Esophageal disease Flashcards
What findings in the history and PE are suggestive of esophageal disease?
- Regurgitation
- Ptyalism
- Bulge in the esopahgus
- Palpate a mass or foreign body
- Pain on palpation (from lesion or esophagitis)
- Signs of pneumonia (ask if coughing)
- Malnutrition
Differential diagnoses for regurgitation - big categories (3)?
- Esophageal obstruction
- Esophageal perforation
- Others
Esophageal obstruction dfdx (7)?
- Foreign body
- Neoplasia
- Stricture
- Vascular ring anomaly
- Hiatal hernia
- Gastroesophageal intussusception
- Cricopharyngeal achalasia
Dfdx for esophageal perforation (3)
- Trauma
- FB
- Neoplasia
Other causes of esophageal disease (4)
- Esophagitis
- Generalized megesophagus (e.g. congenital, idiopathic, polyneuropathy, myasthenia gravis)
- Esophageal diverticulum
- Esophageal fistula with airway or skin
Which differential for an esophageal obstruction is an indication for emergency surgery?
- Gastroesophageal intussusception
- Probably a foreign body too
Which of the dfdx for esophageal disease cannot be resolved with surgery?
- Megaesophagus
- Esophagitis
- Esophageal diverticulum
Where is an esophageal foreign body most likely to lodge (3 locations)?
- At areas of resistance or narrowing, such as the thoracic inlet, the base of the heart, and the diaphragm
What are the layers of the esophagus?
- Mucosa
- Submucosa
- Muscularis
- Adventitia
Factors affecting healing of the esophagus
- Only segmental blood supply
- No omentum
- Lacks a serosa
Why do we tend to avoid esophageal surgery when possible?
- Due to propensity of the esophagus to heal poorly and to stricture
When is esophageal surgery unavoidable
- If manipulation of a FB via endoscopy might cause significant damage to the esophagus (e.g. abrasion from a FB wedged in tight, perforation by FB with sharp projections), surgery is needed
What are the first, second, and third choice for FB removal from the esophagus?
1st: pull esophageal FB out per os via endoscopy
2nd: Push esophageal FB into stomach via endoscopy and remove via gastrotomy
3rd: It’s time for a surgeon if the FB can’t be removed per os or pushed into the stomach
What are the two directions by which esophageal perforation can occur?
- Occur from inside out or outside in
What should you do in patients with a penetrating wound to the neck?
Why (2 reasons)?
- perform endoscopy to check for esophageal perforation because 1.) Consequences of missing a perforation can be serious and 2.) clinical signs may not be apparent for multiple days
What can you check for while assessing the esophagus for perforation?
- Check for tracheal damage the same time by scoping the trachea
- Scope the trachea first
What is the risk of a FB is left for a long time in the esophagus?
- Greater risk of perforation because of ongoing esophagitis and pressure necrosis, which compromise the esophageal wall
- Check for perforation before and after removing esophageal FB
Who do you call if the esophagus is perforated?
- SURGEON
How can you detect perforation of the esophagus?
- Esophagram
- Hole
- Surgery
- May not see the hole until FB is removed
How to do an esophagram?
- Use sterile, non-ionic, iodinated contrast because it might leak into the thorax
- Might not see if the FB is blocking
Why is thoracic esophageal perforation life threatening (3 reasons)?
- It can result in thoracic pathology such as mediastinitis, pleuritis, and pyothorax
- You need to diagnose this condition early (which means you have to have it on your ddx list and look for it with your diagnostics in order to have the best chance of treating successfully
When can medical management alone be considered with esophageal perforation (review)?
- small perforation in otherwise healthy tissue of the cervical esophagus
Treatment for a small perforation in otherwise healthy tissue of the cervical esophagus if not from an esophagostomy tube
- NPO x 3 days, antibiotics, treat for esophagitis (H2 blockers, proton pump inhibitors, GI protectorants)
Treatment needed for a hole made from the removal of an uncomplicated esophagostomy tube?
- No treatment needed
What primary esophageal tumors can be seen secondary to Spirocerca lupi (2)?
- Osteosarcoma
- Fibrosarcoma
What tumors besides those associated with Spirocerca lupi may be seen in the esophagus as primary tumors?
- Squamous cell carcinoma
- Leiomyoma
Treatment for most esophageal tumors?
- Msot reespond poorly to radiation or chemo
- Surgery is possible if caught early
- Most esophageal tumors are advanced beyond the point where surgery makes sense by the time they are diagnosed
How does an esophageal stricture form?
- Circumferential damage to the muscle
Causes of esophageal stricture
- Foreign body, esophagitis (including reflux esophagitis), esophageal surgery, caustic agents
Is hte length of the stricture LONGER or SHORTER than it appears on radiographs or with scope?
- Longer
Treatment of esophageal stricture
- Can be hard to resolve
- Preferred treatment is to dilate the stricture, but clients must be informed that recurrence rate is high
- Surgical resection is a last resort
What is the most common form of vascular ring anomaly?
- Persistent right 4th aortic arch
What causes a PRAA?
- When the aorta forms from the right instead of the left 4th aortic arch, the ligamentum arteriosum gets pulled across the esophagus, causing a partial obstruction
What three things form a ring around the esophagus in a PRAA?
- Base of the heart and pulmonary artery ventrally
- Ligamentum arteriosum on the left and dorsally
- Aortic arch on the right
What radiographic findings are characteristic of a vascular ring anomaly?
