Esophagus: Regurgitation & Dysphagia Flashcards
(95 cards)
1
Q
describe the anatomy of the esophagus from pharynx to the stomach
A
starts dorsal to larynx
runs of left side, dorsal to trachea in mediastinum
through esophageal hiatus in diaphragm
enters stomach at cardia
2
Q
what are the two sphincters of the esophagus (2)
A
- upper esophageal sphincter (UES): cricopharynx
- lower esophagus sphincter (LES): cardia of stomach
3
Q
what are the layers of the esophagus (4)
A
- mucosa
- submucosa
- muscularis: striated in the dog and striated and smooth in cats
- adventitia (no serosa)
4
Q
what innervates the esophagus
A
the vagus nerve (efferent and afferents)
5
Q
how is normal swallowing occur
A
highly coordinated and largely involuntary
Upper esophageal sphincter relaxes and food moves into the proximal esophagus. Peristalsis than moves food down esophagus
Lower esophageal sphincter relaxes before the food gets there and food can empty into stomach. Then contracts to prevent reflex
If primary peristaltic wave fails to get food down a secondary wave will move the food down generated by esophageal distention
6
Q
what is dysphagia
A
difficulty swallowing
7
Q
what is pharyngeal dysphagia
A
try and swallow repeatedly but gag, retch, struggle to drink and may eject food from mouth (immediately after eating)
8
Q
what are the causes of pharyngeal dysphagia
A
failure of UES to relax (achalasia) OR
incoordination between pharyngeal contraction and UES relaxation (asynchrony)
9
Q
what are the signs of esophageal dysphagia
A
usually only 1 swallowing attempt, may or may not be able to drink
may bring up food at any time after eating
10
Q
what is regurgitation
A
passive evacuation of food and/or fluid from esophagus
11
Q
what causes regurgitation
A
local events within esophagus
may be due to structural disease, obstruction or functional disease
12
Q
how do you distinguish between regurgitation and vomiting
A
13
Q
is there prodromal nausea with vomiting or regurgitation
A
usually with vomiting
not with regurgitation
14
Q
is there retching/abdominal effort with vomiting or regurgitation
A
with vomiting yes
not with regurgitation
15
Q
is there food material produced with vomiting or regurgitation
A
sometimes food with both
16
Q
what is the character of the food material produced with vomiting or regurgitation
A
usually digested with vomiting
usually undigested with regurgitation
17
Q
is there bile with vomiting or regurgitation
A
sometimes with vomiting
not with regurgitation
18
Q
what is the pH of vomit and regurgitation material
A
acidic/alkali with vomiting
alkali with regurgitation
19
Q
what is aspiration pneumonia
A
food or water inhaled into lungs
causes chemical injury followed by secondary infection
20
Q
what are the signs of aspiration pneumonia (6)
A
- soft cough
- dyspnea
- tachypnea
- pyrexia
- lung crackles
- +/- nasal discharge
21
Q
what are the signs of aspiration pneumonia on rads
A
radioopacity of the ventral lung fields with air bronchograms
22
Q
what are risk factors of aspiration pneumonia
A
regurgitation or dysphagia
23
Q
what is the treatment for aspiration pneumonia
A
- oxygen therapy if needed
- fluid therapy if needed
- broad spectrum antibiotics
- nebuilization
- coupage
24
Q
what are signs of esophageal disease (9)
A
- regurgitation
- dysphagia
- +/- odynophagia
- +/- ptyalism
- +/- ravenous or reduced appetite
- +/- weight loss
- +/- dehydration
- +/- cervical swelling
- +/- respiratory signs due to secondary aspiration pneumonia
25
what are obstructive esophageal diseases (8)
1. vascular ring anomaly (VRA)
2. foreign body
3. stricture
4. hiatal hernia
5. diverticulum
6. perioesophageal obstruction
7. gastro esophageal intussception
8. parasitic granuloma
26
what are functional esophageal diseases (5)
1. megaesophagus (MO) (congenital or acquired; primary or secondary)
2. esophagitis
3. gastroesophageal reflux
4. lower esophageal sphincter achalasia-like syndrome (rare)
5. cricopharyngeal achalasia or asynchrony (rare)
27
what are the clinical examination abnormalities that can be seen with esophageal diseases (5)
1. hypersalivation
2. poor body condition
3. bulging in neck (food or air)
4. muscle atrophy/weakness (neuromuscular disease)
5. respiratory signs (aspiration pneumonia)
28
what esophageal abnormalities can be seen on rads (6)
1. radioopaque foreign body
2. dilation of esophagus
3. hiatal defects
4. peri-esophageal massess
5. pulmonary changes
6. pneumomediastinum/mediastinitis/pleural effusion
29
what is contrast radiography useful for
1. luminal obstruction
