Case Study:Esophageal Foreign Bodies

Esophageal Foreign Bodies

History
A 9-year-old female spayed Pomeranian presented to the VCA Hollywood Animal Hospital Emergency Service for an esophageal foreign body. Three to four days ago, the patient regurgitated several times after attempting to eat. Since then, the patient has been lethargic and anorexic.

The day prior to presentation, the patient originally presented to her primary veterinarian where diagnostics revealed the following:

Complete Blood Count: Hemoconcentration (58.52%), leukocytosis (24.94x109/L) characterized by mature neutrophilia (21.86x109/L), and thrombocytopenia (125x109/L)

 

Test	Result	Units	Reference Interval
Hematocrit	↑ 58.52	%	37 - 55
White Blood Cell Count	↑ 24.94	109/L	6 - 17
Absolute Neutrophil Count	↑ 21.86	109/L	3 – 12
Platelet Count	↓ 125	109/L	165 - 500

 Serum Chemistry Profile: Hyperglobulinemia (4.6 g/dL)

Test	Result	Units	Reference Interval
Blood Urea Nitrogen	9	mg/dL	7 – 27
Creatinine	0.8	mg/dL	0.5 – 1.8
Phosphorus	3.3	mg/dL	2.5 – 6.8
Calcium	9.1	mg/dL	7.9 – 12.0
Glucose	112	mg/dL	70 – 143
Alanine Transaminase	22	U/L	10 – 125
Alkaline Phosphatase	212	U/L	23 – 212
Gamma Glutanyl Transferase	0	U/L	0 – 11
Total Bilirubin	0.3	mg/dL	0 – 0.9
Cholesterol	178	mg/dL	110 – 320
Total Protein	7.6	g/dL	5.2 – 8.2
Albumin	3.0	g/dL	2.2 – 3.9
Globulin	↑ 4.6	g/dL	2.5 – 4.5

 Fecal: No ova or parasites seen

 Thoracic and Abdominal Radiographs

Findings

Within the thorax, there is a linear mineral opacity object superimposed over the caudal thoracic esophagus, along with moderate surrounding poorly defined soft tissue/fluid opacity. No other significant intrathoracic abnormalities are identified. In the abdomen, there is moderate bilateral renal mineralization. The liver is mildly enlarged. Peritoneal serosal detail is adequate. There is luxation of one of the patellas.
Impressions
Strongly suspected mineral and soft tissue opacity caudal esophageal foreign body. No obvious evidence of a gastric or small bowel or radiopaque foreign material is noted. Moderate bilateral renal mineralization, most likely chronic and incidental. Mild hepatomegaly.

 

Although the client was referred that day for an emergency esophagoscopy for foreign body removal, the client elected to hospitalize for the day for supportive care due to financial constraints (records not available). Upon discharge that evening, the patient appeared brighter and had a small appetite for wet food. However, the patient was once again lethargic and anorexic the next morning, which prompted the presentation to VCA Hollywood Animal Hospital.

Physical Examination
On presentation, the patient was quiet, alert, and responsive. Vitals were within normal limits. The patient had a body condition score of 6/9 with normal muscle condition. Mild hypersalivation was noted. Regurgitation/gagging/coughing was not elicited on cervical palpation, and the abdomen was soft and non-painful. The remainder of the physical exam was unremarkable.

Endoscopy
Due to financial constraints, the client elected not to perform repeat thoracic and abdominal radiographs to confirm the location of the foreign body. This was offered as endoscopy is only able to potentially address esophageal and gastric (and potential very proximal duodenal) foreign bodies due to the length of the scope. The patient’s bloodwork from the day prior was accepted as pre-anesthetic bloodwork.

The patient was pre-medicated with butorphanol 0.2 mg/kg and midazolam 0.2 mg/kg. Propofol 2.5 mg/kg total IV was used for induction, and the patient was intubated with a 4.5 Fr endotracheal tube. The patient was placed in left lateral recumbency, and an esophagoscopy was performed with a Karl Storz 60714 NKS scope (7.9 mm x 140 cm flexible gastroscope). The proximal esophagus appeared normal, and a bone foreign material was identified in the caudal esophagus. The lower esophageal sphincter could not be initially identified due to the shape of the bone. The mucosa surrounding the bone was moderately erythematous and markedly friable.

