TOPICAL REVIEW

Endoscopic Diagnosis of Diseases Causing Vomiting

Michael D. Willard, DVM, MS, DACVIM

Animals that are chronically throwing up can be diagnostic challenges. Endoscopy can be a useful adjunct in the
diagnostic and therapeutic approach to many of these patients; however, it is critical that endoscopic exami-
nations be done properly and carefully. Poorly performed endoscopic examinations can miss important lesions,
especially when poor biopsy technique results in inadequate tissue samples for the pathologist. Likewise, rough
technique (especially when trying to remove foreign objects) can harm the patient.
© 2008 Published by Elsevier Inc.
Keywords: vomit, gastroduodenoscopy, ulcer, tumor, gastritis, duodenititis

“
T hrowing up” is one of the more common complaints of
clients presenting ill dogs and cats to the veterinarian’s
office. Acute vomiting that is not due to a foreign object is
often a self-limiting problem that will resolve as the patient
receives symptomatic/supportive therapy. However, when
vomiting is not self-limiting (ie, it persists and becomes
chronic), then the best way to resolve it is to determine and
treat the underlying cause.
The first step is recognizing that the “throwing up” re-
ported by the owner may be vomition, regurgitation, or ex-
pectoration.1,2 It is important to distinguish between these 3
events because they have different causes that require differ-
ent tests for diagnosis and a wide variety of treatments. A
careful history can sometimes allow the clinician to distin-
guish between these 3 actions (Table 1). However, in some
cases, history is inadequate or results in an inaccurate assess-
ment. Observing the act can sometimes be helpful, but most
patients will not throw up “on demand.” Besides, while pa-
tients that appear to be vomiting (eg, vigorous retching, pro-
dromal signs, bile in the vomited material) are usually vom-
iting, those that appear to be regurgitating (eg, a relatively
passive act without retching or prodromal signs, no bile) may
be either vomiting or regurgitating.
If there is confusion as to which of these 3 events is occur-
ring, then plain thoracic radiographs are typically the next
step because many patients with pulmonary and esophageal
diseases causing expectoration or regurgitation, respectively,
will have discernable radiographic changes. If plain thoracic
radiographs are not helpful, then repeating the study after
oral administration of dilute, liquid barium sulfate substan-
tially increases the sensitivity of the study for esophageal
disease. If no disease is seen on this contrast study, the opti-
From the College of Veterinary Medicine, Department of Small Animal
Clinical Science, College Station, TX USA.
Address reprint requests to: Mailing address: Michael D. Willard, DVM, MS,
DACVIM, 2806 Rayado Ct North, College Station, TX 77845. E-mail:
mwillard@cvm.tamu.edu
© 2008 Published by Elsevier Inc.
1527-3369/06/0604-0171\.00/0
doi:10.1053/j.tcam.2008.08.004
mal approach is to repeat the contrast procedure with barium
mixed with solid food. If there are still no significant changes,
then esophageal disease is still possible, albeit much less
likely, and it is usually appropriate to assume that the patient
is vomiting. If vomiting is strongly suspected, then an exten-
sive evaluation to look for various systemic causes of vomit-
ing, which may include a complete serum biochemistry panel,
specific tests for pancreatitis, and viral or thyroid testing in
cats, plus imaging of the abdomen, is usually the best next
step.
Abdominal imaging may include radiographs and/or ultra-
sound. Radiographs are most helpful in finding radiopaque
foreign objects, pneumoperitoneum, loops of intestine dis-
tended by air, microhepatia, and organomegally. Most prac-
tices can obtain radiographs that are of sufficient quality to
obtain a diagnosis when such can be had by this modality.
However, abdominal ultrasound is much more operator depen-
dent, and the ability to skillfully perform ultrasound is not
nearly as universal as the ability to obtain diagnostic radio-
graphs. Depending on the operator’s skill, ultrasound can find
almost all the same things that radiographs can, although radio-
graphs are more sensitive at detecting microhepatia as well as
small foreign objects and bone lesions. However, ultrasound
is much better at detecting several changes commonly missed
by radiographs (eg, small amounts of abdominal fluid,
changes in layering in the stomach and intestines, infiltrates
in various organs). If clinical pathologic testing and abdom-
inal imaging fail to reveal a cause of vomiting, the next step is
usually endoscopic examination of the upper (and sometimes
lower) GI tract. In general, a patient should not receive en-
doscopy until after it has been evaluated biochemically and
with imaging, unless there is some compelling reason to the
contrary.
Gastroduodenoscopy—Technique
Gastroduodenoscopy is a helpful diagnostic tool.3–5 It can
typically be used to evaluate the alimentary mucosal surface
from the cricopharyngeus to the duodenum and sometimes
the proximal jejunum. It is primarily used to look for esoph-

