Clinical Approach to Dysphagia and Regurgitation (Winston) Flashcards
The Oropharyngeal phase contains the:
- Oral
- Pharyngeal
- Cricopharyngeal (UES relaxation)
What is a cardinal sign of esophageal disease?
Regurgitation
Diagnosis of swallowing disorders:
The following is a signalment for a…
- Congenital disease
- Cleft palate
- Cricopharyngeal achalasia (golden)
- Congenital megaesophagus (great dane)
- Vascular ring anomaly
- Hiatal hernia (shar pei, bull dog)
- Esophageal foreign body
- Infectious disease (uncommon)
Young Animal
Diagnosis of swallowing disorders:
The following is a signalment for a…
- Degenerative disease
- Acquired neuromuscular disorder
- Idiopathic Megaesophagus (german)
- Neoplasia
Older Animal
(T/F) Dysphagia is common in cats
False, it is uncommon. Usually secondary issues structural abnormalities
(T/F) If a cat comes in after having doxycycline, it may come in with esophageal stricture
True
Definition:
Is an abnormal tightening or narrowing of the esophagus
esophageal stricture
A patient presents with dysphagia, what do you think this animal has?
Clinical Signs include:
- Hypersalivation, gagging, multiple swallowing attempts
- +/- poor drinking ability
- +/- dropping food
Oropharyngeal disease
Fluoroscopic barium swallowing study to localize the functional cause of dysphagia:
Failure to prehend food, masticate food, form food bolus at base of the tongue, thrust food bolus into pharynx
Oral Dysphagia
Fluoroscopic barium swallowing study to localize the functional cause of dysphagia:
Failure to contract due to neuromuscular weakness or fibrosis
Pharyngeal Dysphagia
Fluoroscopic barium swallowing study to localize the functional cause of dysphagia:
Failure of UES to relax or failure to contract or does not relax at the right time
Cricopharyngeal Dysphagia
What do you HAVE to rule out first?
- Structural disease or Functional disease
Structural disease
A patient comes in with regurgitation, what do you think it is?
Clinical signs include:
- Normal drinking ability
- No dropping of food
- +/- Dysphagia
- +/- Hypersalivation, gagging, & multiple swallowing attempts
Esophageal disease
A patient with abnormal LES relaxation can present with:
- Regurgitation
- Reflux
- Repeated swallowing
- +/- Cough
A patient that has regurgitation, reflux, repeated swallowing, +/- cough, AND determined to have an abnormal LES relaxation…
Gastroesophageal disease
(T/F) Aspiration pneumonia is a common complication of dysphagia in dogs and cats
True
(T/F) When distinguishing regurgitation from vomiting, rely exclusively on what the “vomit” looks like
False
What diagnostic plans rule out structural disease?
- Radiograph of the thorax AND neck
- Esophagoscopy (esophageal endoscopy)
(T/F) Radiographs can rule-in esophageal disease, but when the thoracic radiographs are normal you cannot rule it out
True
(T/F) Esophagoscopy can rule-out structural disease, but does not give you any information about esophageal function
True
What diagnostic plan rules out functional disease?
Barium swallowing study (fluoroscopic)
Definition:
Acute or chronic inflammatory disorder of the esophageal mucosa
Esophagitis
What is the most commonly recognized cause of reflux esophagitis in dogs and cats?
Recent general anesthesia
*Endogenous cause
“Pill-induced” esophagitis in cats is most commonly caused by what drugs?
- Doxycycline
- Clindamycin
*Exogenous cause
What can gastroesophageal reflux under general anesthesia result on?
- Reflux esophagitis
- Esophageal strictures
- Aspiration pneumonia
Why is general anesthesia may predispose to reflux esophagitis?
- decrease LES pressure
- anesthesia inhibits esophageal motility and clearance
- body position and gravity
- lack of endotracheal tube
(T/F) Endoscopy is more sensitive than radiography for detecting esophagitis
True
(T/F) PPIs are superior to H2 receptor antagonists in raising gastric pH (more basic)
True, especially important for esophagitis involving the DISTAL esophagus
What is the ideal treatment for mild esophagitis?
