What's Your Diagnosis?

What’s Your Diagnosis?

By Norm Nasser BSc DVM

Wallie, a 7 year old male castrated Husky, was brought to the Toronto Veterinary Emergency Hospital with a 2 day history of projectile vomiting. His owner reported that Wallie had a problem with chronic vomiting, doing so weekly for many years. It was confirmed with the owner that Wallie was in fact vomiting, as opposed to regurgitating, as every event appeared to be an active process involving abdominal contractions. Wallie had lost approximately 25% of his body weight, however the owner was unsure over how long this loss had occurred. He had become progressively more lethargic and anorectic over a 2-3 day period, yet was still drinking large volumes of water. His stools remained normal, however there had been a decrease in volume coinciding with his decreased appetite.

On physical examination, Wallie was mentally dull and in lateral recumbency. His body condition was very poor with a BCS of 1/5. He was mildly tachycardic and tachypneic with an increased respiratory effort. He was dehydrated with tacky mucous membranes and a prolonged skin tent. His lung sounds were clear. He was moderately hypotensive with a blood pressure of 102/54 mmHg, having a mean arterial pressure of 65 mmHg.

Bloodwork and urine testing revealed a moderate renal azotemia, increased total solids, moderate hyperlactatemia, moderate hyponatremia, hyperphosphatemia, and hyperglobulinemia. There was a marked leukocytosis represented by a degenerative left shift and monocytosis.

Thoracic radiographs were performed:

rad 1 Nasserirad 2 Nasseri

What is your diagnosis?


Thoracic radiographs revealed a markedly distended esophagus with a large soft tissue opacity in its caudal aspect. This space-occupying opacity resulted in a ventral displacement of the trachea and cardiac silhouette. There was also a patchy interstitial to alveolar pattern in the right cranial and middle lung lobes. The differential diagnosis included an esophageal mass, esophageal foreign body, gastroesophageal intussusception (GEI), and megaesophagus.

A nasoesophageal tube was placed and approximately 1.5L of serosanguinous fluid was evacuated from the esophagus, which immediately improved Wallie’s respiratory and cardiovascular stability.

In order to better characterize the soft tissue density, a thoracic CT examination was performed. Sagittal and dorsal multiplanar reformatted images are shown:

rad 3 Nasserirad 4 Nasseri

This study confirmed the presence of a gastroesophageal intussusception which included herniation of the spleen, duodenum and mesentery into the esophagus. An interstitial to alveolar pulmonary pattern was present, consistent with aspiration pneumonia, bronchopneumonia, atelectasis or fibrosis.

The owners elected to proceed with surgery to reduce the intussusception. On abdominal exploration, part of the stomach, the duodenum and the entire spleen were found invaginated into the distal esophagus. These organs appeared undamaged and, therefore, were reduced in the abdomen. Bilateral gastropexies were performed to avoid the risk of a repeat intussusception.

Although Wallie initially did well post-operatively, his condition started to decline after 24 hours. His suspected aspiration pneumonia worsened and he became oxygen dependent. His esophagus remained distended and there was a suspicion that there were ongoing aspiration events. Based on his decline in condition, eventual requirement for mechanical ventilation and the potential for long-term complications associated with the management of megaesophagus, his owner elected humane euthanasia.

Gastroesophageal intussusceptions are rare and have been observed in both dogs and cats.(1-9) There are chronic recurrent and acute forms of this condition. Invagination of the stomach, or part thereof, into the caudal esophagus, causes esophageal obstruction and, as a result, patients with GEI present with signs of gastrointestinal blockage (vomiting, regurgitation and abdominal discomfort). GEIs are usually reported in patients under 3 months of age, and male German Shepherd dogs or shepherd crosses are overrepresented.(3,5,6) This may be related to the fact that this breed is associated with a higher incidence of congenital megaesophagus. As opposed to small intestinal intussusceptions, which generally carry a good overall prognosis, patients with GEI may have a poor prognosis because of persistent megaesophagus.(9)

Historically, plain and contrast radiographs, fluoroscopy, ultrasound and endoscopy have been used to diagnose GEI.(1,2,3,5) CT examination has not been previously reported as a diagnostic tool, but CT examination should be considered a superior diagnostic modality for diagnosing GEI, as it is non-invasive, fast, involves minimal sedation, and provides a definitive diagnosis, as this case illustrates.