162
Volume 23, Number 4, November 2008 163

Table 1. Selected Historic Findings That Can Assist in

Distinguishing Vomiting from Regurgitation
Sign Regurgitation Vomiting
Prodromal nausea No Usually
(salivation, licking lips,
pacing, anxious
expression)
Retching (forceful, No Usually
vigorous abdominal
contractions or dry
heaves)
Bile No ⫾
Blood ⫾ (undigested) ⫾ (digested or
undigested)

ageal, gastric, and duodenal mucosal disease in patients with

chronic vomiting, although it can also detect (and often re-
move) foreign bodies. Unfortunately, endoscopy sometimes
seems to be more of a novelty or “toy” that people do to have
something “fun” to do, rather than a diagnostic tool that is
understood to require careful training, continued practice, Figure 2. An endoscopic view of the esophagus of a dog. The
and good equipment. As a result, many endoscopic proce- lumen narrows dramatically to a circular opening that is less
dures have been done in a substandard fashion, resulting in than 10% of the circumference of the more proximal esoph-
misdiagnosis and unnecessary procedures. If one is not well agus. This is an example of a benign esophageal stricture.

trained in gastroduodenoscopy or does not have good quality

Figure 1. An endoscopic view of the distal esophagus of a
dog. The mucosa is notably roughed (especially in the 12
o’clock position), and there is an apparent line of blood (from
3 o’clock to 6 o’clock). Both of these changes are consistent
with esophagitis.
equipment, it is worth asking whether the patient would be
better served by referring it to someone with adequate train-
ing and equipment.
An adequate endoscopic examination requires appropriate
anesthesia (so that the patient does not wake or hyperventi-
late during the procedure) and preparation (ie, withholding
food and water for 12-24 hours before the procedure, assum-
ing that the procedure can wait that long). Equipment must
allow clear visualization and sufficient light so that small or
subtle lesions can be discerned. It must also allow one to
remove debris (eg, secretions, blood, ingesta) so that a com-
plete examination is possible.
There are several common mistakes made with performing
gastroduodenoscopy. Sometimes clinicians are so interested
in the stomach that they forget to carefully examine the
esophageal mucosa too. Esophageal lesions can mimic gastric
disease, and/or they may arise secondary to gastric disease
(eg, esophagitis). To perform an effective examination of the
esophagus, the endoscopist must insufflate the esophagus
and keep the tip of the endoscope centralized as it passes
down the esophagus; otherwise, focal lesions can be easily
missed. Because the esophageal mucosa is stratified squa-
mous epithelium, artifactuous, iatrogenic lesions (eg, ero-
sions, bleeding, roughened mucosal surface) are very uncom-
mon; almost any lesion seen in the esophagus is a real lesion.
The lower esophageal sphincter must be carefully examined
to be sure that a hiatal hernia is not present, and the mucosa
164 Topics in Companion Animal Medicine

