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HIATAL AND DIAPHRAGMATIC EVENTRATION IN A LEOPARD (PANTHERA PARDUS) Author(s): Karen S. KearnsD.V.M., Michael P. JonesD.V.M., Ronald M. BrightD.V.M., Robert ToalD.V.M., Robert DeNovoD.V.M., and Susan OroszD.V.M., Ph.D. Source: Journal of Zoo and Wildlife Medicine, 31(3):379-382. Published By: American Association of Zoo Veterinarians DOI: http://dx.doi.org/10.1638/1042-7260(2000)031[0379:HHADEI]2.0.CO;2 URL: http://www.bioone.org/doi/full/10.1638/1042-7260%282000%29031%5B0379%3AHHADEI %5D2.0.CO%3B2

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BioOne sees sustainable scholarly publishing as an inherently collaborative enterprise connecting authors, nonprofit publishers, academic institutions, research libraries, and research funders in the common goal of maximizing access to critical research. Journal of Zoo and Wildlife Medicine 31(3): 379±382, 2000 Copyright 2000 by American Association of Zoo Veterinarians

HIATAL HERNIA AND DIAPHRAGMATIC EVENTRATION IN A LEOPARD (PANTHERA PARDUS)

Karen S. Kearns, D.V.M., Michael P. Jones, D.V.M., Ronald M. Bright, D.V.M., Robert Toal, D.V.M., Robert DeNovo, D.V.M., and Susan Orosz, D.V.M., Ph.D.

Abstract: A 1-yr-old male leopard (Panthera pardus) presented for intermittent anorexia, emaciation, and generalized muscle wasting. Plain radiographs, ultrasonography, and esophageal led to a diagnosis of diaphragmatic eventration with probable concurrent hiatal hernia. An exploratory laparotomy con®rmed both diagnoses, and surgical repair and stabilization were performed. After , the leopard was maintained on small liquid meals for 4 days, with a gradual return to normal diet over 2 wk. By 4 wk after surgery, the leopard was eating well and gaining weight, and it showed no recurrence of clinical signs for 2 yr subsequently, becoming mildly obese. Key words: , eventration, gastropexy, hiatal hernia, leopard, Panthera pardus.