2. mucosal irregularity
3. significant alterations in motility
4. hiatal hernia
30
what are the risks for contrast rads
aspiration pneumonia --\> severe problems
31
what is fluoroscopy useful for
pharyngeal disorders
sublte esophageal motility disorders
32
what can you observe with fluoroscopy (5)
1. oral phase
2. esophageal transit time
3. pooling contrast
4. stalling of boluses
5. gastroesophageal reflux
33
what does esophagoscopy allow assessment of (4)
1. lumen and mucosa (obstructions, inflammation, perforation, hiatal hernia, dilation)
2. biopsy or cytology sampling (rare)
3. foreign body removal
4. balloon dilation of strictures
34
what can be seen on hematology with esophageal diseases
often normal
but if aspiration pneumonia --\> leukocytosis, left shift neutrophilia, monocytosis
35
what can be seen on biochemistry with esophageal diseases
often normal
36
what are the difficulties with esophageal surgery (5)
1. risk of AP on induction of GA
2. thoracotomy for intrathoracic esophagus
3. risk of contamination of thoracic cavity
4. healing challenging
5. fixed length
37
what is esophagotomy
incision into lumen
38
what is esophagectomy
removal of portion
39
what is esophagostomy
creation of opening for feeding tube
40
how is esophagotomy done (7)
1. stabilize patient
2. longitudinal incision
3. two layer closure
4. submucosa is holding layer (always include in sutures)
5. simple interrupted suture pattern (do not leave knots on the wall)
6. check closure integrity
7. treat esophagitis post-operatively
41
what is a congenital vascular ring anomaly
causes significant narrowing and obstruction of esophagus
42
what are the causes of congenital vascular anomaly
persistant right aortic arch (most common)
right aortic arch becomes functional aorta instead of left fourth arch
various other less common vascular anomalies can occur
43
what are the breed dispositions of vascular ring anomaly
GSDs and irish setters
start regurgitating when eaned
often have weight loss and stunting
44
how are congenital vascular ring anomalies treated
surgery to transect ligamentum arteriosum
treat AP and improve body condition before surgery
\>90% have significant clinical improvement
some have ongoing problems with esophageal motility --\> regurgitation
45
what are common sites of obstruction of foreign bodies (3)
1. thoracic inlet
2. heart base
3. just cranial to diaphgram (most common)
46
what are the signs of acute onset foreign body obstruction (5)
1. regurgitation
2. dysphagia
3. odynophagia
4. gagging
5. hypersalivation
47
what can be seen on clinical examination with foreign body obstruction
1. halitosis
2. cervical FB may be palpable
3. systemic signs suggest AP or perforation
48
how are foreign bodies diagnosed
often made on plain radiography
always taken to look for evidence of aspiration pneumonia
49
how are foreign bodies treated (6)
1. stabilize patient
2. GA
3. endoscopic removal is method of choice (remove orally or pushed into stomach)
4. evaluate mucosa (hemorrhage, lacerations, perforation)
5. post-endoscopy radiography to look for perforation
6. treat for esophagitis
50
what are the potential sequelae following a foreign body removal (3)
1. stricture: narrowing of esophageal lumen by fibrous tissue
2. fistula: abnormal tract between esophagus and usually respiratory system
3. diverticulum: pouch like sacculation of esophageal wall
51
what is an esophageal stricture
circular band of scar tissue: secondary to severe esophagitis
52
what are the signs of esophageal strictures
hungry but lose weight
better with liquids
53
how are esophageal strictures diagnosed
difficult to see on plain radiographs
contrast radiography (number, length, location)
endoscopy (cause --\> biopsy)
54
how are esophageal strictures treated (3)
1. endoscopic balloon dilation
2. followed by medical therapy for esophagitis
3. +/- steroids to reduce recurrence
55
what are the types of hiatal hernia
congenital or acquired
56
what are the breeds predispositions to hiatal hernia
shar pei
english/french bull dogs
57
what are the two main types of hiatal hernias (2)
1. sliding: distal esophagus and stomach move into mediastinum through esophageal hiatus
2. perioesophageal: portion of stomach moves into mediastinum through defect adjacent to esophageal hiatus
58
what are the effects of hiatal hernias (3)
1. gastroesophageal reflux due to decrease LES pressure
2. esophagitis
3. hypomotility
59
what are the clinical signs of hiatal hernias (7)
1. congenital is seen soon after weaning
2. regurgitation
3. vomiting
4. hypersalivation
5. hematemesis
