A challenging case: Acute-on-chronic vomiting in a German shepherd
History and presenting complaints
A 2-year-old intact male German shepherd was referred to the Kansas State University Veterinary Medical Teaching Hospital for evaluation of a three-day history of lethargy, diarrhea, anorexia, and vomiting. The owner also reported that the dog had vomited bile-colored liquid every two to three weeks and had had a difficult time gaining weight beginning at 2 months of age. Several months before this evaluation, a veterinarian had examined the dog because of the vomiting and had prescribed cimetidine (5 mg/kg orally b.i.d.).
Three days before referral, the dog had begun vomiting several times a day. The day before referral, the vomitus had become bloody and had increased in volume, and the owner had taken the dog to an emergency clinic. The results of a complete blood count, serum chemistry profile, and coagulation panel had been within reference ranges. Abdominal radiographs had revealed no abnormalities. The emergency veterinarian suspected gastrointestinal ulceration and had instituted treatment with famotidine (2 mg/kg subcutaneously b.i.d.), sucralfate (1 g orally t.i.d.), and metoclopramide (0.4 mg/kg subcutaneously t.i.d.). The next day, the dog had been depressed and continued vomiting large amounts of bloody fluid, so it was referred to the Kansas State University Veterinary Medical Teaching Hospital.
On presentation, the dog was depressed and underweight (90.6 lb [41.2 kg]) and had a body condition score of 3 on a scale of 9, a temperature of 101.5 F (38.6 C), a heart rate of 120 beats/min, and a respiratory rate of 48 breaths/min. The dog had tacky mucous membranes with a capillary refill time of greater than two seconds and was estimated to be 7% dehydrated. The dog's pulse quality was normal.
Abdominal palpation caused mild discomfort, but no abnormalities were palpated. The dog was not experiencing dyspnea, but we saw an abnormal inward and outward wavelike motion in the ventral cervical area as the dog inhaled and exhaled. We also heard the sound of moving fluid originating from the cervical area from as far as several feet away.
Our differential diagnoses for the hematemesis included toxin ingestion, gastrointestinal torsion, a foreign body, and ulceration. We thought a coagulation disorder was unlikely because no abnormalities were identified on the previous day's coagulation profile. Because of the fluid sound and abnormal motion in the cervical area, we suspected esophageal disease, and our differential diagnoses were megaesophagus (congenital or acquired), an esophageal foreign body, esophagitis, or an esophageal stricture. The recent abdominal radiographs were noted to be unremarkable, but they were not available for us to view at the time of referral. The differential diagnosis list was narrowed to toxin ingestion, gastrointestinal torsion, a foreign body, gastrointestinal ulceration, and esophageal disease.