Sickly Dog

Question 1

Mrs Chambers presents the family dog:

• Rocky is a 6 year old, male neutered bull mastiff
• Mrs Chambers reports that Rocky has been vomiting intermittently for the last 10 days

What additional questions would you like to ask?

Answer 1

• What is the vomit like? Look like?
• When does vomiting happen?
• Abdominal effort?
• Eating?
• Drinking?
• Faeces?

Question 2

Create a problem list from:

• the episodes seem very passive, Rocky puts his head down and what looks like undigested food seems to “fall” out of his mouth
• there is no abdominal effort
• no bile/blood is seen in what is brought up
• Mrs Chambers thinks Rocky has lost some weight
• he has a ravenous appetite and sometimes tries to eat what he has brought up
• he passes, brown formed stools twice a day
• he drinks normally but occasionally brings up water

Answer 2

• Regurgitation
• food
• sometimes water?
• Weight loss
• Ravenous appetite, polyphagia?

Question 3

Draw up differentials for rocky, Use DAMNITV and highlight the most common:

• the episodes seem very passive, Rocky puts his head down and what looks like undigested food seems to “fall” out of his mouth
• there is no abdominal effort
• no bile/blood is seen in what is brought up
• Mrs Chambers thinks Rocky has lost some weight
• he has a ravenous appetite and sometimes tries to eat what he has brought up
• he passes, brown formed stools twice a day
• he drinks normally but occasionally brings up water

Answer 3

Anomalous

• Megoesophagus secondary to CNS disease including CNS neoplasia
• hiatal hernia
• vascular ring anomaly
• extra-oesophageal compression

Metabolic

• megoesophagus secondary to:
  
  • hypoadrenocorticism
  • hypokalaemia
  • hypothyroidism

Neoplastic (1ry or metastatic?)

• fibroma/fibrosarcoma
• leiomyoma/leiomyosarcoma
• papilloma/squamous cell carcinoma
• lymphoma

Nutritional

• foreign body

Inflammatory

• oesophagitis post gastric reflux
• - associated with GA
• - complication of severe vomiting/debility
• oesophageal stricture (end result of severe oesophagitis)
• megoesophagus secondary to polymyositis/polyneuritis

Immune-mediated megaoesophagus secondary to:

• Myasthenia gravis
• Systemic lupus erythematosus

Infectious – microbial, parasitic

Idiopathic

• idiopathic megoesophagus
• dysautonomia

Toxic

• megoesophagus secondary to heavy metal (lead)/OP toxicity

Traumatic

• megoesophagus post FB
• oesophagitis – e.g. stomach tube, after oesophageal FB removal
• oesophageal rupture

Vascular

• vascular ring anomaly

Question 4

How can we further investigate this case:

• the episodes seem very passive, Rocky puts his head down and what looks like undigested food seems to “fall” out of his mouth
• there is no abdominal effort
• no bile/blood is seen in what is brought up
• Mrs Chambers thinks Rocky has lost some weight
• he has a ravenous appetite and sometimes tries to eat what he has brought up
• he passes, brown formed stools twice a day
• he drinks normally but occasionally brings up water

Answer 4

Plain lateral thoracic radiograph

Question 5

What is the issue here?

Answer 5

Large oesophagus

Question 6

What further investigations for megaoesophgus can we do?

Answer 6

• Hematological and biochemical analysis of blood samples may be useful to diagnose several underlying causes of acquired megaoesophagus, such as myositis with an elevated creatine kinase (CK) concentration. Further tests, such as an ACTH stimulation test or T4/ TSH levels, may also be indicated if hypoadrenocortiscm is the suspected cause. Congenital idiopathic megaoesophagus is diagnosed in young animals (often of a predisposed breed) in which all other causes have been discounted.
• Plain lateral radiographs should be enough to diagnose
• Endoscopy
• Barium contrast

Question 7

What is seen on radiographs with megaoesophagus?

Answer 7

• A large radiolucent structure dorsal to the trachea on lateral radiographs. It should be noted that it is normal for the oesophagus to contain air if the animal is under general anaesthesia.
• The tissue between the trachea and oesophagus may be compressed producing a radio-opaque tracheal stripe sign along the dorsal surface of the trachea on a lateral radiograph. The trachea may also appear to deviate ventrally. On a dorso-ventral radiograph of the chest, the trachea may be pushed to the right by the enlarged oesophagus.
• Chronic regurgitation increases the risk of developing aspiration pneumonia. If it is present, it produces an alveolar pattern in the cranial and ventral lung lobes.
• With vascular ring anomalies, the oesophagus is usually only dilated cranial to the base of the heart.

Question 8

What are the clinical signs of oesophageal disease?

Answer 8

• Anorexia – non specific sign but will be seen
• Dysphagia
  
  • Pain on eating
  • Gulping/exaggerated swallowing
• Salivation (ptyalism)

Question 9

What are the signs of regurgitation?

Answer 9

• Discomfort?
• Variable time after eating
• Passive process
  
  • Not always! Especially when it comes to cats. They can make a huge hoo ha about it. The pain of something being stuck can make them mouth open/yawm/yelp until whatever in the oesophagus comes up
• Froth/saliva (“egg white”)
• Ph neutral/alkaline

Question 10

What are the clinical signs of vomiting?

