Page 1740 - Cote clinical veterinary advisor dogs and cats 4th

874 Regurgitation

DIAGNOSIS • Fecal floatation (sugar or sodium nitrate Possible Complications
[NaNO 3 ]): rule out S. lupi Weight loss and aspiration pneumonia/
Diagnostic Overview
VetBooks.ir • The first step is to differentiate between • Thoracic CT ± angiogram: esophageal or complications. Pharyngitis, rhinitis, and
aspiration lung injury are the most common
• Bioassay: tetanus and botulism (pp. 127 and
964)
regurgitation (passive) and vomiting (active),
laryngeal paralysis are also reported. Other
although both can occur in the same patient.
Careful questioning, filming, or feeding and thoracic mass, vascular ring anomaly complications vary with the underlying disease
process.
observation of episodes in hospital may TREATMENT
provide clarification. Recommended Monitoring
• The list of potential causes of regurgitation is Treatment Overview • Frequent evaluations of weight and body
different for pets with ME and those without, Identify and treat underlying disease. In condition
and for otherwise healthy pets with ME (e.g., idiopathic ME and IED, treatment is limited • Quantify episodes of regurgitation to gauge
idiopathic or structural cause) and those with to symptomatic and supportive care. response to therapy.
ME and evidence of systemic illness (e.g., • Thoracic radiographs of patients with
endocrinopathy, toxicity, infection, metabolic Acute General Treatment increased respiratory rate/effort or to monitor
diseases). Recognition of systemic illness • If present, address respiratory distress due for resolution of pre-existing pathology. Serial
or its absence often guides next diagnostic to aspiration (pp. 793 and 879) radiographs of asymptomatic patients are not
steps. • Correction of underlying disease process recommended.
• Idiopathic ME/IED is a diagnosis of ○ Immediate intervention for esophageal
exclusion. foreign body (e.g., endoscopy) PROGNOSIS & OUTCOME
○ Address emergent manifestations of
Differential Diagnosis metabolic disorders (e.g., hypoadreno- Depends on the underlying disease process.
• Vomiting cortisolism, hypothyroidism) Idiopathic ME carries a guarded to poor long-
• Expectoration term prognosis, although dogs may do well for
• Oral/pharyngeal dysphagia Chronic Treatment months to years. In juvenile dogs with IED, the
Varies with the underlying disease process: esophagus may continue to mature and motility
Initial Database • Metabolic disorders (see specific disorder) may improve up to 1 year of age.
• CBC: often unremarkable; inflammatory • ME (p. 642)
leukogram (aspiration pneumonia), eryth- ○ Upright feeding of various food consisten- PEARLS & CONSIDERATIONS
rocyte basophilic stippling (lead) cies often useful
• Chemistry: often unremarkable; electrolyte ○ Sildenafil 1 mg/kg PO q 8-12h: improved Comments
changes with systemic metabolic disturbances clinical signs reported in some dogs with • Discrimination between regurgitation and
(e.g., hypoadrenocortisolism) ME vomiting is critical.
• Urinalysis: often unremarkable • LES achalasia-like syndromes ○ Unlike vomiting, with regurgitation there
• Radiographs (cervical and thoracic): identify ○ Pneumatic dilation ± botulinum toxin A: is no active abdominal effort, no appar-
esophageal abnormalities (e.g., ME, esopha- improved clinical signs, weight gain, and ent nausea beforehand, and expectorated
geal foreign body, mass, diverticulum), and improved esophageal motility anecdotally material does not contain bile.
screen for lung injury/pneumonia. described • Aspiration pneumonia may exist in the
○ Heller myotomy and Dorr fundoplication absence of an inflammatory leukogram and
Advanced or Confirmatory Testing may be beneficial in a subset of patients fever.
• Acetylcholine receptor antibody titers: rule with LES achalasia-like syndrome • Antibiotics are not required for all cases of
out myasthenia gravis as cause of ME, which • Promotility drugs: metoclopramide 0.2- aspiration pneumonia, particularly when pets
is indicated for all adult animals with ME 0.5 mg/kg PO q 8-12h: increased LES tone are asymptomatic.
unless another cause is known. and increased gastric emptying
• Fluoroscopy: capable of identifying most ○ Controversial in dogs with ME, helpful Prevention
functional and mechanical obstructions in cases of reflux • Fast pets before general anesthesia to reduce
○ Simultaneous evaluation of swallow and ○ Drugs increasing LES tone: contraindi- risk of esophagitis/stricture.
LES relaxation (or manometry) needed cated for LES achalasia-like syndromes • Administer water after pilling pets.
to diagnose LES achalasia-like syndrome ○ Impendence to bolus flow may occur in • Monthly moxidectin/imidacloprid to prevent
○ Freely fed videofluoroscopic swallow study cases of IED. S. lupi
may reduce the risk of aspiration. • Reflux esophagitis: acid reducers (omeprazole
• Esophagoscopy: strictures, esophagitis, and 1 mg/kg PO q 12h 30 minutes before Technician Tips
diverticula; less reliable than radiography for meals) When clients report vomiting, ask questions
identifying ME necessary to distinguish vomiting (active) from
○ Unless esophageal mass identified, biopsy Nutrition/Diet regurgitation (passive).
seldom indicated • Small, frequent meals
• Reflux scintigraphy: reflux disease/aspiration • Upright feeding (maintained upright Client Education
(not widely available) 5-10 minutes after feeding) may improve Monitor respiratory rate and effort at home.
• ACTH stimulation test: rule out esophageal transit (p. 642)
hypoadrenocortisolism • Gastrostomy/percutaneous endoscopic gas- SUGGESTED READING
• Thyroid testing: thyroid-stimulating hormone trostomy (PEG) tubes in dogs not responsive Pollard R: Imaging evaluation of dogs and cats with
and free T 4 by equilibrium dialysis to rule to upright feeding dysphagia. ISRN Vet Sci 2012, 2012:238505.
out hypothyroidism • Reflux: low-fat meals may facilitate gastric
• Dilute pilocarpine test: rule out dysautonomia emptying. AUTHOR: Megan Grobman, DVM, MS, DACVIM
EDITOR: Leah A. Cohn, DVM, PhD, DACVIM
• Toxin screen: rule out lead, thallium, other • No ideal food texture: consider controlled
toxins diet trials with different consistencies

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