Esophageal & Gastric Disorders in the Horse Flashcards
if the horse is not able to swallow what are the 3 categories of reasons why
- mechanical disorders
- anatomical abnormalities
- neurological
what are mechanical disorders that would prevent the horse from swallowing (5)
- persistent entrapment of epiglottis
- pharyngeal mass
- tongue foreign body
- tongue base neoplasia
- severe temporohyoid osteoathropathy
what are anatomical abnormalities that would prevent the horse from swallowing
palatoschisis
what would neurological reasons be for not be able to swallow (2)
- loss of pharyngeal sensation
- loss of normal coordination –> guttural pouch mycosis, guttural pouch neoplasia
what cranial nerve would cause pharyngeal paralysis
Glossopharyngeal
CN IX
What are the clinical signs of dysphagia (4)
- gagging and neck stretching when attempting to swallow
- nasal regurgitation of feed, saliva
- slow feed consumption
- particularly slow to eat forage
what could a diagnostic work up for dysphagia generally look like (8)
- oral exam: tongue base and ranula
- palpate retropharyngeal region (enlargement of lymph nodes?)
- palpate esophagus (left side, usually not palpable)
- can a stomach tube be passed?
- endoscopy of URT and guttural pouches
- endoscopic visualization of swallowing mechanism
- is pharyngeal sensation and response to stimulation normal
- radiographic investigation of pharynx
what are ddx to glossitis (3)
- tongue foreign body
- tongue squamous cell carcinoma
- sialolith
what is glossitis
inflammation/trauma of the tongue
due to foriegn body, tongue squamous cell carcinoma, sailolith
what would the diagnostic workup of glossitis entail (3)
may need to place probe
rad/CT to determine expense
histopathology to rule out neoplasia
how would you manage glossitis
debridement and lavage
topical, systemic metronidazole
what are the signs of temporohyoid osteoarthropathy be
slow chewing and deglutition
what nerve might be involved with temporohyoid osteoarthropathy
CN VIII
Vestibular nerve
what are the diagnostic features of temporohyoid osteoarthropathy
- endoscopic appearance
- decreased joint movement
- rad/CT to determine extent
how is temporohyoid osteoarthropathy managed
- conservative
- certahyoidectomy (disarticulating the affected side)
what is palatoschisis
cleft palate
embryonic palatal folds fuse rostral to caudal
can affect both hard and soft palate
what are the signs of palatoschisis
neonatal presentation or at weaning
difficulty nursing
aspiration pneumonia
where is the most common site for palatoschisis
cleft of caudal 1/2 to 2/3 of soft palate is most common
margins of cleft run caudally into palatopharyngeal arches
what would the symptoms of glossopharyngeal nerve (IX) damage be (3)
- chronic nasal discharge and slow ingestion
- possibly concurrent aspiration pneumonia
- intermittent epistaxis
how would you diagnose glossophrayngeal nerve damage
endoscopy of URT and guttural pouches to assess pharyngeal sensation and coordination
what are the reasons for glossopharyngeal nerve damage (2)
- guttural pouch mass (may need histopathology)
- guttural pouch mycosis
what is the diagnosis of this
granulomatous mass in guttural pouch
glossopharyngeal nerve damage
what is the prognosis of glossopharyngeal nerve damage due to mycosis
guarded
esophagotomy carries guarded prognosis due to risk of complications
what is equine dysautonomia
neurological disorder
grass sickness
what can equine dysautonomia cause (3)
- ptyalism
- dysphagia
- retrograde peristalsis
damage to enteric plexus plus cranial nerve nuclei
what is a linear esophageal ulceration
acute grass sickness
due to prolonged gastroesophageal reflux
may occur with gastric outflow obstruction
extreme pain on passage of NG tube
what is the clinical presentation of simple esophageal obstruction (4)
- most commonly soon after feeding
- bilateral nasal regurgitation of feed and saliva
- gagging/retching/neck stretching behaviour
- often coughing due to inhalation
how is esophageal obstruction diagnosis
feed material in green nasal discharge
resentment of cranial esophageal palpation
resistance to passage of NG tube
attempts to eat followed by coughing
how is a simple esophageal obstruction managed
heavy sedation and lavage via NG tube
sedation causes head to drop
gravity helps with drainage
what is the most common site of obstruction
dorsal esophagus, thoracic inlet and cardia
how would you lavage esophageal obstruction
under sedation
feed matieral exits via opposite nostril
if material is impacted at top of esophagus may be difficult to get horse to swallow
if its not possible to clear the esophageal obstruction completely what should you do
try again after few hours
remove feed and beeding and leave on water only
repeat procedure
what is the risk of simple esophageal obstructions
aspiration pneumonia at early stage
what else should you do to manage esophageal obstruction
NSAIDs to decrease pharyngeal pain
broad spectrum antibiotics necessary
maintain on soft diet for 7 days post relief of obstruction
consider thoracic rads to determine severity if choke of >12h duration
what are complications of choke
deep ulceration of esophagus
linear ulceration can precede rupture
how do you manage ulceration due to choke (3)
- sucralfate and omeprazole to minimize acidic gastroesophageal reflux
