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ACVIM Specialty 2023 > GI disease: oral, pharyngeal, esophagus > Flashcards

GI disease: oral, pharyngeal, esophagus Flashcards

1
Q

What is juvenile hyperplastic gingivitis?

A

Enlarged, inflamed gingiva in young cats, usually around the cheek teeth

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2
Q

What oral medication has been shown to reduce gingival hyperplasia in dogs?

A

Azithromycin containing dentifrice (8.5%)

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3
Q

What two drugs can cause gingival hyperplasia?

A

Cyclosporine, amlodipine

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4
Q

What 4 muscles are affected in masticatory muscle myositis?

A

Temporal, masseter, medial and lateral pterygoid muscles

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5
Q

What signalment is more commonly affected with masticatory muscle myositis?

A

Young adult to middle age, large breed dogs

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6
Q

What are the clinical signs in the acute phase of masticatory muscle myositis?

A

Painful muscle swelling, lethargy, reluctance to eat, pain on opening the jaw, fever, regional lymphadenopathy, exophthalmus, inability to open the mouth fully

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7
Q

What are the clinical signs in the chronic phase of masticatory muscle myositis?

A

Progressive atrophy of the muscles (can be symmetric or asymmetric), enophthalmus, inability to open the mouth fully

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8
Q

What is the pathogenesis of masticatory muscle myositis? Why does it only occur in these muscles and not other skeletal muscle?

A

Autoimmune destruction of the 2M muscle fibers, which are only found in the masticatory muscles (other skeletal muscles have 2C fibers)

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9
Q

What pathogenic mechanism is thought to contribute to sialadenosis and necrotizing sialometaplasia? What treatment is sometimes successful?

A

Abnormalities of the vagus nerve - some cases respond to phenobarbital

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10
Q

What is craniomandibular osteopathy?

A

Woven, irregular bone proliferation at the body of the mandible, TMJ, and tympanic bulla - occurs in small breed dogs

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11
Q

What is calvarial hyperosteosis? What breed does it occur in?

A

Irregular, progressive, bony proliferation and thickening of the cortical bone of the calvarium. Occurs in young Bullmastiffs

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12
Q

In dogs, the esophagus in comprised of what type of muscle? In cats?

A

Dogs: entirely striated muscle
Cats: 2/3 striated, 1/3 smooth muscle

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13
Q

What is the esophageal mucosa comprised of?

A

Keratinized, stratified squamous epithelium

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14
Q

Name the 4 phases of swallowing

A

Oral preparatory phase, oral phase, pharyngeal phase, esophageal phase

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15
Q

Describe the oral preparatory phase of swallowing

A

Mastication and lubrication of food or liquid. The bolus is modified and prepared for swallowing

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16
Q

What are potential causes of abnormalities in the oral preparatory phase of swallowing?

A

Dental disease, xerostomia (dry mouth), weakness of the lips, tongue, and cheeks

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17
Q

What cranial nerves innervate the lips?

A

V and VII

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18
Q

What cranial nerve innervates the tongue?

A

XII

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19
Q

Describe the oral phase of swallowing

A

Muscular events responsible for moving the bolus from the tongue to the pharynx. Facilitated by movement of the tongue, jaw, and hyoid muscles

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20
Q

When does the pharyngeal phase of swallowing begin?

A

When the bolus reaches the tonsils

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21
Q

What occurs first in the pharyngeal phase of swallowing?

A

Protection of airways: elevation of the soft palate to prevent the bolus from entering the nasopharynx; elevation and forward movement of the larynx and hyoid, retroflexion of the epiglottis, and closure of the vocal folds to protect the trachea

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22
Q

After protection of the airway, what occurs in the pharyngeal phase of swallowing?

A

Synchronized contraction of the middle and inferior constrictor muscles of the pharynx with relaxation of the UES to allow passage of the bolus into the esophagus

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23
Q

What muscle makes up the majority of the upper esophageal sphincter?

A

Cricopharyngeus muscle

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24
Q

Abnormalities of bolus transfer during the pharyngeal phase of swallowing can be divided into 3 categories. Name them and give examples

A

1) Oropharyngeal pump failure: pharyngeal weakness
2) Oropharyngeal and UES asynchrony: neuropathies
3) Pharyngeal outflow obstruction: cricopharyngeal achalasia, tumors, foreign bodies

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25
Q

Primary esophageal peristalsis is induced by what?

