SA GI Medicine 1 - Approaching Swallowing Disorders and Regurgitation

Question 1

Define…
1. Chelitis.
2. Glossitis.
3. Gingivitis.
4. Stomatitis.
5. Gingivostomatitis.
6. Tonsilitis.

Answer 1

Inflammation of the…
1. Lips.
2. Tongue.
3. Gums.
4. Oral mucosa (whole mouth).
5. Gums and oral mucosa.
6. Tonsils.

Question 2

Define…
1. Pharyngitis.
2. Drooling.
3. Ptyalism or hypersalivation.
4. Pseudoptyalism.
5. Halitosis.
6. Dysphagia.

Answer 2

1. Inflammation of the pharynx.
2. Saliva leaving the mouth unintentionally.
3. Excessive production of saliva.
4. Normal amount of saliva leaving the oral cavity.
5. A bad smell to the breath.
6. Difficulty swallowing food or liquid - structural or functional (oropharyngeal or occasionally oesophageal.

Question 3

Define…
1. Odynophagia.
2. Regurgitation.
3. Gastro-oesophageal reflux.
4. GERDs.
5. Oesophagitis.
6. UES.
7. LES.

Answer 3

1. Swallowing pain (oropharyngeal or oesophageal).
2. Passive return of food (oesophageal).
3. Reflux of gastric acid and enzymes into the oesophagus.
4. Gastro-oesophageal reflux disease – a group of conditions leading to gastro-oesophageal reflux disease.
5. Inflammation of the oesophagus.
6. Upper oesophageal sphincter.
7. Lower oesophageal sphincter.

Question 4

How could swallowing problems present?

Answer 4

• Patient dropping food out of mouth.
• Hypersalivation.
• Weight loss/failure to thrive.
• Secondary coughing/dyspnoea (aerodigestive) – lung issue presents as aspiration.
• Secondary inappetence / interest in food but reluctant to eat.
• Pain.
• Retching/gagging.
• Regurgitation.
• Noisy swallowing.
• Excessive gulping.
• Secondary halitosis.
• Secondary nasal discharge.
• Secondary blood-tinged saliva.

Question 5

Establishing regurgitation causes.

Answer 5

Difficult to determine if regurgitation or vomiting.
Oesophageal FB likely?
Any meds that may cause this?
Recent anaesthesia?
Other GI signs?
Generalised neuromuscular clinical signs?
- Struggling to climb stairs/on furniture.
- Scuffing paws while walking.
- Difficulty standing up.
Any coughing/dyspnoea?

Question 6

What is seen in regurgitation compared to vomiting?

Answer 6

Undigested food.
Passive / no abdominal effect/movement.
Straight after eating (can be delayed).
No gagging/retching etc.
pH neutral as no gastric acid.
Brainstem is not involved.

Question 7

Physical examination of the regurgitating patient.

Answer 7

Full CE.
- Generalised vs. localised disease.
- Neuro exam?
- Hydration / volaemic status.
- Body condition.
Conscious vs sedation / GA.
- Pre-GA bloods.
- Difficulty opening the mouth.
- Airway obstruction.
- Brachycephalic breeds.
- Reflux and aspiration.

Question 8

Oropharyngeal exam.

Answer 8

Trauma / FB.
Pain on palpation.
Dental disease.
Lip folds, MMs, tonsils, roof of mouth.
Muscle mass (may indicate neuromuscular issue) (CK, anti-2M antibodies for MMM, AChR antibodies for myasthenia gravis) - consider muscle biopsy).
Jaw opening - comfortable and full?
Check underneath the tongue.
Check for oral masses (e.g. gingivitis, epulis, feline eosinophilic granuloma, melanoma) and inflammatory disease - may be worth sampling while under GA.
Check for ulceration and burns (chewing due to neuro deficits, electrical wire burns, uraemic ulcers, viral cause).
Check for salivary gland disease (refer).
Check the LNs.

Question 9

Problem list - dysphagia.

Answer 9

Structural - structural abnormality.
– e.g. FB.
– e.g. mass lesion –> inflammatory, cyst, granuloma, abscess, neoplasia.
Functional - functional abnormality.
– carry out normal physical exam.
– e.g. neuromuscular issue.

Question 10

Problem list - drooling.

