Esophageal foreign bodies, esophagitis and strictures (Proceedings)


Esophageal foreign bodies, esophagitis and strictures (Proceedings)

Apr 01, 2009

Esophageal foreign bodies and esophagitis have the potential, if not identified and treated, to cause esophageal strictures or megaesophagus, which can be more difficult to treat. Failure to consider the possibility of regurgitation in the patient presented for vomiting could lead to delays in diagnosis, treatment errors, and undesired complications such as aspiration events, esophageal perforations and esophageal stricture formation. The common esophageal diseases of dogs and cats that are the focus of these notes, are esophageal foreign bodies, esophagitis, and esophageal strictures; megaesophagus, another important esophageal disease, has been discussed separately elsewhere. Less common, but still important, causes of esophageal disease include esophageal neoplasia and gastroesophageal intussusception.

Esophageal foreign bodies

The diagnosis of esophageal foreign bodies is often straightforward as most animals, particularly dogs, will have a history of foreign body ingestion witnessed by owners followed by typical clinical signs. Some animals, however, have no suggestive history, and in such patients, the diagnosis of an esophageal foreign body could be delayed if the clinician does not ask the right questions of an owner to arouse suspicion that the patient is actually regurgitating, and not vomiting, which is the most common owner complaint associated with esophageal foreign bodies. The author has seen dogs with esophageal foreign bodies that have been present for approaching 3 weeks, primarily because the attending clinician did not suspect that the patient was regurgitating and not vomiting. Once the suspicion of an esophageal foreign body is raised, confirmation of the diagnosis will often be evident on plain thoracic radiographs on which the foreign body will be seen. If needed, administration of a contrast agent can facilitate detection of an obstruction, but there is a risk of aspiration of contrast agent in patients with esophageal disease.

Esophageal foreign bodies are considered emergencies. The longer a foreign body resides in the esophagus, the greater the potential for complications such as aspiration pneumonia, esophageal perforation, or development of bronchoesophageal fistulas. Treatment of esophageal foreign bodies centers on removal of the foreign body. Endoscopic retrieval is possible in many, but not all, animals with foreign bodies. The preferred approach is to remove the foreign body orally as long as the foreign object can be securely grasped and advanced toward the oral cavity without inducing more serious injury. The author has used large (as large a diameter as the patient can safely accommodate) tubes with some length that are passed through the oral cavity into the esophagus, and then passed the endoscope through this "speculum" to help maneuver foreign bodies out of the esophagus, typically by drawing them partially into the tube. This strategy has proven successful for removal of bones and other foreign bodies, such as fishhooks, with sharp points. Other helpful tools to have on hand include wire baskets and rat-tooth grasping forceps. If a foreign body can't be removed orally, the next option is to push the object into the stomach. In the stomach, the object may be repositioned and grasped for oral removal, or retrieved by gastrotomy; bones are often left in the stomach where gastric acid will quickly demineralize the bone and allow passage without surgery. When it comes to retrieval of esophageal foreign bodies, in the author's view there are no real rules save two that govern one's approach: do not cause additional esophageal injury, and protect the endoscope. Creative thinking and use of "unconventional" tools can be helpful and are not only allowed, but encouraged as the situation demands!

If the foreign body cannot be retrieved or pushed into the stomach, then positioning the object as close to the cardia as possible can facilitate removal through a gastrotomy, with the surgeon reaching through the cardia into the esophagus to remove the foreign body. The last option for removal of esophageal foreign bodies is esophagotomy, which carries a high rate of post-operative complications because of healing properties of the esophagus. Ideally, after foreign body retrieval, the esophagus should be carefully inspected endoscopically for esophagitis, or evidence of perforation. Esophagitis can be treated as noted below. Patients with perforations should be treated with broad-spectrum antibiotics.