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CAEM Pt. 2 > LA Sx Exam #2: Esophagus, Rectum, Anus > Flashcards

LA Sx Exam #2: Esophagus, Rectum, Anus Flashcards

1
Q

Path of the esophagus in the horse

A

Begins dorsal to the trachea and goes to the LEFT as it moves caudal

*Three regions = cervical, thoracic, and small abdominal portion

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2
Q

Important structures surrounding the esophagus that we should watch out for (3)

A

1) Common carotid artery
2) Vagosympathetic trunk
3) Recurrent laryngeal nerve (mainly the left)

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3
Q

Four histologic areas of the esophagus

A

1) OUTER = outer fibrous layer (no serosa in abdominal area)
2) Muscular layer in concentric overlapping spirals, striated proximally and smooth m near the cardia, relatively inelastic
3) Submucosa = tensile strength for closure
4) Mucosa = stratified squamous epithelium in longitudinal folds the “close” the lumen when relaxed, very elastic and mobile

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4
Q

DDx for ingesta coming out of the nose (2)

A

1) Choke

2) Ruptured stomach

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5
Q

What fun thing happens when you incise into the esophagus?

A

Mucosa/submucosa separate from the outer layer and adventitia

*Could accidentally force a nasogastric tube through the tissue w/ a ruptured esophagus

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6
Q

Describe the esophageal blood supply

A
  • Arcuate
  • Segmental
  • Minimal collateral circulation = can’t really perform resection and anastamoses
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7
Q

Dx? Ptyalism, dysphagia, regurgitation of ingesta, head/neck extension, coughing, agitation, sweating, grinding teeth, attempts to swallow

A

Early choke - esophageal impaction or obstruction

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8
Q

Progression of choke signs from acute to chronic

A

Chronic = anorexia, dullness, depression, dehydration = metabolic abnormalities (loss of bicarb and Cl with regurg and drooling)

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9
Q

Causes of choke (7)

A

1) Feed or bedding = carrots, apples, ground grains (too finely ground, inadequate saliva), sugar beet pulp (powder = too dry), wood shavings
2) Gluttonous behavior
3) Eating before cooling down
4) Sedation, alpha-2 agonists like romifidine (most problematic, xylazine = least)
5) Dental abnormalities, not chewing properly
6) Pre-existing lesions like strictures
7) Rare = foreign body (selective eaters)

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10
Q

Diagnosis of choke (6)

A
  • Clinical signs
  • PE = palpate laryngeal/cervical region, thoracic auscultation (aspiration pneumonia), hydration status (PCV, TP, electrolyte conc), oral exam w/ speculum
  • Nasogastric intubation = both dx and tx
    +/- Endoscopy = not really helpful, only really evaluates the mucosa
  • Radiology = gas due to rupture? air pockets distal/proximal to obstruction? visualize obstruction?
  • Contrast studies = negative w/ air (cuffed NG tube and sedation), positive w/ barium or aqueous contrast (no sedation), BOTH
  • Pressure esophagram = cuffed NG tube and liquid barium/water soluble contrast, shows esophageal distensibility
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11
Q

Things to remember about nasogastric intubation

A
  • Use the largest NG tube = easier to pass, occludes the esophagus, avoids twisting and displacement of the tube
  • Can used cuffed NG or ET tubes
  • Use SEDATION
  • Keep the head DOWN
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12
Q

What do you do if you can’t relieve the esophageal obstruction?

A

*Depends on what you suspect the cause is = some food may soften and pass in 12 hours
- NSAID’s
+/- Antibiotics (worried about aspiration pneumonia)
- Remove all food
- Muzzle
- In a bare stall
- Only access to water
- Repeat attempts to relieve obstruction
- Can try esophageal lavage under general anesthesia

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13
Q

What should you do after having relieved the esophageal obstruction?

A

*Time w/ aftercare depends on duration and nature of obstruction
- Withhold field = likely to be flaccid and hypomotile
- Slowly introduce small quantities of soaked feed or lush grass (ideal)
- NSAID’s
- Antibiotics
- Expectorants if concerned about aspiration pneumonia
+/- Other dx if recurrent

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14
Q

Use of endoscope with esophageal choke

A

Allows you to evaluate the mucosa following an obstruction, start caudal and move rostral

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15
Q

How do differentiate between esophageal peristalsis and stricture on radiograph?