Answer 10

Pseudoptyalism:
- physiological in response to food.
- conformation.
- dysphagia including obstructive disease.
Ptyalism or hypersalivation:
- bitter taste.
- drugs.
- oral disease/ulceration.
- nausea.
- acid reflux (GERD).
- hepatic encephalopathy in cats.
- rabies.

Question 11

Problem list - halitosis.

Answer 11

Inflammation/infection/necrosis in oral or pharyngeal cavities including dental disease/neoplastic disease.
Internal causes:
- respiratory disease.
- gastric disease – poor gastric emptying.
- Metabolic disease e.g. renal disease.
External causes:
- peri-anal disease.
- coprophagia (consumption of faeces).

Question 12

Differential diagnoses for swallowing disorders.

Answer 12

Oral pain.
Oral mass.
Oral trauma.
Neuromuscular disease.

Question 13

Differential diagnoses for regurgitation.

Answer 13

Oesophageal disease.
- Structural (consider location):
– luminal.
– intraluminal.
– extra-luminal.
– sphincters (UES, LES).
– stricture.
– can be congenital (vascular ring anomaly e.g. PRAA) or acquired (e.g. FB/neoplasia/GO intussusception).
- Functional:
– nerves or neuromuscular junctions.
– muscles.
– primary disease e.g. metabolic:
–> electrolytes K and Ca.
–> endocrinopathies (e.g. hypothyroidism, hyperadrenocorticism).

Question 14

… what can be a cause of oesophageal obstruction?

Answer 14

• bones, sticks, needles, fishhooks, rawhide chews.
• can lodge anywhere – obstructive, cause regurgitation, may still be able to drink.
  Raw feeding w/ bones is a risk.

Question 15

… What is GER?

Answer 15

Gastroesophageal reflux.
Reflux of gasric acid and enzymes into the oesophagus.
Leads to inflammation.
Acute causes - anaesthesia.
Chronic causes - obesity, lower oesophageal sphincter disease, GERD.
See subtle signs e.g. discomfort, lip smacking, hypersalivation, unexplained pain, belching.

Question 16

…Causes of GERD?

Answer 16

Hiatal hernia - congenital or age related.
– sliding = dynamic.
– para-oesophageal = moves parallel to the oesophagus.
– gastroesophageal intussusception (severe, rare).
LES dysfunction.
- breed related (brachycephalic breeds).
- local oesophagitis.
Underlying chronic enteropathy.

Question 17

…What factors put brachycephalic dogs at greater risk of reflux?

Answer 17

Hiatal hernia.
Increased respiratory effect and negative intrathoracic pressure, drawing in gastric contents to the oesophagus.
Decreased oesophageal motility.
Weaker oesophageal sphincter.

Question 18

Problem list - oesophagitis.

Answer 18

Peri-anaesthetic reflux.
Ingestion of:
- caustic chemicals.
- hot liquids/foods.
- FBs.
- irritants (doxycycline).
Chronic GERD.
Persistent vomiting.
Can lead to oesophageal strictures - iatrogenic oesophagitis can also occur after stricture dilation e.g. ballooning.
Excessive stomach acid - e.g. gastrinoma, MCT.

Question 19

… what clinical signs could be seen w/ oesophagitis?

Answer 19

Pain when swallowing/difficulty swallowing/dysphagia.
Inappetence/anorexia/reluctance to eat.
Regurgitation.
Salivation.
Weight loss/failure to thrive.

Question 20

Problem list - regurgitation - Megaoesophagus

Answer 20

X-rays need to be taken conscious as some anaesthetic drugs can cause oesophageal dilation, which may lead to a false diagnosis.
Diffuse – lots of differentials:
- idiopathic (rule out all other differentials).
- myasthenia gravis – AChR ab’s.
- diffuse oesophagitis (Hx anaesthesia, chronicity).
- hypoadrenocorticism.
- hypothyroidism.
- neuromuscular disease.
- dysautonomia (rare).
Focal:
- vascular ring anomaly – heart base location in young dogs.
- FB.
- stricture.
- space-occupying lesion.
Aspiration pneumonia risk:
- tachypnoea.
- pyrexia.
- lethargy, inappetence.
- important cause of death.
- treat w/ IV ABX.