Clinical Approach to Dysphagia and Regurgitation (Winston)

Question 1

The Oropharyngeal phase contains the:

Answer 1

• Oral
• Pharyngeal
• Cricopharyngeal (UES relaxation)

Question 2

What is a cardinal sign of esophageal disease?

Answer 2

Regurgitation

Question 3

Diagnosis of swallowing disorders:
The following is a signalment for a…
- Congenital disease
- Cleft palate
- Cricopharyngeal achalasia (golden)
- Congenital megaesophagus (great dane)
- Vascular ring anomaly
- Hiatal hernia (shar pei, bull dog)
- Esophageal foreign body
- Infectious disease (uncommon)

Answer 3

Young Animal

Question 4

Diagnosis of swallowing disorders:
The following is a signalment for a…
- Degenerative disease
- Acquired neuromuscular disorder
- Idiopathic Megaesophagus (german)
- Neoplasia

Answer 4

Older Animal

Question 5

(T/F) Dysphagia is common in cats

Answer 5

False, it is uncommon. Usually secondary issues structural abnormalities

Question 6

(T/F) If a cat comes in after having doxycycline, it may come in with esophageal stricture

Answer 6

True

Question 7

Definition:
Is an abnormal tightening or narrowing of the esophagus

Answer 7

esophageal stricture

Question 8

A patient presents with dysphagia, what do you think this animal has?
Clinical Signs include:
- Hypersalivation, gagging, multiple swallowing attempts
- +/- poor drinking ability
- +/- dropping food

Answer 8

Oropharyngeal disease

Question 9

Fluoroscopic barium swallowing study to localize the functional cause of dysphagia:
Failure to prehend food, masticate food, form food bolus at base of the tongue, thrust food bolus into pharynx

Answer 9

Oral Dysphagia

Question 10

Fluoroscopic barium swallowing study to localize the functional cause of dysphagia:
Failure to contract due to neuromuscular weakness or fibrosis

Answer 10

Pharyngeal Dysphagia

Question 11

Fluoroscopic barium swallowing study to localize the functional cause of dysphagia:
Failure of UES to relax or failure to contract or does not relax at the right time

Answer 11

Cricopharyngeal Dysphagia

Question 12

What do you HAVE to rule out first?
- Structural disease or Functional disease

Answer 12

Structural disease

Question 13

A patient comes in with regurgitation, what do you think it is?
Clinical signs include:
- Normal drinking ability
- No dropping of food
- +/- Dysphagia
- +/- Hypersalivation, gagging, & multiple swallowing attempts

Answer 13

Esophageal disease

Question 14

A patient with abnormal LES relaxation can present with:

Answer 14

• Regurgitation
• Reflux
• Repeated swallowing
• +/- Cough

Question 15

A patient that has regurgitation, reflux, repeated swallowing, +/- cough, AND determined to have an abnormal LES relaxation…

Answer 15

Gastroesophageal disease

Question 16

(T/F) Aspiration pneumonia is a common complication of dysphagia in dogs and cats

Answer 16

True

Question 17

(T/F) When distinguishing regurgitation from vomiting, rely exclusively on what the “vomit” looks like

Answer 17

False

Question 18

What diagnostic plans rule out structural disease?

Answer 18

• Radiograph of the thorax AND neck
• Esophagoscopy (esophageal endoscopy)

Question 19

(T/F) Radiographs can rule-in esophageal disease, but when the thoracic radiographs are normal you cannot rule it out

Answer 19

True

Question 20

(T/F) Esophagoscopy can rule-out structural disease, but does not give you any information about esophageal function

Answer 20

True

Question 21

What diagnostic plan rules out functional disease?

Answer 21

Barium swallowing study (fluoroscopic)

Question 22

Definition:
Acute or chronic inflammatory disorder of the esophageal mucosa

Answer 22

Esophagitis

Question 23

What is the most commonly recognized cause of reflux esophagitis in dogs and cats?

Answer 23

Recent general anesthesia
*Endogenous cause

Question 24

“Pill-induced” esophagitis in cats is most commonly caused by what drugs?

Answer 24

• Doxycycline
• Clindamycin
  *Exogenous cause

Question 25

What can gastroesophageal reflux under general anesthesia result on?

Answer 25

- Reflux esophagitis - Esophageal strictures - Aspiration pneumonia

Question 26

Why is general anesthesia may predispose to reflux esophagitis?

Answer 26

- decrease LES pressure - anesthesia inhibits esophageal motility and clearance - body position and gravity - lack of endotracheal tube

Question 27

(T/F) Endoscopy is more sensitive than radiography for detecting esophagitis

Answer 27

True

Question 28

(T/F) PPIs are superior to H2 receptor antagonists in raising gastric pH (more basic)

Answer 28

True, especially important for esophagitis involving the DISTAL esophagus

Question 29

What is the ideal treatment for mild esophagitis?