A

Wait and re-radiograph to see if it’s persistent

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16
Q

True or false? Carrot and apple piece chokes in the esophagus resolve spontaneously

A

True

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17
Q

True or false? Rough foreign bodies or food parts in the esophagus resolve spontaneously

A

False

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18
Q

Sequelae of excessive nasogastric tube use

A

Esophageal rupture

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19
Q

True or false? Pushing tight esophageal obstructions into the thorax may help in relieving the choke

A

FALSE - make them more difficult to remove

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20
Q

Sequelae of a prolonged tight esophageal obstruction

A
  • Mucosal ulceration
  • Stricture
  • Necrosis
  • Rupture
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21
Q

Preferred treatment method for rough esophageal impactions or impactions not responsive to conservative treatment?

A

Esophagotomy (less traumatic than repeated NG manipulations)

Standing or under GA (majority = GA under dorsal recumbency)

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22
Q

True or false? Esophagotomy sites are commonly infected upon closure

A

True, often place a suction drain to mitigate any infection

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23
Q

What does not having a serosal layer cause?

A

Decreased rapid healing ability

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24
Q

What may you have to do if the esophagus is compromised?

A

Insert an esophagostomy tube

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25
Q

Dx? Skin wound draining saliva, cellulitis, emphysema (left to right), edema in brisket and forelimbs, fever, restless, dull, depressed

A

Esophageal rupture

*Clinical signs vary based on whether the skin is open or closed

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26
Q

Causes of esophageal rupture (6)

A
  • TRAUMA
  • Long standing obstruction
  • Foreign body perforation
  • Excessive force
  • Extension of infection from perivascular infection
  • Prolonged nasogastric intubation in animals with ileus = necrosis
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27
Q

Sequelae to esophageal rupture (2)

A

1) Horner’s syndrome = damaged vagosympathetic trunk
2) Roarer = damaged recurrent laryngeal
3) Spread of infection along fascial planes = septic mediastinitis, pleuritis, aspiration pneumonia, laminitis, death
4) Carotid rupture

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28
Q

Treatment of esophageal rupture

A
  • Drainage of SQ
  • Debridement of tissue and primary closure
    *Not ID’ed early enough = drain and close by second intention
  • Systemic antibiotics
  • NSAID’s
  • Tetanus prophylaxis
  • Fluid therapy
  • Extraoral feeding by placing a distal tube
    +/- Tracheostomy
  • Head support
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29
Q

Do you need to close the esophagostomy site when you remove the tube?

A

No - will close down on its own

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30
Q

Common cause, treatment, sequelae of mucosal esophageal ulceration

A
  • Cause = longstanding esophageal impaction
  • Tx: NSAID’s, antibiotics, soft food for 60 days
  • Sequelae = epithelialize and resolve or stricture
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31
Q

Dx? Recurrent episodes of choke, inability to pass a normal NG tube

A

Esophageal stricture

32
Q

How long does it take for esophageal strictures to occur? Tx?

A
  • Occur 15-30 days after insult
  • Diameter increases from 30-60 days, greatest change at 45 days (leave them along until then)
  • Tx: soft feed elevated from ground (food acts as a bougienage to dilate)
33
Q

Common sequelae to esophagostomies? Tx?

A

> Traction diverticulum = dx as a wide necked opening on barium swallow study
- Tx: nothing, usually don’t have complications, just monitor

34
Q

Pulsation diverticulum and tx

A

> Defect in musculature that causes a flask-shaped out pouching
+ Swelling in the neck that gets larger over time
*Risk of obstruction or rupture
- Tx = surgically repair

35
Q

Which do we need to surgically repair - traction or pulsation diverticuli?

A

Pulsation = risk obstructing or rupturing

36
Q

What is the distal continuation of the small colon?

A

Rectum (from pelvic inlet to anus)

37
Q

What muscle prevents anal prolapse during defecation?

