Incidence and characterization of esophagitis following esophageal foreign body removal in dogs: 60 cases (1999^2003)

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1 Retrospective Study Journal of Veterinary Emergency and Critical Care 17(2) 2007, pp doi: /j x Incidence and characterization of esophagitis following esophageal foreign body removal in dogs: 60 cases (1999^2003) Alexandre Rousseau, DVM, DACVIM, DACVECC, Jennifer Prittie, DVM, DACVIM, DACVECC, John D. Broussard, DVM, DACVIM, Philip R. Fox, MS, DVM, DACVIM, ACVECC and James Hoskinson, DVM, DACVR Abstract Objective: To characterize the presence of esophagitis in dogs after esophagoscopy for diagnosis and treatment of esophageal foreign body and to relate the degree of esophageal injury to clinical signs and outcome. Design: Retrospective study. Animals, intervention, and measurements: Medical records of 60 dogs with esophageal foreign bodies diagnosed between January 1999 and December 2003 were reviewed. Information obtained from the medical records included age, breed, and sex; type and duration of clinical signs; physical examination, radiographic, and esophagoscopy findings; type and location of foreign body; surgical intervention; morbidity, and outcome. Animals were divided into 2 cohorts based upon the degree of esophageal injury detected during esophagoscopy: mild esophagitis or moderate-to-severe esophagitis. Data were then compared between the groups. Results: Dogs with moderate-to-severe esophagitis had a longer duration of clinical signs, were more likely to present for lethargy and regurgitation/vomiting, and had a longer time to recovery. This cohort had significantly greater morbidity including esophageal stricture, perforation, necrosis, and diverticulum formation, as well as aspiration pneumonia, pneumothorax, severe tracheal compression, and death. Dogs with mild esophagitis were more likely to present to the hospital for gagging. Conclusions: This study demonstrated a wide range of injury associated with esophageal foreign bodies. The degree of esophagitis appears to relate to the duration and severity of some of the clinical signs. (J Vet Emerg Crit Care 2007; 17(2): ) doi: /j x Keywords: canine, dysphagia, endoscopy, esophagoscopy, gastric tube, regurgitation Introduction Esophageal foreign bodies are a frequent cause of dysphagia and regurgitation in the dog. 1 4 Because esophageal foreign bodies pose substantial risk for injury when lodged, they are generally considered to be medical emergencies. 5,6 Damage to the esophagus is influenced by the foreign body type, size, sharpness, and duration of obstruction. Clinical signs associated with esophageal foreign bodies are variable. 4,7 Esophageal foreign bodies may cause early complications such as esophagitis, esophageal perforation, mediastinitis, Bobst Hospital of the Animal Medical Center, New York, NY, USA. Address correspondence and reprint requests to: Dr. Alexandre Rousseau, DACVECC, DACVIM, Sorrento Valley Rd, San Diego, CA alexandre.rousseau@vshsd.com pneumothorax, and aortic perforation. 2,7 9 Furthermore, delayed complications may develop including esophageal stricture or diverticulum formation and broncho-esophageal fistulas. 8,10,11 There is some evidence to suggest that patients with esophageal perforation have a longer duration of clinical signs before presentation, 8 but the relationship between clinical signs, duration of foreign body entrapment, and outcome has not been clarified. This study hypothesized that the severity of esophagitis resulting from esophageal foreign bodies influences clinical signs and outcome. Thus, the purpose of the present study was to characterize the presence of esophagitis in dogs that underwent esophagoscopy to diagnose and treat esophageal foreign bodies and to relate the degree of esophageal injury to duration and type of clinical signs and outcome. & Veterinary Emergency and Critical Care Society

2 A. Rousseau et al. Materials and Methods Medical records of dogs that presented to the Bosbt Hospital of the Animal Medical Center with esophageal foreign bodies between January 1999 and December 2003 were reviewed. Only dogs with a record of esophagoscopy were included in the study. For all included dogs, signalment, history, clinical signs, physical examination findings, and clinicopathologic test results were recorded. Thoracic radiographs were evaluated for pulmonary, mediastinal, and/or pleural pathology. Endoscopic reports were reviewed for foreign body type and location and degree of esophageal damage at the time of esophageal foreign body removal. Also recorded were morbidity associated with esophageal foreign body removal, time to recovery (defined as the period of time between esophageal foreign body removal