diagnosis & treatment
TRANSCRIPT
Diagnosis & Treatment Diseases of the Cranial Coelom
J. Jill Heatley DVM MS DABVP DACZM
Reptile Diagnosis and Treatment
• Challenges at most steps in the process
• Treatment options remain anecdotal
• Further Investigation continues
• Antibiotics
• Analgesics
• pharmacokinetics
• Doses
• Options
• Thought process
Diagnosis
Exam
Sample
Evaluate
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Overview
• Organ Based
• Trachea
• Lung
• Esophagus
• Stomach
• Thyroid
• Thymus
• Parathyroids
• Ultimobranchial
• Diseases
• Common
• Nontraumatic
• Diagnosis
• Techniques
• Treatment
• Techniques
• Options
• Efficacy
Start
Stop
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Goals
• Diagnostic
• Clinical signs
• reported in literature
• Expected
• Screening Diagnostics
• Useful
• Clinical Pathology
• Imaging
• Etiology Diagnostics
• For “Definitive” Diagnosis
• Culture
• PCR
• Serology
• Histopathology
Diagnostic Options
Literature Review
Abstracted
Recommendations
Use in NonTarget Species
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Goals
• Treatment
• Options
• Best treatment options
• Literature review
• Anecdotal
• Dose modification
Literature Review
Recommendations
Off-Label Use
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TracheaSo much more than just a path to the Lung / Air Sac
Diseases
Diagnosis
Treatment
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Tracheal DiseaseTrauma
Obstruction
Tracheitis
Neoplasia
Tracheal Disease Diagnosis
• Pediatric human bacterial tracheitis clinical course
• prodromal upper respiratory illness
• Fever
• Inspiratory stridor
• Cough
• Acute obstructive airway disease
• May occur
• respiratory distress
• acute respiratory decompensation
• Require endotracheal intubation or tracheostomy, ICU.
• Complications
• Pneumonia, toxic shock syndrome, cardiopulmonary arrest, death
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Necrotizing Tracheitis
• Sequella
• Bacterial - Mycoplasmosis
• Fungal
• Viral - Herpes Virus, Iridovirus, Nidovirus, Coronavirus, Adenovirus, Ferlavirus (OPMV)
• Proliferation of etiologic agents in tracheal mucosa
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Tracheitis
• Proliferation in tracheal mucosa
• Necrotizing tracheitis sequella
• Mycoplasmosis
• Herpesvirus
• Tortoises, Green Sea Turtles (LETD)
• Iridovirus
• Nidovirus
• Coronavirus
• Adenovirus
• Ferlavirus(OPMV)
• Fungal Diseases
Viral, Bacterial
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Tracheal Virus
• Adeno-like Virus in Esophageal and Tracheal Mucosa of a Jackson's Chameleon (Chamaeleo jacksoni)
• Jacobsen 1990
• A 6-month-old, 15-g, Jackson’s Chameleon
• 3 days anorexia, 1.5 days Opisthotonos, death More common than you thought
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Tracheal Obstruction• Complete Tracheal Rings
• Chelonians, crocodilians
• Proximal tracheal some snakes
• Indian and Burmese pythons (Python molurus) and western rattlesnakes (Crotalus viridis)
• Monitor for obstruction when using smaller endotracheal tubes.
• Cuffed ET tubes contraindicated
• Reactive trachea, healing by adhesions or stenosis (as in Avian species) yet to be decribed
Not reported in Reptiles
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Vitamin A deficiency• Degeneration/ Metaplasia of epithelium
• Including lung faveoli
• Rhinitis
• Lung, respiratory tract disease
• External Clinical signs
• Poor epithelial quality
• Skin
• Nails
• Conjunctivitis
Plasma [Vitamin A]; Liver vitamin A
San-Jose LM at al. Vitamin E, vitamin A, and carotenoids in male common lizard tissues. Herpetologica. 2012 Mar;68(1):88-99.
Hypovitaminosis A
Chelonians
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Tracheal Obstruction
Clinical Signs
• Ball Python Python regius
• Chondroma
• Respiratory noise, wheezing, episodic harsh breathing
• severely dyspneic, open mouth breathing.
