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V '04 REVIEW Masterpage CE Article #2 Esophagitis and Esophageal Strictures Alan Glazer, DVM, DACVIM a Patricia Walters, VMD , DACVIM , DACVECC New England Animal Medical Center West Bridgewater, Massachusetts ABSTRACT: Esophagitis and esophageal strictures are relatively uncommon but significant diseases in companion animals. Often, an esophageal disorder is suspected based on the animal’s medical history and clinical signs. Esophagitis and acquired esophageal strictures are caused by prolonged contact of caustic substances or foreign bodies with the esophageal lining, leading to mucosal injury. In cases of stricture, damage extends into the submucosal and muscular layers. Timely detection and appropriate management of esophagitis and esophageal strictures significantly improve nutritional status, dysphagia, and pain and often return the animal to a normal quality of life. This article reviews the current literature and focuses on the diagnosis and treatment of esophagitis and esophageal strictures caused by fibrosis secondary to esophageal inflammation. sophageal diseases cause a range of clinical cosa , and muscle . The mucosa is lined by squa - signs , including regurgitation, weight loss, mous epithelium and overlies the submucosa. In E and respiratory distress. The diagnosis of dogs, the muscle layer is composed entirely of esophagitis is challenging and often requires skeletal muscle ; in cats , the distal third is smooth specialized procedures such as endoscopy. If muscle. The esophagus does not have a serosal inflammation damages the submucosa and layer; instead , it is covered by adventitia (Figure 1). muscularis, a cicatrix may develop , resulting in The esophagus has upper and lower sphinc ters. obstruction of the esophageal lumen and more The upper esophageal sphincter is composed of the serious illness. However, significant advances cricopharyngeus and thyropharyngeus muscles. have been made in the treatment of esophagitis The lower esophageal sphincter (LES) is made and esophageal strictures. With appropriate up of muscle layers around the esophagus and management of esophageal disease , veterinary diaphragmatic crura (Figure 2). These layers are patients can have considerable improvement of thought to create a pressure barrier that prevents clinical signs and return to normal lives. reflux of gastric contents into the esophagus. The LES relaxes during swallowing to allow ingesta to NORMAL ANATOMY pass into the stomach. It has been suggested that AND PHYSIOLOGY the location of the LES could play a role in the •Take CE tests The esophagus is made up of occurrence of reflux. In theory, an intraabdominal • See full-text articles three layers : mucosa, submu - LES prevents reflux because the positive pressure aDr. Glazer discloses that he in the abdomen puts more force on the esopha - CompendiumVet.com owns shares in Pfizer Inc. gus relative to the stomach and increases barrier May 2008 281 COMPENDIUM 282 CE Esophagitis and Esophageal Strictures PATHOPHYSIOLOGY The normal physiologic defenses against esophageal inflammation are the LES , the esophageal mucosal lin - ing, clearance of the esophagus via peristalsis, the neu - tralizing effect of alkaline saliva, and esophageal cell turnover. Esophagitis is defined as inflammation and dis - ruption of the esophageal mucosa with resultant expo - sure of the esophageal submucosa. Causes of esophagitis include gastroesophageal reflux, vomiting, and ingestion of foreign bodies, caustic substances, or medications. Anesthesia-induced gastroesophageal reflux is the most commonly reported cause in the veterinary literature .2–6 The factors that affect the likelihood that a refluxate will cause esophageal damage are the content of the refluxate, the contact time, and the effectiveness of nor - mal esophageal defense mechanisms. Studies have shown that a refluxate with a pH less than 4 is most likely to cause damage. The presence of pepsin and bile acids in refluxate has also been shown to damage the esophageal lining .7–11 Increased damage is correlated Figure 1. Cross-section of the esophagus. with prolonged contact of these substances with the esophageal mucosa. Normally, the esophagus clears most refluxate with primary and secondary peristaltic waves, pressure. Consequently, some humans who do not have an and the bicarbonate present in salivary secretions neutral - abdominal esophageal component are more prone to pri - izes any residual refluxate. In animals, esophageal inflam - mary gastroesophageal reflux disease. However, a recent mation has been shown to decrease LES tone, which study of greyhounds and beagles indicated that dogs vary leads to further reflux, thus creating a vicious cycle. 