Cryptosporidium and Microsporidia are major opportunistic pathogens in individuals with HIV, frequently causing gastrointestinal manifestations. Molecular identification of these parasites provides crucial insights into their transmission dynamics, clinical relevance, and zoonotic potential. This cross-sectional study investigated 275 HIV-infected patients in Alborz Province, Iran (2018-2020). Stool samples were examined using Ziehl-Neelsen and modified trichrome staining, followed by PCR amplification and sequencing of the 18S rRNA and GP60 genes for Cryptosporidium spp., and the ITS region for Enterocytozoon bieneusi and Encephalitozoon intestinalis. Associations between parasitic infections and demographic/clinical variables were analyzed using univariate and multivariable methods. Molecular analysis identified Cryptosporidium spp. in 7.6% and Microsporidia in 9.1% of patients, including E. bieneusi (6.5%), E. intestinalis (2.5%), and mixed infections (1.8%). Subtyping revealed that C. parvum (5.8%) predominantly belonged to subtype family IId (IIdA20G1, IIdA19G1), while C. hominis (1.8%) was IdA15G1. E. bieneusi genotypes D, Peru6, and J were detected-genotype J being reported for the first time in Iranian HIV-positive patients. Infections were significantly associated with clinical symptoms including chronic diarrhea, abdominal pain, vomiting, and fever. The highest rates of infection were found among patients with CD4 + counts < 200 cells/µL, no history of ART, animal contact, and use of well water. This study highlights the clinical and epidemiological significance of Cryptosporidium, E. bieneusi, and E. intestinalis in HIV-infected individuals. The identification of zoonotic genotypes and their association with gastrointestinal symptoms and immunosuppression emphasizes the need for routine molecular screening, targeted public health interventions, and adoption of One Health strategies to control transmission.

Longitudinal study of chronic nausea and vomiting and its associations with sleep-related leg cramps in the US general population

Diagnosis and management of chronic nausea and vomiting

Rapunzel syndrome is a rare form of gastric trichobezoar that extends into the small intestine, most diagnosed in adolescent girls with compulsive disorders such as trichotillomania and trichophagia. We report the case of a 13-year-old girl treated at the University Hospital of Oran, highlighting the anesthetic, surgical, and psychiatric aspects of her management. The patient presented with chronic abdominal pain, recurrent vomiting, and progressive weight loss. Imaging revealed a large trichobezoar extending to the jejunum. Preoperative optimization included rehydration, correction of electrolyte imbalances, and nutritional support. Laparoscopic extraction was performed under general anesthesia, with careful airway management due to the risk of aspiration. Postoperative care involved intensive monitoring, gradual refeeding, multimodal analgesia, and early psychiatric intervention to prevent recurrence. This case underscores the importance of a multidisciplinary approach to optimize patient outcomes.

Nausea exacerbations in patients with gastroparesis and functional dyspepsia (FD) require the use of rescue medications with concomitant adverse effects. We hypothesized that non-invasive vagal nerve stimulation (nVNS) may provide an effective and safer alternative for such symptoms. This pilot study included 41 patients with chronic nausea, attributed to gastric etiology with or without delayed gastric emptying. After a one-week observation period, patients self-administered nVNS for exacerbations of nausea: 4weeks on one side of the neck (left or right based on the patient's preference), followed by a 2-week washout and then another 4weeks of nVNS on the other side. The primary endpoint was a reduction in the use of anti-nausea rescue medications. Compared to baseline, nVNS reduced the average number of rescue medications used per day by half. The initial side of stimulation did not appear to influence the outcome. Although the use of nVNS in this study was not designed to influence chronic sustained symptoms, robust changes were also seen in abdominal pain, reflux, indigestion, constipation, depression, and some autonomic symptoms. Paradoxically, daily vomiting episodes increased during the 4-week period after nVNS was initiated but remained steady thereafter. "As-needed" nVNS may reduce the use of rescue medications for exacerbations of nausea. Additionally, several relatively unexpected benefits across a variety of other symptoms were observed. These results should inform larger randomized sham-controlled trials in these disorders with limited therapeutic alternatives. gov registration number NCT04857281. Date of registration, 2021-04-20.