Treatment usually involves exploratory laparotomy with unilateral or bilateral gastropexies (3-7), however there has been some success with endoscopic reduction of the GEI and gastropexy.(8, 9)

Wallie’s signalment was not typical of most GEI patients. As well, his chronic weight loss and history of vomiting were unlike the usual acute or chronic presentations of GEI. Therefore, he likely had a predisposing illness such as an esophageal motility disorder, intermittent hiatal hernia, or a malabsorptive gastrointestinal disease that made him vomit chronically. This chronic disease might have made him more susceptible to the development of GEI.

Although rare, GEI should be considered when esophageal soft tissue opacities are noted on thoracic radiographs, regardless of species, age or breed.

References:

  1. Van Camp S, Love NE, Kumaresan S. Radiographic diagnosis – gastroesophageal intussusception in a cat. Vet Radiol Ultrasound. 1998 ;39(3):190-2.
  2. Martínez NI, Cook W, Troy GC, Waldron D. Intermittent gastroesophageal intussusception in a cat with idiopathic megaesophagus. J Am Anim Hosp Assoc. 2001; 37:234–237.
  3. Pietra M, Gentilini F, Pinna S, Fracassi F, Venturini A, Cipone M. Intermittent gastroesophageal intussusception in a dog: clinical features, radiographic and endoscopic findings, and surgical management. Vet Res Commun. 2003; 27:783–786.
  4. Graham KL, Buss MS, Dhein CR, Barbee DD, Seitz SE. Gastroesophageal intussusception in a Labrador retriever. Can Vet J. 1998; 39:709–711
  5. Von Werthern CJ, Montavon PM, Fluckinger MA. Gastro-oesophageal intussusception in a young German shepherd dog. J Small Anim Pract. 1996; 37:491–494.
  6. Greenfield CL, Quinn MK, Coolman BR. Bilateral incisional gastropexies for treatment of intermittent gastroesophageal intussusception in a puppy. J Am Vet Med Assoc. 1997; 228:693–694.
  7. Clark GN, Spodnick GJ, Rush JE, Keyes ML. Belt loop gastropexy in the management of gastroesophageal intussusception in a pup. J Am Vet Med Assoc. 1992; 201(5):739-42.
  8. McGill SE, Lenard ZM, See AM, Irwin PJ. Nonsurgical treatment of gastroesophageal intussusception in a puppy. J Am Anim Hosp Assoc. 2009; 45:185–190.
  9. Shibly S, Karl S, Hittmair KM, Hirt RA. Acute gastroesophageal intussusception in a juvenile Australian Shepherd dog: endoscopic treatment and long-term follow-up. BMC Vet Res. 2014; 10:109.

Dr. Norm Nasser was born and raised in Scarborough, Ontario. After completing a General BSc, he entered the Veterinary Medicine program at the University of Guelph. Dr. Nasser earned his Doctorate in Veterinary Medicine from the Ontario Veterinary College in 2003. In order to get more experience in the challenging world of emergency medicine, Dr. Nasser traveled to the United States and successfully completed a rotating small animal internship in Annapolis, Maryland. After completing his internship, Dr. Nasser returned to Canada and has spent his first 5 clinical years honing his skills in emergency medicine by managing referral cases in a busy private practice. He has been a proud member of the ER team at the TVEH since its inception in 2009. In his free time, Dr. Nasser enjoys photography, traveling, basketball and spending time with his family.

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