A

Levator ani muscle

38
Q

True or false - animals have two anal sphincters

A

True - internal and external

39
Q

Most common cause of equine rectal tears

A

> IATROGENIC secondary to rectal palpation

- Other = breeding accident, parturition/dystocia, impactions, rectal thrombosis, idiopathic (fairly common)

40
Q

Grade I rectal tear

A

Mucosa and submucosa only

41
Q

Grade II rectal tear

A

Muscular layers only

42
Q

Grade IIIa rectal tear

A

All layers (mucosa, submucosa, muscular) except serosa

43
Q

Grade IIIb rectal tear

A

All layers (mucosa, submucosa, muscular, serosal) except mesorectum and retroperitoneal tissues

44
Q

Grade IV rectal tear

A

Full thickness tear extending into the peritoneal tear

45
Q

Clinical signs of a rectal tear

A

+ Sudden release of pressure on rectal palpation
+ Direct palpation of organs on rectal palpation
+ Blood on sleeve during rectal palpation
+ Colic, progressing to depression
+ Hemorrhagic feces
+ Tenesmus
+ Signs of peritonitis
+ Signs of endotoxemia (hyperemic to purple MM, toxic line dorsal to incisors, tachypnea and tachycardia, sweating)
+ Prolapse of intestines out the anus

46
Q

Drugs we use to sedate the horse to examine for rectal tears

A
  • Epidural of lidocaine
  • Xylazine +/- butorphanol
  • Buscopan = anti-spasmodic
  • Lidocaine directly into rectum (diluted in tap water)
47
Q

Diagnosis of rectal tears

A
  • Sedation and epidural
  • Bare arm or surgeon glove rectal exam = go SLOWLY and lubricate
    +/- Tube speculum or endoscope (rectal folds can obscure)
  • CBC and abdominocentesis = indicative of peritonitis (esp. if grade III or IV)
48
Q

First things you should do, as a practitioner, for grade III or IV rectal tears

A

1) Inform the owner = inherent risk of rectal palpation
2) Apply appropriate tx = epidural, evacuate and pack the rectum with cotton material 10 cm orad to defect, close anus w/ purse string
* Administer banamine, broad spectrum antibiotics, +/- fluid tx for shock
3) Refer ASAP

49
Q

Treatment of grade I and II rectal tears

A
  • Antibiotics, Ex: TMS
  • Soft feed, Ex: grass, moistened pellets, bran mash, NO hay
  • Laxatives, Ex: MgSO4 or mineral oil, 4 L every 4 hours to soften feces, decrease bulk
  • May take 4-6 weeks to fully heal
50
Q

Surgical treatments for rectal tears (3)

A

1) Direct suture repair = may want to wait a few days for grade 3 for edema and friable tissues to “heal”
2) Temporary rectal lining bypass = dorsal recumbency and GA, sutured oral to the tear, falls out in 10 days
3) Loop or end colostomy bypass = suture colon to body wall

51
Q

Why is the loop or end colostomy not a favorable option? (2)

A

1) Prone to complications

2) Requires a second surgery to reverse the process

52
Q

Complications of rectal tears

A

1) Peritonitis
2) Endotoxemia
3) Laminitis
4) Abscessation
5) Formation of adhesions
6) Stricture at tear site
7) Diverticulum at tear site

53
Q

Prognosis of rectal tears

A
  • Good for grade I and II
  • 70% for grade III
  • Poor for grade IV
  • Direct suturing = 75% survival
54
Q

What is the most important thing to remember about rectal tears?

A

Prevention&raquo_space;> treatment, use lube, go slow, sedate, use lidocaine/buscopan

55
Q

Causes of rectal prolapse

A
  • Diarrhea
  • Dystocia
  • Parasitism
  • Colic
  • Proctitis = inflammation of rectum
  • Rectal tumors
  • Foreign bodies
  • Short tail amputations, affects musculature around the anus (really just in sheep)
56
Q

Type I rectal prolapse

A

Rectal mucosa and submucosa protrude from the anus

*More common finding

57
Q

Type II rectal prolapse

A

Complete prolapse of the full thickness rectal ampulla (retroperitoneal portion)

*More common finding

58
Q

Type III rectal prolapse

A

Type II (complete and full thickness prolapse of retroperitoneal rectal portion) with small colon intussception into the rectum

59
Q

Type IV rectal prolapse

A

Peritoneal rectum and variable amount of small colon intusscept through the anus

*Seen with dystocias

60
Q

Clinical signs of rectal prolapse

A

+ Mucosal mass (type I, II, III) or tube (type IV) protruding from anus
+ Variable amounts of edema, bruising, cyanosis, necrosis
+ Colic and peritonitis (types III and IV) due to disruption of vasculature