and successful reinstitution of oral alimentation), and clinical outcome. Assessment of esophagitis following esophageal foreign body removal was characterized using the Savary Miller classification 12 as follows: grade I esophagitis represented a single erosion; grade II esophagitis represented confluent erosions; grade III esophagitis represented circular, confluent erosions; and grade IV esophagitis represented esophageal ulceration, stenosis, or perforation. Based upon this severity grading, dogs with esophageal foreign bodies conformed to 2 basic cohorts, a mild esophagitis group and a moderate-tosevere esophagitis group. Dogs with mild esophagitis included those without gross esophageal lesions or grade I or II esophagitis. Dogs with moderate-to-severe esophagitis included those with grade III or IV esophagitis. These 2 groups were then compared with regard to signalment, duration of clinical signs, physical examination findings, presence of concurrent disease, radiographic abnormalities, endoscopic findings, type and location of esophageal foreign bodies, and time from esophageal foreign body removal to recovery. The Student t-test and Mann Whitney rank sum test were used to analyze continuous data. The Fisher exact test was used to compare groups with categorical data. A Po0.05 was considered significant. Results Complete medical records were identified for 60 dogs that underwent esophagoscopy for esophageal foreign body removal between January 1999 and December One dog had 3 different events. Only the first event was preserved for statistical analysis. Esophagitis was judged to be mild in 30 dogs and moderateto-severe in the other 30 dogs. Age (mean SD) did not differ significantly (P ) between the mild Table 1: Signalment, duration of clinical signs, frequency of complication, and days to recovery for dogs with mild esophagitis (ME) or moderate-to-severe esophagitis (MSE) following esophageal foreign body removal Variable ME (n 5 30) MSE (n 5 30) P- value Age (years) n ( 4.37) ( 3.96) Sexw Male 19 (63) 15 (50) Female 11 (37) 15 (50) Body weight (kg)z ( ) ( ) Duration (days) of clinical signs 0 (0 4) 3 (0 14) o0.001 before hospital presentationz Early complicationsw 2 (7) 9 (30) 0.04 Total complicationsw (n 5 53) 2 (7) 16 (53) o0.001 Days to recoveryz (n 5 50) 1 (0 6) 8 (1 37) o0.001 n Data are given as mean ( SD). wdata are given as number (percentage). zdata are given as median (range). esophagitis group ( ) and moderate-to-severe esophagitis group ( ). Fifty-three of the 60 dogs (88.3%) were small breeds weighing o10 kg (Table 1). Body weight did not differ significantly (P ) between the mild esophagitis group (median, 4.3 kg; range, ) and the moderate-to-severe esophagitis group (median, 6.4 kg; range, ). Twenty breeds of dogs were recorded, and the Yorkshire Terrier and Shih Tzu were the most commonly represented breeds (8/60, 13.3%; and 7/60, 11.7%, respectively). Thirty-four of the 60 dogs (57%) were male and 26 (43%) were female. There was no significant difference in gender (P ) between cohorts. Duration of clinical signs before presentation was significantly shorter for dogs with mild esophagitis compared with dogs with moderate-to-severe esophagitis (Po0.001). All dogs in the mild esophagitis cohort had clinical signs 4 days before presenting to the hospital while 8/30 (27%) dogs in the moderate-to-severe cohort had clinical signs for 5 days or longer before hospital presentation. Twenty-two of 30 mild esophagitis group dogs (73%) presented on the day that clinical signs developed compared with 4/30 (13%) dogs in the moderate-to-severe group. Compared with dogs with mild esophagitis, dogs with moderate-to-severe esophagitis had a statistically greater incidence of lethargy and regurgitation/vomiting. Dogs with mild esophagitis were significantly more likely to present for gagging (Table 2). Clinical pathology testing (complete blood count [CBC] and serum biochemistry panel) was performed in 5 dogs in the mild esophagitis group and 17 dogs in the moderate-to-severe group. Compared with the mild 160 & Veterinary Emergency and Critical Care Society 2007, doi: /j x