Answer 29

Minimal treatment, feeding smaller-sized fat-restricted meals (enhanced gastric emptying) - prognosis is good

Question 30

What is the ideal treatment for moderate to severe esophagitis?

Answer 30

Gastric acid suppression and prokinetics - prognosis is guarded or poor in severe cases

Question 31

Treatment for esophagitis: Binds to eroded mucosa and promotes effective mucosal barrier protection

Answer 31

Sucralfate

Question 32

Treatment: List the gastric acid suppression proton pump inhibitors:

Answer 32

Omeprazole

Question 33

Treatment for esophagitis: List the gastric acid suppression H2 receptor antagonists:

Answer 33

Famotidine & Ranitidine

Question 34

Esophagitis treatment: What is a more potent prokinetic and is more effective at reducing GER in dogs?

Answer 34

Cisapride (compared to metoclopramide)

Question 35

The following clinical signs are for... - gagging, salivation, dysphagia, regurgitation/vomiting (ACUTE) - Depression, anorexia - Cough, dyspnea, and fever - Palpable cervical esophageal mass (Warning: Aspiration pneumonia, esophageal perforation)

Answer 35

Esophageal Foreign Body

Question 36

(T/F) Surgical removal (esophagotomy) only if endoscopic failure

Answer 36

True

Question 37

What can be some complications if the FB is left for too long in the esophageal?

Answer 37

- Esophagitis (which may heal as a stricture) - Esophageal perforation

Question 38

Definition: Abnormal narrowing of the esophageal lumen

Answer 38

Esophageal Stricture

Question 39

Oral doxycycline/clindamycin tablets in cats is one of the most common causes for _______________

Answer 39

Esophageal Stricture

Question 40

The following are clinical signs for... - Initially, subtle "hard to swallow" that can be missed by owners - Progressive dysphagia and odynophagia (painful swallowing) for solid foods - Regurgitation - Ravenous appetite - Weight loss

Answer 40

Esophageal Stricture

Question 41

What is a definitive procedure for differentiating benign from malignant esophageal stricture?

Answer 41

Esophagoscopy

Question 42

(T/F) A balloon dilation of esophageal stricture is typically a "one and done" procedure

Answer 42

False, it typically requires multiple dilations under general anesthesia every 5-7 days (average is 3 to 5 times)

Question 43

Defenition: Congenital malformation of great vessels and branches that entraps the intrathoracic esophagus

Answer 43

Vascular Ring Anomaly

Question 44

What is the most common vascular ring anomaly in dogs and cats?

Answer 44

Persistent right aortic arch (PRAA)

Question 45

The following clinical signs are describebing ... - Regurgitation of solid food at weaning - Usually < 6 months of age - Weight loss or failure to gain weight (despite a good appetite) - Cough, dyspnea, fever, pulmonary crackles (Secondary to aspiration pneumonia)

Answer 45

Vascular Ring Anomaly

Question 46

Signalment (young animal) and compatible history of regurgitation during weaning are highly suggestive of a ________________________

Answer 46

Vascular Ring Anomaly (german, Irish setters)

Question 47

Definition: Severe lack of motility of the esophagus resulting in a dilated flaccid esophagus

Answer 47

Megaesophagus

Question 48

Although there are many potential causes of megaesophagus in dogs, what is the most common diagnosis?

Answer 48

Idiopathic Megaesophagus

Question 49

(T/F) Megaesophagus is also common in cats

Answer 49

False, it is uncommon in cats, Hiatial hernia and reflux esophagitis appear to be important underlying causes

Question 50

When considering megaesophagus as a diagnosis, what do you need to make sure to rule out first?

Answer 50

Rule out obstruction in the distal esophagus as this can also result in a diffusely dilated esophagus

Question 51

List some of the secondary causes of Megaesophagus:

Answer 51

- Neurogenic - Neuromuscular junction (myasthenia gravis, others) - Muscular (myopathy, myositis) - Other (hypoadrenocorticism, lead toxicity, etc.)

Question 52

What is the first part of the diagnosis of megaesophagus and complications?

Answer 52

- Survey neck and thoracic radiographs - Barium swallow (tend not to do them)

Question 53

Myasthenia gravis accounts for 25-30% of dogs with acquired megaesophagus. Therefore, an _____________________ (for diagnosis of myasthenia gravis) should be performed in every dog with acquired megaesophagus.

Answer 53

acetylcholine receptor antibody titer

Question 54

______________ may present with facial, pharyngeal, laryngeal, and esophageal involvement without appendicular weakness and mimic idiopathic megaesophagus.

Answer 54

Focal myasthenia