Megaesophagus

Wendy Blount, DVM Cats Are Not Little Dogs Speed of Esophageal Transit • Dog – 75-100 cm/sec • Cat – 1-2 cm/sec Why?? • Striated muscle (dogs) faster than smooth (cats) So What?? • Eating fast causes more vomiting in cats than dogs • Tube feeding must be slower in cats • Cats are more susceptible to esophagitis due to caustic substances such as doxycycline Cats Are Not Little Dogs

Muscle Type • Dog – entirely striated • Cat – cranial 2/3 striated, caudal 1/3 smooth So What?? Cisapride, metoclopramide, ranitidine and nizatidine work on smooth muscle – Will work better on cats with megaesophagus when compared to dogs Bethanecol works on striated muscle Megaesophagus - Etiology

Generalized Megaesophagus Entire esophagus is affected

Localized megaesophagus Usually proximal to obstruction Megaesophagus - Etiology

Localized megaesophagus Usually proximal to obstruction

Esophageal Stricture Causes • trauma • caustic substance swallowed – doxycycline Megaesophagus - Etiology

Localized megaesophagus Usually proximal to obstruction

Esophageal Stricture Causes • trauma • caustic substance swallowed – doxycycline Megaesophagus - Etiology

Localized megaesophagus Usually proximal to obstruction Gigi • 14 year SF standard poodle • Just swallowed an apple core • having difficulty breathing Megaesophagus - Etiology

Localized megaesophagus Usually proximal to obstruction Gigi Megaesophagus - Etiology

Localized megaesophagus Usually proximal to obstruction Lessons from Gigi • Megaesophagus is not always chronic • Acute esophageal foreign bodies sometimes pass with a little time (1 hr) • If your patient does something unexpected, reassess Megaesophagus - Etiology

Localized megaesophagus Usually proximal to obstruction Esophageal foreign body Where are they most common? • thoracic inlet • base of the heart • Lower esophageal sphincter Most common symptom of esophageal foreign body • Unrelenting gagging Megaesophagus - Etiology

Localized megaesophagus Usually proximal to obstruction Megaesophagus - Etiology

Localized megaesophagus Usually proximal to obstruction

Parasites • Spirocerca lupi Megaesophagus - Etiology

Localized megaesophagus Usually proximal to obstruction Megaesophagus - Etiology

Localized megaesophagus Usually proximal to obstruction Neoplasia • Esophageal neoplasia – SCC, Leiomyoma/LMSA (GIST) • Mediastinal mass – which tumors? – Lymphosarcoma – Thymoma Megaesophagus - Etiology

Localized megaesophagus Usually proximal to obstruction 8-10 month old F pit pull • Surrendered to animal shelter • Thin body condition - BCS 2/9 • Respirations are rapid and shallow • Mucous membranes pink, CRT <2 sec • Coughing Megaesophagus - Etiology

Localized megaesophagus Usually proximal to obstruction 8-10 month old F pit pull DDx • Lung disease – alveolar or interstitial pneumonia • Esophageal disease + pneumonia • Pleural effusion, Diaphragmatic hernia • (Congestive heart failure – congenital defect) • (lymphoma/other neoplasia, airway disease) Megaesophagus - Etiology

Localized megaesophagus Usually proximal to obstruction 8-10 month old F pit pull Megaesophagus - Etiology

Localized megaesophagus Usually proximal to obstruction

Vascular Ring Anomaly • persistent right aortic arch (PRAA) • ring by left subclavian artery and brachiocephalic trunk Megaesophagus - Etiology

Localized megaesophagus Usually proximal to obstruction 5 month old M sharpei • Purchased dog 1 month ago • Gets frantic and gags for 15-30 minutes after eating dry food • No problem with canned food • Getting worse Megaesophagus - Etiology

Localized megaesophagus Usually proximal to obstruction Megaesophagus - Etiology

Localized megaesophagus Usually proximal to obstruction Congenital • Esophageal diverticulum – where? – Base of the heart • Breed? – English Bulldog Generalized Megaesophagus