- dietary management
- complete hay replacement ration
what are secondary esophageal obstructions (4)
- pulsion diverticulum
- traction diverticulum
- stricture formation
- persistent right aortic arch
how would you manage a secondary esophageal obstruction
- depends on cause: pulsion vs traction
- surgery more likely to be required for full thickness mural cicatrix
what are the clinical signs of esophageal obstruction dilation (2)
- recurrent bouts of choke depending on size diverticulum
- tends to deteriorate with age in congenital cases due to poor wall tone
how could you diagnose recurrent esophageal obstruciton dilation (3)
- endoscopy
- double contrast esophagram
- radiograph to investigate aspiration
how would you manage recurrent esophageal obstruction dilation
- cervical pulsatile diverticuli can be repaired surgically
- can empty manually
- dietary management only for larger diverticuli
what are the clinical signs of esophgeal strictures (2)
- regurgitation of ingesta + saliva
- maybe history of neck trauma/bite
what is shown here
esophageal stricture
how are esophageal strictures managed
full thickness lesion requires esophagomyotomy to release mucosa
endoscopic assessment during surgery to determine success
how are esophageal strictures treated surgically
luminal diameter restored by longitudinal esophagomyotomy
separation of outer and inner layers of the esophageal wall
tube passed during surgery
what are the clinical signs of cervical esophageal rupture (4)
- swelling and pain at site of rupture
- may be draining tract
- subcutaneous emphysema
- cardiorespiratory compromise if mediastinitis
how would you diagnose cervical esophageal rupture (2)
- constrast esophagram
- may release feed material if debriding
how are cervical esophageal rupture managed (5)
- immediate establishment of drainage to prevent mediastinitis
- surgical debridement is essential
- placement of tube orally or tube esophagostomy ventral to site (primary repair likely to dehisce)
- monitor for sepsis
- treatment of local cellulitis
what clinical challenges with cervical esophageal rupture (6)
- maintenance of nutrient intake
- electrolyte balance
- concurrent aspiration pneumonia
- management of cellulitis
- possible endotoxemia, laminitis
- severe emphysema
what are complications of cervical esophageal rupture (3)
- may succumb to complications of endotoxemia
- recurrent choke likely post recovery
- may be laryngeal hemiplegia due to sympathetic trunk damage
what are clinical signs of thoracic/abdominal esophageal rupture (2)
- elevated temperature and resp rate
- progressive septic pleural effusion
how would you diagnose thoracic/abdominal esophgeal rupture (3)
- esophageal endoscopy in unexplained pleural effusions
- thoracic ultrasound
- thoracocentesis & cytology
how would manage thoracic/abdominal esophageal rupture
hopeless prognosis
rapid diagnosis most essential feature
liked to idiopathic muscular hypertrophy of esophagus in some cases
where is the stomach located
left side
caudal to diaphragm and liver
what side is the pylorus and duodenum
to the right
what are the omental and ligament attachments of the stomach
to the liver, duodenum, pancreas, diaphragm and spleen
how do you ultrasound the stomach
find the cranioventral border
follow dorsocaudally to determine size and filling
what correltates with grastric volume when ultrasounding the stomach
height at ICS 12 correlates to gastric volume
how thick should the stomach wall be
wall thickness ~9mm
what is shown here
stomach
where are the pyloric outflow and duodenum landmark when US the stomach
right ICS 10-11
duodenum cranial to pole of right kidney
ultrasound window between right liver and right dorsal colon
what is the wall thickness of the duodenum
<4mm
what are clinical signs with acute gastric distention (4)
- acute colic
- possible rupture
- peritonitis
- endotoxemia
what are the clinical signs with chronic gastric distention (4)
- weight loss and reduced rate of feed intake
- increased water intake
- recurrent mild colic
- pendulous abdomen +/- ventral edema
what are clincal signs of chronic gastric inflammation (2)
- may be symptom free, progressing to acute colic
- change in dietary preference
what are the clinical signs of chronic gastric ulceration (2)
- loss of performance; decreased forward movement
- anterior abdominal pain
what are parasitic infections of the gastric
gasterophilus larvae
what are dysmotility gastric disorders (4)
- equine dysautonomia
- acute gastric dilation
- gastric impaction
- chronic gastric dilation
what are ulcerative gastric disorders
equine gastric ulceration syndrome
perforation and rupture
what are gastric neoplastic disorders
squamous cell carcinoma
what are inflammatory equine gastric disorders (2)
- inflammatory polyps
- glandular ulceration and gastritis
what are risk factors for acute gastric dialtion (2)
- excess or fermentable feed
- incorrect management
what are clinical signs of acute gastric dilation (4)
- acute abdominal pain
- spotaneous nasogastric reflux
- progressive acidosis
- endotoxemia
how is acute gastric dilation diagnosed
based on presentation
how is acute gastric dilation treated (4)
- gastric decompression and lavage
- IV fluid support
- correction of acidosis
- management of endotoxemia
