DISEASES OF THE ESOPHAGUS

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DISEASES OF THE ESOPHAGUS

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Approach to Esophageal Disease

• Obstructive lesions
• Stricture, foreign body, vascular ring anomaly
• Motility disorders
• Megaesophagus, hiatal hernia
• Inflammatory disease
• Esophagitis
• Miscellaneous
• Diverticulum, perforation

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General Approach to Esophageal Disorders

• D Degenerative
• A Anomaly, Anatomic
• M Metabolic
• N Neoplastic, Nutritional
• I Inflammatory, Infectious, Immune, Idiopathic
• T Traumatic, Toxic

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DAMN IT Approach to Esophageal Disorders

• D
• A Megaesophagus, Foreign body, Vascular ring
  anomaly, Hiatal hernia
• M
• N Squamous cell carcinoma, other neoplasia
• I Esophagitis (due to gastric acid reflux)
• T Stricture, Trauma (caustic substance
  ingestion)

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DAMN IT Approach to Megaesophagus

• D
• A Congenital megaesophagus, secondary to
  stricture or vascular ring anomaly
• M Addisons, hypothyroidism?
• N Neurologic, secondary to neoplasia
• I Esophagitis, SLE, idiopathic
• T Lead toxicity

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Anatomy and Physiology

• Function is transport of food, water, and saliva
  from mouth to stomach
• Lies to the left of the cervical trachea
• Upper esophageal sphincter
• Prevents reflux of ingesta from esophagus
• Body of esophagus innervated by vagus nerve
• Dog - skeletal muscle only
• Cat - increasing amounts of smooth muscle in
  distal third

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

• Lower esophageal sphincter
• Prevents reflux of ingesta and gastric acid into
  esophagus
• Primary peristaltic waves initiated by
  oropharyngeal phase of swallowing
• move ingesta through UES down to stomach
• Secondary peristaltic waves stimulated by
  remaining intraluminal ingesta

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Signs of Esophageal Disease

• regurgitation
• dysphagia
• odynophagia
• ptyalism
• exaggerated swallowing
• polyphagia /- weight loss
• signs of secondary complications (aspiration
  pneumonia)

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Signs associated with oropharyngeal and/or
proximal esophageal disorders

• Odynophagia
• Ptyalism
• Exaggerated swallowing

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Regurgitation vs.Vomiting

• passive food rolls out
• expulsion of food or fluid from the esophagus
• influenced by mechanical events in the esophagus

• active preceded by hypersalivation, retching,
  and abdominal contractions
• contents of stomach and duodenum
• centrally-mediated reflex

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Regurgitation vs. Vomiting

• undigested food
• tubular
• white to clear frothy liquid (mucus and saliva)
• fresh blood
• putrefaction of food
• /- immediately after eating

• partially digested food
• unformed
• bile-stained liquid
• coffee-grounds appearance to blood
• low pH
• timing variable in relation to eating

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Tubular Appearance to Regurgitated Food
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Review

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

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Review

• What is the most reliable way to differentiate
  between vomiting and regurgitation?
• Active (retching, heaving, abdominal
  contractions.) vs. passive event (rolls out)

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Diagnosis of Esophageal Disease

• Signalment
• breed and age

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Diagnosis of Esophageal Disease

• History
• events that preceded onset (foreign body or
  chemical exposure, recent anesthesia or
  nasogastric tube)
• onset and duration
• signs intermittent or consistent?
• systemic neuromuscular signs present?
• are both vomiting and regurgitation occurring?

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Physical Examination

• Normal oral exam? Severe halitosis? Pain on
  swallowing?
• Mass, foreign body, or distension of cervical
  esophagus?
• Nasal discharge, cough, pulmonary crackles, or
  fever (aspiration pneumonia)?
• Profound weight loss? (seen with chronic, severe
  esophageal disease)

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Clinical findings that may be associated with
megaesophagus

• Horner's syndrome and/or noncompressible cranial
  thorax with a cranial mediastinal mass
• muscle weakness, atrophy, or pain with
  generalized neuromuscular disease
• neurologic deficits with primary CNS disease

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Important Diagnostic Test Observe the Animal
Eating
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Other Diagnostics

• Radiography
• survey films
• barium swallow
• flat films
• fluoroscopy (referral centers)
• Endoscopy
• diagnostic and/or therapeutic
• Tracheal wash (if aspiration pneumonia is
  suspected)

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Major Esophageal Disorders

• Megaesophagus
• idiopathic
• secondary
• Foreign body
• Esophagitis
• PRAA
• Hiatal hernia

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Megaesophagus
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Megaesophagus Definitions

• Esophageal hypomotility a decrease in esophageal
  tone or peristalsis that may be segmental or
  diffuse
• Megaesophagus term used when a diffuse severe
  motility disorder results in a large flaccid
  esophagus
• idiopathic (congenital or acquired)
• secondary

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Approach to Megaesophagus

• D
• A Congenital megaesophagus, secondary to
  stricture or vascular ring anomaly
• M Addisons, hypothyroidism?
• N Neurologic, secondary to neoplasia
• I Esophagitis, SLE, idiopathic
• T Lead toxicity

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Breed Predisposition to Congenital Megaesophagus

• INHERITED
• Wirehaired fox terrier
• Miniature schnauzer
• Note megaesophagus is rare in cats

