diseases of the esophagus approach to esophageal disease

DISEASES OF

THE ESOPHAGUS

Approach to Esophageal Disease

Obstructive lesions Obstructive lesions Stricture, foreign body, vascular ring anomalyStricture, foreign body, vascular ring anomaly

Motility disorders Motility disorders MMegaesophagus, hiatal herniaegaesophagus, hiatal hernia

Inflammatory diseaseInflammatory disease EsophagitisEsophagitis

MiscellaneousMiscellaneous Diverticulum, perforationDiverticulum, perforation

General Approach to Esophageal Disorders

D = DegenerativeD = Degenerative A = Anomaly, AnatomicA = Anomaly, Anatomic M = MetabolicM = Metabolic N = Neoplastic, NutritionalN = Neoplastic, Nutritional

I = Inflammatory, Infectious, Immune, IdiopathicI = Inflammatory, Infectious, Immune, Idiopathic T = Traumatic, ToxicT = Traumatic, Toxic

DAMN IT Approach to Esophageal Disorders

DD A = Megaesophagus, Foreign body, Vascular ring A = Megaesophagus, Foreign body, Vascular ring

anomaly, Hiatal herniaanomaly, Hiatal hernia MM N = Squamous cell carcinoma, other neoplasiaN = Squamous cell carcinoma, other neoplasia I = Esophagitis (due to gastric acid reflux)I = Esophagitis (due to gastric acid reflux) T = Stricture, Trauma (caustic substance T = Stricture, Trauma (caustic substance

ingestion)ingestion)

DAMN IT Approach to Megaesophagus

DD A = Congenital megaesophagus, secondary A = Congenital megaesophagus, secondary

to stricture or vascular ring anomalyto stricture or vascular ring anomaly M = Addison’s, hypothyroidism?M = Addison’s, hypothyroidism? N = Neurologic, secondary to neoplasiaN = Neurologic, secondary to neoplasia I = Esophagitis, SLE, idiopathicI = Esophagitis, SLE, idiopathic T = Lead toxicityT = Lead toxicity

Anatomy and Physiology

Function is transport of food, water, and saliva Function is transport of food, water, and saliva from mouth to stomachfrom mouth to stomach

Lies to the left of the cervical tracheaLies to the left of the cervical trachea Upper esophageal sphincterUpper esophageal sphincter

Prevents reflux of ingesta from esophagusPrevents reflux of ingesta from esophagus Body of esophagus innervated by vagus nerveBody of esophagus innervated by vagus nerve

Dog - skeletal muscle onlyDog - skeletal muscle only Cat - increasing amounts of smooth muscle in distal Cat - increasing amounts of smooth muscle in distal

thirdthird

Normal Feline Esophagus (Herringbone pattern in distal 1/3)

Anatomy and Physiology

Lower esophageal sphincterLower esophageal sphincter Prevents reflux of ingesta and gastric acid into Prevents reflux of ingesta and gastric acid into

esophagusesophagus Primary peristaltic waves initiated by Primary peristaltic waves initiated by

oropharyngeal phase of swallowingoropharyngeal phase of swallowing move ingesta through UES down to stomachmove ingesta through UES down to stomach

Secondary peristaltic waves stimulated by Secondary peristaltic waves stimulated by remaining intraluminal ingestaremaining intraluminal ingesta

Signs of Esophageal Disease regurgitationregurgitation dysphagia dysphagia odynophagia odynophagia ptyalism ptyalism exaggerated swallowingexaggerated swallowing polyphagia +/- weight losspolyphagia +/- weight loss signs of secondary complications signs of secondary complications

(aspiration pneumonia)(aspiration pneumonia)

Signs associated with oropharyngeal and/or proximal esophageal disorders

OdynophagiaOdynophagia PtyalismPtyalism Exaggerated swallowingExaggerated swallowing

Regurgitation vs.Vomiting

passivepassive: food : food “rolls out”“rolls out”

expulsion of food expulsion of food or fluid from the or fluid from the esophagus esophagus

influenced by influenced by mechanical mechanical events in the events in the esophagus esophagus

active: active: preceded preceded by hypersalivation, by hypersalivation, retching, and retching, and abdominal abdominal contractions contractions

contents of contents of stomach and stomach and duodenumduodenum

centrally-mediated centrally-mediated reflex reflex

Regurgitation vs. Vomiting

undigested food undigested food tubulartubular white to clear white to clear

frothy liquid frothy liquid (mucus and saliva) (mucus and saliva)

fresh bloodfresh blood putrefaction of food putrefaction of food +/- immediately +/- immediately

after eating after eating

partially digested foodpartially digested food unformedunformed bile-stained liquidbile-stained liquid ““coffee-grounds” coffee-grounds”

appearance to bloodappearance to blood low pHlow pH timing variable in timing variable in

relation to eatingrelation to eating

“Tubular” Appearance to Regurgitated Food

Review

What is the most reliable way to What is the most reliable way to differentiate between vomiting and differentiate between vomiting and regurgitation?regurgitation?