what are sequelae to endotoxemia in acute gastric dilation (2)
- laminitis
- acute renal failure
what are gastric complications that can occur during acute gastric dilation (3)
- transient loss of motility
- delayed emptying
- serosal tear
how do you manage the complications of acute gastric dilation (4)
- gastroscopic assessment
- risk fo secondary impaction
- complete pelleted ration
- altered feeding freq
what are risk factors for acute gastric impactions (5)
- poor dentition
- old age
- trichobezoars (hair ball)
- persimmon seeds
- inappropriate feeding
what are the clinical signs of acute gastric impactions (3)
- acute colic presentation
- endotoxemia
- possible rupture
how are acute gastric impactions diagnosed (3)
- resistance to stomach tube
- ultrasonography
- gastroscopy
how are gastric impactions managed (2)
- gastric lavage: remove soluble material
- continuous lavage
how would you do continuous lavage to treat gastric impactions
5L/hour as continuous infusion via indwelling tube
position in terminal esophagus
alterante electrolytes with water to prevent Na+ overload
daily mineral oil
how long might it take for a gastric impaction to resolve
may take 3-6 days
what are the risk factors of chronic gastric impactions
not known
increased in warmbloods
what are the clinical signs of chronic gastric impaction (5)
- failure to gain weight/weight loss
- change in abdominal silhouette
- change in demeanour
- ventral edema
- acute colic +/- prior recurrent colic
how are chronic gastric impactions diagnosed (5)
- resistance to stomach tube
- enlarged gastric outline
- stomach may be palpable
- gastroscopy: impaction often vertically stacked
- may be up to esophageal cardia
how do you treat chronic gastric impactions
prolonged continuous gastric lavage
aim to empty stomach
how do you manage chronic gastric impactions (3)
- permanent turnout
- no forage other than grass
- complete pelleted ration if required
what is the prognosis of chronic gastric impactions
progressive further dilation of stomach, spontaneous rupture possible
2-4 years from presentation
dependent on speed of initial diagnosis
lifelong diligent management
what are the risk factors of equine gastric ulceration syndrome (EGUS) (8)
- decreased access to grazing
- high intake of concentrate rations
- prolonged periods without forage
- intesive training at >70% VO2max
- other GI disorders
- NSAIDs
- crib biting
- pregnancy
what are the clinical signs of equine gastric ulceration syndrome (EGUS) (3)
- loss of performance
- decreased feed intake
- colic as severity increases
how is equine gastric ulceration syndrome (EGUS) diagnosed (2)
- gastroscopy
- sucrose absorption may be herd screening tool
what are stratified squamous ulceration scores
scored from 0-1 with lesions > 3 of clinical significance
what is stratified squamous ulceration based on
surface area is primary determinant of score
grade these ulcerations
grade 0
grade 1
grade 2
what grade is this ulcer
grade 3
what grade is this ulcer
grade 4
what is grandular ulceration
mostly scored from 0-4
gross appearance of lesions very variable
erythema to ulceration
what grade is this glandular ulcer
grade 0
what grade is this glandular ulcer
grade 1
what grade is this glandular ulcer
grade 2
what grade is this glandular ulcer
grade 3
what grade is this glandular ulcer
grade 4
what lesions are more siginficant in glandular ulceration (think location)
lesions affecting pyloric motility
what are the gross appearance of glandular inflammatory lesions (6)
- erythema
- flat, hemorrhagic
- raised, hemorrhagic
- flat, diptheritic
- raised diptheritic
- combination
what are the presenting signs of equine glandular polyps (3)
- recurrent colic
- weight loss
- short episodes of acute pain
what is prognosis of equine glandular polyps based on
- size
- response to treatment
how are squamous erosion and ulceration treated with EGUS
omeprazole 4mg/kg SID 4-6 weeks
tapered dose for 2 weeks
sucralfate 20mg/kg 3-4 x daily
how can squamous erosion and ucleration in EGUS be managed (5)
- increased access to forage and grazing
- decreasd or stop concentrate feed
- decreased intesity of exercise
- chaff feeds prior to exercise
- reduce other stressors
how are squamous erosion and ulceration in EGUS prevented
improved management to reduce risk factors
gastroguard 1mg/kg at start of training
how are glandular ulceration and inflammation in EGUS treated
longer term depending on type of lesion
omeprazole 4mg/kg SID 4-6 weeks + reassessment prior to reducing
sucralfate 20mg/kg x3 daily
how are refractory glandular ulcerative lesions of EGUS treated
diphtheritic membrane or inflammation
addition of doxycycline 10mg/kg BID in sucralfate carrier (muco-adhesive)
further 4wk course of omeprazole
what additional therapies can be used to treat glandular ulcertive EGUS lesions
- pectin-lecithin complex may be beneficial
- antacids? multiple unproven supplements
how are inflammatory polyps treated in EGUS
similar treatment initially
longer treatment course
lifelong management to prevent obstruction of pyloric canal
strict dietary control
what further investigations are needed if you diagnose inflammatory polyps in EGUS
histopathological investigation
freq and significance of lesions
assessment of risks
rational approach to management and prevention