3 Esophagitis and esophageal foreign body in dogs Table 2: Presenting clinical signs for dogs diagnosed with mild esophagitis (ME) or moderate-to-severe esophagitis (MSE) following esophageal foreign body removal over number of dogs in which information was recorded Clinical signs ME (n 5 30) MSE (n 5 30) P-value Lethargy 3/19 (16%) 13/17 (76%) o0.001 Anorexia 3/6 (50%) 16/20 (80%) 0.29 Gagging 16/30 (53%) 5/30 (17%) Vomiting/regurgitation 11/30 (37%) 24/30 (80%) Retching 8/30 (27%) 6/30 (20%) 0.76 Coughing 5/30 (17%) 3/30 (10%) 0.71 Odynophagia 7/30 (23%) 5/30 (17%) 0.75 Ptyalism 11/30 (37%) 7/30 (23%) 0.40 Dyspnea 3/30 (10%) 2/30 (7%) Elevated temperature 1/19 (5%) 8/27 (30%) 0.06 esophagitis group, the most frequent abnormalities observed in the moderate-to-severe group were leukocytosis (416,300 cells/ml) (9/17 [53%] versus 1/5 [20%]), mature neutrophilia (411,500 cells/ml) (8/17 [47%] versus 2/5 [40%]), a left shift (4300 bands/ml) (10/17 [59%] versus 1/5 [20%]), and monocytosis (41350 cells/ml) (6/17 [35%] versus 0/5 [0%]). Biochemistry panels were not different between groups. Radiographic examinations, cervical, thoracic, or abdominal radiographs were made at the time of hospital presentation in 43 dogs (21 dogs in the mild esophagitis group and 19 dogs in the moderate-to-severe group). Esophageal foreign bodies were radiographically visible in all patients. Thoracic radiographs from dogs with mild esophagitis (n 5 22) and moderate-to-severe esophagitis (n 5 20) were reviewed for evidence of pulmonary, mediastinal, or pleural pathology. A diagnosis of pneumonia was made in 2/22 mild esophagitis group dogs. In the moderate-to-severe-group dogs, pneumonia (5/20), mediastinitis (2/20), and pneumothorax (1/20) were detected. All endoscopic procedures were performed with a flexible video-gastroscope a or colonoscope. b Definitive endoscopic location of esophageal foreign bodies was recorded in 25/30 dogs with mild esophagitis and 27/30 dogs with moderate-to-severe esophagitis. The most common site of foreign body entrapment was the caudal esophagus just cranial to the cardiac sphincter in 15/25 dogs in the mild esophagitis group and in 19/29 dogs in the moderate-to-severe esophagitis cohort (P ). The foreign body was removed endoscopically in 16/30 (53%) dogs with mild esophagitis and in 16/30 (53%) dogs in the moderate-to-severe esophagitis group. The foreign body was pushed aborally into the stomach to be digested in 14/30 (47%) dogs with mild esophagitis and 11/30 (37%) dogs in the moderate-to-severe esophagitis group. Subsequent gastrotomy for definitive foreign body removal was performed in 2 animals in the moderate-to-severe esophagitis group. On 3 occasions, despite the use of different techniques, dogs in the moderate-to-severe esophagitis group had foreign bodies that were impossible to dislodge endoscopically and thoracotomy with esophagotomy (n 5 2) and gastrotomy (n 5 1) were performed. One dog was euthanized intraoperatively due to extensive esophageal necrosis. The types of esophageal foreign bodies endoscopically visualized or removed were compared between cohorts. Twenty of 30 (67%) mild esophagitis group dogs and 26/30 (87%) moderate-to-severe esophagitis group dogs had a single bone lodged in their esophagus. Only 2 dogs had 2 bones concurrently lodged at the time of endoscopy. Other observed foreign bodies included rawhides (n 5 3) and dental bones (n 5 3), a rubber ball (n 5 1), a fishhook (n 5 1), a bottle cap (n 5 1), an apple (n 5 1), a plastic bottle (n 5 1), and a piece of foam (n 5 1). There was no significant difference in type of foreign body between the groups (P ). Gastric tubes were placed in 21/30 (70%) dogs with moderate-to-severe esophagitis. These tubes were placed endoscopically (PEG-tube c ) on 18 occasions and surgically 3 times. One owner declined feeding tube placement. No dogs that had mild esophagitis underwent gastric tube placement. Complications were categorized as occurring secondary to the esophageal foreign bodies or resulting from therapy. Only 2 mild esophagitis group dogs had evidence of early complications (aspiration pneumonia). One of which did not respond to therapy and died. Nine moderate-to-severe esophagitis group dogs developed early foreign body complications including esophageal perforation (n 5 2), esophageal necrosis (n 5 1), aspiration pneumonia (n 5 4), pneumothorax (n 5 1), and severe tracheal compression and death (n 5 1). Delayed esophageal foreign body complications were identified in 6 dogs with moderate-to-severe esophagitis and included esophageal stricture (n 5 5) and esophageal diverticulum (n 5 1). Five of 21 moderate-to-severe esophagitis group dogs had gastric-tube complications. Four had tube-site infection and a fifth dog developed tube-site necrosis that required surgical debridement. Overall, dogs with moderate-to-severe esophagitis had significantly more early complications than dogs with mild esophagitis (P ). Delayed complications were not compared between groups due to low reevaluation frequency in dogs with mild esophagitis. At the time of hospital discharge, dogs in the moderate-to-severe esophagitis group were more commonly judged to require adjunctive medical therapies than & Veterinary Emergency and Critical Care Society 2007, doi: /j x 161