7,11–13 with respect to whether the position of the gastroe - The LES normally relaxes only during swallowing. sophageal junction is intrathoracic or intraabdominal. This However, in humans, transient lower esophageal relax - Patients with recurrent respiratory signs should be evaluated for esophageal disease, as should patients that present with regurgitation and gastrointestinal disturbances. finding implies that an intraabdominal LES may not be ations have been reported that do not seem to be related essential to prevent reflux in dogs. 1 to swallowing but have been correlated with reflux When a bolus of ingesta reaches the caudal pharynx, events .7 Primary gastroesophageal reflux disease is rare afferent sensory fibers stimulate the swallowing center in animals but has been reported in cats. 14 Gastric dis - in the brain. Respiration is temporarily inhibited while tention and certain anesthetic drugs decrease LES tone , efferent motor fibers stimulate the esophagus via the increasing the likelihood of reflux events. In animals, vagus nerve , causing primary peristalsis to transport the morphine, thiopentone, propofol, xylazine , and atropine ingesta aborally. Secondary peristalsis is similar to pri - all decrease LES tone or increase the likelihood of mary peristalsis except that the impulse is initiated by reflux. 15–17 One study in animals suggests that fasting for esophageal distention. As food approaches the stomach, longer than 24 hours before surgery is more likely to transmission of sensory information results in relaxation cause reflux under anesthesia than fasting less than 4 of the LES . Innervation of the esophagus is mainly hours. The ideal fasting interval suggested by the authors parasympathetic from the vagus nerve. of this study is 8 to 12 hours. 17 COMPENDIUM May 2008 Esophagitis and Esophageal Strictures CE 283 Figure 2. Normal anatomy of the canine and feline esophagus. Body position during anesthesia is not associated with doxycycline, NSAIDs, potassium chloride, and quini - an increase in reflux despite the finding that LES barrier dine—have been shown to induce severe esophagitis and pressure is decreased in dogs positioned in sternal esophageal strictures. 20 In cats, tetracyclines are most recumbency. 18,19 Intraabdominal surgical procedures are frequently associated with esophagitis. 21–23 Tetracycline more likely to cause gastroesophageal reflux than other formulations tend to be very acidic , and prolonged expo - types of procedures. Ovariohysterectomy is the proce - sure to them results in inflammation of the esophageal dure most commonly associated with increased reflux. 18 mucosa that may progress to formation of a stricture. However, any anesthetic event increases the likelihood Esophageal stricture formation results from extensive of gastroesophageal reflux. damage to the esophageal lining. Esophageal inflamma - In humans, some oral medications—tetracycline, tion that extends through the mucosa into the submu - May 2008 COMPENDIUM 286 CE Esophagitis and Esophageal Strictures cosa and muscularis leads to collagen deposition and In animals with suspected esophageal disease, results of scarring. If the scarring is severe enough, an esophageal the following should be obtained: complete blood count, stricture develops. Other causes of esophageal stricture serum chemistry profile, urinalysis, and thoracic and include congenital strictures, persistent right aortic arch, neck radiography. Systemic disorders that cause similar and extramural esophageal compression secondary to a signs of increased appetite with weight loss, such as dia - mass. These causes are beyond the scope of this article. betes mellitus and hyperthyroidism, should be ruled out. Survey thoracic radiographs can disclose the cause of HISTORY AND CLINICAL SIGNS esophageal disease in cases of neoplasia, megaesophagus, Animals with esophageal disease often have a variety or foreign body ingestion and should also be evaluated of clinical signs , including ptyalism, regurgitation, dys - for the presence of aspiration pneumonia. phagia, repetitive swallowing, odynophagia (painful Survey thoracic radiographs are insensitive for the swallowing), and weight loss. Events of particular inter - detection of esophagitis or esophageal stricture. A positive est in the medical history include exposure to caustic contrast barium esophagogram is more useful for deter - substances, recent medications, and surgeries. It is mining the presence of strictures and evaluating important to differentiate regurgitation from vomiting esophageal motility. However, administration of barium to and to recognize that esophageal disease and regurgita - patients with esophageal disease carries the risk of aspira - tion may be part of a more complex disorder such as tion. If fluoroscopy is available, it is a valuable adjunct to foreign body
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