Thursday, February 3, 2011

324. Megaoesophagus case study report -

Chinese New Year. Feb 4, 2011.

The owner of the 8-year-old, spayed, female skin-and-bone dog phoned me to invite me to dinner of the 2nd day of Chinese New Year, tomorrow Feb 5, 2011.

"How's the poodle?" I asked. Yesterday, the wife was quite pleased that the dog did not vomit for the past 24 hours when I phoned for a feedback. I had hospitalised the emaciated dog that had refused to eat the reduced home-cooked food offered from Jan 28, 2011 to Jan 31, 2011.

"The poodle is OK," he asked his wife about the vomiting episodes while keeping me on hold. "She is playing with the Silkie in the balcony." This is where plants and grass are present, being a ground floor apartment.

"I had instructed your wife that the poodle should be separated from the Silkie (who bullies her) and not be near the plants (the poodle has a depraved appetite and would eat grass and soil, impacting the stomach and intestines).

"Don't worry," he said. "I am watching them."

"You monitor them every second?" I was incredulous. "You don't read your newspapers and do other things? All the poodle needed was access to the plants, branches and grass and take some mouthfuls and get constipation."

It was fortuitous that he had phoned me to let me know the time of dinner for tomorrow. I had expected his wife and him to be more careful and comply with the vet instructions.

The dog was emaciated and was going to die (of malnutrition) before Chinese New Year as she had lost appetite and was the thinnest dog in Singapore I had ever seen. I refer to dogs that had been well loved and cared for.

That was why the owners decided to consult me. The husband believed in giving the dog asparagus and multi-vitamins for the past 3 years but had not sought a second veterinary opinion since the first vet diagnosed stomach tumour some 3 years ago and had declared to me: "The vet predicted that this dog would not live more than 3 months and see..see...now, it is 3 years and she is still alive!" He was quite proud as he does his treatment with asparagus and multivitamins being his main methods much to the disappointment of his wife.

This foreseeing of the future continues to haunt vets who forecasted death as it is 3 years now and the emaciated poodle is still alive. "She will die before Chinese New Year," I said when I saw the dog with her pale gums on Jan 28, 2011 (6 days before CNY). Apparently his asparagus and multi-vitamin therapy and home-cooked food in small amounts must have failed after so many years.

"Unless your dog responds to the IV protein and dextrose multivitamin drips and treatment, she will not survive past the Chinese New Year." I showed the owners the pale gums. Other than pus in the eyes (a sign of poor health), the dog was looking normal if you consider a skin-and-bone dog that can stand up and walk a bit as being normal. She was still alive due to the perseverance of the wife feeding her small amounts of cereal and home-cooked food a few times a day. It was not a nice thing to say. There are other kinder ways of giving bad news, by beating around the bush. Unfortunately, owners do mis-construe and from experience, I have become frank and brutally honest about the prognosis.

As for the husband, he was introduced to me as he was in the veterinary field and so he did not object much. However he said: "Your student is not well trained by you," referring to the first vet who diagnosed stomach tumour. I had told him that this vet had interned with me some 20 years ago before she went to study "pre-vet course" in Malaysia and got admitted to am Australian Vet School. I am quite inspired by her perseverance as she did not complete her A levels and studies night classes for the A levels. Most vets get their A levels normally and go to study vet course. As a result of this remark by the husband, I should keep quiet about knowledge of my past interns in future!

Dr Vanessa got the owners to sign a hospitalisation consent form as we work as a team on this case and she was a hands-on vet. "She would be given anti-vomiting medication to prevent vomiting," she said in response to the complaint that the dog had been vomiting.

" Well, it is not as simple as that," I discussed the history of the case with her as this was the first time she saw this dog. I had visited the home of this dog and knew a bit about her life-style.

"I don't think anti-vomiting medication will work in the long term," I discussed with Dr Vanessa the history of this case. "This poodle had been 'vomiting' 1-2 hours after food per day for the past 3 years after a vet had diagnosed stomach tumour and advised against feeding dry dog food 3 years ago. She was not seen by another vet or reviewed again."