A

Swallowing

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26
Q

Secondary esophageal peristalsis is induced by what?

A

Distention of the esophageal lumen by the bolus that has failed to be propelled into the stomach by primary peristalsis

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27
Q

Muscular dystrophy is more common in what two dog breeds?

A

Bouvier des Flandres, Cavalier King Charles

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28
Q

Cricopharyngeal dysphagia is more common in what dog breeds?

A

Cocker and Springer Spaniels, Golden Retrievers (achalasia)

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29
Q

Pharyngeal weakness as the only sign of myasthenia gravis has been described in what percent of affected dogs?

A

1%

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30
Q

What laboratory test should be performed in all dogs with dysphagia?

A

Acetylcholine receptor antibody test

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31
Q

On fluoroscopy, timing of the swallow can be measure from when the epiglottis closes over the larynx to when it opens. How many frames does this take in a healthy dog?

A

5-6 frames (each frame 1/30 of a second)

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32
Q

Name 6 potential causes of pharyngeal weakness

A

Myasthenia gravis, muscular dystrophy, polymyositis, hypothyroidism, cranial nerve neuropathy, infection, neoplasia, trauma

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33
Q

Cricopharyngeal dysphagia can be characterized into two disorders. What are they?

A

Cricopharyngeal achalasia - failure of the UES to relax
Cricopharyngeal asynchrony - lack of coordination between UES relaxation and pharyngeal contraction

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34
Q

What is the cause of cricopharyngeal asynchrony?

A

Weak pharyngeal muscles are unable to propel the bolus through the UES in a timely manner

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35
Q

What form of bolus do patients with cricopharyngeal dysphagia display more trouble swallowing?

A

Liquids

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36
Q

When does cricopharyngeal dysphagia typically present?

A

At the time of or shortly after weaning

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37
Q

Most patients with cricopharyngeal achalasia display what structural change on imaging?

A

Prominent thickening of the cricopharyngeus muscle (cricopharyngeal “bar”)

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38
Q

What is the definitive treatment for cricopharyngeal achalasia?

A

Surgical myotomy or myectomy of the cricopharyngeus muscle

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39
Q

What does cricopharyngeal myotomy involve?

A

Incision of the cricopharyngeus muscle to the level of the pharyngeal mucosa (can be performed transcervically or endoscopically)

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40
Q

What procedure can be performed for temporary treatment of cricopharyngeal achalasia? How long does it last?

A

Injection of botulinum toxin into the circopharyngeus muscle - lasts 3-4 months

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41
Q

What is the mechanism of action of botulinum toxin A?

A

Acts at the presynaptic cholinergic nerve terminal to block the release of acetylcholine - weakens contraction of the muscle in a dose-dependent manner

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42
Q

What is the most common cause of high grade esophagitis and stricture in dogs?

A

Gastroesophageal reflux under anesthesia

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43
Q

Gastroesophageal reflux under anesthesia preceded the development of esophageal strictures in what percent of cases?

A

46-65%

44
Q

What anesthetic agents can cause a decreased in LES pressure, leading to GER?

A

Atropine, morphine, acepromazine, thiopental, xylazine, and isoflurane

45
Q

Describe the pathogenesis of esophageal stricture formation

A

Damage to the muscularis layer of the esophagus leads to fibroblastic proliferation and contraction

46
Q

Balloon dilation of an esophageal stricture provides what type of stretch while bougienage provides what type of stretch?

A

Balloon = radial dilation
Bougienage = longitudinal forces

47
Q

Administration of what drug into the submucosa of a stricture site prior to dilation has been associated with reduced rate or re-stricture? What is the dose

A

Triamcinolone 2.5mg per quadrant, injected into all 4 quadrants

48
Q

A persistent right aortic arch is hereditary in what breeds?

A

German Shepherd, Irish Setter

49
Q

How is a persistent right aortic arch corrected?

A

Surgical resection of the persistent ligmentum arteriosum with balloon dilation of the esophagus

50
Q

Surgical correction of a persistent right aortic arch results in improved esophageal motility in what percent of patients?

A

> 90%; some have persistent esophageal hypomotility

51
Q

What parasite can cause esophageal granulomas in dogs?

A

Spirocirca lupi

52
Q

Esophageal granulomas can undergo malignant transformation into what tumor types?

A

Fibrosarcoma or osteosarcoma

53
Q

What is the treatment for esophageal granulomas secondary to Spirocirca lupi infection?