• exaggerated / pronounced inspiratory effort
• Expiratory wheezing
• Head, neck flexed dorsal, 90˚ angle to body during inspiratory efforts
• Tracheitis/Pneumonia -Providencia rettgeri
• acute respiratory distress, severe dyspnea, open mouth breathing, moist rales, glottal bubbles, head and neck vertical position. Copious thick yellow tracheal discharge
• Green Sea turtles Chelonia mydas
• Phaeohyphomycosis
• alive but lethargic “stranded” , subsequently died.
• Honduran Milk Snake Lampropeltis hondurensis
• Salmonella arizonae
• Bicephalic
• No premortem clinical signs, Unexpected death
Tracheal Obstruction
Green turtle
Chelonia mydas
Stranded Indian River Lagoon, Florida, USA,
cranial trachea obstructed by locally extensive, ulcerated mass.
Scale bar ~ 0.4 cm.
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Tracheal Malformation
• Honduran Milk Snake
• No antemortem clinical signs
• Atypically Wide, collapsed tracheal rings
• Necrotic epithelial debris/Inflammatory cells
• Luminal obstruction
• Salmonella arizonae
• Radiographs, Necropsy Diagnosis
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Bronchial Collapse
• Hermann’s tortoise, Testudo hermanni boettgeri
• 45 YOA, therapy resistant respiratory distress several months
• Clinical Signs limited to:
• Marked inspiratory distress, wheezing sounds during inspiration.
• Inspiratory distress increased with neck extended.
• Respiratory distress persisted with neck extension and sedation.
Clinical Signs
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Tracheobronchial collapse
Pulmonary-tracheobronchial prolapse
New Caledonian giant gecko, Leach’s gecko
(Rhacodactylus leachianus) 3y male
1-day hx lethargy, labored breathing, coelomic distention.
Intermittent dyspnea, pronounced expiratory stridor
Moderate coelomic tympany
DDX: infectious respiratory disease, obstructive condition leading to pneumocoelom, gas distended gastrointestinal tract, or lung hyperinflation.
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CLINICAL DIAGNOSIS
2 kg , 1.7 m juvenile boa constrictor
Good BCS, anorexic for 3 weeks
Rescued from a rescue 3 weeks ago,
Companion snake dies two weeks ago with “neurologic signs”
Snake held head vertically, open mouth breathing
10% dehydration
Retained spectacles, cloudy anterior chambers OU
HISTOPATHOLOGY
Hepatitis
Nephritis
Glossitis
NL: lungs, trachea, glottis. Lung viral isolation negative
SNAKES HOLD UP THE PROBLEM….
Snake dyspnea
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URTD
• Common causes of primary upper respiratory tract disease
• Trauma
• Mycoplasma agassizzi in North American tortoises,
• tracheal chondromas in ball pythons (Python regius)
• herpesviruses, iridoviruses in tortoises,
• Tortoises with mycoplasmosis, herpesvirus, iridovirus similar signs; dyspnea, serous to mucopurulent nasal discharge, rhinitis, conjunctivitis
• Stomatitis and glossitis
• present in herpesvirus infections, not mycoplasmosis
• Sudan plated lizard (Gerrrhosaurus major) with dyspnea
• Obstructive periglottal lesions with eosinophilic intranuclear inclusions
• Herpesvirus
Is it Upper or Lower Respiratory Tract Disease
Is It Both????
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Lung Disease
Pneumonia
• SubOptimal Husbandry
• Bacterial
• Chlamydia spp. • puff adders - Bitis arietans
• Greek tortoises - Testudo graeca
• Mycoplasma • Crocodilians, Torts
• Burmese python Python molurus bivittatus
• proliferative tracheitis, pneumonia.
• Viral - paramyxoviridae, reoviridae
• Traumatic
• Turtle HBC, pulmonary hemorrhage sequela to shell
• Parasitic
• Pentastomids, Rhabdias, Roundworms, Intranuclear coccidia
• Fungal – candida spp RES
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Pneumonia• High fever, shaking chills
• Cough with phlegm
• Shortness of breath
• Chest pain when breathing or coughing
• Pediatric - may lack signs of infection
• vomit, fever cough, restless, sick, tired, lack energy
• Geriatric, Immune Suppressed
• fewer and milder symptoms, hypothermic.
• Older adults who have pneumonia sometimes have sudden changes in mental awareness.
Human Symptoms
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Pneumonia
• Early stage clinical signs difficult to detect.
