Page 679 - Cote clinical veterinary advisor dogs and cats 4th

Esophageal Stricture (Benign) 311

• Cough, increased respiratory rate or effort Initial Database • Balloon dilation entails passing an inflatable
may be seen if the patient has concurrent • CBC, serum chemistry panel, urinalysis balloon catheter into the stricture site and
VetBooks.ir PHYSICAL EXAM FINDINGS ○ Inflammatory leukogram possible if tissue and increase the esophageal luminal Diseases and Disorders
inflating it to tear/break down the scar
results likely normal; changes are nonspecific
aspiration pneumonia (p. 793).
diameter.
aspiration pneumonia
• Typically normal if acute
○ Dehydration possible if stricture is severe
• Weight loss if chronic • Thoracic/abdominal radiographs are indicated • Bougienage involves passing rigid dilators of
gradually increasing size through the stricture
• Ptyalism or gagging in regurgitating patients. site.
• Coughing, fever, or increased broncho- ○ Plain thoracic radiographs may be normal • Both methods require concurrent endoscopic
vesicular sounds if aspiration pneumonia but may document air/food cranial to or fluoroscopic guidance to perform the
has occurred the stricture or demonstrate pulmonary procedure accurately and safely and iden-
changes due to aspiration pneumonia. tify complications (e.g., esophageal tear)
Etiology and Pathophysiology ○ Abdominal radiographs are usually early.
• Acid reflux during anesthesia is the most unremarkable. • Intralesional injection of glucocorticoids,
important cause of benign strictures topical application of mitomycin C, 3- or
in dogs. Although infrequent, it is very Advanced or Confirmatory Testing 4-quadrant nicking of the stricture before
important. • Esophagoscopy (p. 1098) is the test of dilation, insertion of a stent, and/or use of a
• Drug-induced esophagitis (especially doxy- choice for diagnosing esophageal strictures, balloon-esophagostomy tube may help reduce
cycline and clindamycin) is important in esophagitis, and other anatomic esophageal the chance of stricture recurrence after the
cats. abnormalities. Endoscopy can also be used dilation procedure; however, no technique
• Esophageal foreign bodies and esophagitis for dilation of the stricture (ballooning or is uniformly successful.
secondary to chronic persistent vomiting may bougienage). • Lifelong dietary management may be neces-
also be responsible. • Contrast radiographs may reveal strictures sary in some patients.
• Infrequently, benign esophageal stricture or esophageal motility defects. Liquid or • Patients with any residual stricture will
follows esophageal Pythium spp infection paste barium may pass through a stricture so be at increased risk for esophageal foreign
or prior esophageal surgery (e.g., to remove quickly that diagnosis is impossible without body.
foreign bodies, masses). fluoroscopy; using contrast-impregnated food
• Esophageal stricture formation requires is much more sensitive. Contrast imaging Chronic Treatment
substantial esophageal injury (usually chemi- may diagnose multiple strictures when the • Animals with severe strictures often require
cal or mechanical) causing inflammation endoscope cannot pass through the first many dilations to achieve an esophageal
extending to the submucosal or muscular stricture (p. 1062). opening sufficiently large to accommodate
layers. Subsequent normal repair processes • Fluoroscopy is often needed to identify liquid or gruel diets.
include formation of fibrous connective lower esophageal sphincter defects causing • Patients with esophagitis due to gastroesopha-
tissue, which narrows or closes the esophageal reflux. geal reflux often require long-term therapy
lumen. • Abdominal ultrasound rarely finds abdominal (proton pump inhibitors, prokinetics).
causes of gastroesophageal reflux (e.g., large
DIAGNOSIS hepatic masses putting pressure on the Nutrition/Diet
stomach). May need a softened or gruel-like diet if stricture
Diagnostic Overview cannot be resolved. Occasionally, gastrostomy
• Regurgitation is an indication for thoracic TREATMENT tube feeding may be required.
radiographs. If no abnormality is seen,
barium contrast radiography or esophagos- Treatment Overview Possible Complications
copy is then warranted. Therapeutic goals are to remove the obstruction, • The main catastrophic complication of
• A barium contrast esophagram can be protect esophageal mucosa from additional stricture dilation is esophageal rupture or
diagnostic, but fluoroscopy or, better still, injury, and eliminate the cause of the injury. perforation. Severe hemorrhage rarely occurs
use of barium-impregnated food may be Return to normal anatomy is not always pos- but can be life-threatening.
necessary. sible, in which case being able to maintain • Stricture recurrence often occurs if the dila-
• Benign strictures are usually obvious during nutrition and minimize regurgitation by feeding tion procedure is too aggressive and produces
esophagoscopy unless 1) the patient is large soft diets is considered a success. excessive inflammation.
and the stricture relatively minor, or 2) the • Aspiration pneumonia is possible if the
stricture is so close to the lower esophageal Acute General Treatment patient continues to regurgitate or does not
sphincter that it is mistaken for being part • Resolution of the cause of the stricture (e.g., have well-controlled dietary management
of the sphincter. acid reflux, persistent vomiting, foreign body) (e.g., dog gets into the garbage or is allowed
and treatment of esophagitis if present to eat foods that will not pass).
Differential Diagnosis (p. 312)
Regurgitation: • If the stricture is mild (soft foods pass PROGNOSIS & OUTCOME
• Esophagitis through the stricture site with minimal
• Esophageal foreign body clinical signs, and no weight loss occurs), • The prognosis for mild strictures is good.
• Esophageal mass (granuloma, parasites, management may be attempted by dietary • The prognosis for severe strictures, especially
neoplasia) modification (feeding soft or liquid foods those that are several centimeters long and
• Esophageal motility disorders (megaesopha- in frequent, small meals). requiring multiple dilations is guarded.
gus, congenital or acquired) • Strictures refractory to conservative dietary • If the patient can be managed on softened
• Esophageal diverticulum management require dilation. If this is not diets with minimal to no regurgitation,
• Persistent right aortic arch possible, a gastric feeding tube must be treatment is considered successful. Complete
• Gastroesophageal reflux during anesthesia placed to allow maintenance of hydration resolution of severe strictures may fail, and
(history of anesthesia is important) and nutrition (p. 1109). these patients must be maintained on
• Gagging/dysphagia • Dilation can be accomplished by ballooning softened, semiliquid to liquid diets, or even
• Oropharyngeal, nasopharyngeal disease or esophageal bougienage. with the use of feeding tubes.

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