CASE REPORT tissue opacities thought to represent liver lobes and A 1-yr-old male leopard (Panthera pardus) was spleen. A was present cranial to examined for intermittent anorexia and apparent this mass (Fig. 1). of at least 3 mo duration. Physical ex- An esophagram using barium sulfate (Sol-o- amination under chemical restraint using estimated pake, E-Z-EM Inc., Westbury, New York 11590- weight revealed emaciation with generalized mus- 5021, USA, diluted 50/50 by volume with water, cle wasting. Hematologic abnormalities (based on 3.5 ml/kg) showed megaesophagus with irregular normal reference values from the International Spe- margins caudally and ventral deviation of the car- cies Information System, Apple Valley, Minnesota dia. Ultrasonography con®rmed the presence of 55124, USA) included a nonregenerative normo- , , and congested liver tissue cytic normochromic anemia (hematocrit ϭ 22.9%, within the mass observed on radiographs. A pre- reference ϭ 37.0 Ϯ 5.4%; 5.21 ϫ 10 red blood cells sumptive diagnosis of diaphragmatic eventration [RBC]/␮l, reference 8.28 ϫ 106 Ϯ 1.46 ϫ 106 RBC/ was made. From these diagnostic tests, it was dif- ␮l; MCV ϭ 43 ¯, reference ϭ 45.3 Ϯ 5.4 ¯; MCH ®cult to ascertain whether a hiatal hernia was pre- ϭ 14.4 pg, reference ϭ 15.2 Ϯ 1.8 pg) and a leu- sent as well. was included in kocytosis with left shift, neurophilia, and eosino- the differential diagnoses, but it appeared less prob- philia (total white blood cells [WBC] ϭ 29,100/␮l, able on the basis of the radiographic appearance of reference ϭ 13,740 Ϯ 4022 WBC/␮l; 16,300 seg- the diaphragm. mented neutrophils/␮l, reference ϭ 10,340 Ϯ 3872 Endoscopic examination (Fujinon gastroscope, neutrophils/␮l; 7,860 bands/␮l, reference ϭ 1,216 EPX301A, 9.6 mm, Wayne, New Jersey 07470, Ϯ 2,455 bands/␮l; 3,780 lymphocytes/␮l, reference USA) of the revealed mild in¯ammation ϭ 1,746 Ϯ 974 lymphocytes/␮l; 1,160 eosinophils/ orad, with ¯uid pooling. More caudally, severe ero- ␮l, reference ϭ 528 Ϯ 516 eosinophils/␮l). Serum sions were observed with multifocal areas of dis- chemistry analysis, urinalysis, and feline infectious coloration and hemorrhage. Cranial to the gastro- disease serology (feline leukemia virus, feline im- esophageal junction, an eccentric intramural mass munode®ciency virus, feline infectious , almost completely obstructed the esophageal lu- and Toxoplasma) were unremarkable. men. Samples of the esophageal mucosa were taken Radiographs revealed a large soft tissue opacity for cytology, and biopsies of the intraluminal mass contiguous with the dorsal diaphragm. Contents of were submitted for culture and histopathology. The the mass appeared to include a partially gas-®lled stomach appeared grossly normal. stomach, small intestine, and several triangular soft Cytology of the esophageal mucosa showed ev- idence of in¯ammation with sepsis. All bacteria cultured were normal enteric organisms. No evi- From the Departments of Comparative Medicine dence of neoplasia was noted on cytology or his- (Kearns, Jones, Orosz), Small Animal Clinical Sciences topathology. These ®ndings were most consistent (Bright, DeNovo), and Large Animal Clinical Sciences (Toal), College of Veterinary Medicine, University of Ten- with a diagnosis of re¯ux esophagitis, which nessee, Knoxville, Tennessee 37901-1071, USA. Present strengthened the suspicion that a hiatal hernia was address (Kearns): Department of Clinical Sciences, Col- also present, causing gastroesophageal re¯ux. lege of Veterinary Medicine, Cornell University, Ithaca, Eight days after initial presentation, an explor- New York 14850, USA. atory laparotomy was performed. On the basis of

379 380 JOURNAL OF ZOO AND WILDLIFE MEDICINE

Figure 1. Survey radiographs show diaphragmatic eventration. an estimated body weight of 23 kg, the leopard was simple interrupted sutures of 0 polypropylene. The restrained with ketamine (Ketaset௡, Fort Dodge excess diaphragmatic tissue was incorporated until Laboratories Inc., Fort Dodge, Iowa 50501, USA; the left hemidiaphragm protruded no farther cranial 5 mg/kg i.m.) and xylazine (BenVenue Laborato- than the normally positioned right hemidiaphragm. ries, Bedford, Ohio 44146, USA; 1 mg/kg i.m.), Finally, a left-sided incisional gastropexy, using the intubated, and maintained on iso¯urane (IsoFlo௡, fundus of the stomach, was performed with 0 poly- Abbott Laboratories, North Chicago, Illinois 60064, propylene suture.2 USA) in oxygen. A standard ventral midline ap- After surgery, the leopard was maintained on Ca- proach to the revealed an abnormally en- nine/Feline A/D (Hills Pet Nutrition Inc., Topeka, larged esophageal hiatus, allowing herniation of ab- Kansas 66601, USA) for the ®rst 4 days, followed dominal organs. Viscera that had moved through by a gradual return to a normal amount and con- the hiatus into the thoracic cavity included the left sistency of food over the next 2 wk. Trimethoprim± medial and quadrate liver lobes with gallbladder, sulfamethoxazole (BioCraft Laboratories Inc., Elm- approximately 20 cm of small intestine, and the en- wood Park, New Jersey 07407, USA; 30 mg/kg tire spleen and stomach. In addition, a large portion b.i.d. p.o.) and sucralfate (Marion Merrell Dow of the diaphragm just lateral to the hiatus appeared Inc., Kansas City, Missouri 64114, USA; 1 g, b.i.d. to be thin-walled and ¯accid, and it protruded cra- p.o.) were administered to treat the re¯ux esopha- nially. Additional small intestine was displaced cra- gitis. By 4 wk after the operation, the leopard was nially into this cupola. All viscera appeared viable no longer anorectic or lethargic and appeared to be and were placed in their normal anatomic positions. gaining weight. There was no recurrence of clinical The left and right ventrolateral aspects of the signs. At a follow-up examination, the body weight esophagus were sutured to the diaphragm along the was 41 kg. Radiographs taken 5 yr postoperatively edge of the hiatus with two simple interrupted 0 were normal (Fig. 2). polypropylene sutures (Prolene௡, Ethicon, Johnson and Johnson Co., Somerville, New Jersey 08876, DISCUSSION USA) on each side (esophagopexy).7 The redundant Eventration is a thinning of the diaphragmatic diaphragmatic tissue was then plicated with seven tissue, resulting in a more cranial position of the KEARNS ET AL.ÐLEOPARD HIATAL HERNIA 381