Review

What is the most reliable way to What is the most reliable way to differentiate between vomiting and differentiate between vomiting and regurgitation?regurgitation?

Active (retching, heaving, abdominal Active (retching, heaving, abdominal contractions.) vs. passive event (“rolls out”)contractions.) vs. passive event (“rolls out”)

Diagnosis of Esophageal Disease SignalmentSignalment

breed and agebreed and age

Diagnosis of Esophageal Disease HistoryHistory

events that preceded onset (events that preceded onset (foreign body or foreign body or chemical exposure, recent anesthesia or nasogastric chemical exposure, recent anesthesia or nasogastric tube) tube)

onset and duration onset and duration signs intermittent or consistent? signs intermittent or consistent? systemic neuromuscular signs present?systemic neuromuscular signs present? are both vomiting and regurgitation are both vomiting and regurgitation

occurring?occurring?

Physical Examination

Normal oral exam? Severe halitosis? Normal oral exam? Severe halitosis? Pain on swallowing?Pain on swallowing?

Mass, foreign body, or distension of Mass, foreign body, or distension of cervical esophagus?cervical esophagus?

Nasal discharge, cough, pulmonary Nasal discharge, cough, pulmonary crackles, or fever (aspiration crackles, or fever (aspiration pneumonia)?pneumonia)?

Profound weight loss? (seen with Profound weight loss? (seen with chronic, severe esophageal disease)chronic, severe esophageal disease)

Clinical findings that may be associated with megaesophagus Horner's syndrome and/or Horner's syndrome and/or

noncompressible cranial thorax noncompressible cranial thorax with a cranial mediastinal masswith a cranial mediastinal mass

muscle weakness, atrophy, or pain muscle weakness, atrophy, or pain with generalized neuromuscular with generalized neuromuscular diseasedisease

neurologic deficits with primary neurologic deficits with primary CNS diseaseCNS disease

Important Diagnostic Test: Observe the Animal Eating

Other Diagnostics

RadiographyRadiography survey filmssurvey films barium swallowbarium swallow

flat filmsflat films fluoroscopy (referral centers)fluoroscopy (referral centers)

EndoscopyEndoscopy diagnostic and/or therapeuticdiagnostic and/or therapeutic

Tracheal washTracheal wash (if aspiration(if aspiration pneumonia is suspected)pneumonia is suspected)

Major Esophageal Disorders

MegaesophagusMegaesophagus idiopathicidiopathic secondarysecondary

Foreign bodyForeign body EsophagitisEsophagitis PRAAPRAA Hiatal herniaHiatal hernia

Megaesophagus

Megaesophagus: Definitions

Esophageal hypomotility: a decrease Esophageal hypomotility: a decrease in esophageal tone or peristalsis in esophageal tone or peristalsis that may be segmental or diffusethat may be segmental or diffuse

Megaesophagus: term used when a Megaesophagus: term used when a diffuse severe motility disorder diffuse severe motility disorder results in a large flaccid esophagusresults in a large flaccid esophagus idiopathic (congenital or acquired)idiopathic (congenital or acquired) secondarysecondary

Approach to Megaesophagus

DD A = Congenital megaesophagus, secondary A = Congenital megaesophagus, secondary

to stricture or vascular ring anomalyto stricture or vascular ring anomaly M = Addison’s, hypothyroidism?M = Addison’s, hypothyroidism? N = Neurologic, secondary to neoplasiaN = Neurologic, secondary to neoplasia I = Esophagitis, SLE, idiopathicI = Esophagitis, SLE, idiopathic T = Lead toxicityT = Lead toxicity

Breed Predisposition to Congenital Megaesophagus INHERITEDINHERITED

Wirehaired fox terrierWirehaired fox terrier

Miniature schnauzerMiniature schnauzer

* Note: megaesophagus * Note: megaesophagus is rare in catsis rare in cats

SUSPECTED TO BE SUSPECTED TO BE INHERITEDINHERITED

Great DaneGreat Dane

German shepherdGerman shepherd

Labrador retrieverLabrador retriever

NewfoundlandNewfoundland

Shar peiShar pei

Irish SetterIrish Setter

Siamese cats*Siamese cats*

Important Causes of Secondary Megaesophagus Myasthenia gravisMyasthenia gravis Lead poisoningLead poisoning HypoadrenocorticismHypoadrenocorticism Hypothyroidism (?)Hypothyroidism (?) SLESLE PolyneuropathyPolyneuropathy PolymyopathyPolymyopathy