• SUSPECTED TO BE INHERITED
• Great Dane
• German shepherd
• Labrador retriever
• Newfoundland
• Shar pei
• Irish Setter
• Siamese cats

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Important Causes of Secondary Megaesophagus

• Myasthenia gravis
• Lead poisoning
• Hypoadrenocorticism
• Hypothyroidism (?)
• SLE
• Polyneuropathy
• Polymyopathy

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Specific Diagnostic Testing

• Acetylcholine receptor antibody titer
• Tensilon test
• Blood lead concentration
• ACTH stimulation test
• T3, T4, FT4
• FANA
• EMG, muscle biopsy

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Treatment of Megaesophagus

• treat primary disease if one is found
• small frequent meals with the animal in an
  upright position
• experiment with foods of differing consistency
  (gruel/bolus/Bil-Jac)
• feeding tube if severely malnourished
• treat aspiration pneumonia early detection is
  key
• no prokinetic drug therapy has proven effective

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Megaesophagus with Aspiration Pneumonia
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Megaesophagus Prognosis

• Some dogs with congenital megaesophagus may
  improve in time with diligent supportive care
• Idiopathic acquired megaesophagus is usually
  irreversible. With attentive supportive care some
  animals live for months to years
• Aspiration pneumonia is the most common cause of
  death

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Esophageal Foreign Bodies

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Treat Esophageal Foreign Bodies as Emergencies!!!

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Esophageal Foreign Bodies

• Lodge at narrowed areas of the esophagus
• 1. Thoracic inlet
• 2. Base of the heart
• 3. Hiatus of the diaphragm

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Common Esophageal Foreign Bodies

• Bones
• Rawhide chews
• Needles (cats)
• Fish hooks
• String
• Toys
• Hairballs (cats)

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Clinical Signs

• Ptyalism
• Anorexia
• Apparent pain
• Exaggerated swallowing
• Regurgitation
• Signs may be minimal

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Radiographic Diagnosis
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Diagnostic Evaluation

• Usually a straightforward diagnosis on survey
  and/or contrast radiographs
• Use organic iodide for contrast radiography if
  perforation is suspected
• Use esophagoscopy to confirm the diagnosis and
  for treatment

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Treatment

• Use esophagoscopy to remove the object and assess
  mucosal damage
• Extract orally if this can be done with minimal
  trauma
• Advance the object into the stomach
• Bones and rawhides usually dissolve once in the
  stomach
• Remove other objects via gastrotomy
• Be alert for complications such as perforation
  and mediastinitis, esophageal stricture, and
  bronchoesophageal fistula
• Avoid esophageal surgery if at all possible

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Esophagitis

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Causes of Esophagitis

• Foreign bodies
• Caustic or irritating substances
• Thermal injury from overheated (microwaved) food
• Gastroesophageal (GE) reflux secondary to general
  anesthesia, persistent vomiting, hiatal hernia,
  or indwelling nasogastric or esophagostomy tubes

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GE Reflux under Anesthesia Predisposing Factors

• Some preanesthetic agents (anticholinergics and
  tranquilizers)
• Prolonged fasting
• Age
• Increased pressure during intra-abdominal
  surgical manipulation (vs. extra-abdominal
  procedures)

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Perpetuation of Esophagitis

• GE reflux from any cause can result in
  esophagitis
• Esophagitis can impair esophageal motility
• Poor motility delays acid clearance from distal
  esophagus -gt perpetuates esophagitis
• Local inflammation can reduce LES tone, allowing
  more GE reflux

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Clinical Signs of Esophagitis

• Regurgitation
• Anorexia /- apparent hunger
• Vomiting episode followed by development of
  regurgitation suggests esophagitis has developed
• Partial stricture may develop allowing liquids to
  be retained better than solids

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Radiographic Diagnosis of Esophagitis

• Survey radiographs usually normal occasionally
  small amounts of gas
• Contrast radiographs often normal mucosa may
  appear irregular

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Endoscopic Diagnosis of Esophagitis

• Endoscopic findings include
• Mucosal erythema
• Hemorrhage
• Increased friability
• Erosions or ulcers
• Open GE sphincter

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Mild Esophagitis
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Treatment of Esophagitis

• Frequent feedings of soft food severe cases may
  require a gastrostomy tube
• Metoclopramide (Reglan) to increase GE sphincter
  pressure
• Omeprazole to inhibit gastric acid secretion
• Antibiotics (such as ampicillin) are often
  administered but have no proven benefit

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Treatment, contd.

• Be prepared to refer to treat stricture by
  balloon catheter dilation

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Hiatal Disorders

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Types of Hiatal Disorders

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

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

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Gastroesophageal Intussusception
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Esophageal NeoplasiaSquamous Cell Carcinoma
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Vascular Ring AnomaliesPersistent right aortic
arch
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Case Taffy 4 y.o. F Great Dane
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Taffy History

• 3 month history of regurgitation 30-120 minutes
  after eating
• Ravenous appetite
• Weight loss

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Taffy Diagnostic Plan

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Taffy Diagnostic Plan

• CBC, Chemistry profile, (UA), fecal
• Ach receptor antibody titer
• ACTH stimulation test
• T4
• FANA
• Blood lead

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Taffy Outcome

• Diagnosis Idiopathic acquired megaesophagus
• Therapeutic plan
• Small frequent meals of canine growth diet
• Train to eat on stairs (elevated feeding)
• Teach owner to observe carefully for coughing,
  fever, or reduced appetite

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