Two Onsets • Congenital – apparent by 3 months of age • Acquired – often geriatric Why is the Difference Important? Prognosis • Congenital – guarded • Acquired – short term always guarded – long term often guarded, but potentially good • depending on the cause. Generalized Megaesophagus

Two Types of acquired ME: • Megaesophagus alone • ME as part of a generalized myopathy, neuropathy or junctionopathy

Why Do We Care? If the underlying cause of weakness is not treatable, the animal will not do well Generalized Megaesophagus

What is Junctionopathy? Disease of the myoneural junction

Most Common Junctionopathy Myasthenia gravis

Who has diagnosed a case of myasthenia gravis? Generalized Megaesophagus - Alone

The most common esophageal disease in dogs and cats is megaesophagus

Causes – two most common • Idiopathic • Myasthenia gravis Generalized Megaesophagus - Alone

The most common esophageal disease in dogs and cats is megaesophagus

Causes – two most common Idiopathic• Idiopathic megaesophagus • Myasthenia gravis

paraneoplastic megaesophagus Generalized Megaesophagus - Alone

Esophagitis Chronic inflammation can result in ileus Causes of esophagitis: • Gastroesophageal reflux • Hiatal hernia, GERD • Chronic GDV, GERD • Foreign body removed prior to stricture • Exposure to a caustic substance Oreo

6 year old SF DSH • Regurgitating for 2-3 months and choking on food, always within 1 hour of eating • now several times weekly • Has lost 1-2 pounds • Otherwise, has not acted sick • Does better with hard foods than soft foods CBC, panel/lytes, FeLV/FIV, T4, fecal - NSAF Oreo Oreo

ACh receptor antibody 0.6 nmol/l Abdominal ultrasound - NSAF Tx: • Dexamethasone 1 mg SC • In 2 days start prednisone 5 mg PO BID x 5 days, then 5 mg PO SID x 7 days, then 5 mg QOD – Increase dose if symptoms recur • Mestinon® syrup 3 mg PO BID x 10 days, then increase by 3mg per dose every week up to 12 mg PO BID, to control regurgitation Generalized Megaesophagus

Myasthenia gravis • Auto-immune disorder • Autoantibodies against Ach receptors

There are four kinds of MG 1. Congenital 2. Acquired Focal • Esophagus, pharynx/larynx, +facial nerve 3. Acquired Generalized 4. Acquired Acute Fulminant Generalized Megaesophagus

There are four kinds of MG Why do we care?? Different Prognoses • Congenital – poor • Acquired Acute Fulminant – dismal • Acquired Focal and Generalized – Long term potentially good – Most cases of acquired MG resolve within a year – Short term guarded – 50% die of aspiration pneumonia during therapy Generalized Megaesophagus

ME as part of generalized weakness

Causes: • Congenital myopathy, neuropathy, junctionopathy • Hypothyroidism (? Gaynor et al, 2009) • Hypoadrenocorticism • Muscular dystrophy • Dysautonomia – more common in cats Generalized Megaesophagus

ME as part of generalized weakness

Causes: • Immune mediated disease – Systemic Lupus Erythematosis – Dermatomyositis – Polymyositis • Giant axonal neuropathy - GSD • Congenital myasthenia gravis Generalized Megaesophagus

ME as part of generalized weakness

Causes: • Hereditary myopathy of Labradors • Lead toxicity • Thallium toxicity • Organophosphate toxicity Vomiting, Regurgitation, Coughing

Time with respect to eating Expulsion Process Premonitory Signs

CONFUSING!!! Vomiting, Regurgitation, Coughing

Vomiting Regurgitation Coughing Hardly digested to Hardly digested to White and foamy liquid liquid Smell variable May smell sour and Not usually foul fermented smelling Rarely has mucus Often is slimy with May contain mucus mucus or pus Digested blood Blood is rare May be blood tinged suggests vomiting May contain bile Never bile stained Never bile stained Clues in the History - ME

Signs of Aspiration Pneumonia Coughing Fever Dyspnea Cyanosis Acute death Can have coughing without regurgitation Coughing can be due to pressure of enlarged esophagus on the trachea Clues in the History - ME