Answer 10

• Signs of nausea
• Active process
• Abdominal retching
• Bilious fluid and/or stomach contents
  
  • Yellow staining is a sign that the animal has actually vomited
  • Use descriptive terms to help the owner e.g. yellow fluid
• Acidic ph

Question 11

What is this?

Answer 11

Vomiting?

A wound or ulcer? You would expect it to be more coffee coloured if it had been in the stomach acid.

Question 12

What is this?

Answer 12

Regurgitation?

E.g. tubular structures of food from the oesophagus

Question 13

What are the clinical signs of aspiration pneumonia?

Answer 13

• Nasal discharge
• Coughing
• Tachypnoea/dyspnoea

Question 14

What do you want to obtain from clinical history with oesophageal disease?

Answer 14

• Acute or chronic?
• Any systemic signs?
  
  • Generalised weakness?
  • Exercise intolerance?
  • Laryngeal paralysis?
  • Greater aspiration risk
• Any recent anaesthesia or significant vomiting
• Reflux under anaesthetic is a huge risk factor to oesophagus stricture
• Check the history!!! Understand what they have had done lately
• Are there any other clinical signs to support your differntials?
• Cyclical vomiting – can cause oesophagitis which predisposing to stricture formation

Question 15

Why do you want to do both left and right lateral views in oesophageal disease?

Answer 15

• Aspiration pneumonia may not show up on one view but not the other!
• One lateral view – upper lung is highlighted but it may be in the recumbent lobe

Question 16

What are the risks of a contrast radiography?

Answer 16

• Aspiration
• Oesophageal tears - leak contrast agent

Question 17

What is this?

Answer 17

•This is a cat with barium – dilation of the oesophagus through the whole length.

Question 18

What are the clinica signs of dysautonomia?(6)

Answer 18

• Dry mouth and nose
• Constipation?
• Urine retention
• Regurgitation
• Dilated pupils
• Bradycardia

Question 19

What tests can we do to investigate oesophageal disease?

Answer 19

Blood tests: are often unhelpful!

• Haematology for any evidence of
• 2ry infection/systemic inflammation?
• Anaemia of chronic disease?
• Markers of lead toxicity?
• Biochemistry (& urine sg)
• Evidence of systemic disease?
• Creatine kinase suggesting myositis?
• Specific tests
• Acetyl choline receptor antibody?
• Serum lead?
• Toxoplasma/neospora?
• Endocrine tests to rule out or rule in
• Hypoadrenocorticism
• Hypothyroidism

Question 20

What is fluoscopy good for?

Answer 20

Assessing swallowing and oesophageal motility disorders

Question 21

What is an oesophageal stricture associated with? (2)

Answer 21

• Reflux during anaesthesia &/or major surgery
• Severe persistent vomiting

Question 22

What is an iateogenic cause of oesophageal stricture?

Answer 22

Doxycycline in cats

Question 23

What is this?

Answer 23

Endoscope of oesophageal stricture

Down oesophagus and reach this hole

Not the stomach entrance as only halfway down the thorax (use markers on the scope). You will not get scope through this! Tight and fibrous.

They form very quickly!

Question 24

What are the signs of myasthenia gravis?

Answer 24

• Regurgitation
• Generalised muscle weakness

Question 25

What is the problem with myasthenia gravis?

Answer 25

Prblem at the NMJ - Ach receptors

Question 26

What type of disease is Myasthenia gravis?

Answer 26

May be focal (affecting oesophagus only) or generalised disease

Question 27

What 3 sites do FB tend to get stuck in the stomach?

Answer 27

Thoracic inlet, Over base of the heart (major vessels in the way so be careful with lacerations) Proximal to the cardia

Question 28

How can you treat an oesophageal stricture once identified and managed?

Answer 28

* balloon dilation * bougienage? * stents

Question 29

What is this?

Answer 29

No need for contrast agent as a clear evidence of megaoesophagus Can see tracheal stripe sign

Question 30

How can we manage megaoesophagus?

Answer 30

* Feed * Postural feeding * Try different types of diet * Balls of food * Gruel * PEG tube? Bypass stomach so great for nutrition but doesn’t stop the egg white saliva regurgitation so can still aspirate their own gloop * Treat aspiration pneumonia

Question 31

What is a differential for salivation and dysphagia?

Answer 31

RABIES

Question 32

What virus is rabies?

Answer 32

Lyssavirus

Question 33

What is the history and clinical signs with rabies?

Answer 33

* Clinical history * bite wound in the preceding 3 weeks to 6 months? * in practice this is often not noticed * Early clinical signs * anorexia, depression, mild ataxia * Progression * hyperesthesia, hypermetria * regional pruritus * recumbency, coma * DEATH

Question 34

What are the 3 forms of rabies?

Answer 34

* furious (most common form in dogs) * recumbency * biting and aggressive behaviour * convulsions, exaggerated response to tactile stimuli * vocalization * dumb (most common in horses) * depression, febrile * ataxia, drooped head * profuse salivation, yawning, tongue flaccidity * paralytic (most common form in cattle, but they also get the dumb form) * lameness, paraparesis, recumbency

Question 35

What can underlying neuro signs predispose rabies animals to?

Answer 35

* oesophageal obstruction * salivation