Specific Diagnostic Testing

Acetylcholine receptor antibody titerAcetylcholine receptor antibody titer Tensilon testTensilon test

Blood lead concentrationBlood lead concentration ACTH stimulation testACTH stimulation test TT33, T, T44, FT, FT44

FANAFANA EMG, muscle biopsyEMG, muscle biopsy

Treatment of Megaesophagus

treat primary disease if one is foundtreat primary disease if one is found small frequent meals with the animal in an small frequent meals with the animal in an

upright positionupright position experiment with foods of differing experiment with foods of differing

consistency (gruel/bolus/Bil-Jac)consistency (gruel/bolus/Bil-Jac) feeding tube if severely malnourished feeding tube if severely malnourished treat aspiration pneumonia; early detection is treat aspiration pneumonia; early detection is

keykey no prokinetic drug therapy has proven no prokinetic drug therapy has proven

effectiveeffective

Megaesophagus with Aspiration Pneumonia

Megaesophagus: Prognosis

Some dogs with congenital Some dogs with congenital megaesophagus may improve in time megaesophagus may improve in time with diligent supportive carewith diligent supportive care

Idiopathic acquired megaesophagus is Idiopathic acquired megaesophagus is usually irreversible. With attentive usually irreversible. With attentive supportive care some animals live for supportive care some animals live for months to years months to years

Aspiration pneumonia is the most Aspiration pneumonia is the most common cause of deathcommon cause of death

Esophageal Foreign Bodies

Treat Esophageal Foreign Bodies as

Emergencies!!!

Esophageal Foreign Bodies

Lodge at narrowed areas of the esophagus Lodge at narrowed areas of the esophagus

1. Thoracic inlet1. Thoracic inlet

2. Base of the heart2. Base of the heart

3. Hiatus of the diaphragm3. Hiatus of the diaphragm

Common Esophageal Foreign Bodies BonesBones Rawhide chewsRawhide chews Needles (cats)Needles (cats) Fish hooksFish hooks StringString ToysToys Hairballs (cats)Hairballs (cats)

Clinical Signs

PtyalismPtyalism AnorexiaAnorexia Apparent painApparent pain Exaggerated swallowingExaggerated swallowing RegurgitationRegurgitation Signs may be minimalSigns may be minimal

Radiographic Diagnosis

Diagnostic Evaluation

Usually a straightforward diagnosis on survey Usually a straightforward diagnosis on survey and/or contrast radiographsand/or contrast radiographs

Use organic iodide for contrast Use organic iodide for contrast radiography if perforation is suspectedradiography if perforation is suspected

Use esophagoscopy to confirm the Use esophagoscopy to confirm the diagnosis and for treatmentdiagnosis and for treatment

Treatment

Use esophagoscopy to Use esophagoscopy to remove the object and remove the object and assess mucosal damageassess mucosal damage Extract orally if this can be done with minimal Extract orally if this can be done with minimal

traumatrauma Advance the object into the stomachAdvance the object into the stomach

Bones and rawhides usually dissolve once in the Bones and rawhides usually dissolve once in the stomachstomach

Remove other objects via gastrotomy Remove other objects via gastrotomy

Be alert for complications such as Be alert for complications such as perforation and perforation and mediastinitis, esophageal stricture, and mediastinitis, esophageal stricture, and bronchoesophageal fistulabronchoesophageal fistula

Avoid esophageal surgery if at all possibleAvoid esophageal surgery if at all possible

Esophagitis

Causes of Esophagitis

Foreign bodiesForeign bodies Caustic or irritating substancesCaustic or irritating substances Thermal injury from overheated Thermal injury from overheated

(microwaved) food(microwaved) food Gastroesophageal (GE) reflux Gastroesophageal (GE) reflux

secondary to general anesthesia, secondary to general anesthesia, persistent vomiting, hiatal hernia, or persistent vomiting, hiatal hernia, or indwelling nasogastric or indwelling nasogastric or esophagostomy tubesesophagostomy tubes

GE Reflux under Anesthesia: Predisposing Factors Some preanesthetic agents Some preanesthetic agents