Weight loss Can be severe Neurologic deficits – LMN Signs Depressed spinal and cranial nerve reflexes Large, easily expressed bladder Constipation Laryngeal paralysis Muscular abnormalities Muscle atrophy with generalized weakness Muscle pain with polymyositis Zoey

10 year old SF Aussie

CC: Has not been able to control her bladder for about 6 weeks, occasionally vomits (once a month); taking SMZ • She does not seem to be aware of urination – it just dribbles out, wakes up in a puddle • Her bladder empties when owner lifts her • Had a bout of this 4 months ago, responded to treatment with Proin®; phenylpropanolamine no longer works • Occasionally feces drops out as she walks • Appetite and water intake are fine, energy is fine; CBC/panel 6 weeks ago NSAF Zoey

Exam: • *Very* anxious dog – owner says this is lifelong • Pupils dilated and minimally responsive PLR – owner say she squints in sunlight • Took her outside to urinate – she urinates a little while walking , but bladder is still very full, and easily expressed • Mild CP deficits rear limbs • Spinal nerve reflexes 1+ in rear limbs • STT - >20mm/min OU Zoey

CBC – NSAF Panel/lytes – BUN 31 UA – USG 1.024, cocci on urine sediment

Abdominal US: • Kidneys mildly hyperechoic with dilated renal pelves Urine C&S – pending Pelvic rads - NSAF Tx: started marbofloxacin 50 mg PO SID x 21 days Zoey • Pilocarpine 0.1% 2 drops each eye • Pupils 25% smaller in 15 minutes, with bilateral rather normal PLR • Pupils 50% smaller in 45 minutes • Pupils pinpoint at 1 hour • Atropine OU did not dilate pupils

Dx - Dysautonomia Zoey Tx – marbofloxacin 50mg PO SID pending urine culture • Taught owner to manually express bladder • DES 1 mg 1-2x weekly • Bethanechol 10 mg PO TID

Urine culture – methicillin resistant Staph • Susceptible to amikacin, chloramphenicol, doxycycline and marbofloxacin • Resistant to 17 antibiotics • Continued marbofloxacin for 6 weeks • Urine culture within 1 week of stopping marbofloxacin Zoey CBC, Panel/lytes - NSAF Urine culture – another Staph • Susceptible to everything but ampicillin, enrofloxacin and SMZ • Tx – Clavamox 250 mg PO BID x 4 weeks • Urine culture negative after this round

Plan • Recheck BUN, UA and urine culture in 30 days • Continue manual expression of bladder, Bethanechol, Proin, DES • CBC q6months Dysautonomia First cases in Scottish horses in the 19 century First reported in the cat in 1982, first dog in 1983 Degeneration of autonomic ganglia and failure of autonomic function History: • Vomiting, regurgitation, diarrhea • Anorexia weight loss, lethargy • Dyspnea, coughing • Photophobia • Dysphagia, dysphonia • Dysuria, urinary incontinence • Onset over 1-2 weeks Dysautonomia

Exam: • Decreased anal tone • Absent PLR, moderate mydriasis • Third eyelid prolapse • Dry mucous membranes and eyes • Crusty nose, nasal discharge • Dyspnea, pulmonary crackles, fever • Cachexia, weakness • Global LMN weakness and CP deficits on neuro exam • Large urinary bladder that is easy to express • Heart rate and blood pressure relatively low Dysautonomia

Diagnosis: • Thoracic rads may show megaesophagus and/or aspiration pneumonia • Ileus, bladder distension on abdominal imaging • Schirmer Tear Test less than 10mm OU • CBC, panel, CSF tap may be normal if no systemic complications Dysautonomia

Diagnosis: Pilocarpine test • Place 1-2 drops 0.05% pilocarpine in one eye • Check PLR every 15 minutes for one hour • Normal dogs show minimal response • If dysautonomia, miosis due to denervation hypersensitivity • Can be false negatives

• Chronic OP toxicity can produce similar results • Adding atropine will reverse the miosis in OP toxicity but not dysautonomia No tachycardia in response to atropine injection Dysautonomia