- Big dilation upstream of the ligament arteriosum at the base of the heart
Treatment for PRAA
- Surgical transection of the ligamentum arteriosum (which is just a fibrous band at this point)
Approaches for PRAA
- Lateral thoracotomy or thorascopically
When should surgery be done for PRAA? Why?
- As soon as you can get them safely into surgery
- Not an emergency but needs to be done sooner rather than later for recovery
What might you need to treat first before going into surgery for PRAA?
- May need to 1st treat pre-existing pneumonia or malnutrition (e.g. via gastrostomy tube) to make a patient a good surgical candidate
Postop care for PRAA with feeding
- Continue upright feeding with liquid diet initially
- Gradually switch to normal feeding over 1-2 months if the patient is improving
When do you recheck an esophagram with PRAA?
- 1-2 months
Prognosis for PRAA
- Esophagus has been distended orad of PRAA for a long time, so it takes time for it to return to normal function (if ever)
- Some recover fully, others always retain some degree of esophageal dysfunction
Timing of surgery - how does it impact prognosis for PRAA?
- The sooner surgery is done in the lifetime of an animal, the better (chronic distension of the esophagus can damage the muscle and nerves to the point where they cannot recover)
What often causes the 20% mortality in the immediate postop period of PRAA?
- Aspiration pneumonia that occurs perioperatively (or was pre-existing) _/0 debilitated patient
Of the 80% of patients that make it through the immediate postop period for PRAA, what % improve postop?
- Of the 80% that make it through the immediate postop period, 70-92% improve postop
What other procedure should be recommended alongside correction of PRAA, and why?
- Recommend neutering as PRAA is a congenital condition that may have an inherited component
What causes a hiatal hernia?
- Weakness in the esophageal hiatus of the diaphragm allows the orad portion of the stomach to move cranially into the chest
- Several ways it can occur but individual types are not important at this time
What is the nature of signs for hiatal hernia, and why?
- SIgns are often intermittent because herniation comes and goes
Does hiatal hernia involved regurgitation or vomiting?
- BOTH because it involves the esophagus and the stomach
Predisposed breeds for hiatal hernias
- Bulldogs and sharpeis
- Often young
- Should be on your dfdx for a young (<3 years) regurgitating/vomiting dog of these breeds
Radiographs for hiatal hernia
- May show dilated esophagus, gas-filled density in caudal thorax, rugal folds in thorax
- Condition may not always be seen on radiographs as the hernia can slide in and out
What is the first line of treatment for hiatal hernia - medical or surgical?
- Medical
Components of medical management for hiatal hernia (3)
- H2 receptor blockers
- GI protectorants
- Prokinetic drugs
Prognosis if hiatal hernia improves and resolves with medical management
- Good
If medical management improves hiatal hernia but signs persist after 1 month of meds, what is often the next step?
- Surgery
Prognosis for hiatal hernia if surgery if no response to medical management initially or if signs persist after 1 month of meds even with some improvement?
- Good
Prognosis if no surgery for a hiatal hernia that hasn’t responded to medical management
Why?
- Poor
- Prone to severe esophagitis and stricture
Is gastroesophageal intussusception an emergency?
- YES
Where does the stomach telescope relative to the esophageal lumen with gastroesophageal intussusception?
- INSIDE
How is a gastroesophageal intussusception different from a hiatal hernia?
- Very acute, sudden, and fast
Most common history of a dog with gastroesophageal intussusception
- Young dogs with a history of esophageal disease
Onset and clinical signs with gastroesophageal intussusception
- Acutely to peracutely ill
- SIgns may include regurgitation/vomiting +/- blood, abdominal pain, dyspnea (due to distended stomach occupying the thorax; also due to pain), shock and death
Radiographic appearance of gastroesophageal intussusception
- Dilation of the distal esophagus with a soft tissue mass near the lumen
Treatment for gastroesophageal intussusception
- Early diagnosis
- Aggressive management (fluids, oxygen analgesics, etc.), and emergency surgery
- While starting medical management is critical, this is one of those conditiosn where you won’t be able to fully stabilize the patient before going to surgery and reducing the intussusception
List the esophageal conditions that warrant emergency surgery (3)
- Gastroesophageal intussusception
- Esophageal perforation
- Foreign body
Postop monitoring for esophageal surgery
- TPR
- MM
- CRt
- Pulse quality
- Pain
- Urination/defecation
- Vomiting/regurgitation
- Incision
- Activity
- If aspiration pneumonia also monitor SPO2, chest radiographs
Medications postop for esophageal surgery
- Hydration and electrolytes/glucose (many are young patients so need glucose maintained)
- Antibiotics should be given prophylactically/perioperatively but don’t need to be continued unless indicated
- Analgesia
- Treat esophagitis (sucralfate, H2 blocker)
- Treat aspiration pneumonia (e.g. O2, nebulization, coupage, antibiotics) if present
Thoracostomy tube for esophageal surgery
- May be placed due to surgery on the thoracic esophagus
Nutrition for esophageal surgery
- VERY important as they may be malnourished since they couldn’t consistently get food into the stomach
- Feeding may be oral (if esophagus is not too compromised) or via feeding tube (use gastrostomy tube if stomach is healthy)
- Keep upright while feeding and 10-20 minutes afterwards if problems with esophageal motility
Postop food consistency for esophageal surgery
- Liquid
