Diseases of the esophagus (Proceedings)


Diseases of the esophagus (Proceedings)

Apr 01, 2008


Esophagitis may be caused by chemical injury from ingested substances, gastroesophageal reflux (secondary to general anesthesia, hiatal defects, persistent vomiting, malpositioned nasoesophageal/pharyngostomy tubes), or esophageal foreign bodies. Disturbances in esophageal motility may accompany esophagitis regardless of the cause. The reported prevalence of acute esophagitis is low; however, this is likely an underestimation due the subtlety of clinical signs and radiographic findings associated with this disorder. Clinical signs vary as to the type of chemical injury, severity of inflammation, and extent of esophageal involvement. Esophagitis is an endoscopic diagnosis that does not require mucosal biopsy. Mucosal abnormalities that may be observed include increased erythema, erosions, and alterations in mucosal texture. Lesions are usually evident in the distal esophagus, adjacent to and including the LES.

Treatment - Mild esophagitis frequently resolves with minimal treatment other than dietary management. Provide frequent, smaller-sized meals of a low-fat, high-protein content to enhance LES tone and to minimize reflux. Animals having more severe esophagitis will require drug therapy and gastrostomy tube feeding. Sulcralfate suspension (0.5-1.0 g PO TID) is the most beneficial and specific therapy for reflux esophagitis. Administer metoclopramide (0.1-0.2 mg/lb per os, SC, TID) or cisapride (0.05-0.25 mg/lb per os BID) to decrease esophageal reflux (by increasing LES pressure) and to promote gastric emptying. Gastric acid secretory inhibitors (ranitidine 0.5 -1.0 mg/lb PO or IV BID; famotidine 0.25-0.5 mg/lb PO SID; omeprazole 0.35 mg/lb PO SID) should be given to decrease acidity of gastric juice. The duration of drug therapy is empirical and varies with severity of signs and endoscopic lesions. Mild lesions are treated for 5-7 days; moderate-to-severe esophagitis is treated for 2-3 weeks. The prognosis in most cases of esophagitis is good with appropriate medical therapy. Animals having severe disease warrant a guarded prognosis as stricture or segmental or generalized hypomotility may occur.

Esophageal Foreign Bodies

Foreign bodies are a common cause for esophageal dysphagia in the dog but are rare in cats. They usually lodge at points of minimal esophageal distension including the thoracic inlet, at the base of the heart, or at the diaphragmatic hiatus. The most common objects ingested are bones, fish hooks, needles, sticks, and play toys. Retained foreign bodies cause partial or complete mechanical obstruction. Muscle spasm and tissue edema occur around the foreign body making passage of the object down the esophagus more difficult. Mucosal abrasion, laceration, and perforation may occur with sharp or angular objects which are lodged intraluminally. The severity of clinical signs is related to the size of the foreign body and duration of esophageal obstruction. Most dogs and cats with large esophageal foreign bodies are presented for evaluation of acute onset of regurgitation, dysphagia, odynophagia, gagging, and excessive salivation. Survey and contrast radiology show the presence of the foreign material, aspiration pneumonia and/or evidence of perforation. Esophagoscopy should be performed to confirm the diagnosis and to assess secondary mucosal damage.

Treatment - Esophageal foreign bodies are medical emergencies and should be promptly removed. Endoscopic removal of foreign bodies using a flexible instrument which accommodates a variety of retrieval (grasping) instruments is usually successful. Thoroughly evaluate the esophageal mucosa following foreign body extraction for hemorrhage, lacerations, and perforations. Obtain post-procedural thoracic radiographs to access for pneumomediastinum/pneumothorax. Restrict food or water for 24 hours depending on the extent of esophageal trauma. Animals with severe mucosal damage will require complete esophageal rest and gastrostomy tube feedings. Initiate medical therapy for esophagitis. Esophageal perforations are successfully treated with broad-spectrum antibiotics such as ampicillin (11 mg/lb SC, IM, IV TID). The prognosis after endoscopic foreign body removal is generally excellent. Significant esophageal trauma or large perforation carries a guarded prognosis.