• Nonspecific - lethargy, anorexia weight loss
• Lizards
• Sneezing, serous - mucoid DC, severe cases of pneumonia, increased respiratory effort
• Snake
• Serous - purulent nasal DC, wheezing, respiratory secretions in oral cavity, stomatitis.
• Increased respiratory efforts, dyspnea
• Open mouth breathing cranial aspect of body extended to facilitate air movement through “filled” trachea
• Chelonia
• Stomatitis, necrotizing lesions, abscesses
upper & lower respiratory tract disease.
• Open mouth breathing - severe, chronic , obstructive processes hypertrophy of upper respiratory tract epithelium.
• Aquatic species
• buoyancy problems, inability to dive,
• unilateral or bilateral gas pockets in the lungs
• consolidation of lung parenchyma.
• Differing percussion of carapace
Clinical Signs
Upper Respiratory Disease
Lower Respiratory Disease
HEAT SEEKING BEHAVIOR
Inspiratory/Expiratory
Lung Sounds
Respiratory RATE
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Trachea & LungsRespiratory Rate
at least 1 minute
preferably unrestrained/ observational
Repeat at POTZ if necessary
Noise or difficulty
Inspiratory or Expiratory
Percuss
Auscult…?
Obtain Temperature
Heart Rate
REPORT IN CASE REPORTS
Physical Exam
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Respiratory Diagnostics• Respiratory sample
• Tracheal
• Percutaneous
• Surgical
• Image
• Noninvasive – RAD, CT, MRI
• Invasive – Endoscopy, Surgery
• Blood
• Hematology – CBC, Chem, Blood Gases
• Acute Phase Proteins
• Serology – Antibody Response
• Capnography
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Respiratory Diagnostics
• Adequate Uncontaminated Sample
• Cytology
• Histopathology
• PCR
• Culture
• Above all do no harm
• Avoid iatrogenic patient damage
• Respiratory Arrest or Death
GOALS
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Respiratory Diagnostics
• IMAGING
• Glottal Swab
• Tracheal Swab
• Tracheal Lung Lavage
• BAL, TTW
• Percutaneous Lung Aspirate
• Fine-needle aspiration
• Craniodorsal aspect prefemoral fossa in chelonians via long needle
• Risk greater, use with caution
• Vessel Confluence
• Endoscopy
• ventrolateral celiotomy and pneumotomy (40% - 50% SVL) endoscope directly into the lungs.
• Chelonian lungs
• Prefemoral via septum horizontale
• Temporary carapacial osteotomy
• Flexible bronchoscopy techniques - Large species
OPTIONS
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ARAV ExoticsCON JheatleyDVM
Radiography Lung / Trachea
• Lack of radiographic contrast of soft tissues of the coelomic cavity is common in reptiles and prevents individual recognition of several coelomic organs.
• Plain radiographs
• Trachea can be evaluated in snakes and lizards.
• In snakes limited diagnostic tool for lung evaluation ---------CONSIDER CT, MRI
• Evaluation of lung fields using horizontal beam radiographs may reveal fluid in the lungs
• Lungs pattern classification scheme not applicable to reptiles
• Radiographic signs of pulmonary disease become apparent only at a late stage
• “If pneumonia is suspected, clinician should rely on the clinical examination of the patient and combine results of different diagnostic tests, such as bronchoalveolar lavage, haematologicalscreening, bronchoscopy and radiography to obtain the diagnosis”
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Computed tomography for the diagnosis andtreatment monitoring of bacterial pneumoniain Indian pythons (Python molurus) Pees et al.
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Lung CTImprovement of Disease
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Tracheal Imaging
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Lateral radiograph, cranial 16 cm of ball python intraluminal, irregularly marginated, soft tissue opacities (arrows) silhouetting with the ventral wall of the trachea. TRACHEAL CHONDROMA
Herman’s TortoiseCervical Region Caudal to Tracheal Bifurcation
NORMAL CT
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R bronchus black arrowL bronchus white arrow hypodense (-980 HU) structures
Herman’s TortoiseCervical Region Caudal to Tracheal Bifurcation
Bronchial Collapse
BLACK ARROW
R bronchus hypodense (-980 HU) figure-8 due to central collapse
WHITE ARROW
L brochus nearly completely collapsed barely visible
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Tracheal Imaging
FAIL
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Rat Snake
RATSNAKE HBC, Found in parking lot
Multiple episodes open mouth breathing Possible free gas cranial to the heart. Rupture of respiratory tract suspected.