4 A. Rousseau et al. mild esophagitis group dogs including antibiotics (21/28 [75%] versus 7/29 [24%], respectively) and promotility drugs (15/28 [54%] versus 4/29 [14%], respectively). Acid-reducing medications were used in 13/29 (45%) surviving mild esophagitis group dogs compared with 19/28 (68%) surviving moderate-to-severe esophagitis group dogs. Endoscopic esophageal reevaluation was performed on one dog with mild esophagitis that had a previous diagnosis of stricture; no esophagitis was visualized. Seventeen moderate-to-severe esophagitis group dogs had endoscopic esophageal reevaluation including 3 dogs that were reevaluated twice. These studies confirmed esophageal stricture in 5 dogs. None of these dogs required esophageal balloon dilation procedures. The earliest and latest diagnoses of stricture were made 9 and 21 days after esophageal foreign body removal, respectively. Reevaluation contrast esophagram was performed on one dog with mild esophagitis and one dog with moderate-to-severe esophagitis. The latter was diagnosed with an esophageal diverticulum. The time to recovery was significantly shorter in dogs with mild esophagitis (Po0.001). Of the 60 dogs with esophageal foreign bodies, 3 died, 50 survived, and 7 were lost to follow-up before successful reinstitution of oral alimentation. Discussion The present retrospective study suggests that dogs with mild esophagitis have a shorter duration of signs; milder, more localized clinical signs; fewer complications; and a shorter time to recovery than dogs with moderate-to-severe esophagitis following esophageal foreign body removal. The duration of clinical signs before clinical presentation has been reported to correlate with degree of esophageal wall damage, 3 and this finding was confirmed in this study. Dogs with moderate-to-severe esophagitis had a significantly longer duration of clinical signs when compared with mildly affected dogs. As esophageal injury is associated with duration of foreign body-induced pressure, 5,6 early removal is key to improve outcome. Transmural esophageal necrosis can lead to leakage of ingesta, serum, bacteria, and toxins into the mediastinum and pleural space. Subsequent mediastinitis and pleuritis could result in severe systemic clinical signs. 7 The toy breeds and non-sporting breeds were the most commonly reported in this study. The toy group represented 52% of all esophageal foreign body cases, but was also the most prevalent group presenting to the hospital, comprising 28% of canine visits during the present study. The non-sporting group represented 20% of esophageal foreign body cases despite being fourth in hospital prevalence (11.7%), behind the sporting group and the terrier breeds (22% and 12.4%, respectively). The terrier group, particularly the West Highland White Terrier, has been reported to be overrepresented for acquiring esophageal foreign bodies. 10,13,14 Most of the dogs in the present study were young to middle age without gender predilection. Clinical signs referable to concurrent systemic disease such as lethargy, anorexia, and elevated rectal temperature, were more common in the moderate-tosevere esophagitis group dogs. Alternately, signs of localized discomfort (i.e., gagging, retching, coughing, and ptyalism) were more commonly observed in the mild esophagitis group dogs. This difference in presentation was also reflected in the clinicians diagnostic approach. Dogs that were eventually diagnosed with moderate-to-severe esophagitis had a CBC and biochemistry panel submitted more commonly possibly due to the patients status and/or behavior before and following esophageal foreign body removal. These findings are consistent with previous suppositions that the severity of clinical signs is correlated with the extent of the esophageal damage and the degree of obstruction. 7 Degree of obstruction was not evaluated in the present study. In dogs with esophageal foreign bodies, elevated numbers of immature neutrophils have been cited as an indication of esophageal perforation. 8 In the present study, immature neutrophils were more commonly reported in moderate-to-severe esophagitis group versus mild esophagitis group dogs. The 2 dogs with esophageal perforation also had a left shift, although the other 9 dogs with a left shift did not have evidence of perforation. Other inflammatory markers including leukocytosis, mature neutrophilia, and monocytosis were also more common with increasing esophageal damage. Therefore, a left shift more likely reflects the severity of esophagitis rather than esophageal perforation specifically. Flexible endoscopy is considered the mainstay of foreign body removal 5 mainly because it permits evaluation of the foreign object and esophageal integrity. In the present study, esophagoscopy was 95% (57/60) successful in removal or dislodgment of esophageal foreign bodies. All dogs that required surgery for removal were moderate-to-severe esophagitis group dogs. In canine patients, bone foreign bodies are the most common cause of esophageal obstruction ranging in incidence from 47% to 100% in reported series, 2,13 15 and this type of obstruction accounted for 80% of esophageal foreign bodies in this study. In order to objectively compare the esophageal damage, criteria from the Savary Miller classification were used to sort dogs into 2 distinct groups. In people, this classification is 162 & Veterinary Emergency and Critical Care Society 2007, doi: /j x