must be carefully examined for evidence of gastroesophageal

reflux-induced esophagitis.
Once inside the stomach, the most common mistake is
failure to perform a careful, methodical search of the entire
gastric mucosal surface. It is critical that the stomach be
distended sufficiently to allow the entire mucosal surface to
be examined, meaning that there are no folds of mucosa,
which can be hiding erosions or foreign bodies. At the same
time, if the stomach is overdistended, it can cause the patient
to hyperventilate and have gastric peristalsis, both of which
will impair the endoscopist’s ability to critically evaluate the
stomach. If mucus, debris, or blood is present on the mucosal
surface, it should be removed via suction or retrieval forceps
so as to be able to examine the underlying mucosa. This is
especially important when looking for a source of gastroin-
testinal (GI) bleeding. It must be remembered that a diseased
stomach typically does not empty as rapidly as normal, hence
it is best to fast these patients for at least 24 hours before the
procedure. The last meal should consist of moist food, not
dry kibble, to assist with more rapid and complete emptying.
Likewise, avoid using barium sulfate or sucralfate within 24
hours of the procedure because they can also obscure visual-
ization. Be sure to retroflex the tip of the scope and carefully Figure 4. An endoscopic view of the stomach of a cat. There
examine the cardia and fundus, an area where many foreign are numerous nodules in the 9 o’clock to 11 o’clock position.
objects lay unnoticed because the tip of the scope tends to go These nodules represent eosinophilic infiltrates. The cat had
past them as it enters the stomach from the lower esophageal hypereosinophilic syndrome.
sphincter. For a description of how to perform this retroflex
(or J) maneuver, the inexperienced endoscopist should view
gastric anatomy and proper procedures for gastroscopy, which have been published in numerous books and re-
views.3,4,5 The gastric mucosa is not as resistant to iatrogenic
artifacts as is the esophageal mucosa, but such lesions are
relatively uncommon. Examining the interior of the pylorus
can be difficult, especially when it is diseased and attendant
swelling makes it hard to distend and examine the mucosal
surface as the tip of the scope is advanced through the narrow
channel.
It is often critical to evaluate and biopsy the duodenum,
more so than the stomach, because, in the author’s opinion,
enteritis seems to occur much more commonly than gastritis.
A complete examination of the upper GI tract includes ex-
amination of the duodenal mucosa and as much of the jeju-
num as can be safely accessed. Do not be satisfied with
blindly passing the biopsy forceps into the duodenum. Like-
wise, the endoscopist should strive to enter the duodenum
without using a biopsy forceps as a “guidewire” because this
technique often results in iatrogenic damage to the duodenal
mucosa. Again, it is important to keep the tip of the scope
centralized so as to be able to see the entire surface of the
duodenum. This also includes observing the duodenal pa-
pilla. It is common to cause iatrogenic erosions in the prox-
imal duodenum as the tip of the scope attempts to negotiate the
curve just past the pylorus. However, this does not preclude the
endoscopist from attempting to navigate this curved passage-
Figure 3. An endoscopic view of the stomach of a dog with way while causing minimal surface damage. By keeping the
gastric pythiosis. The gastric mucosal surface is very rough scope tip centralized and insufflating carefully, the endoscopist
(despite the stomach being inflated) and spontaneously should be able to safely intubate the duodenum and maximize
bleeding. This is an example of very severe gastritis. the diagnostic yield of the procedure while minimizing prob-
Volume 23, Number 4, November 2008
lems. Under no circumstances should the endoscope be forced
into the duodenum, because significant iatrogenic damage to
the mucosa or perforation can result.
In an effort to help ensure that adequate endoscopic
examinations are performed, criteria for endoscopic re-
port forms have been developed and endorsed by the Com-
parative Gastroenterology Society and the European Soci-
ety of Comparative Gastroenterology (http://www.wsava.
org/StandardizationGroup.htm). These forms have guided
entry (ie, boxes to check off) that attempt to make the operator
perform a complete endoscopic examination or at least state
clearly what was and what was not examined.
It is usually critical to obtain high-quality tissue samples,
especially from the duodenum. Specifics on how to obtain
high-quality tissue samples have been published elsewhere.6
The endoscopist should routinely query the pathologist ex-
amining the biopsies to see if they are providing excellent
tissue samples. One of the major advantages of endoscopic
biopsy over surgical biopsy is the ability of the endoscopist to
see mucosal lesions that are invisible from the serosal surface,
and to direct the biopsy forceps to sites that appear diseased,
thereby maximizing the chance for an accurate diagnosis of
mucosal disease. The mere fact that the patient has dramatic
clinical signs does not mean that the causative lesions are
uniformly distributed throughout the entire intestinal tract,
or even that a diseased segment of the intestine is uniformly
affected. In many cases, even severely diseased sections of the
165
intestines have areas that are severely affected and nearby
areas that are either normal or affected to a much less extent.
This is why it is critical to take multiple tissues samples from
the duodenum and stomach, regardless of gross appearance.
Selected Endoscopic Findings in “Vomiting”
Patients
Esophagitis (Fig 1) may be secondary to vomiting for any
number of causes.7,8 However, even when it is secondary to
some other disease that is causing vomiting, the esophagitis
can be severe enough to cause clinical signs on its own.
Esophagitis is usually very easy to detect, assuming that one
can see the esophageal mucosa. Normal esophageal mucosa
is very resistant to mechanical trauma, and any evidence of
bleeding or erosion strongly suggests esophagitis.
Esophageal cicatrix (Fig 2)9 is usually easy to detect unless
one is examining a large dog with a small endoscope, in
which case the tip of the endoscope may slip through the
stricture without the operator noticing the stricture. Care-
fully making sure that the tip of the endoscope is centralized
as it passes through the esophagus will help prevent this
mistake. It is especially important to look for strictures near
the lower esophageal sphincter; it is easy to assume that a
stricture at this location is simply the lower esophageal
sphincter and not notice that it is actually a narrowing in
front of the opening.