4: Possible hemorrhage cranial to the heart.
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COACHWHIP HBC
traumatized "flattened" region is skeletally unremarkable. Irregular skin margins are present along the left body wall throughout this region. On several images, barium paste marks the grossly traumatized region. Fragmented gas is present within the GI tract.
Conclusions: Trauma in the mid body, just caudal to the lungs. Spinal displacement is not appreciated.
Lung
• Tracheal (lung) lavage preferred to glottal swab
• Cytology, microbiology, PCR
• Sedation or light anesthesia
• Lidocaine glottis
• sterile catheter into the lung
• Sterile endotracheal tube placement
• From snout to cranial third of the coelom
• insert through glottis, avoid oral mucosa
• Aspiration of exudate
• 0.5 ml of 0.9% sterile saline per 100 g of body weight instilled
• 1-10 mg/kg
• Rotate patient, gentle reaspiration reattempted.
• For unilateral lung disease, direct catheter into affected lung with curved stylet, confirm placement radiographically
Diagnostics
August 2016 ARAV ExoticsCON JheatleyDVM
Tracheal Wash• Bronchofaveolar Lavage
• American Alligator , Healthy
• Small amounts of mucous
• Low numbers in 90% of samples
• ciliated columnar epithelium
• Cuboidal epithelium
• Keratinized squamous cells
• No
• Bacteria, parasites, seasonal change
• NORMAL SNAKE, TORTOISE, TURTLE
• Unreported
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Trachea / Lung
• Snakes , Lizards
• fine-diameter (1 to 2.7 mm), rigid endoscope examine the trachea enter the lung(s) examination / diagnostic
• Preoxygenation recommended, tracheal occlusion tolerated
• Direct visual guidance of scope necessary to avoid tracheal damage
• Snakes
• Ventrolateral celiotomy / pneumotomy
• 40% - 50% SVL ; Pulmonoscopy
• Chelonian
• Sharp bronchial bend before entering the lungs, makes endotracheal approach to chelonian lung impossible (rigid endoscope)
• Caudal prefemoral, soft-tissue approach
• through septum horizontale
• thin, horizontal membrane separates lungs from viscera
• Transcarapace temporary carapacial osteotomy
• direct examination and collection of tissue biopsies
• Large reptiles
• Typical flexible bronchoscopy techniques
Endoscopy
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Lung Endoscopy
• Left lateral recumbency
• Entry site
• 90 (95) ventral scales caudal to head,
• 9 scales lateral right side
• Vertical 8-10 mm interscalar skin incision
• Blunt subcutis dissection, identify ribs, intercostal space
• Hemostats penetrate intercostal muscles, separate 2 adjacent ribs
• Inflation of lungs for ID, Penetrate with hemostats
• 3-4 mm pneumotomy
• Skin closure only
• BIOPSY SPECIMEN HANDLING:
• gently shake from forceps into tube with saline then decanted and replaced with fixative.
Ball Pythons (Python regius)
Tracheal Wash Sample Options
• Wet mount
• Microscopic exam protozoa, parasitic ova
• Lugol’s iodine
• 1 - 2 drop ethanol / ml of sample
• Microbiologic swab soaked w sample transport media (culturette)
• Bacterial & fungal culture media
• Fresh, air-dried smear
• cytologic and microbiologic staining
• PCR, Viral culture
• Lung Biopsy – Histopath, PCR, Cytologic Imprint, Culture
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Culture interpretation challenging
• Most bacteria isolated from reptiles with pneumonia are aerobic Gram-negative rods
• Chlamydia, Mycoplasma, Fungi
• Glottal Culture
• 3 boa constrictors (Constrictor constrictor), 3 Indian pythons (Python molurus), 2 reticulated pythons (Python reticulatus)
• Pneumonia Snakes - criteria - oral/ nasal bubbling respiration, open mouth breathing, rhinitis, nasal discharge, and rales on lung auscultation
• No anaerobes cultured
• Quantity of bacteria greater from diseased snakes than those apparently healthy
• Glottal culture results matched those obtained from necropsy of snakes suffering pneumonia
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Snake Glottal Culture results
Bacteria Pneumonia Healthy
Aeromonashydrophila
1 2
E. Coli 0 1
Klebsiella spp. 0 1
Pasteurella spp. 1 0
Proteus spp. 1 1
Pseudomonas spp. 1 6
Salmonella spp. 3 1
August 2016 ARAV ExoticsCON JheatleyDVM
Reptile Respiratory Culture
• The tracheal lavage more sensitive than pharyngeal swabs.