The bone was successfully removed using a snare. On re-exploration, the region was markedly ulcerated. The lower esophageal sphincter still had not been visualized.

On closer inspection of the ulcerated region, a full thickness esophageal perforation was identified. The heart could be seen beating in the thoracic cavity.

Immediately following this, the patient became cyanotic, and esophagoscopy was discontinued. Within seconds, the patient arrested, and CPR performed for 15 minutes did not result in a spontaneous return to circulation.

Discussion
Bones are the most common type of foreign body involved in canine esophageal foreign bodies1–4. Other common types of foreign bodies include fish hooks, treats, balls, and wooden sticks^1,2,5. Young small breed dogs, such as West Highland White Terriers, Jack Russell Terriers, Shih Tzus, and Chihuahuas, are over-represented^1,3. Patients may present with gagging, retching, coughing, vomiting, regurgitation, hypersalivation, dysphagia, and/or odynophagia^1,3,5. Diagnosis is typically achieved through radiography^3,5.

Possible complications of esophageal foreign bodies include esophagitis, esophageal stricture, esophageal perforation, and aspiration pneumonia^1,2,5. The duration of clinical signs before presentation is correlated with the severity of esophagitis, risk for esophageal perforation, and need for surgical intervention^1,3,4,6. Bones, fish hooks, and esophageal foreign bodies present for greater than 72 hours have been associated with an increased risk of perforation¹.

Endoscopy is the treatment of choice for removal of the foreign body or dislodgement of the foreign body into the stomach for digestion or surgical extraction^1,4,5. Esophageal perforation or hemorrhage during the procedure are associated with increased mortality². Undergoing surgery after failed endoscopic attempts and repeating endoscopy if surgery is recommended but declined are also associated with increased mortality².

If an esophageal perforation is identified, surgery is often recommended⁵. In patients in which surgery is not an option, medical management with IV fluids, IV antimicrobials, analgesia, and gastroprotectants may be an option^1,5.

Conclusion
Dogs with esophageal foreign bodies should be referred for emergency esophagoscopy +/- surgery, as the duration of clinical signs is associated with increased morbidity and mortality. Although emergency surgery for an esophageal perforation remains the gold standard, some dogs with an esophageal perforation may survive to discharge with medical management alone.

 

Authored by: 

Melody Chen, DVM, MS

Practice Limited to Internal Medicine

melody.chen@vca.com

References
1. Sterman AA, Mankin KMT, Ham KM, Cook AK. Likelihood and outcome of esophageal perforation secondary to esophageal foreign body in dogs. J Am Vet Med Assoc. 2018 Oct 15;253(8):1053–6.

2. Burton AG, Talbot CT, Kent MS. Risk Factors for Death in Dogs Treated for Esophageal Foreign Body Obstruction: A Retrospective Cohort Study of 222 Cases (1998-2017). J Vet Intern Med. 2017 Nov;31(6):1686–90.

3. Thompson HC, Cortes Y, Gannon K, Bailey D, Freer S. Esophageal foreign bodies in dogs: 34 cases (2004-2009): Esophageal foreign body in dogs. J Vet Emerg Crit Care. 2012 Apr;22(2):253–61.

4. Juvet F, Pinilla M, Shiel RE, Mooney CT. Oesophageal foreign bodies in dogs: factors affecting success of endoscopic retrieval. Ir Vet J. 2010 Dec;63(3):163.

5. Teh H, Winters L, James F, Irwin P, Beck C, Mansfield C. Medical management of esophageal perforation secondary to esophageal foreign bodies in 5 dogs: Medical management of esophageal perforation. J Vet Emerg Crit Care. 2018 Sep;28(5):464–8.

6. Rousseau A, Prittie J, Broussard JD, Fox PR, Hoskinson J. Incidence and characterization of esophagitis following esophageal foreign body removal in dogs: 60 cases (1999?2003). J Vet Emerg Crit Care. 2007 Jun;17(2):159–63.