6. poor body condition
7. dyspnea
60
how are small hernias treated
medical management for esophagitis
61
how are large hernias treated
surgical: narrow esophageal hiatus, pexy esophagus, pexy fundus of stomach
62
what are the primary esophageal neoplasias (4)
1. fibrosarcoma/osteosacroma (dog)
2. leiomyosarcoma (dog)
3. leimyoma (dog)
4. squamous cell carcinoma (cat)
63
what are the neoplasias that can affect the esophagus (3)
1. primary esophageal
2. peri esophageal
3. metastatic
64
what are the signs of esophageal neoplasia (5)
1. progressive esophageal obstruction
2. odynophagia
3. anorexia
4. weight loss
5. depression
65
how are esophageal neoplasia diagnosed
1. plain/contrast films
2. esophagoscopy (biopsy/cytology)
66
what is the prognosis of esophageal neoplasia
often poor
67
what can cause parasitic granulomas
spirocerca lupi
nematode
beetle is intermediate host
68
what are the types of megaesophagus
69
what is megaesophagus
diffuse esophageal dilation and aperistalsis
70
what breed predispositions to congenital megaesophagus
1. irish setter
2. GSD
3. great danes
71
what are secondary megaesophagus (7)
1. myasthenia gravis
2. severe esophagitis
3. hypoadrenocorticism
4. generalized myopathies
5. generalized neuropathies
6. toxins
7. hypothyroidism
72
what are the clinical signs of megaesophagus (6)
1. regurgitation
2. dysphagia
3. +/- hypersalivation
4. weight loss
5. +/- respiratory signs
6. +/- signs of underlying disease
73
what can be seen on rads in megaesophagus
dilated with air, fluid or ingesta
look for signs of aspiration pneumonia
74
what is shown here
megaesophagus
75
what is shown here
megaesophagus
76
how is megaesophagus treated (5)
1. treat underlying cause if secondary
2. postural feeding
3. ideal food consistency varies
4. sildenafil
5. treat aspiration pneumonia
77
how do you look for secondary causes of megaesophagus (3)
1. hematology/biochemistry
2. acetly choline receptor antibodies (myasthenia gravis)
3. ACTH stimulation test (neuor exam --\> evidence for myopathies or neuropathies)
78
why does metoclopramide not help dogs
acts on smooth muscle rather than skeletal muscoe and tends to close the lower sphincter
may be helpful in cats where there is more smooth muscle
79
how do you diagnose esophageal dysmotility
need fluoroscopy
80
how is esophageal dysmotility treated
same as megaesophagus
81
what is myasthenia gravis
end of motor nerves acetylcholine is released to stimulate the skeletal muscle via the acetylcholine receptor across the neuromuscular junction
82
what is the most common secondary cause of megaesophagus
myasthenia gravis
83
what are the types of myasthenia gravis
1. congenital
2. acquired
84
what is acquired myasthenia gravis
due to antibody production against acetly choline receptors at motor end plates
85
how is myasthenia gravis diagnosed (2)
1. tensilon test: generalized only, non-specific
2. acetyl choline receptor antibody assay: acquired only
86
how is myasthenia gravis treated (2)
1. pyridostigmine
2. consider injectable: needs to get to stomach
87
what is the prognosis of myasthenia gravis
esophageal function may improve with treatment
about 50% respond
88
what are the side effects of pyridostigmine (6)
muscarinic:
1. salivation
2. micturition
3. bradycardia
4. arrhythmias
5. hypotensions
6. weakness
89
what are causes of esophagitis (5)
1. chronic vomiting
2. gastroesophageal reflux (can be secondary due to GA)
3. ingestion of caustic agents
4. capsule retention (doxycycline)
5. foreign bodies
90
what are the clinical signs of esophagitis (7)
1. variable (asymptomatic to severe)
2. dysphagia
3. regurgitation
4. odynophagia
5. hypersalivation
6. food avoidance
7. weight loss
91
how is esophagitis diagnosed
inflammation seen endoscopically
biopsy usually necessary
likely under diagnosed
92
how is esophagitis treated (5)
1. small low fat high protein meals
2. +/- withold food PO
3. sucralfate liquid
4. metoclopramide
5. gastric acid secretory inhibitors (PP inhibitors)
93
what are the causes of gastroesophageal reflux
disorder of LES allowing reflux of fluids/ingesta into esophagus
leads to esophagitis
94
what is gastroesophageal reflux due to (5)
1. chronic vomiting
2. gastric emptying disorder
3. hiatal hernia
4. upper airway obstruction
5. anesthesia
95
how is gastroesophageal reflux treated (5)
1. avoid high fat diets (to encourage rapid gastric emptying)
2. sucralfate suspension
3. gastric acid secretory inhibitors
4. metoclopramide (help close the lower esophageal sphincter)
5. surgery for upper airways in brachycephalic dogs helps