• Most common bacteria:
• Pseudomonas aeruginosa, Klebsiella pneumoniae, Stenotrophomonas maltophila.
Most common fungi - Aspergillus sp. , yeast In boids
75% Pythons bacteriologic results considered pathologic.
48% Tortoises mycologic results were considered pathologic.
Aerobic cultivation on standard media: Columbia-Agar with sheep blood, brilliant-green-, Sabouraud-Agar recommended as an initial diagnostic measure in reptiles with respiratory signs
Additional pathogens (viral ,Mycoplasma) should also be checked
August 2016 ARAV ExoticsCON JheatleyDVM
Trachea & LungsTreatment
Trachea Treatment
• Pediatric Tracheitis Serious Consequences
• Close observation and monitoring
• Early admin of broad spectrum antibiotics
• Pain management
• Aggressive airway clearance
• Fluid therapy
• Nutritional support
• Contact precautions
• Drugs
• Expectorants, proteolytics, mucolytics, bronchodilators
• ANECDOTAL, Modification for pediatric dosing
• Trachea blood supply limited, consider Nebulization
• Surgical
• Lung cannulation, tracheal resection…ball pythons
HUMAN
REPTILE
OPTIONS
Pneumonia Treatment
• Parenteral, Nebulization, POTZ, Supportive Care
• Appropriate antibiotic therapy
• Mycoplasma spp. lack call wall
• Fluoroquinolones, Azithromycin, Clarithromycin
• Tissue necrosis: Iatrogenic radial nerve paralysis in chelonians: repeated injections into the antebrachium. eradication Mycoplasma unknown, lifelong carriers.
• Fungal pneumonias
• Itraconazole, intrapulmonary application of amphotericin B
• herpesvirus infection
• Acyclovir, famcyclovir
• Appropriate antiparasitic therapy for Rhabdias spp. and fluke spp.
• Ivermectin is toxic in chelonians
August 2016 ARAV ExoticsCON JheatleyDVM
Pneumonia Treatment
• Surgical treatment of pentastomids
• Medical treatment of pentastomids
• Egyptian toads – Fenbendazole formulary dose – sepsis, death
• intrapulmonary application of amphotericin B
• Endoscopy sample trancarapacial
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Texas Tortoise 17
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Clinical Signs
• Atlas
• Adult male Russian Tortoise
• Referral for increased respiratory rate
• Overweight
• Radiographs
• Endoscopy
• Liver Biopsy
Non Specific
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August 2016 ARAV ExoticsCON JheatleyDVM
APLung field size ?
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Endoscopic ViewAtlas’ Liver
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Esophagus
• Esophageal Disease Rare?