Treatment:

Bethanechol 1.25-5 mg PO BID or 0.05 mg/kg SC BID • SC seems to work better • Can help with urination and secretion • Can gradually increase to effect • Side effect – can increase vomiting and aspiration pneumonia

Pilocarpine eye drops • Can assist tear production and photophobia

Artificial tears OU PRN, Genteel®, Soothe XP®

Elevated feedings, prokinetics, permanent Gtube Dysautonomia

Prognosis:

Grave

Mortality 70-90%

Those who survive have significant disability and progressively debilitate

10-30% can be managed long term Dysautonomia

Pathology:

50% have megaesophagus 20% have aspiration pneumonia

Can diagnose with histopath on necropsy Widespread degeneration of the autonomic nerves and ganglia

More than 50% are rural, outdoor dogs

Exposure to Clostridium toxins and/or paraneoplastic disease may play a role in pathogenesis Clues in the History - Quiz

Signs of myasthenia gravis Weakness worsens with exercise Change in barking Difficulty eating or swallowing Weak or absent palpebral reflex – fatigues Signs of hypoadrenocorticism Vomiting and diarrhea (especially with blood) Lethargy and weakness PU-PD Shock if severe Clues in the History - Quiz

Signs of hypothyroidism Obesity Symmetrical truncal alopecia Dry eye Pyoderma, dermal hyperpigmentation

Signs of lead toxicity Vomiting and diarrhea Seizures, dullness, behavior changes, apparent blindness Clues in the History - Quiz

Signs of immune mediated disease Muscle pain - polymyositis Joint pain or swelling - polyarthritis Anemia - IMHA Thrombocytopenia – ITP Skin pustules, mucous membrane ulcers Fever Diagnosis of Megaesophagus

The test that most often diagnoses ME Radiographs – Barium Esophagram • Normal esophagram shows lines only Diagnosis of Megaesophagus

The test that most often diagnoses ME Radiographs – Barium Esophagram • Normal esophagram shows lines only • Barium will pool in the esophagus if ME Diagnosis of Megaesophagus

The test that most often diagnoses ME Radiographs – Barium Esophagram • Normal esophagram shows lines only • Barium will pool in the esophagus if ME • Can assess wall thickness • May see filling defect of radiolucent foreign body, ulcer, or mass • Can sometimes see a herringbone pattern in the distal feline esophagus, due to mucosal folds Diagnosis of Megaesophagus

The test that most often diagnoses ME Radiographs – Barium Esophagram Procedure: • Administer 5-20 ml barium paste, liquid or barium coated food • Paste gives the best coating, but can be dangerous if aspirated • If motility problem with good tone, it may take barium coated food to see abnormalities ***WARN OWNER OF DANGER OF THIS PROCEDURE*** Diagnosis of Megaesophagus

The test that most often diagnoses ME Radiographs – Survey Abdominal • May see radiopaque foreign body if heavy metal poisoning • May see a gas filled stomach if generalized GI motility disorder • May see displaced pylorus of chronic gastric volvulus. Diagnosis of Megaesophagus

The test that most often diagnoses ME Fluoroscopy • The best way to evaluate mild to moderate esophageal hypomotility • 5-20 cc liquid barium per bolus first • Then liquid barium mixed with canned food • Then liquid barium coated kibble • Strictures may show no abnormalities with liquid barium bolus Diagnosis of Megaesophagus

Minimum database for suspected regurgitation CBC, serum profile Electrolytes and venous blood gases Urinalysis Fecal flotation and direct wet mount Thoracic and cervical radiographs Abdominal rads, ultrasound Diagnosis of Megaesophagus

Patterns in Minimum Database - Quiz CBC Aspiration pneumonia • Neutrophilia with left shift • Activated lymphocytes and monocytes Immune mediated disease (rare) • Absolute reticulocyte count 300,000 • HCT 16% • Spherocytes Diagnosis of Megaesophagus Patterns in Minimum Database - Quiz Serology Hypothyroidism • Elevated triglycerides • Elevated cholesterol Hypoadrenocorticism • Azotemia (elevated BUN, creat, phos) • Hypercalcemia • Hyperkalemia • Hypoalbuminemia • Hypoglycemia Diagnosis of Megaesophagus