We hospitalised the dog, took blood samples, X-rays, gave the IV drips, antibiotics and Vit K1. My assistant gave her an enema and several hard stool lumps I had palpated in the abdomen passed out. No abdominal pain at all in this dog during palpation. The kidneys, liver and spleen could not be palpated. Some gas in the intestines. That was all in a shrunken abdomen with no fat.
Hospitalisation was important to observe the timing of the dog vomiting. Was vomiting just after eating and drinking or later? In this case, it does happen after and later!

However the dog did not vomit when given canned food in small amounts. The dog did vomit some hours after eating dry food I instructed to be given. She had an excellent appetite and would drink water as much as given. I deduced that the dog regurgitated rather than vomited due to retention of food in the distal oesophagus. There is a condition called megaoesophagus in dogs.

The dog is likely to suffer from megaesophagus. Earlier, I palpated her painful throat. She objected strongly, tilted her head and suddenly, around 50 ml of liquid just "spilled out of her throat." This was one sign of megaoesophagus.

My assistant Mr Saw quickly took a piece of towel to wipe off the liquid.
So this was not a vomiting case but a regurgitation case.

Other than megaoesphagus, this dog could be suffering from myasthenia gravis. The first symptom of this immune mediated disease in the older dog is due to megaoesphagus. Myasthenia occurs when nicotinic acetylcholine receptors malfunction. This leads to the muscles not contracting. The scenario would be as follows: the distal end of the oesophagus - oesophageal sphincter - not contracting and thereby accumulating food and water without being pushed them into the stomach, intestines not pushing stools out causing- constipation.

The owner's wife complained that the dog had been having constipation and passes rock-hard stools for a long time. This constipation would be due to this neuromuscular disease which is said to be an immune-mediated disease.

Yet if vets see the superficial view, this emaciated poodle was vomiting, not regurgitating based on the owner's complaint of vomiting. So, it was possible that the first vet diagnosed stomach tumour/dog food allergy, as claimed by the owner. Sometimes, the owner might have misconstrued the veterinarian's diagnosis as this was some 3 years ago.

Persistent vomiting in a dog needs reviews but the owners did not do so. Nor did they get a second opinion. It is usually a matter of economics.

"The dog could be suffering from megaoesophagus," I said to Dr Vanessa and my assistant Mr Saw who is a Myanmar vet graduate. I asked Mr Saw: "Have you heard of megaoesophagus?" Mr Saw shook his head. "This is an uncommon disease. This poodle could have acquired megaoesophagus at the age of 5 years. Now she is 8 years old."

Small animal veterinary medical cases are usually routine as in many professions. There are the usual common cases of skin problems and vomiting due to gastroenteritis. And we could get fooled by a rare case of regurgitation.

In megaoesophagus, the dog "vomits 1-2 hours" after eating. This is not vomiting but regurgitation. To the owner, it is vomiting and in many cases of foreign bodies or tumours in the distal oesophagus or stomach, it would be vomiting soon after eating.

Such cases needed more time in history taking and a house visit. The dog also ate sticks, grass and plants. So, it was possible that it had a piece of stick or branch had damaged proximal oesophagus such that it became dilated and trapped the small amounts of home-cooked food and water that the owner gave in the past 3 years (leading to emaciation). This condition could be existing at the same time as the acquired megaoesphagus.

I had 4 X-rays taken of the neck and the abdomen. "It should not be just one lateral view," I said to Dr Vanessa as we normally do that to lower veterinary costs for the owners. Was there a stomach tumour? It was possible. I had not thought of taking a chest X-ray to check aspiration pneumonia as the dog had no breathing difficulty and I had not diagnosed megaoesophagus definitely at the time of admission. I had a feeling that it could be megaoesophagus but the husband's complaint of expensive vets (vets making a lot of money, he always said to me) kept restraining me from doing the chest X-rays for this first consultation. It ought to have been done in retrospective review. I had told the owner the costs would be more than $500 and there was no guarantee that there was a cure. Yet, without the tests, the husband would save money and assumed it was stomach tumour. The dog would pass away soon and he would save money. Money was a hard fact of life and sometimes, the unwillingness of the owner to spend money affected the dog's diagnosis and treatment.

Back to the patient, I reviewed the X-rays. The poodle's abdomen was impacted with hard stools due to the lack of contraction of the muscle involving peristalsis (oesophageal sphincter and large intestines). The normal stools passed out after an enema and 3 days of hospitalisation and being fed canned food.