BackgroundFunctional gastrointestinal disorders, including mostly functional dyspepsia (FD) and irritable bowel syndrome, are highly prevalent in human patients. FD is a complex condition in human gastroenterology and is characterized by abdominal discomfort, epigastric pain or burning, postprandial fullness, or early satiety. To our knowledge, such a syndrome, in the absence of organic, metabolic, or systemic causes, has not been reported in dogs. We aimed to provide a comprehensive description of the presentation of suspected canine functional dyspepsia in a retrospective case series. All records of dogs suspected of having dyspeptic clinical signs were studied. Laboratory data, imaging results and gastroscopic findings unlikely to explain the intensity of clinical signs were mandatory for inclusion.ResultsTwenty-nine dogs were retrospectively enrolled. All presented with signs of gastrointestinal discomfort but results from bloodwork, abdominal ultrasonography, endoscopy, and histopathology did not fully account for the severity of the clinical signs observed. FD was found to predominantly affect females (66%) and was most associated with vomiting (97%), abdominal pain (58%), intermittent diarrhoea (52%), pica (52%), compulsive chewing behaviours (48%), and belching or excessive yawning (41%), along with other signs of upper gastrointestinal discomfort. The median duration of clinical signs was 1.5 years, with a median age of onset also at 1.5 years. Various treatments were attempted with varying success, including dietary changes, antacids, prokinetics, and steroids. Follow-up data were available for 21 dogs, of which 76% demonstrated clinical improvement over a median follow-up period of 12 months. Interestingly, anxiety disorder of the owner was commonly reported.ConclusionsFunctional dyspepsia is a clinically emerging functional gastrointestinal disorder in dogs, especially in toy and small breed, middle-aged, female dogs, characterized by chronic gastrointestinal discomfort and vomiting in the absence of confirmed organic disease. The clinical picture of intense abdominal crisis with highly involved and anxious owners is out of step with the results of investigations. Overlap with food-responsive enteropathies, immunosuppressant-responsive enteropathies, or gastroduodenal dysmotility disorders is still of concern, potentially triggered by emotional disorders. Canine FD could reflect a gut-brain axis disturbance and should be included in the differential diagnosis of refractory canine upper digestive disorders. Tailored therapeutic approaches, including dietary modifications, antacids, and prokinetic agents, may offer clinical benefit.

BackgroundCesarean section (CS) is one of the most frequently performed surgical procedures worldwide. Spinal anesthesia (SA) has become the preferred anesthesia technique for CS due to its advantages over general anesthesia, including better maternal hemodynamic stability and improved neonatal outcomes. However, maternal knowledge and attitudes toward SA significantly influence decision making and perioperative experiences. This study aimed to assess the knowledge, awareness, and attitudes of Palestinian women toward SA during CS.MethodsA cross-sectional study was conducted among Palestinian women aged 18–60 years who met the inclusion criteria and voluntarily provided informed consent. Data were collected using a structured, validated questionnaire distributed through social media platforms and maternity wards in Palestinian hospitals. A sample size of 384 participants was calculated using OpenEpi, with a 95% confidence level and a 5% margin of error. Statistical analysis was performed using SPSS version 26.ResultsA total of 415 Palestinian females were included. The mean age was 27.3 ± 6.8 years. More than half expressed a preference for spinal anesthesia (SA) over general anesthesia (GA) for cesarean delivery. Knowledge levels were generally low, with less than 10% demonstrating high awareness. Although 63% had heard of regional anesthesia, fewer were familiar with SA specifically. Misconceptions were frequent; the majority failed to identify the correct injection site, and over half were unaware that SA could be used during active labor. While most participants recognized that SA allows maternal consciousness during surgery, less than one-third correctly identified its reduced fetal exposure compared to GA. Among those expressing concerns, the most commonly reported barriers were fear of chronic back pain, headaches, permanent paralysis, painful injection, intraoperative awareness, nausea or vomiting, and hypotension.ConclusionAlthough a significant proportion of Palestinian women were willing to receive spinal anesthesia, many exhibited concerns and misconceptions about its safety and effects. These findings highlight the need for improved patient education and counseling on SA to enhance maternal confidence and decision-making. Addressing these concerns through targeted awareness programs could lead to better patient experiences and outcomes in cesarean deliveries.

Median Arcuate Ligament Syndrome: The Past and the Future.