Figure 2. Radiographs following surgical repair of diaphragmatic eventration and hiatal hernia.

intact diaphragm.9 This condition is more frequent- atal have occurred secondary to trauma or ly reported in humans than in animals. It is usually after diaphragmatic hernia repair.3 Eventration may congenital, but it may be acquired secondary to exist with or without concurrent hiatal hernia.4 Con- trauma. In humans with diaphragmatic eventration, genital diaphragmatic eventration with coexisting the normal anatomy of the gastroesophageal angle esophageal hiatal hernia has been reported in a is disrupted by displacement of the stomach into Shetland sheepdog.4 In cases without hiatal hernia, the expanded diaphragmatic sac. re¯ux esophagitis is not an expected sequel because A hiatal hernia occurs when enlargement of the the lower esophageal sphincter is not displaced into esophageal hiatus of the diaphragm allows abdom- the thorax. inal contents to protrude into the thorax.7 There are The predominant clinical sign in patients with two main types of hiatal hernias in animals. The hiatal hernia is regurgitation, which appears to be sliding type, in which the gastroesophageal junction due to the gastroesophageal re¯ux.7 In normal ani- and frequently the stomach are displaced into the mals, several factors are involved in preventing thorax and the one present in this leopard, is the gastroesophageal re¯ux. These factors include nor- most commonly reported.5 Re¯ux esophagitis is a mal anatomic position of the lower esophageal frequent sequel. Large sliding hernias are uncom- sphincter (LES), adequate tension of the gastro- mon and, as in this case, may include liver, spleen, esophageal ligament, and presence of a high-pres- and intestines. Paraesophageal hernias, in which the sure zone in the caudal esophagus.1 These condi- stomach is displaced through a diaphragmatic de- tions are compromised when the LES is displaced fect adjacent to the hiatus, are rarely reported in into the thorax. Resulting gastroesophageal re¯ux dogs and cats.5 The gastroesophageal junction re- causes an esophagitis, which is associated with de- mains in the abdomen and re¯ux esophagitis is creased esophageal motility. Many animals develop therefore less prevalent.6 Although most cases re- a megaesophagus and subsequent aspiration pneu- ported in dogs and cats are congenital, acquired hi- monia.7 Other clinical signs that may occur include 382 JOURNAL OF ZOO AND WILDLIFE MEDICINE ptyalism, dyspnea, weight loss, and anorexia.5 A have primary sphincter incompetence, as is com- concurrent diaphragmatic eventration may also monly observed in humans with hiatal hernias, cause dyspnea because of decreased functional re- structural reinforcement of the sphincter should not sidual capacity and abnormal diaphragmatic move- be necessary. The recommended surgical manage- ment.8 This leopard was unusual in that emaciation ment in dogs and cats is simple reduction and sta- and intermittent anorexia were the only presenting bilization.7 The preferred treatment for diaphrag- signs. Despite the presence of a megaesophagus matic eventration is diaphragmatic plication, partic- and severe esophagitis, no regurgitation was ob- ularly in symptomatic cases.8 In this case, the pli- served. cation of the diaphragm performed during the hiatal Survey radiographs facilitate diagnosis of hiatal hernia repair simultaneously eliminated the even- hernia and eventration. Radiographic diagnosis of tration. diaphragmatic eventration is based on the presence This case of a hiatal hernia and diaphragmatic of a bulging or arched diaphragm with unbroken eventration in a leopard was managed by simple continuity.4 A sliding hiatal hernia implies cranial reduction and stabilization, and by plication, re- displacement of the gastroesophageal junction spectively. It is the ®rst report of either disorder