Minimal treatment, feeding smaller-sized fat-restricted meals (enhanced gastric emptying)
- prognosis is good
What is the ideal treatment for moderate to severe esophagitis?
Gastric acid suppression and prokinetics
- prognosis is guarded or poor in severe cases
Treatment for esophagitis:
Binds to eroded mucosa and promotes effective mucosal barrier protection
Sucralfate
Treatment:
List the gastric acid suppression proton pump inhibitors:
Omeprazole
Treatment for esophagitis:
List the gastric acid suppression H2 receptor antagonists:
Famotidine & Ranitidine
Esophagitis treatment:
What is a more potent prokinetic and is more effective at reducing GER in dogs?
Cisapride (compared to metoclopramide)
The following clinical signs are for…
- gagging, salivation, dysphagia, regurgitation/vomiting (ACUTE)
- Depression, anorexia
- Cough, dyspnea, and fever
- Palpable cervical esophageal mass
(Warning: Aspiration pneumonia, esophageal perforation)
Esophageal Foreign Body
(T/F) Surgical removal (esophagotomy) only if endoscopic failure
True
What can be some complications if the FB is left for too long in the esophageal?
- Esophagitis (which may heal as a stricture)
- Esophageal perforation
Definition:
Abnormal narrowing of the esophageal lumen
Esophageal Stricture
Oral doxycycline/clindamycin tablets in cats is one of the most common causes for _______________
Esophageal Stricture
The following are clinical signs for…
- Initially, subtle “hard to swallow” that can be missed by owners
- Progressive dysphagia and odynophagia (painful swallowing) for solid foods
- Regurgitation
- Ravenous appetite
- Weight loss
Esophageal Stricture
What is a definitive procedure for differentiating benign from malignant esophageal stricture?
Esophagoscopy
(T/F) A balloon dilation of esophageal stricture is typically a “one and done” procedure
False, it typically requires multiple dilations under general anesthesia every 5-7 days (average is 3 to 5 times)
Defenition:
Congenital malformation of great vessels and branches that entraps the intrathoracic esophagus
Vascular Ring Anomaly
What is the most common vascular ring anomaly in dogs and cats?
Persistent right aortic arch (PRAA)
The following clinical signs are describebing …
- Regurgitation of solid food at weaning
- Usually < 6 months of age
- Weight loss or failure to gain weight (despite a good appetite)
- Cough, dyspnea, fever, pulmonary crackles (Secondary to aspiration pneumonia)
Vascular Ring Anomaly
Signalment (young animal) and compatible history of regurgitation during weaning are highly suggestive of a ________________________
Vascular Ring Anomaly (german, Irish setters)
Definition:
Severe lack of motility of the esophagus resulting in a dilated flaccid esophagus
Megaesophagus
Although there are many potential causes of megaesophagus in dogs, what is the most common diagnosis?
Idiopathic Megaesophagus
(T/F) Megaesophagus is also common in cats
False, it is uncommon in cats, Hiatial hernia and reflux esophagitis appear to be important underlying causes
When considering megaesophagus as a diagnosis, what do you need to make sure to rule out first?
Rule out obstruction in the distal esophagus as this can also result in a diffusely dilated esophagus
List some of the secondary causes of Megaesophagus:
- Neurogenic
- Neuromuscular junction (myasthenia gravis, others)
- Muscular (myopathy, myositis)
- Other (hypoadrenocorticism, lead toxicity, etc.)
What is the first part of the diagnosis of megaesophagus and complications?
- Survey neck and thoracic radiographs
- Barium swallow (tend not to do them)
Myasthenia gravis accounts for 25-30% of dogs with acquired megaesophagus. Therefore, an _____________________ (for diagnosis of myasthenia gravis) should be performed in every dog with acquired megaesophagus.
acetylcholine receptor antibody titer
______________ may present with facial, pharyngeal, laryngeal, and esophageal involvement without appendicular weakness and mimic idiopathic megaesophagus.
Focal myasthenia