Figure 5. A, An endoscopic view of a cat’s stomach. A suture (blue, threadlike material) is exiting from a prior gastrotomy
site. Apart from the suture, this is a normal gastrotomy site. There are 2 mucosal ulcerations seen at the 9 o’clock position.
The mucosa is somewhat swollen at the site, as seen by the ulcers being slightly raised. This change is not unexpected in benign
ulcers. B, An endoscopic view of a dog’s stomach. There are several slightly reddened and somewhat roughened areas on the
mucosa. These areas represent mucosal erosions. Erosions are less deep than ulcers (see A) and are easy to miss during
endoscopic examination of the stomach.
166
Figure 6. An endoscopic view of a dog’s stomach. There is a
large, deep ulcer on the incisura angularis. Furthermore, this
area is clearly much larger than normal. This ulcer is the
result of an underlying scirrhous carcinoma disrupting the
mucosal surface. This is a typical appearance of a malignant
ulcer. Furthermore, it is almost impossible to obtain good
quality tissue samples from the ulcer because the tissue is very
dense and hard.
Gastrititis has several endoscopic appearances.10 One may
see mucosal erythema (Fig 3), mucosal irregularity (Fig 4),
and/or ulceration or erosion (Figs 5, A and B). Not all ulcers
and erosions bleed, and failing to see fresh red or digested
brown blood in the lumen does not lessen the possibility of
ulcers or erosions being the cause of vomiting. Nonneoplastic
ulcers tend to have deep depressions in the mucosa with
minimal elevation or thickening of the surrounding tissues.
Neoplastic ulcers (Fig 6) tend to be obviously associated with
marked mucosal thickening. It is important to biopsy all such
lesions, unless the cause is obvious (eg, administration of
nonsteroidal antiinflammatory drugs). Scirrhous carcinomas
and lymphomas are the most common causes of gastric ul-
ceration due to neoplasia. Lymphomas are easy to biopsy,
but scirrhous carcinomas are extremely dense and hard, mak-
ing it almost impossible to obtain a good tissue sample. The
inability to biopsy such lesions with endoscopic biopsy for-
ceps tends to suggest scirrhous carcinoma or pythiosis.
Parasites are seldom seen in the stomach, but finding a
nematode attached to the gastric mucosa is almost definitive
for Physaloptera (Fig 7). Physaloptera can cause chronic and
consistent vomiting in dogs, and ova are almost never found
on fecal examinations. They seldom cause problems in cats.
Gastric masses are often thought to be essentially diagnos-
tic of malignancy. This is incorrect. Gastric antral mucosal
Topics in Companion Animal Medicine
hyperplasia (Fig 8)11 and gastric polyps can be very large and
yet curable, assuming that the patient is not euthanized be-
cause of a presumptive diagnosis of cancer. All masses should
be biopsied; however, it is understood that submucosal infil-
trative processes may be difficult to adequately sample with
flexible endoscopic forceps.12 In particular, leiomyomas and
leiomyosarcomas13 can bleed very profusely, causing ex-
tremely dramatic clinical presentations, but they tend to have
a relatively good prognosis because most can be surgically
resected.
Foreign bodies are usually found easily if the stomach is
clear of food and other obscuring material. The operator
must remember to retroflex the tip of the scope and examine
the fundic area because this is a common area for them to
reside, essentially hiding in plain sight. Removing foreign
objects can be very easy or quite challenging, depending on
the foreign object. A full discussion of techniques for remov-
ing foreign objects is available elsewhere,1,14 but some basic
principles bear repeating. First, removal of foreign objects is
better accomplished with finesse and planning as opposed to
trying to overcome resistance by pulling hard. Overly aggres-
sive pulling can cause more trauma (eg, laceration and bleed-
ing) than what the foreign object caused in the first place.
Second, a variety of retrieval instruments may be necessary to
reliably remove most foreign objects. A high-quality 4-wire
basket (ie, one that has very soft, flexible wires and opens to
at least 20 mm), either a shark’s tooth or alligator jaws for-
ceps, and a W-type coin retrieval device are the minimal
pieces of equipment recommended to have on hand to reli-
Figure 7. An endoscopic view of the stomach of a dog. The
white nematode is attached to the gastric mucosa and had to
be pulled off with biopsy forceps. This is the classic appear-
ance of Physaloptera rara.
Volume 23, Number 4, November 2008 167
Second, it is critical to avoid over-insufflating the esophagus,
lest an esophageal ulcer rupture causes tension pneumotho-
rax. Esophageal foreign objects should be dealt with
promptly, as soon as the patient is ready for anesthesia. This
is in distinction to many nonobstructing gastric foreign ob-
jects that can wait until later in the day or even the next day.
Although foreign bodies, ulcers, erosions, strictures, and
masses can be seen in the duodenum, most of the time the
major endoscopic finding is loss of normal duodenal mucosal
texture, suggesting an infiltrative disease (Fig 9). Although
one cannot distinguish inflammatory infiltrates from neo-
plastic infiltrates by gross appearance, finding such a lesion
gives the endoscopist confidence that the cause of the vomit-
ing has probably been found.

