Regurgitation/Vomiting
Basic Information 
Epidemiology
Risk Factors
• Elevated stress levels due to overstimulation and overcrowding
• Consumption of too large a meal
• Temperature below digestive requirement
• Infection altering physiologic or digestive processes
• Anatomic intestinal obstructions
• Neonatal congenital gastrointestinal defects
Contagion and Zoonosis
Clinical Presentation
History, Chief Complaint
• A complete history and thorough physical exam are needed to narrow down potential causes of regurgitation and vomiting.
• Expelled food found on the cage floor
• It is often difficult for owners to differentiate between regurgitation and vomiting.
• Some clients may provide feeding records that may help clinicians to associate a pattern for the regurgitation/vomiting and to determine the severity of the condition.
• Inactivity and increased basking frequency
• Snakes housed at a temperature that is too cool will expel food that is relatively fresh and undigested.
• Regurgitation and vomiting are uncommon in chelonians and when seen are considered serious symptoms of illness. One exception to this is iatrogenic regurgitation/vomiting associated with parenteral injections of enrofloxacin.
• Animals demonstrating symptoms of regurgitation and vomiting may display prolonged disinterest in feeding.
Physical Exam Findings
• Animals suffering from frequent vomiting may present dehydrated with acid-base and electrolyte imbalances.
• Emaciation/cachexia may be evident in an animal that is unable to keep food items down over an extended period of time.
• Animals with advanced symptoms may be dull, inactive, and unresponsive.
Etiology and Pathophysiology
• Improper husbandry is the most common cause of regurgitation and vomiting in reptiles.
• The most common mistakes include keeping the reptile at a lower temperature than required for adequate digestion and postprandial handling, especially in snakes.
• Infectious causes for gastritis and subsequent regurgitation/vomiting are common, including:
Viral disease such as IBD virus in boid snakes
Gastrointestinal parasites, including coccidia (cryptosporidiosis and others), amoebae, cestodes, and nematodes (ascariasis)
Toxins such as pesticides, including organophosphates and bufotoxins, may cause vomiting. Iatrogenic vomiting can be caused by drugs such as enrofloxacin, miticides, levamisole, xylazine, and apomorphine.
Intestinal obstructions or lesions associated with food consumption, surgery, or disease may induce regurgitation and vomiting.
• These causes disrupt normal esophageal or gastric function and/or motility, resulting in impaired digestion, stasis, putrification, and passive (regurgitation) or active (vomiting) discharge of ingesta.
• Regurgitation typically is associated with an esophageal or pharyngeal problem.
• Gastroesophageal sphincter incompetence is a common gastric issue that causes regurgitation.
• Both vomiting and regurgitation are symptoms of an underlying problem, not diseases themselves.
Treatment 
Therapeutic Goals
Acute General Treatment
• Fluid therapy (starting at 10-30 mL/kg/24h) and monitoring of hematocrit, electrolytes, and uric acid (urea in aquatic species)
• Administration of antibacterial or antiparasitic drugs if these pathogenic organisms are found
Good initial choices (pending culture and sensitivity) would include combination therapy, such as a quinoline or aminoglycoside, and a third- or fourth-generation cephalosporin or penicillin.
For example, enrofloxacin (10 mg/kg IM, SC, PO every 24-48 hours) and ceftazidime (20-40 mg/kg IM or SC every 72 hours) or piperacillin (100-200 mg/kg IM or SC every 24-48 hours)
Or amikacin (5 mg/kg IM or SC initial dose followed by 2.5 mg/kg IM or SC every 72 hours) and ceftazidime (20-40 mg/kg IM or SC every 72 hours) or piperacillin (100-200 mg/kg IM or SC every24-48 hours)
Systemic antimicrobial regimens are continued for a minimum of 4 weeks. The length of treatment will be based on clinical response and follow-up evaluations.
Fenbendazole at 25 mg/kg PO q 7 days for 3 treatments. Posttreatment fecal examinations should be performed, and treatment repeated as necessary.
Cryptosporidium species are not susceptible to many of the older anticoccidials. Some empirical drugs and doses that may be used include:
Nitazoxanide (Navigator) 25 mg/kg PO q 24 h × 5 days, then 50 mg/kg PO q 24 h × additional 23 days. This drug has perhaps the most promise of any currently available anticryptosporidial based on mammalian data. Some data show that azithromycin in combination with nitazoxanide may be useful in mammals. See Cryptosporidiosis.
Entamoeba/amoeba (see Entamoebiasis):
Metronidazole 20-50 mg/kg orally every 2-3 days (3-5 doses) for clinically ill reptiles.
Colubrids (e.g., king snakes, milk snakes, indigo) and rattlesnakes may be more sensitive and should use the lower dose. Pharmacokinetic studies in green iguanas and yellow rat snakes recommended 20 mg/kg orally every 48 hours.
The effectiveness of specific gastrointestinal supportive medications (used in mammals) for esophagitis and gastritis is unknown in reptiles, and the doses are empirical.
However, used in conjunction with specific treatments based on diagnostic results, these medications may help to provide comfort from gastrointestinal distress in reptile patients.
Prognosis and Outcome 
With appropriate supportive care, dietary management, and chemotherapeutics, the prognosis for acute vomiting is good but guarded if chronic and long-standing.
Pearls & Considerations 
Comments
• Assisted or force feeding without restoring natural physiologic parameters can be detrimental.
• If the underlying cause can be accurately identified, the symptoms of regurgitation and vomiting can be eliminated.
• Snakes with cryptosporidiosis vomit infrequently.
• Reiterate that regurgitation and vomiting are symptoms, not a disease.
Funk, RS. Vomiting and regurgitation. In: Mader DR, ed. Reptile medicine and surgery. ed 2. Philadelphia: WB Saunders; 2006:939–940.
Mitchell, MA, et al. Clinical reptile gastroenterology. Vet Clin North Am Exot Anim Pract. 2005; 8:277–298.
Regal, PJ. Thermophilic response following feeding of certain reptiles. Copeia. 1966; 3:588–590.