5 Esophagitis and esophageal foreign body in dogs utilized to assess esophageal damage secondary to gastric reflux, guide therapy, and evaluate prognosis. 12 Although with esophageal foreign bodies the esophageal trauma is mostly caused by the foreign body itself and the process of foreign body retrieval, the Savary Miller classification was useful in objectively categorizing the dogs. In the present study complications other than esophagitis were detected in 13 dogs (22%), and all but 2 of those dogs were in the moderate-to-severe esophagitis group. Early complications such as esophageal perforation, pleuritis, pneumothorax, mediastinitis, and esophagitis generally result from direct damage by the foreign object or the effort associated with its removal. Damage to the deeper layers of the esophageal wall may cause excessive fibroplastic proliferation resulting in delayed complications like stricture. 4 Untreated esophagitis can predispose to gastro-esophageal reflux and contribute to further damage of the esophageal wall. 7 In fact, esophagitis has been shown experimentally to diminish lower esophageal sphincter pressure in cats 16 and in dogs. 17 The present study documents differences in clinical signs and morbidities between dogs with mild esophagitis and those with more substantial injury. Animals with circumferential erosions of esophageal mucosa, ulcerations, and perforation (moderate-to-severe esophagitis group dogs) had longer duration of clinical signs before presentation, more early complications, and a longer recovery time than dogs with no visible esophageal damage, focal, or confluent erosions (mild esophagitis group dogs). Footnotes a b c GIF XQ140, Olympus America Inc., Center Valley, PA. PCF 100, Olympus. Ponsky pull PEG kit, 20F, Bard Access System Inc., Salt Lake City, UT. References 1. Pearson H. Symposium on conditions of the canine esophagus-1. Foreign bodies in the esophagus. J Small Anim Pract 1966; 7: Ryan WW, Greene RW. The conservative management of esophageal foreign bodies and their complications: a review of 66 cases in dogs and cats. J Am Anim Hosp Assoc 1975; 11: Guilford WG, Strombeck DR. Diseases of swallowing, In: Guilford WG, Center SA, Strombeck DR, Williams DA, Meyer DJ. eds. Strombeck s Small Animal Gastroenterology. Philadelphia: WB Saunders; 1996, pp Tams TR. Diseases of the esophagus, In: Tams TR. ed. Handbook of Small Animal Gastroenterology. Philadelphia: Saunders; 2003, pp Duncan M, Wong RKH. Esophageal emergencies: things that will wake you from a sound sleep. Gastroenterol Clin N Am 2003; 32: Jeen YT, Chun HJ, Song SH, et al. Endoscopic removal of sharp foreign bodies impacted in the esophagus. Endoscopy 2001; 33: Zimmer JF. Canine esophageal foreign bodies: endoscopic, surgical, and medical management. J Am Anim Hosp Assoc 1984; 20: Parker NR, Walter PA, Gay J. Diagnosis and surgical management of esophageal perforation. J Am Anim Hosp Assoc 1989; 25: King JM. Esophageal foreign body and aortic perforation in a dog. Vet Med 2001; 96: Spielman BL, Shaker EH, Garvey MS. Esophageal foreign body in dogs: a retrospective study of 23 cases. J Am Anim Hosp Assoc 1992; 28: Kyles AE. Esophagus, In: Slatter D. ed. Textbook of Small Animal Surgery. Philadelphia: Saunders; 2003, pp Ollyo JB, Fontolliet CH, Brossard E, et al. Savary s new endoscopic classification of reflux esophagitis. Acta Endoscop 1992; 22: Houlton JEF, Herrtage ME, Taylor PM, et al. Thoracic oesophageal foreign bodies in the dog: a review of ninety cases. J Small Anim Pract 1985; 26: Lüthi C, Neiger R. Esophageal foreign bodies in dogs: 51 cases ( ). Eur J Compar Gastroenterol 1998; 3(2): Moore AH. Removal of oesophageal foreign bodies in dogs: use of the fluoroscopic method and outcome. J Small Anim Pract 2001; 42: Eastwood GL, Castell DO, Higgs RH. Experimental esophagitis in cats impairs lower esophageal sphincter pressure. Gastroenterology 1975; 69: Henderson RD, Mugashe F, Jeejeebhoy KN, et al. The role of bile and acid in the production of esophagitis and the motor defect of esophagitis. Ann Thorac Surg 1972; 14: & Veterinary Emergency and Critical Care Society 2007, doi: /j x 163