IntroductionCannabinoid Hyperemesis Syndrome (CHS) is a condition associated with long-term cannabis use, marked by recurrent episodes of nausea, vomiting and abdominal pain, typically relieved by hot showers—a nearly pathognomonic feature. It often develops after years of heavy cannabis use, with symptoms recurring cyclically every few weeks to months while the individual continues to use cannabis. Symptom resolution is generally observed after cessation. Though cannabis is commonly used to relieve nausea (as in chemotherapy-induced vomiting), in susceptible individuals, prolonged use paradoxically induces these symptoms, presenting a diagnostic and therapeutic challenge. Recognizing CHS is increasingly important as global cannabis consumption rises.ObjectivesThe aim of this study is to review the clinical presentation of CHS, highlighting key diagnostic features, current management strategies and treatment.MethodsA comprehensive case report of a 27-year-old female with a history of heavy cannabis use was conducted. She presented with severe nausea and vomiting for two weeks following reported cannabis cessation. A thorough clinical evaluation was undertaken to better understand the clinical presentation of CHS. Additionally, a literature review was performed using PubMed to gather relevant clinical articles on CHS.ResultsThe patient exhibited hallmark features of CHS, including a prolonged history of cannabis use beginning in adolescence, recurrent episodes of severe nausea, vomiting, abdominal pain, the typical compulsive use of hot showers for symptom relief and lack of response to conventional antiemetic treatments. These features, combined with the patient’s lack of motivation to discontinue cannabis despite symptom recurrence, strongly support the diagnosis of CHS. Although she had a history of an eating disorder and presented with the Russell sign and dental damage consistent with chronic vomiting, no psychiatric comorbidities or body image disturbances were identified.ConclusionsCHS remains an under-recognized condition that poses diagnostic challenges. This case reinforces the need to inquire about cannabis use in patients presenting with cyclic vomiting, abdominal pain and weight loss. CHS symptoms and pathophysiological mechanisms can mimic other important diseases, such as eating disorders or gastrointestinal pathologies. Challenges in managing CHS include patient skepticism regarding the role of cannabis as a cause of symptoms, perceived benefits of cannabis and a lack of other effective therapies. Management of CHS involves both acute symptomatic treatment and long-term cessation of cannabis use. Acute interventions may include fluid resuscitation, haloperidol administration, and topical capsaicin application. However, the only definitive treatment is complete abstinence from cannabis, which leads to symptom resolution in the vast majority of cases.Disclosure of InterestNone Declared

Cannabis is a highly discussed topic in medicine today. From therapeutic applications in conditions such as chronic pain, multiple sclerosis, epilepsy, chemotherapy-induced nausea and vomiting, and inflammatory bowel disease to the growing prevalence of recreational use, cannabis remains at the forefront of medical and societal conversations. In this review, we will explore the history of marijuana use in medicine, examine the current evidence supporting its pharmacological benefits, and delve into its impact on the developing brain. Additionally, we will highlight the pivotal role pharmacists play in this evolving landscape and guide you through the latest research findings.

Ocimum sanctum L. also referred to as Tulsi, and Croton bonplandianus Baill., commonly referred to as Ban Tulsi or Jungle Tulsi, are two powerful medicinal herbs deeply rooted in traditional medicine, especially within the Indian subcontinent. This comprehensive review delves into the ethnobotanical properties and pharmacological activities of these remarkable plants. Tulsi, often hailed as the "Queen of Herbs," has long been revered for its versatile therapeutic characteristics. It is traditionally utilized to address a wide array of health issues, including chronic fever, dysentery, haemorrhage, vomiting, eye disorders, respiratory infections, diabetes, and gastric and hepatic disorders. Furthermore, Tulsi exhibits antifertility, anti-inflammatory, radiation protection, antibacterial, antioxidant, anticancer, as well as antifungal characteristics, making it a truly multifaceted medicinal herb. On the other hand, Jungle Tulsi is sought after for its efficacy in treating skin diseases, hypertension, wounds, diabetes, cancer, constipation, abdominal dropsy, and various infectious disorders. Like Tulsi, Jungle Tulsi also showcases a broad variety of pharmacological activities, that includes antifungal, hepatoprotective, wound healing, antimicrobial, antioxidant, and anti-inflammatory properties. Given pressing challenge of multidrug-resistant microbial strains, the exploration of novel plant-based antimicrobial agents is more crucial than ever. Tulsi and Jungle Tulsi emerge as promising sources due to their broad-spectrum pharmacological activities. However, further research, including clinical trials and mechanistic studies, is essential to fully unravel the therapeutic potential of these herbs and to develop standardized, safe, and effective herbal formulations.