A

Doramectin - 3 subcutaneous injections given at 14 days intervals or oral administration once a day for 6-12 weeks

54
Q

What are esophageal diverticula?

A

Circumscribed sacculations of the esophageal wall that affect motility

55
Q

How do congenital esophageal diverticula form?

A

Abnormalities in embryologic development permit herniation of the esophageal mucosa through a defect in the muscularis

56
Q

How do acquired pulsion diverticula form?

A

Develop from increased intraluminal pressure secondary to obstruction (stricture, etc) or altered motility

57
Q

How to acquired traction diverticula form?

A

Result from peri-esophageal inflammation and fibrosis - adhesions to adjacent tissues distort the esophageal lumen and create sacculations. Grass awn migration is a common cause

58
Q

What is the most common cause of regurgitation in dogs?

A

Megaesophagus

59
Q

Congenital megaesophagus in cats is rare, but what breed may be predisposed?

A

Siamese

60
Q

The pathogenesis of congenital megaesophagus is poorly understood, but what may be involved?

A

Defect in vagal afferent innervation of the esophagus

61
Q

Myasthenia gravis accounts for what percent of acquired megaesophagus in dogs?

A

25-30%

62
Q

Name 5 causes of acquired secondary megaesophagus in dogs?

A

Myasthenia gravis, hypoadrenocorticism, lupus myositis, polymyopathy, polyneuropathy, dysautonomia, lead poisoning, severe esophagitis

63
Q

If the onset of megaesophagus is acute, and acetylcholine receptor antibody titers are in the “grey zone” (0.3-0.6), what should you do?

A

Repeat titers in 4-8 weeks

64
Q

Name 3 common causes of GERD in dogs

A

Hiatal hernia, anesthesia, chronic vomiting leading to a weakened LES, gastric atony

65
Q

Why are signs of GERD worse at night?

A

Transient relaxation of the LES occurs while sleeping, along with loss of the swallow reflex

66
Q

Name 3 clinical signs of GERD in dogs

A

Lip smacking, hard swallowing, panting - often worse at night

67
Q

What is a sialocele?

A

A collection of saliva that has leaked from a damaged salivary duct/gland and is surrounded by granulation tissue

68
Q

How often do sialoceles recur after surgical removal of the gland/duct?

A

5-14%

69
Q

Sialoceles that are refractory to surgical removal may respond to what therapy?

A

Radiation therapy - 16 or 20 Gray in 4 Gray fractions - achieved complete remission in 54% and partial response in 45%

70
Q

Name two potential causes of esophageal varices

A

Portal hypertension (hepatic cirrhosis, etc), congenital or acquired arteriovenous communications, increased cranial vena cava resistance (thrombi, masses)

71
Q

Name 2 potential clinical signs of esophageal varices in dogs

A

Ptyalism and hematemesis

72
Q

Explain the difference between “downhill” and “uphill” esophageal varices

A

Downhill: extend downward or caudally, usually secondary to superior vena cava obstruction
Uphill: extend upward or cranially, commonly associated with portal hypertension

73
Q

Unlike in humans, what clinical sign is rare in dogs with esophageal varices?

A

Hemorrhage - not seen in 25 dogs in Slead’s retrospective

74
Q

In one study of dogs presenting for cough with no GI signs, what percent demonstrated swallowing abnormalities?

A

80.6%

75
Q

The pharyngeal phase of swallowing is mediated by sensory afferents of what cranial nerves?

A

IX and X

76
Q

What airway protective behaviors occur during vomiting? During regurgitation?

A

Vomiting: laryngeal adduction, soft palate elevation
Regurgitation: none

77
Q

GER has been documented in what percent of healthy, asymptomatic dogs?

A

41%

78
Q

What is the most common form of hiatal hernia in dogs and cats?

A

Type I = sliding hiatal hernia

79
Q

In cats with hiatal hernias, what percent had evidence of upper airway disease/obstruction?

A

29%

80
Q

What is the median survival time for cats with hiatal hernias? Did cats treated surgically or medically survive longer?

A

Overall MST 959 days
Medically - 2559 days
Surgically - 771 days

81
Q

What risk factors increase the odds of GER post-anesthesia?

A

Male (OR 9.2), overweight BCS (12.3), gastrointestinal surgery (30.5) and requirement for a dexmedetomidine CRI after surgery (9.6)

82
Q

Does prophylactic administration of maropitant and metoclopramide decrease the incidence of GER post-anesthesia?