• Sea Turtles
• Ulcerative & Fibrinous esophagitis
• Traumatic esophageal perforation common lesion
• FOREIGN BODY
• long line tuna fishery
• Esophageal impaction with balls of crude oil in 2 turtles (2.15%)
• Viral Lesions
• Ranavirus
• Adenovirus
Diseases
Diagnosis
Treatment
ARAV ExoticsCON JheatleyDVM
Panther Chameleon• No gross lesions observed
• Oral cavity thick yellow mucoid discharge
• Sepsis
• Microscopic Lesions
• Esophagus
• Lymphoplasmacytic heterophilis esophagitis with ulceration
3 yoa Male
Anorexia, Open mouth breathing, Frothing at the mouth
Profuse Ptyalism
Increased upper respiratory noise
August 2016 ARAV ExoticsCON JheatleyDVM
Human esophagitis
• Symptoms
• Odynophagia
• Retrosternal pain upon swallowing
• Dysphagia, Nausea, Substernal burning pain
• ANOREXIA
• Diagnosis
• Endoscopic Visualization
• Brush samples - cytology +/- Culture
• More sensitive than biopsy
• Blind brush sample sensitivity good 75-84%
• Treatment
• ID, etiologic treatment
• Analgesia, Liquid topical anti-ulcer medication
• Sulcralfate, calcium alginate
Rare, Immunocompromise
Herpes simplex, Cytomegalovirus, Candidiasis, Idiopathic
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StomachDiseases
Diagnosis
Treatment
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Stomach Diseases
• Trauma
• Foreign Body Ingestion, Caustic Insult
• Neoplasia
• Gastric Neuroendocrine Carcinoma
• Endoparasitism
• Cryptosporidiosis, Physaloptera
• Gastritis - Bacterial/ Fungal/ Toxic/Viral
• Poor husbandry commensal overgrowth
• Ulcers (gastric)
• Nutritional/Renal
• Gout, Mineralization
August 2016 ARAV ExoticsCON JheatleyDVM
Gastritis
• Inflammatory Response Lining of Stomach
• Acute - “severe thermal burns, major surgery, anti-inflammatory agents, corticosteroid administration, toxins, and infectious diseases”
• Chronic “Chronic poor husbandry, neoplasia, bacterial infections”
• Diptheritic necrotizing gastritis Rosy Boa (Lichanaura trivergata) – Salmonella arizonae -32-33
• Atrophic gastritis – RES, Herman’s tortoises (Testudo hermanii)
• Helicobacter associated gastritis (5/28 histopath )–
• Cuoro spp. Asian box turtles
• Californian Desert Tortoise (Gopherus agasizzi) -
August 2016 ARAV ExoticsCON JheatleyDVM
Stomach Clinical Signs
• Anorexia, Nausea, Vomiting
• Frank or digested blood
• Vomitus, Feces
• Midbody Swelling
• Ill-thrift
• Pain or tenderness upper abdomen
• Pain upon eating
• Bruxism
• HUMAN COMMON CAUSES: H. pylori, NSAIDS, Vitamin B Deficiency
August 2016 ARAV ExoticsCON JheatleyDVM
Gastric Disease Clinical Signs• 5 y Male Diamond python Morelia spilota spilota
• Regurgitation, anorexia, discrete coelomic distention, Firm, immobile mass, 2/ 3 SVL
• Adenocarcinoma
• Adult Male Madagascar tree boa Sanzinia madagascarensis
• 3 m regurgitation, weight loss. marked cachexia, lethargy, weakness
• Cryptosporidium
• 8 y Female Green Iguana Iguana iguana
• Reduced condition, pain upon abdominal palpation, vomiting 2 days
• Radiolucent foreign body
• 2 Reticulated pythons Python reticulatus 7 & 20 y
• Dullness, anorexia,lethargy; Dysecdysis, firm papillomas mucosal masses
• Ascardia galli ulcerative gastritis
August 2016 ARAV ExoticsCON JheatleyDVM
Gastric Disease Clinical Signs
• Gastric neuroendocrine carcinoma of bearded dragons
• Anorexia
• Vomiting
• Hyperglycemia
• Anemia
• Gastric Ulcers in green iguanas, Iguana iguana; 3
• Nonspecific clinical signs: apathy, anemia, anorexia, vomiting
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Stomach
Diagnosis
Sample Decision
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Image
Radiographs +/- Contrast
CT, MRI, Endoscopy Ultrasound (GAS )
Noninvasive Sample
Blood, Plasma, Serum Fecal, Cloacal Lavage
Occult Blood – remains unvalidated for reptiles
Invasive Sample
Gastric Wash
Endoscopy, Surgery
Stomach Diagnostics
•CBC Chem
•GI Assay
Blood
•Cytologic•Histologic
GI
•PCR•Culture
Etiologic
Sample options
• CBC, Chem – nonspecific Pb, Zn metallic FB Vitamin Levels
• GI Specific Assays – not validated for reptiles
• Gastrin Immunoassay - serum gastrin concentration
• Diagnostic test of choice for diagnosis of gastrinoma
• Feces– Float, Direct, Sedimentation, Cytology, PCR , Acid Fast, Culture
• Gastric Wash - above + pH evaluation
• Biopsy – Histopathology, Special stains
• Gastric neuroendocrine carcinoma
• Deep tissue section biopsy, (surgical approach) may be necessary
August 2016 ARAV ExoticsCON JheatleyDVM
August 2016 ARAV ExoticsCON JheatleyDVM
Gastric Lavage• Catheter advanced to the midcoelom
• as far as possible into esophagus large snakes
• Lavage tubes measure snout to midcoelom
• inadequate insertion - regurgitation
• excessive insertion gastric penetration
• gavage sample (centrifuged, if necessary)
• wet-preparation direct microscopy, microbiology, cytology
• Flotation, culture/ PCR Acid fast staining
• Occult blood in herbivores?