A 52-year-old female was admitted to the hospital with chronic diarrhoea, vomiting, and weight loss. She also reported dyspnea on exertion, palpitation, and hypertension. She had recently been diagnosed with Grave’s thyrotoxicosis with carbimazole-induced agranulocytosis with lithium toxicity. Physical examination revealed signs of thyrotoxicosis with right heart failure with atrial fibrillation. Thyroid gland examination revealed a diffuse, firm, nontender goiter. On cardiovascular examination, a grade III pansystolic murmur in the mitral area was found. ECG showed atrial fibrillation. Transthoracic echocardiography showed a flail posterior mitral leaflet (PML) with severe mitral regurgitation (MR). After initial conservative treatment, radioactive iodine ablation was done and her dyspnea, leg edema and diarrhoea gradually improved and she achieved stable thyroid and cardiac function with β blocker only. A follow-up visit after 6 months documented the absence of cardiac symptoms. There were no murmurs clinically and only mild MR on echocardiography. This case demonstrates the importance of cardiac evaluation in hyperthyroidism as treatment of thyroid abnormalities can reverse these cardiac manifestations. J Assoc Clin Endocrinol Diabetol Bangladesh, January 2023; 2 (1): 24-27

ObjectivesThis study aimed to assess the prevalence of hypocobalaminaemia (B12 <400 pg/ml) and hypercobalaminaemia (B12 >1000 pg/ml), describe the clinicopathological abnormalities and the diagnostic imaging findings in a referral population of cats in the UK, and identify the underlying disease processes associated with both conditions.MethodsA retrospective study of cats that had their serum cobalamin concentration assessed between December 2016 and December 2023 at a single referral hospital; 216 cats were included. Patient outcome was established from the clinical records.ResultsA total of 76 (35%) cats had hypocobalaminaemia and 67 (31%) cats had hypercobalaminaemia. The most common diagnoses were chronic enteropathy (CE) in 39/76 (51%) hypocobalaminaemic cats and 39/67 (58%) hypercobalaminaemic cats (P = 0.001), and high-grade lymphoma in 14/76 (18%) hypocobalaminaemic cats and 11/67 (16%) hypercobalaminaemic cats (P = 0.438). The most common clinical signs were chronic vomiting in 36/76 (47%) hypocobalaminaemic cats and 24/67 (36%) hypercobalaminaemic cats (P = 0.005), hyporexia in 40/76 (53%) hypocobalaminaemic cats and 21/67 (31%) hypercobalaminaemic cats (P <0.001), and chronic diarrhoea in 12/76 (16%) hypocobalaminaemic cats and 21/67 (31%) hypercobalaminaemic cats (P = 0.001). The most common abnormalities identified on abdominal ultrasound were lymphadenomegaly and thickened intestines in 49/76 (64%) hypocobalaminaemic cats and 28/67 (42%) hypercobalaminaemic cats (P = 0.0025). Median survival time was 274 days in the hypocobalaminaemic group and 711 days in the hypercobalaminaemic group (P = 0.001). The hypocobalaminaemic cats exhibited significantly reduced survival time compared with hypercobalaminaemic cats (odds ratio 2.4 vs 0.4, respectively) (P <0.001).Conclusions and relevanceThis study suggests that cobalamin has limited diagnostic utility in differentiating between underlying disease processes; chronic diarrhoea and CE are more common in hypercobalaminaemic cats in contrast with the previous literature. Hypocobalaminaemia is associated with reduced survival in this cohort of cats; therefore, early cobalamin supplementation is recommended.