A

Not in the 2019 JAVMA paper

83
Q

What risk factors increase the odds of regurgitation and vomiting post-operatively?

A

Gastrointestinal surgery (OR 11.5), premedication with acepromazine (5.4), hx of vomiting/regurgitation (5.1), emergency surgery (4), neurologic surgery (3.2), sevoflurane (2.3)

84
Q

When evaluating GER in healthy dogs by nuclear scintigraphy, what percent of healthy dogs experienced reflux?

A

All of them. In 5/12, it refluxed all the way to the pharynx

85
Q

Name 4 potential treatment options for lower esophageal sphincter achalasia in dogs

A

Sildenafil, mechanical dilation, botulism toxin A injection, surgical myotomy and fundoplication

86
Q

Mechanical dilation and botulism injection improved clinical signs in how many dogs with lower esophageal sphincter achalasia? How long did the improvement last?

A

100% of dogs improved by 21 days - BW increased 20%, regurgitation decreased by 80%
Lasted 40 days

87
Q

Balloon dilation resulted in resolution of esophageal strictures in what percent of cases?

A

59% (not all had triamcinolone injected, only done twice)

88
Q

Placement of a balloon dilatation esophagostomy tube (B tube) resulted in improved modified dysphagia scores in what percent of animals?

A

97%

89
Q

What is the goal of a B tube?

A

Placed after initial dilation of the stricture under anesthesia. Goal is to cause microtrauma to the previously dilated stricture, preventing fibrosis and contraction

90
Q

How long are B tubes kept in place?

A

6 weeks, dilated twice daily

91
Q

What features on video fluoroscopy can be used to identify lower esophageal sphincter achalasia?

A

Bird beak sign 63%, esophageal fluid line 68%, megaesophagus 73%, failure of the LES to open during pharyngeal swallowing (100%)

92
Q

Of dogs/cats undergoing esophageal surgery, what is the complication rate and what complications occur?

A

54% overall - persistent regurgitation, esophageal stricture formation

93
Q

What risk factors are associated with increased complications after esophageal surgery?

A
  • Type of surgery - partial esophagectomy with R&A
  • Mass lesion, larger lesion size
94
Q

Following esophageal surgery, what are negative prognostic indicators for survival to discharge?

A

Pneumomediastinum, leukopenia

95
Q

In a review of 222 dogs with esophageal foreign bodies, what was the most common foreign material and where was it?

A

Osseous material (81%), distal esophagus (50%)

96
Q

What percent of esophageal foreign bodies are able to be removed endoscopically?

A

91.8% (222 dog study 2017); 83.6% (224 dog study 2018)

97
Q

In a review of 222 dogs, what was the fatality rate for esophageal foreign bodies? What was associated with mortality?

A

5% mortality - associated with need for surgical intervention, esophageal perforation (OR 65), post procedure esophageal hemorrhage (OR 11.8)

98
Q

What percent of dogs develop esophageal strictures post-foreign body removal?

A

2.1% (2017 study); 11.2% (2018 study)

99
Q

In a study of 52 cats with foreign bodies, what percent were successfully retrieved endoscopically? How often did radiographs identify foreign material?

A

94% retrieval rate, 48% identified on rads

100
Q

In a study of 52 cats with foreign bodies, what percent of cats had major complications?

A

15% overall - higher in cats with esophageal foreign bodies than gastric

101
Q

Esophageal perforation is more common with what type of foreign body?

A

Fish hook

102
Q

In a JVIM study evaluating 114 dogs with esophageal foreign bodies, what was associated with severe esophagitis and major complications?

A

Foreign body present for >24 hours

103
Q

What percent of brachycephalic dogs present with gastrointestinal signs prior to airway surgery?

A

Overall 56%, but it was 93% in Frenchies, 58% in bulldogs, and only 16% in pugs

104
Q

What surgical technique can be used to prevent regurgitation in brachycephalic dogs?

A

Circumferential esophageal hiatal rim reconstruction and esophagopexy

105
Q

Brachycephaly is associated with what abnormalities on fluoroscopic swallowing studies?

A

Esophageal dysmotility characterized by prolonged esophageal transit time, GER, and hiatal hernia

106
Q

Pre-treatment with maropitant and famotidine as well as the reduced use of opioids reduced post-operative regurgitation in brachycephalics by what percent?

A

From 35% to 9%

ACVIM Specialty 2023 (38 decks)

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