Patterns in Minimum Database Diagnosis of Megaesophagus

Patterns in Minimum Database

Fecal Examination Standard sugar and salt flotation solutions will not give great yields of Spirocerca lupi larvated eggs Sodium nitrate or direct wet mount is often more sensitive Jovi

• 1-1/2 year old SF Great Dane • 120 lbs • CC – Referred for chronic cough and vomiting • Not eating for 2 days • Exam – BCS 4/6, temp 104F • Neuro Exam - NSAF Jovi

• CBC – PCV 30% – Neutrophils 38,000/ul – Monocytes 2,700/ul • panel – albumin 2.2 g/dl • UA – no abnormalities • Electrolytes/blood gases - normal • Thoracic radiographs Jovi Jovi

• DDx Generalized Megaesophagus – Idiopathic – Hypothyroidism ?? – Hypoadrenocorticism – Localized myasthenia gravis – Esophagitis – (Dysautonomia) – (Muscular Dystrophy) – (Peripheral Neuropathy) – (Systemic Junctionopathy) Jovi

• Thyroid Panel – TSH - undetectable – TT4 – 2.9 (low) – fT4 - normal • ACTH Stimulation Test – Pre ACTH cortisol – 0 ug/dl – Post ACTH cortisol – 0 ug/dl • Anti Ach Receptor Antibody – negative • Scope??? Jovi

• Dx – Megaesophagus due to hypoadrenocorticism – Secondary aspiration pneumonia – Sick euthyroid (NTIS) Jovi • Tx 1. Prednisone 10 mg PO SID 2. Amoxicillin 1500 mg PO BID x 4-8 weeks – Ciprofloxacin 500 mg PO BID x 4-8 weeks – Follow pneumonia with chest x-rays 3. Jovi eventually needed treatment also with mineralocorticoids – Megaesophagus due to Addison’s responds well to treatment Diagnosis of Megaesophagus

Tests indicated in every dog and cat with ME Thyroid panel • TSH, T4, freeT4 (TAMU GI Lab) • freeT4ED is indicated if T4 is low, to rule out antithyroid antibodies Cortisol Testing – Addison’s (TAMU GI Lab) Myasthenia gravis titer • Comparative Neuromuscular Laboratory, UC-Davis Getting a positive test result on one of the above should not preclude testing for the others. A significant number of ME patients have 2 or even all 3 of these problems concurrently (Polyendocrine Disease) Diagnosis of Megaesophagus

Baseline Cortisol • > 2 ug/dL highly unlikely to have hypoadrenocorticism • if not receiving corticosteroids, mitotane, or ketoconazole ACTH Stimulation Test • **Different protocols for dogs and cats** (handout) 1. Baseline cortisol 2. cosyntropin (Cortrosyn®) 5 mcg/kg IV 3. Cats – post 30 minutes and 1 hour • Dogs – post 1 hour Using dog protocol for dogs can result in false positive Treatment of Megaesophagus

Elevated Feedings THE PRIMARY TREATMENT IF THE ANIMAL IS TO BE FED BY MOUTH MAKE SURE YOU SPEND ENOUGH TIME WITH THE OWNER TO FULLY EXPLAIN THIS, AS THEIR PET’S LIFE CAN DEPEND ON IT Treatment of Megaesophagus Elevated Feedings • Upper body should be elevated 45-90 degrees. • Hold this position for 10 minutes after eating • Do this also prior to periods of known prolonged lateral recumbency (sedation, sleeping) • Small frequent meals (2-4 or more a day) • Avoid feeding for several hours before bedtime • Experiment with food type to determine which works best for the patient • Lots of how to videos on www.youtube.com • “Bailey Chair” Treatment of Megaesophagus