Background: Mitochondrial neurogastrointestinal encephalomyopathy (MNGIE) is an ultrarare autosomal recessive metabolic disorder caused by mutations in the TYMP gene. The reported endocrine manifestations include diabetes, hyperlipidemia, and hypertriglyceridemia. However, growth hormone deficiency has not been previously described in the literature. Case presentation: This case describes a 19-year-old male with genetically confirmed MNGIE who presented with severe malnutrition (BMI 10.9 kg/m²) requiring total parenteral nutrition (TPN). Initially, he was developing normally, then the patient began experiencing chronic abdominal pain, vomiting, and diarrhea at age 11, along with noticeable short stature. Despite normal insulin-like growth factor 1 (IGF-1) levels, growth hormone deficiency was diagnosed through suboptimal responses to glucagon and clonidine stimulation tests. At age 13, he underwent duodenojejunostomy for superior mesenteric artery (SMA) syndrome, but symptoms persisted. Diagnostic workup, including endoscopy, imaging, and serological tests, excluded inflammatory bowel disease and celiac disease. Genetic testing confirmed a homozygous pathogenic mutation in the TYMP gene (p.Gly145Arg). Brain MRI revealed leukoencephalopathy with T2 and FLAIR hyperintensities in the centrum semiovale and parietal regions, which was consistent with MNGIE. Despite TPN therapy, the patient’s condition continues to progress, highlighting the need for early diagnosis and multidisciplinary management in MNGIE. Conclusion: This case highlights a novel presentation of growth hormone deficiency in MNGIE, offering new insights into its endocrine involvement. Despite treatment with somatotropin and TPN, patients’ nutritional improvement has remained limited, underscoring the need for more targeted therapies. Future research should focus on the link between mitochondrial dysfunction and endocrine abnormalities in MNGIE.

Background: Upper gastrointestinal tract (GIT) disorders in dogs are a significant concern in veterinary medicine, as they can lead to various clinical manifestations ranging from mild discomfort to severe systemic illness. The upper GIT encompasses the oesophagus, stomach and duodenum, with disorders affecting these organs potentially resulting in symptoms such as vomiting, inappetite and dehydration. Given the wide range of possible conditions that can affect the upper GIT in dogs, early and accurate diagnosis is essential to initiate appropriate treatment and management strategies. The present study investigated the affections of GIT in dogs. Methods: During the study period, from May to October 2024, 2042 dogs were screened, presented at VCC, College of Veterinary Science and Animal Husbandry, Jabalpur (M.P.). Among them, 132 dogs were suspected of having GIT affections, out of which 30 dogs were selected for radiographic, abdominal sonography and endoscopic examination in which 28 dogs were confirmed to have upper GIT affections. Result: The overall occurrence of upper GIT affections in dogs was recorded as 01.37% and among the suspected dogs, it was 21.21%. The most consistent clinical signs observed were chronic vomiting (100%), followed by inappetite (92.86%), dehydration (89.29%), retching (57.14%), haematemesis (32.14%), weight loss (28.57%), ptyalism (21.43%) and dysphagia (10.71%). The ultrasonographic, radiographic and endoscopic examination revealed higher occurrence of chronic gastritis 50.00% (14/28) followed by gastric ulcers and erosions 35.71% (10/28), gastric foreign body 10.71% (3/28), oesophagitis 07.14% (2/28), megaoesophagus 03.57% (1/28) and sialocele 03.57% (1/28).

Chronic gastroduodenal disorders are more prevalent among young women, many of whom are hormonal contraception users. We aimed to evaluate the effects of hormonal contraception on symptom severity and gastric myoelectrical activity in people with chronic gastroduodenal disorders. This analysis was conducted on a large international cohort of patients who met Rome IV criteria for chronic nausea and vomiting syndrome or functional dyspepsia and had undergone body surface gastric mapping using Gastric Alimetry. Symptoms were continuously reported on 0-10 Likert scales using a validated symptom logging app. One hundred twenty-seven people were included: 43 women using hormonal contraception, 30 not using hormonal contraception, 30 postmenopausal women, and 24 men. Hormonal contraception users had higher nausea than nonusers (3.80 [interquartile range 2.00-5.42] vs 2.25 [0.20-4.43]; P < 0.05), particularly when using combined oral contraceptives with hormone-free intervals compared with continuous use (5.20 [4.30-6.00] vs 2.40 [1.70-3.80], P = 0.02). Premenopausal women were more symptomatic than postmenopausal women and men ( P < 0.001). Principal Gastric Frequency was higher in hormonal contraception users (median 3.1 cpm vs 3.00 cpm, P < 0.001) and highest with progestogen-only formulations ( P < 0.02). Women with gastroduodenal disorders on hormonal contraception experience increased nausea in comparison with nonusers, with substantial variation dependent on contraceptive type. Hormonal contraception users also demonstrated modified gastric electrophysiology. These results imply that nonhormonal contraceptive alternatives should be trialled as a means to reduce symptoms in gastroduodenal disorders.