Figure 8. An endoscopic view of the pyloric area of a dog.
The area is enlarged and protruding, plus there is some di-
gested blood as seen by the dark material. This is benign,
gastric antral mucosal hypertrophy. It cannot be visually dis-
tinguished from malignancy; it must be biopsied to make this
distinction.
Diagnostic Confusion
Although there are several areas that are potentially confus-
ing in the diagnosis and treatment of chronic vomiting, the
differentiation between inflammatory bowel disease, well-
differentiated small cell lymphoma,15 and food-responsive
enteropathy in the cat can be especially difficult. The inter-
ested reader is encouraged to read more about small cell
lymphoma in the article on that subject in this issue. First,
inflammatory bowel disease is a diagnosis of exclusion,
meaning that one cannot diagnose it simply by finding in-
flammatory cell infiltrates or architectural changes in the in-

ably remove the most common foreign objects. Third, the

endoscopist must learn to be innovative when necessary and
not rely on being able to find a written description of how to
retrieve every type of foreign body. Concurrent use of over-
tubes and rigid endoscopes with the flexible endoscope can
be helpful, especially in helping foreign objects go through
the lower esophageal sphincter and the cricopharyngeal
sphincter. After the foreign body is removed, the stomach
and small intestine should be re-inspected to be sure that
there is not another foreign object further “down stream”
and that endoscopic removal of the foreign object did not
cause damage that needs to be treated. Finally, if a foreign
body is removed, but the clinician is a bit surprised that the
patient should be vomiting because of such an apparently
innocuous foreign body (eg, nonobstructing cloth, small
pieces of plastic, and so forth), consider the possibility that
the foreign object is a result of pica and is not the cause of the
vomiting. In such cases, it is usually wise to obtain some
tissue samples and hold them back in case the patient contin-
ues to vomit after the foreign bodies have been removed.
Endoscopic diagnosis and removal of esophageal foreign
objects have special nuances that are important. First, rigid Figure 9. An endoscopic view of the duodenum of a cat. This
endoscopes and retrieval devices are often more effective mucosal surface does not have the normal “shag rug carpet”
than more expensive flexible equipment. This is especially appearance with lots of small, finger-like projections. Rather,
true for fish hooks that have become embedded in the esoph- the surface is flat and somewhat resembles mud that has dried
ageal mucosa and other larger foreign objects (eg, bones) that and now has cracks in it. This is a class appearance of a
are apparently lodged and do not respond to gentle pulling. severely infiltrated duodenal mucosa.
168
testinal mucosa. Such histologic changes may also occur sec-
ondary to dietary allergy/intolerance. The only way to know
if the patient will respond to diet is to feed well-planned
elimination diets and observe the response. Cobalamin defi-
ciency may hinder clinical response in cats, and it is reason-
able to measure serum cobalamin concentrations or supple-
ment cobalamin while changing diet.16
GI lymphoma in the cat (and perhaps the dog, too) might
be best diagnosed with ileal biopsies as opposed to duode-
nal.17 Although it can be hard or impossible to enter the ileum
of the cat with an endoscope, it is possible to blindly pass the
biopsy forceps through the ileo-colic valve and obtain high-
quality ileal tissue samples in probably ⬎85% of cases. Ileal
biopies are similarly helpful in dogs, but it appears that they
are of greatest use in cats because of the relatively high prev-
alence of lymphoma in that species. It is important to note
that in many cases in which ileal biopsies allow a diagnosis
that duodenal biopsies cannot make, there is no ultrasono-
graphic evidence that the ileum is more diseased than the
duodenum.
References
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man EC (eds), Textbook of Veterinary Internal Medicine ed 6.
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