This "constipation" seem to support a diagnosis of megaoesphagus with myasthenia gravis. There could be an oesophageal carcinoma as a consequence of megaoesphagus.

An X-ray of the distal oesophagus with barium meal was not done. Or X-rays of the chest. The husband was frugal and so I had to be understanding. Not that he could not afford the veterinary fees but he had been cursing my mentor (another vet) regarding veterinary fees and had preferred self-treatment of his sick dogs. Times are hard and I can understand the need to be thrifty.

This case is tentatively diagnosed as megaoesophagus or megaesopohagus (in U.S spelling). The last two days had been "vomit-free" days and the wife was much relieved and happy. The dog would put on weight and if not much damage had been done to the heart or kidneys, this dog should live longer. Blood tests showed low red cells and haemoglobin. There was an unusually low level of serum urea and creatinine. This case needed further investigation for oesophageal tumours.

X-ray also revealed a dilated proximal oesphageal region. It was possible that there was a foreign body (stick or tree branch) stuck on the dorsal part of the proximal oesophagus, causing pain over the years and granulomatous tissues. Over the past 3 years of inflammation, the partially obstructed proximal oesophagus dilates to form a sac as seen by an opaque area in the cranial area of the oesopohagus distal to the epiglottis. Can you see it?

The dog is skin and bones now. If she is suffering from myasthenia gravis, anti-cholinesterase drugs will reverse the overall muscle weakness and there will be no "vomiting" and "constipation".






Veterinary medicine throws out a challenging case now and then. Red herrings like "vomiting" when they are actually "regurgitation." It is enough to make any vet go crazy. For the last 2 days, there was no regurgitation and the dog had regained pinkness in the gums and should put on weight. The wife would weigh herself and the dog and keep records of feeding. Usually it is the wife who is the care-giver and if she does comply with veterinary instructions (restricted prescription dog food canned mainly with a 3 pieces of pelleted food in small amounts and 30 ml of water each time, 6x/day every 2-hourly for the first week and reviews again) , this poodle would regain her weight and health first.

Further investigations would be needed and sometimes the owner has to be proactive and to want to spend the money on veterinary services.

I also forecasted death before the Chinese New Year since this was a dog with skin and bones. She survived past the Chinese New Year (2nd day of New Year as I write this article) but I had given her the necessary IV drips to live.

The prognosis is guarded. I don't think this poodle would live past 2 years. I dare not make a prediction as I may be proven wrong as what the first vet did. It is possible that there is a stick or branch stuck in the distal oesophagus. The dog can pass bowels normally in the last 2 days much to the delight of the wife. So, is it a case of myasthenia gravis or not? Another review if needed. The mystery has not been resolved yet.

Interesting case report written by a lady intern waiting for her 'A'-level results and before admission to vet course overseas.

Jan 31, 2011
Toy poodle “.....” with vomiting problem
Diagnosis
Dog has been vomiting regularly for 3 years
Blood test—normal, with slight anaemia; kidney tests show poor health
x-ray of stomach and neck taken
1st vet suspected problem with stomach but is likely to be in the throat—foreign body/tumour; dog has habit of eating grass and stones; 1st vet diagnosed an allergy to dog food hence home cooked food has been given to it since
2nd vet notes that dog vomits about ½ hour after eating and has advised the feeding of 1/3 portion home cooked food. Dog has become emaciated, is now unable to take anesthetic for surgery.
Treatment
Fed 5pcs of D/D and ¼ can K/D hourly; dog needs to gain weight and regain health before a surgery can be done. Antibiotics and multivitamins also given.
CONCLUSION
Megaoesophagus in the dog is a condition where there is a decreased or absent contraction of the muscles of the oesophagus. It can be congenital or acquired. Its cause may be idiopathic or it may be due to tumour (oesophageal carcinoma), vascular ring (heart blood vessels congenital) or obstruction (foreign body e.g. stick or bone inside distal oesophagus, endoscope or X-rays), neuromuscular dysfunction (myasthenia gravis).


Pic and updated webpage will be at:

http://www.toapayohvets.com/web1/20110204megaoesophagus-regurgitation-dog-toapayohvets-singapore.htm


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