉或高腎上腺皮質(zhì)機(jī)能減restingcortisol ood 刺激前可的松檢測時(shí)很好的排查檢easyandrewardingto治療簡單且見效don’tusesteroidsastherapeutictrialunlessyouareSUREdoghashypoadrenocorticism腎上腺皮質(zhì)機(jī)能減病病因找CauseTreatTreat治療疾MajorCauseofCongenitalEsophagealWeakness性食道遲緩的主要原特發(fā)賁門失弛緩癥樣綜合反獲得性遲

性遲Lookfor

特發(fā)病因找

特發(fā)

Treat治療疾THERAPYFORCONGENITAL性食道癥的治Dietary Gruel泡軟THERAPYFORCONGENITAL性食道癥的治Dietary Gruel泡軟Meatballs(espwithpartial肉丸（特別是在不完全遲緩的病例中Cannedfood罐D(zhuǎn)ryfood干NormalfindinginBulldogsandShar斗斗牛犬和沙皮犬的影像學(xué)正常表MSUSig:5yrF(s)

主訴 HPI:Vomitin bean1weekao.No signs;producesfoodbutnobileorblood PE:Obese,體格檢查：肥胖，虛“...manydoctorsinthisspeciality[radiology]relyheavilyonfirstimpression–gestalt–rapidlydistinguishingnormalfromabnormal,drawingconclusionswithinsecondsofviewinganimage.”，看了幾秒鐘影像結(jié)果便得出結(jié)論。page179,J.Thenextthreedogsallhavethesamedisease–whatisit?接下來的三只犬所患為同種疾是什么病TAMUSig:2yrM(c)基本信息：2歲去勢雄性達(dá)爾瑪西亞犬CC:“Vomiting”主訴 HPI:Presentsincegotdog1monthago.Dogeatsravenously,thenvomitsfoodwithin3-4minutesofeating.Nobileorbloodseen.Dogdroolsconstantly.Recentlyhastroubleswallowing Not體格檢查：未見明顯異TAMUSig:5monthFGermanshorthairedCC:“Vomiting”主訴 HPI:Startedvomiting8daysago.Started clearliuid.Nextda vomitedbloodandsticks.Laparotomyshowedinflamed nowvomitsfluid&blood. PENormal體格檢查：正TAMU PCV=20%(35-紅細(xì)胞壓積=20%（35-Profile:Albumin=1.9gm/dl(2.5-白蛋白=1.9mg/dl（2.5-TAMU Sig:10yrF(s)基本信息：10歲絕育雌 HPI:Beganvomitingbile21daysago.Surgery–removedlinearforeignobjecton12daysago.Vomitingcontinues:2ndsurgery9daysago–findnothing 異物。吐 ：9天接受二次手術(shù)——未發(fā)現(xiàn)異常。 Depressed,tight體格檢查：情緒低落，腹壁緊Whichdiseasedothesedogs這些患犬患有什么病BEsohaealforeinHiatalhernia食道裂孔