61
Q

Non-surgical treatment of rectal prolapse

A
  • Epidural
  • Reduction w/ application osmotic agent (glycerin, sugar, lidocaine, MgSO4)
  • Purse string suture (umbilical tape), keep it tight and untie every 2-4 hours to empty rectum
  • Laxatives
  • Temporary starvation (12-24 hrs) to decrease rectal volume
  • Soft feed
  • Peritoneal fluid/laparoscopy to observe the viability of the mesocolon and colon
62
Q

Surgical treatment of rectal prolapse (2)

A

1) Submucosal resection = circumferential incision mucosa to mucosa
2) Resection and anastamosis = full thickness incision
* Stylet or spinal needle across the anus to hold it in/out

63
Q

Prognosis of rectal prolapse

A
  • Type I and II = good

- Type III and IV = guarded to poor, dependent on the degree of vascular damage

64
Q

Dx? Mass near rectum (lateral or dorsal), mild colic, depression, lethargy, inappetence, decreased fecal output, tenesmus, fever

A

Perirectal abscess

65
Q

Etiologies of perirectal abscesses

A
  • Idiopathic = most common
  • Previous rectal tear
  • Rectal puncture
  • Rectal inflammation
  • Gravitation of gluteal abscess post-injection
  • Lymphadenopathy from Strep equi zoo or E. coli
66
Q

Dx of perirectal abscess

A
  • Rectal palpation = firm, submucosal mass
  • Aspirate transcutaneously or transrectally
  • Culture and sensitivity of aspirate
  • U/S - may not differentiate between lymph node, abscess, or hematoma
67
Q

Treatment of perirectal abscess

A
  • Sedation and epidural (or local anesthesia)
  • Establish drainage = lateral via percutaneous, dorsal via rectum, ventral via vagina or percutaneous
  • Flush daily (up to 5-7 days)
  • Laxatives
  • NSAID’s
    +/- Sx in younger horses with lymph node abscessation (antibiotics, NSAID’s laxatives, dietary modification)
68
Q

Prognosis for perirectal abscesses

A

GOOD - as long as there’s not involvement of the abdominal cavity or organs

69
Q

Dx? Neonate with tenesmus, signs of colic, progressive abdominal distension, no fecal passage, no meconium staining, straining of rectum SQ during straining, toxemic

A

Atresia ani

70
Q

Is atresi ani or recti common in horses?

A

No - more common in pigs or cattle

71
Q

What should you always check if you suspect atresia ani or recti?

A

For other congenital abnormalities

Ex: atresia coli, renal aplasia/hypoplasia/dyplasia, absence of a tail, musculoskeletal deformities, microophthalmia, rectovaginal fistula, other urogenital abnormalities

72
Q

Dx of atresia ani or recti

A
  • Signalment and clinical signs
  • Digital rectal palpation
    +/- Imaging = U/S or rads
73
Q

Treatment of atresia ani with complete rectal pouch

A
  • Incise persistent anal membrane and skin caudal to anal sphincter
  • Suture rectal wall to skin
  • Close any communication with the urogenital tract with inverting sutures
74
Q

Treatment of atresia recti

A
  • Blunt dissection cranially
  • Pull rectal pouch caudally
  • Suture rectum SQ
  • Incise pouch and suture mucosa to skin
  • Close any communication with the urogenital tract w/ inverting sutures
75
Q

Prognosis with atresia ani and recti

A
  • Ani or recti = favorable
  • Normal anal sphincter may not be obtained
  • Coli is present = prognosis is poor
76
Q

Most common perineal tumors (2) Clinical signs?

A

1) SCC = necrotic, foul smelly, locally invasive, slow to met
2) Melanomas = solitary/multiple nodules (common in older > 15 yo grey horses)

  • Other = polyps, leiomyosarcoma, adenocarcinoma
77
Q

Dx and tx of perineal tumors

A
  • Dx = histopath via biopsy

- Tx = surgical excision, cryosurgery, laser surgery, radiation tx, immunotherapy, bypass the rectum procedure

CAEM Pt. 2 (27 decks)

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