• Lugol’s iodine allows visualization of encysted Entamoeba spp, kills live protozoa
Imaging Esophagus Stomach
• Lack of radiographic contrast of soft tissues of the coelomic cavity is common in reptiles and prevents individual recognition of several coelomic organs.
• Esophagus (only in lizards) and gastrointestinal tract (if the intestines are ingesta- or gas-filled) can be evaluated in snakes and lizards
• Contrast Radiography, CT MRI helpful
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Soft-shelled turtleHook in esophagus
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Gastritis
• Red Eared Sliders (n=22)
• Radiographic Evidence
• annular-shaped radiolucency visible left half of the plastron
• Accumulation of gas in the stomach -typical finding for gastritis.
• Inappropriate Diet/ Husbandry
August 2016 ARAV ExoticsCON JheatleyDVM
Lateral view which shows gastritis. Globular gas-filled stomach marked
Contrast Radiographic Imaging Bearded Dragon DV Radiograph
15 min
gavage 15 ml/kg 35% w/v barium suspension - thoracic esophagus.
WHITE ARROWS
esophageal folds
BLACK ARROWS
Gas filled colon
R of coelomic cavity
Contrast ImagingAnesthesia not required
Time consuming (POTZ)
Economical
Radiologist not required
GI Transit time
Mucosal defects
Gastrointestinal anatomy
Obstruction (+/-)
Gastric culture, pH
Fluconazole-Resistant Candida Species in Tortoises
• Antifungal susceptibility of Candida spp. from tortoises (Chelonoidis spp.).
• Oral cavity & cloaca of 77 animals (60 tortoises) collected.
• 2% Sabouraud dextrose agar + chloramphenicol, ID via morph and biochem.
• 66 isolates from tortoises
• 27 C. tropicalis, 27 C. famata, 7 C. albicans, 4 C. guilliermondii 1 C. intermedia,
• MIC amphotericin B, itraconazole, fluconazole from 0.03125 to 0.5, 0.03125 to >16 and 0.125 to >64, respectively.
• 19 azole-resistant strains (14 C. tropicalis and 5 C. albicans) found.
• Testudines carry azole-resistant Candida spp.
• Fungal colonization of feeding tubes (UF, Jacobsen) - chlorhexidine/nystatin
August 2016 ARAV ExoticsCON JheatleyDVM
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Surgical treatment may be required for alleviation of
gastrointestinal bloat and mass removal
Stomach, Esophagus Treatment Options
• Optimize Husbandry
• Treat/ Remove Etiologic Agent
• Antibiotic/ Antifungal/ Antiparasitic
• Analgesia
• Antinausea agents? -unvalidated for reptiles
• Acid Control
• H2 blockers –cimetidine, famotidine - unvalidated for reptiles, Stomach pH
• Antacid (Calcium supplement, TUMS)
• Physical Barrier
• Sucralfate, Sodium alginate ---pH appropriate
• Dysbiosis? Probiotics/ Transfaunation
• CULTURE LACKING
August 2016 ARAV ExoticsCON JheatleyDVM
Gastritis Diet
• Broccolli - Suphoraphene kills H. pylori
• Brassica oleracea - May limit iodine upate and induce goiter
• Garlic – Antimicrobial/ Antifungal agent –Antitoxin agent
• Rats, goats, parrots, chicken, dogs and cats toxic
• Probiotic – Lactobacillus / Bifidobacteria
• Vitamin A – healthy epithelium - sweet potato / yam, carrots, leafy greens, asparagus, apricots
August 2016 ARAV ExoticsCON JheatleyDVM
Thyroid• Ecdysis, Endocrine Function, Hematopoesis, Tail
Regeneration
• Experimentally
• Thyroidectomy: increased shedding frequency, testicular regression
• Thyroid dysfunction causes: improper light cycle, hibernation, thermal gradient
• Hypothyroidism
• Tortoises: Galapagos, Aldabra, Sulcata
• Goiter, Clinical disease
• Hyperthyroidism
• Green Iguana (Iguana iguana) thyroid follicular adenoma• weight loss, polyphagia, hyperactivity, aggression, tachycardia,
palpable ventral cervical mass, loss of dorsal cervical spines
• Corn snake (Pantherophis guttatus) hyperecdysis
• African Helmetted Turtle (Pelmedusa subrufa) Reduced appetite, continual shedding
Diseases
Diagnosis
Treatment
ARAV ExoticsCON JheatleyDVM
Hypothyroidism
• Top differential for thyroid enlargement in Tortoise
• Goiter
• Obesity/ Dietary Imbalance
• iodine-deficient soils (occur worldwide)
• Dietary goitrogens
• bok choy, broccoli, cabbage,
• cauliflower, kale, mustard seed, rapeseed,
• soy bean sprouts, and turnips.