in through the hiatus into the caudal . It this species. Since long-term medical therapy may be diagnosed radiographically by identi®cation would have been impractical in a large exotic cat, of the abnormally located gastroesophageal junc- it was critical that surgical intervention result in a tion cranial to the diaphragm.4 In this case, at the successful outcome. The unusual presentation in time radiographs were made, the gastroesophageal this case underscores the importance of considering junction was contiguous with the diaphragm as it hiatal hernia as a differential diagnosis in young bulged forward. The bulging diaphragm created cachectic animals, even when regurgitation is not ventral bending of the caudal mediastinum, distort- observed. ing the gastroesophageal junction. Diagnosis of this LITERATURE CITED disorder may be aided by positive contrast ¯uoro- 1. Baue, A. E., and R. E. Hoffer. 1967. The effects of scopic examination revealing reduced esophageal experimental hiatal hernia and histamine stimulation on motility or gastroesophageal re¯ux due to LES in- the intrinsic esophageal sphincter. Surg. Gynecol. Obs. competence. Endoscopy is helpful in assessing the 125: 791±799. severity of the re¯ux esophagitis. In this leopard, 2. Bojrab, M. J. (ed.). 1990. Current Techniques in eventration was diagnosed radiographically, but ®- Small Animal Surgery, 3rd ed. Lea and Febiger, Phila- nal diagnosis of the hernia was not conclusive until delphia, Pennsylvania. surgery, when it was apparent that the stomach and 3. Bright, R. M., J. E. Sackman, C. DeNovo, and R. other organs had since moved into the thoracic cav- Toal. 1990. Hiatal hernia in the dog and cat: a retrospec- ity and a large hiatal hernia was visualized. tive study of 16 cases. J. Small Anim. Prac. 31: 244±250. 4. Dhein, C. R., C. A. Rawlings, E. Rosin, J. M. Lo- In many cases, hiatal hernia may be managed sonsky, and J. N. Chambers. 1980. Esophageal hiatal her- medically. Dietary modi®cation, with or without nia and eventration of the diaphragm with resultant gas- the use of antisecretory drugs and prokinetic troesophageal re¯ux. J. Am. Anim. Hosp. Assoc. 16: 517± agents, may be enough to keep less severe cases 522. asymptomatic.3 In cases where endoscopic exami- 5. Ellison, G. W., D. D. Lewis, L. Phillips, and G. B. nation shows severe esophagitis, or when medical Tarvin. 1987. Esophageal hiatal hernia in small animals: therapy has yielded unsatisfactory results, surgical literature review and a modi®ed surgical technique. J. Am. repair is indicated.3,4 The goal of surgical repair is Anim. Hosp. Assoc. 23: 391±399. to anatomically reduce and stabilize the hernia. Sta- 6. Miles, K. G., E. R. Pope, and A. E. Jergens. 1988. Paraesophageal hiatal hernia and pyloric obstruction in a bilization is accomplished using plication of the di- dog. J. Am. Vet. Med. Assoc. 193: 1437±1439. aphragm to narrow the hiatus and eliminate any 7. Prymak, C., H. M. Saunders, and R. J. Washabau. concurrent eventration, esophagopexy involving 1989. Hiatal hernia repair by restoration and stabilization ®xation of the caudal esophagus to the diaphragm, of normal anatomy: an evaluation in four dogs and one and gastropexy to prevent cranial displacement of cat. Vet. Surg. 18: 386±391. the stomach.5,7 8. Ribet, M., and J. L. Linder. 1992. Plication of the In humans, surgical repair of hiatal hernias in- diaphragm for unilateral eventration or paralysis. Eur. J. volves fundoplication for structural reinforcement Cardiothorac. Surg. 6: 357±360. 9. Wayne, E. R., J. B. Campbell, and J. D. Burrington. of the LES.4 This procedure has previously been 1974. Eventration of the diaphragm. J. Pediatr. Surg. 9: used in dogs but has been associated with compli- 643±651. cations such as , reherniation, and gastric tympany.3,7 Since dogs and cats do not appear to Received for publication 6 November 1998