食道異Esophagitis食道Spirocercalupi狼旋尾線E-ESOPHAGITIS:食道炎：病Organisms(especially原（尤其是真菌ESOPHAGITIS:食道炎：病Organisms 原（真菌Foreignobjects異ESOPHAGITIS:食道炎：病Organisms 原（真菌Foreignobjects異ESOPHAGITIS:食道炎：病Organisms 源（真菌Foreignobjects異Causticagents刺激性物質(zhì)doxycycline多西環(huán)素clindamycin克林霉素ESOPHAGITIS:食道炎：病Organisms 源（真菌Foreignobjects異物Gastricacid胃酸Excessivegastricacidity胃酸分泌過ESOPHAGITIS:食道炎：病Organisms 源（真菌Foreignobjects異物Gastricacid胃酸Excessivegastricacidity胃酸分泌過Excessive 過ESOPHAGITIS:食道炎：病Organisms 源（真菌Foreignobjects異物Gastricacid胃酸Excessivegastricacidity胃酸分泌過Excessive 過IatrogenicIatrogenic(postanesthesia)醫(yī)源性（麻醉后ESOPHAGITIS:食道炎：病Organisms 源（真菌Foreignobjects異物Gastricacid胃酸Excessivegastricacidity胃酸分泌過Excessive 過Iatrogenic(postanesthesia)醫(yī)源性（麻醉后Spontaneousgastric自發(fā)性胃酸反ESOPHAGITIS:CLINICAL食道炎：臨床癥Milddisease:“spitup”white輕度發(fā)病：“吐出”白ESOPHAGITIS:CLINICAL食道炎：臨床癥Milddisease:“spitup”white輕度發(fā)病：“吐出”白Moderatedisease:poorappetite,regurgitatefood中度發(fā)病：食欲差，食物反ESOPHAGITIS:CLINICAL食道炎：臨床癥Milddisease:“spitup”white輕度發(fā)病：“吐出”白Moderatedisease:poorappetite,regurgitatefood中度發(fā)病：食欲差，食物反Severedisease:anorexiadroolinseverepain,regurgitation,vomiting重度發(fā)病：厭食、流涎、劇痛、反流ESOPHAGITIS:食道炎：診History(e.g.,repeatedvomiting,prior病史（如：術(shù)前反 ESOPHAGITIS:食道炎：診History(e.g.,repeatedvomiting,prior病史（如：術(shù)前反 Physicalexamination(oral體格檢查（口腔病變ESOPHAGITIS:食道炎：診History(e.g.,repeatedvomiting,prior病史（如：術(shù)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:食道炎：診History(e.g.,repeatedvomiting,prior病史（如：術(shù)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(nèi)窺鏡檢查（敏感性和特異性均最佳PRINCIPALSOF治療原TheesophagusisNOTsensitiveto食道對酸不敏CHEMICAL化學(xué)清Theulcerated/erodedesophagusisULTRA-SENSITIVEtoevenminuteamountsofacidYoumusttrytocomple y“clear”thestomachofacid你必須盡量將胃里的酸完全“清除ESOPHAGITIS:食道炎：治Protonpump–質(zhì)子泵抑制H-2receptorH-2受體拮抗ANTI-ACIDDRUGS:抗酸藥：質(zhì)子泵抑制劑 inhibitors質(zhì)子泵抑制IrreversiblyinhibitH+-K++Omeprazole(1-2m 奧美拉唑（1-2mg/kgPOPantoprazole(1mg/kgIV泮托拉唑（1mg/kgIVANTI-ACIDDRUGS:抗酸藥：質(zhì)子泵抑制劑Startworkingimmedia y,butrequire2-5daystoachieve aleffect可能引起腹ESOPHAGITIS:食道炎：治Reflux:thetwo-edgedsword反流：雙向通Gastroesophagel胃食道反

食道ESOPHAGITIS:食道炎：治Reflux:thetwo-edgedsword反流：雙向通Gastroesophagel胃食道反

食道食道

Gastroesophageal胃食道反ESOPHAGITIS:食道炎：治Reflux:thetwo-edgedsword反流：雙向通Gastroesophagel 胃食道反 食道食道

Gastroesophageal胃食道反ESOPHAGITIS:食道炎：治ANTACIDS抗酸治PROKINETICS促動(dòng)力治VolumeCisapride(0.1-0.5mg/kgPOq12-24h)betterthanmetoclopramideMosaprideavailablesoon?Metoclopramide(0.25mg/kgIV,PO,q8-12h)moreeffectiveonliquidsRanitidine(2.2-4.4mg/kgPO,IVq8-容量清 利(0.1-0.5mg/kgPOq12-24h)比甲氧氯普胺好莫沙必利很快可以買到了?甲氧氯普(0.25mg/kgIVPOq8-12h)注射劑更雷尼替丁(2.2-4.4mg/kgPOIVq8-ESOPHAGITIS:食道炎：治ANTACIDS抗酸治PROKINETICS促動(dòng)力治gesics(esp疼痛管理（尤其是局部ESOPHAGITIS:食道炎：治ANTACIDS抗酸治PROKINETICS促動(dòng)力治gesics(esp疼痛管理(特別是局部使用 4%viscouslidocaineor2%lidocainejellyat4-5ml/kgPO0.1ml/kgof4lidocaine4%ESOPHAGITIS:食道炎：治ANTACIDS抗酸治PROKINETICS促動(dòng)力治gesics疼痛管Gastrostomytube(rarelyneeded)胃管(很少用到ESOPHAGITIS:食道炎：治ANTACIDS抗酸治PROKINETICS促動(dòng)力治gesics疼痛管Gastrostomytube(rarelyneeded)胃管(很少用到ESOPHAGITIS:食道炎：治ANTACIDS抗酸治PROKINETICS促動(dòng)力治gesics疼痛管Gastrostomytube(rarelyneeded胃管（很少用到Antibiotics/Steroids?抗生素/皮脂類固醇藥物ESOPHAGITIS:食道炎：預(yù)防 Shouldwebegivingdogs/catspreanestheticdosesofPPI’sand/orWhatdotheseradiographs以下情況在X線片上的征象如何Segmentalesophagealweakness局部食道遲Esophagitis食道DForein 異EStricture狹Diverticulum憩E-LoweresohaealBlindpouchabouttoperforateEsophagealTAMUSig:1yrF(s)基本信息：1絕育雌吉娃 主訴：呼 ，喘鳴HPI:3monthsagowasspayed–noproblems:“soon”afterwardshad