(anticholinergics and tranquilizers)(anticholinergics and tranquilizers) Prolonged fastingProlonged fasting AgeAge Increased pressure during intra-Increased pressure during intra-

abdominal surgical manipulation abdominal surgical manipulation (vs. extra-abdominal procedures)(vs. extra-abdominal procedures)

Perpetuation of Esophagitis

GE reflux from any cause can result in GE reflux from any cause can result in esophagitisesophagitis

Esophagitis can impair esophageal motilityEsophagitis can impair esophageal motility Poor motility delays acid clearance from Poor motility delays acid clearance from

distal esophagus -> perpetuates esophagitisdistal esophagus -> perpetuates esophagitis Local inflammation can reduce LES tone, Local inflammation can reduce LES tone,

allowing more GE refluxallowing more GE reflux

Clinical Signs of Esophagitis

RegurgitationRegurgitation Anorexia +/- apparent hungerAnorexia +/- apparent hunger Vomiting episode followed by development Vomiting episode followed by development

of regurgitation suggests esophagitis has of regurgitation suggests esophagitis has developeddeveloped

Partial stricture may develop allowing Partial stricture may develop allowing liquids to be retained better than solidsliquids to be retained better than solids

Radiographic Diagnosis of Esophagitis

Survey radiographs usually Survey radiographs usually normal; occasionally small normal; occasionally small amounts of gas amounts of gas

Contrast radiographs often normal; Contrast radiographs often normal; mucosa may appear irregularmucosa may appear irregular

Endoscopic Diagnosis of Esophagitis

Endoscopic findings include:Endoscopic findings include: Mucosal erythemaMucosal erythema HemorrhageHemorrhage Increased friabilityIncreased friability Erosions or ulcersErosions or ulcers Open GE sphincterOpen GE sphincter

Mild Esophagitis

Treatment of Esophagitis

Frequent feedings of soft food; severe Frequent feedings of soft food; severe cases may require a gastrostomy tubecases may require a gastrostomy tube

Metoclopramide (Reglan) to increase Metoclopramide (Reglan) to increase GE sphincter pressureGE sphincter pressure

Omeprazole to inhibit gastric acid Omeprazole to inhibit gastric acid secretionsecretion

Antibiotics (such as ampicillin) are often Antibiotics (such as ampicillin) are often administered but have no proven administered but have no proven benefitbenefit

Treatment, cont’d.

Be prepared to refer to treat Be prepared to refer to treat stricture by balloon catheter stricture by balloon catheter dilationdilation

Hiatal Disorders

Types of Hiatal Disorders

1. Hiatal hernia - a protrusion of any 1. Hiatal hernia - a protrusion of any structure (usually distal esophagus structure (usually distal esophagus and stomach) through the and stomach) through the esophageal hiatus of the diaphragm esophageal hiatus of the diaphragm into the esophagusinto the esophagus can be intermittent (“sliding”)can be intermittent (“sliding”) most are congenital (Shar pei)most are congenital (Shar pei) treat as for esophagitis if symptomatictreat as for esophagitis if symptomatic

Sliding Hiatal Hernia

2. Gastroesophageal intussusception 2. Gastroesophageal intussusception - prolapse of the stomach (and - prolapse of the stomach (and occasionally spleen, proximal occasionally spleen, proximal duodenum, or omentum) into the duodenum, or omentum) into the distal lumen of the esophagusdistal lumen of the esophagus Rare surgical emergenciesRare surgical emergencies Reported in young male dogsReported in young male dogs

Gastroesophageal Intussusception

Esophageal Neoplasia:Squamous Cell Carcinoma

Vascular Ring Anomalies:Persistent right aortic arch

Case: “Taffy” 4 y.o. F Great Dane

“Taffy” : History

3 month history of regurgitation 30-120 3 month history of regurgitation 30-120 minutes after eatingminutes after eating

Ravenous appetiteRavenous appetite Weight lossWeight loss

“Taffy”: Diagnostic Plan

“Taffy”: Diagnostic Plan

CBC, Chemistry profile, (UA), fecalCBC, Chemistry profile, (UA), fecal Ach receptor antibody titerAch receptor antibody titer ACTH stimulation testACTH stimulation test TT44

FANAFANA Blood leadBlood lead

“Taffy”: Outcome

Diagnosis – Idiopathic acquired Diagnosis – Idiopathic acquired megaesophagusmegaesophagus

Therapeutic plan – Therapeutic plan – Small frequent meals of canine growth dietSmall frequent meals of canine growth diet Train to eat on stairs (elevated feeding)Train to eat on stairs (elevated feeding) Teach owner to observe carefully for coughing, Teach owner to observe carefully for coughing,

fever, or reduced appetitefever, or reduced appetite