• Feed these food items intermittently, or only small % of herbivorous reptile diet.
August 2016 ARAV ExoticsCON JheatleyDVM
Thyroid Diagnosis
• Thyroid function
• Total T4 Thyroid Releasing Hormone
• Total T3 Thyroid Stimulating Hormone
• Free T3
• Free T4
• Imaging – CT, MRI, U/S
Total T4 values in reptilian species
Species Total T4 (nmol/L) Reference
Green iguana (Iguana iguana) 3.81 ± 0.84
Corn snakes (Elaphe guttata) 0.45–6.06
Milk snakes (Lampropeltis triangulum) 0.27–2.94
Ball python (Python regius) 0.93–4.79
Red-tailed boa (Boa constrictor) 0.24–3.98
Desert tortoise (Gopherus agassizii) 0.35–4
Eastern snake-necked turtle (Chelodina longicollis) 0.69 ± 0.11
Sulcata Tortoise
August 2016 ARAV ExoticsCON JheatleyDVM
Tortoises
• Desert Tortoises
• Gopherus aggasizii
• Seasonality
• Males differ from Females
• T3 difficult to detect
• Sulcata Tortoises
• Reference Interval
August 2016 ARAV ExoticsCON JheatleyDVM
Thyroid Treatment
• Hypothyroidism
• Levothyroxine supplementation
• Hyperthyroidism
• Thyroidectomy
• Methimazole
• Dietary management
• Avoid goitrogens
• Iodine supplementation
Ultimobranchial GlandsDiseases
Diagnosis
Treatment
ARAV ExoticsCON JheatleyDVM
Primary Disease of the ultimobranchialglands remains unreported.
• Cellular calcium homeostasis• Smooth muscle contraction
• Heart rate• Vasodilation• Blood pressure
• Pain, Heat• Ossification• Innate Immune response – antibacterial,
antifungal
Ultimobranchial bodies
Ultimobranchial bodies Diagnostics• [Calitonin]
• Evaluate as for Metabolic Bone Disease
• [Blood Pressure]
• Heart Rate
• Glucocorticoids
• Intestinal calcium absorption, PTH Renal calcium absorption
Bone calcium resorption
Thymus
• True thymic disease rare
• R/O seasonal change
• R/O generalized lymphatic proliferation
• Infectious, inflammatory
• Thoracic CT
• Human autoimmune component
• Red cell aplasia, hypogammaglobulinemia
• CBC, reticulocyte count, serum protein EPH
• Thymoma Thymic carcinoma
• Lymphoma, Teratoma, Seminoma, Primary lung carcinoma
• Biopsy recommended prior to complete resection
• Equivocal results still possible
Diseases
Diagnosis
Treatment
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Parathyroid• Metabolic Diseases of the Bone
• Nutritional, Renal Secondary Hyperparathyroidism
• Remain commonly diagnosed in reptile practice
• Clinical findings: Fasciculation etc.
• Radiography
• Ionized calcium
• Renal assessment
• Primary parathyroid gland disease extremely rare in humans undescribed in reptiles
• Primary hyperparathyroidism (PHP)
• Lack of PTH assay
• Few normative ionized calcium values for reptiles
• Human diagnosis
• routine screening of blood calcium
• elderly patients with confusion and dehydration
• Confirmation for radioimmunoassay
Diseases
Diagnosis
Treatment
ARAV ExoticsCON JheatleyDVM
Much thanks for your attention
Questions?
August 2016 ARAV ExoticsCON JheatleyDVM