Elevated Feedings

• Upper body should be elevated 45-90 degrees. • Hold this position for 10 minutes after eating • Do this also prior to periods of known prolonged lateral recumbency (sedation, sleeping) • Small frequent meals (2-4 or more a day) • Avoid feeding for several hours before bedtime • Experiment with food type to determine which works best for the patient Treatment of Megaesophagus Treatment of Megaesophagus Treatment of Megaesophagus Treatment of Megaesophagus Treatment of Megaesophagus Treatment of Megaesophagus Treatment of Megaesophagus Treatment of Megaesophagus Treatment of Megaesophagus Treatment of Megaesophagus Treatment of Megaesophagus Tube Feeding Temporary gastrostomy • can help stabilize until megaesophagus can be improved, if the cause is treatable • Often required for 1-3 months • extremely helpful for aspiration pneumonia • Medications given by tube are more assured of absorption – PO meds are a problem for ME dogs – May need to compound injectables – NEVER GIVE DOXYCYCLINE PILL BY MOUTH TO A PATIENT WITH ME (suspension OK) Treatment of Megaesophagus

Tube Feeding

Permanent gastrostomy • Place a Pezzar tube first • When stoma is well healed, replace with low profile gastrostomy tube • Medications given by tube long term • Owners have to be vigilant to keep their pets from taking in food by mouth • If they do take food PO, they need to keep the pet’s front end elevated for 10 minutes. Treatment of Megaesophagus Prokinetics • Metoclopramide, cisapride - empty the stomach faster to minimize GER and regurgitation • Cisapride – may actually improve esophageal function – Seems to work more consistently in cats – Response in dogs varies from dramatically positive to no response • Bethanechol – dogs only • Ranitidine, Nizatidine – esp. if esophagitis • Low dose erythromycin Treatment of Megaesophagus

Treat aspiration pneumonia

• Broad spectrum antibiotics – gram negatives, positives and anaerobes – Long term therapy might be needed for chronic recurring aspiration pneumonia • IV fluid therapy – overhydration to keep respiratory secretions coming up • Coupage • + Nebulization • Gastrostomy tube • NPO – including medications Treatment of Megaesophagus

Treat esophagitis – 2 weeks after resolution of clinical signs

• Sucralfate - PO – Do not give within 1-2 hours of any other PO meds • Prokinetics • Proton pump blockers – short term • H2 blockers – long term Treatment of Megaesophagus

Treat underlying cause • Hypoadrenocorticism – Prednisone 0.1 mg/lb/day + DOCP/Flurinef® • Myasthenia gravis – Pyridostigmine 1-3 mg/kg PO BID-TID – Prednisone in cats + in dogs • Hypothyroidism (rarely effective) • PRAA – surgery, if early enough • Stricture – balloon or bougie • Spiracerca lupi, muscular dystrophy – difficult to treat Treatment of Megaesophagus

Immunosuppression – SKEERY!!

• Might be indicated for: – Myasthenia gravis – SLE – Polymyositis • Only as a last resort for MG in dogs. • Dangerous for those with aspiration pneumonia • Some dogs with MG can decompensate when immunosuppressed Treatment of Megaesophagus

Immunosuppression – SKEERY!!

• Drugs: – Prednisone • Start at 0.25 mg/lb/day and gradually increase to immunosuppression if tolerated – Azathioprine • Start at 0.5 mg/kg PO SID, and then double if tolerated • Eventually wean down to the lowest effective dose over 2-3 months or more • Those who respond to immunosuppression may be able to be weaned off Mestinon® • Use MG titer to know how long to continue therapy – Begin the weaning process when titer negative – Check monthly to make sure not weaning too fast Enya 14 day old female orphan kitten • Making gurgling noises while bottle nursing • She gets panicky while nursing • Owner has bottle raised hundreds of kittens – She knows abnormal when she sees it