Abstract Superior mesenteric artery syndrome is a rare condition that causes duodenal obstruction due to compression by the superior mesenteric artery and the aorta. It can be related to congenital or acquired factors that reduce the aortomesenteric angle and distance. The clinical presentation is nonspecific and often mimics other causes of upper gastrointestinal obstruction. The diagnosis requires a high index of suspicion and a correlation of clinical symptoms with radiographic findings. We report a case of a 17-year-old female patient who presented with chronic abdominal pain, vomiting, and weight loss. She was diagnosed with superior mesenteric artery syndrome based on an abdominal computed tomography scan that showed a reduced aortomesenteric angle of 30° and a reduced aortomesenteric distance of 7 mm. She was treated conservatively with anticoagulation therapy, dietary modification, and physical activity. She reported symptom improvement and weight gain after 2 weeks of treatment. This case illustrates the challenges and pitfalls in diagnosing superior mesenteric artery syndrome.

Gastroparesis is a symptomatic chronic stomach disease characterized by objective sings of delayed gastric emptying in the absence of mechanical obstruction. Gastroparesis is rarely documented in routine clinical practice. This disease is usually suspected, examined and diagnosed in patients with a syndrome of intense and prolonged nausea, vomiting, early satiety, epigastric pain, which occur as a result of muscular, nervous or rhythmic abnormalities of gastric functioning. Although delayed gastric emptying is a determining feature of gastroparesis, other aspects of gastric neuromuscular dysfunction, such as maladaptation and visceral hypersensitivity, may also contribute to the symptoms of gastroparesis. The symptoms of gastroparesis often overlap with those of other functional gastrointestinal disorders, including chronic unexplained nausea and vomiting syndrome, cyclic vomiting syndrome, various impaired "gut-brain" interactions, and, first of all, functional dyspepsia. This article presents a review of different examinations in gastroparesis from a gastric motility perspective. In clinical gastroenterological practice, gastroparesis is considered one of the most complex conditions due to the disagreements regarding the definition, range of symptoms, diagnosis and optimal therapeutic strategy, particularly due to the lack of treatment methods with proven efficacy. The article reviews current data on epidemiology, etiologic factors, pathophysiological concepts, and substantiates the need for proper diagnosis of gastroparesis. The methods for treating functional gastroparesis such as diet therapy, prokinetics, antiemetics and symptom relief drugs are described in detail. In addition, the rationale for the use of itopride prokinetic and rebamipide gastroprotector is presented.

Nausea can coexist in functional dyspepsia (FD) but the literature is poor in reporting whether this symptom is mainly triggered by meal ingestion. Moreover, the prevalence of nausea in FD is understudied. Adult patients with a disorder of gut-brain interaction (DGBI) recruited in secondary and tertiary care facilities completed the enhanced Asian Rome IV questionnaire with additional questions to address the relationship between nausea and food intake. A comparison of nausea and the prevalence of meal-related nausea was made among FD subgroups and with chronic nausea and vomiting syndrome (CNVS), both according to Rome IV criteria. Of the 1075 DGBI patients that completed the survey, 443 were classified as having FD and 44 other patients fulfilled diagnostic criteria for CNVS. The PDS-EPS overlap group had a higher prevalence of nausea compared to PDS and EPS patients. In PDS patients with nausea, nausea was significantly more often meal-related (than in PDS-EPS overlap, EPS, and CNVS patients). All patients with meal-related nausea reported that nausea started mostly (> 85% of times) within 60 min after the meal. When comparing western and eastern participating centers, nausea was more prevalent in patients from western sites. Nausea is a highly prevalent symptom in FD with a higher prevalence in the PDS-EPS overlap group. However, meal-related nausea is more common in PDS. The pathophysiology of nausea in FD and its implication for medical treatment require further studies.

Abstract A 4‐year‐old, female, neutered Chihuahua cross was presented with a history of chronic apparent vomiting and coughing. Upon further questioning, regurgitation was suspected rather than vomiting. Conscious thoracic radiographs revealed generalised megaoesophagus. The dog was diagnosed with focal myasthenia gravis based on a positive acetylcholine receptor antibody titre 2.33 nmol/L (&lt;0.6 nmol/L). The dog responded to pyridostigmine treatment (0.5 mg/kg every 12 hours, increasing to 1.6 mg/kg every 12 hours) with reduced frequency of regurgitation episodes. In this case, differentiation between vomiting and regurgitation was crucial for appropriate diagnostic testing and treatment. Pyridostigmine is the treatment of choice for both focal and generalised myasthenia gravis. The dose must be titrated to control clinical signs in both forms of the disease.