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 ExaminationOn 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 sticks1,2,5. Young small breed dogs, such
as West Highland White Terriers, Jack Russell Terriers, Shih Tzus, and Chihuahuas,
are over-represented1,3. Patients may present with
gagging, retching, coughing, vomiting, regurgitation, hypersalivation,
dysphagia, and/or odynophagia1,3,5. Diagnosis is typically
achieved through radiography3,5.
Possible complications of esophageal foreign bodies include esophagitis,
esophageal stricture, esophageal perforation, and aspiration pneumonia1,2,5. The duration of clinical
signs before presentation is correlated with the severity of esophagitis, risk
for esophageal perforation, and need for surgical intervention1,3,4,6. 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
extraction1,4,5. 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 option1,5.
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:
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.
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