Exam • BAR, well hydrated and in good body condition • Can see air puffing in the esophagus as she breathes Enya Thoracic Radiographs Enya Thoracic Radiographs Enya Diagnoses – megaesophagus with Aspiration pneumonia Treatment • Sucralfate 0.5cc PO BID • Tube feed for 1 week • Amoxicillin 5 mg by tube BID • Separate from male litter mates Megaesophagus resolved in 2 weeks Adopted at 10 weeks of age Enya is 7 years old now and doing very well Megaesophagus - Prognosis Severe dilation often carries a poor prognosis, no matter the cause median survival 90 days Spirocerca – rarely can be effectively treated Acquired idiopathic megaesophagus carry a variable prognosis, depending on: • Use of permanent gastrostomy • Response to cisapride • Tendency to develop aspiration pneumonia Congenital megaesophagus • Guarded in general • Occasionally a puppy will have resolution at 6-12 months All patients with ME are at risk for sudden death due to aspiration and respiratory obstruction Megaesophagus - Prognosis Examples of Acquired ME with treatable cause Potentially good long term prognosis • Short term treatable esophagitis • Stricture of short term duration – If stricture can be fixed with serial dilation • Addison’s Disease • Myasthenia gravis – focal, acquired, uncomplicated • PRAA – if surgically repaired prior to permanent damage to esophagus Augustus

6 yr CM English Bulldog • Regurgitates minutes to 1 hour after eating • Happens with canned or dry food • Patient feels well

Exam • BAR, well hydrated and in overweight body condition Augustus Barium Upper GI Contrast Study • Scout films Augustus Barium Upper GI Contrast Study • Scout films Augustus Barium Upper GI Contrast Study • Scout films – pulmonary parenchyma and trachea unremarkable for body condition, degree of inspiration and breed – mild distention of the mid and caudal thoracic esophagus with fluid and/or gas (lateral view) – focal soft tissue opacity to left of mediastinum at rib 11-13 (VD view) – widening of the cranial mediastinum due to fat (VD) – mass effect in cranial mediastinum not seen on lat – several hemivertebrae, butterfly vertebrae, kyphosis at T11, rib crowding, ventral spondylosis at T11 Augustus Barium Upper GI Contrast Study • Barium Esophagram Augustus Barium Upper GI Contrast Study • Barium Esophagram Augustus Barium Upper GI Contrast Study • Barium Esophagram – multifocal positive contrast is seen within the caudal cervical and intrathoracic esophagus – focal indentation of contrast at T11 with esophagus focally dilated cranially (film 1) – linear filling caudal to indentation - probable rugal folds – Dx - sliding esophageal hernia (likely hiatal hernia) – FILM 2 - indentation not identified; small dilation immediately cranial to the stomach, may represent persistent small esophageal hernia Augustus Treatment • Esophagitis – Sucralfate, omeprazole then famotidine • Prokinetics – cisapride • Possible surgical correction – Not for the faint of heart Summary • PowerPoint Presentation – 1 slide & 6 slides per page • Instructions for Adrenal Testing in Dogs and Cats • Lab Submission Forms – TAMU GI Lab Endocrine Submission Form, Discounted Shipping Info – Comparative Neuromuscular Laboratory Submission Form and submission instructions • Client Information Handout – Dysautonomia • Myasthenia gravis – Hiatal Hernia • Polyendocrine Failure – Hypoadrenocorticism – Hypothyroidism – Megaesophagus Handouts

• Client Drug – Famotidine Handouts – Fludrocortisone – Azathioprine – Metoclopramide – Bethanechol – Nizatidine – Cimetidine – Omeprazole – Cisapride – Pantoprazole – DES – Phenylpronaolamine – DOCP – Prednisone – Doxycycline – Pyridostigmine – Erythromycin – Ranitidine – Esmomeprazole – Sucralfate Acknowledgements Tams TR, Chapter 4, “Diseases of the Esophagus,” in Todd R Tams Small Animal Gastroenterology, 2nd Edition. Adam Honeckman, DACVIM Mobile Veterinary Diagnostics, Orlando FL Margie Scherck, DABVP, VIN Consultant Christine Prior, DVM, DVM, Longview TX Animal Shelter Carol Adams, DVM, Central Plains Vet Clinic Animal Clinic of North Longview Connolly Animal Clinic, Eastex Vet Clinic – Nacogdoches TX