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Figure 1—Lateral (A) and ventrodorsal (B) radiographic views of the thorax of an 8-week-old 2.68-kg (5.9-lb) sexually intact female German Shepherd Dog with a history of acute regurgitation, vomiting, and anorexia.

History An 8-week-old 2.68-kg (5.9-lb) sexually intact female German Shepherd Dog was referred for evaluation because of multiple episodes of acute vomiting and regurgitation and anorexia. Before referral, the patient received a diagnosis of pneumonia; antimicrobials and a highly palatable, high-calorie diet were prescribed. On physical examination, the patient was bright, alert, and responsive with a body condition score of 1.5/5. The dog was tachypneic with a respiratory rate of 50 breaths/min. All other vital signs were within reference limits. A CBC revealed leukocytosis (36,390 leukocytes/µL; reference range, 6,000 to 17,000 leukocytes/µL), characterized by marked absolute neutrophilia (31,100 neutrophils/µL; reference range, 3,000 to 12,000 neutrophils/µL). Serum biochemical analysis revealed moderate hyponatremia (134 mmol/L; reference range, 142 to 150 mmol/L); mild hypokalemia (3.2 mmol/L; reference range, 3.4 to 4.9 mmol/L); moderate hypochloremia (96 mmol/L; reference range, 106 to 127 mmol/L); and mild hemoglobinemia (11.6 g/dL; reference range, 12 to 17 g/dL). On blood-gas analysis, moderate respiratory acidosis was evident on the basis of a high Pco2 (53.8 mm Hg; reference range, 35 to 40 mm Hg) value and a low pH (7.29; reference range, 7.35 to 7.45) value. Three-view thoracic radiography was performed (Figure 1). Determine whether additional imaging studies are required, or make your diagnosis from Figure 1—then turn the page → This report was submitted by Kiran Vasudeva, DVM, PhD; Samantha Norris, DVM; Aaron Wehrenberg, DVM; and William R. Widmer, DVM; from the VCA Advanced Veterinary Care Center, 7712 Crosspoint Commons, Fishers, IN 46038. Dr. Vasudeva’s present address is Department of Clinical Sciences, College of Veterinary Medicine, Tuskegee University, Tuskegee, AL 36088. Address correspondence to Dr. Vasudeva ([email protected]).

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Figure 2—Same radiographic images as in Figure 1. Notice the soft tissue opacity consistent with the stomach and spleen (white arrows) within the caudal portion of the gas-distended esophagus (white arrowheads) on both views. On the lateral view, notice the narrowing of the carina (black arrow), reduced lung volume with atelectasis or aspiration pneumonia or both (asterisks), a ventrally deviated trachea (large black arrowhead), and the dorsal wall of the distended esophagus (small black arrowheads). On the ventrodorsal view, the esophagus occupies most of the right hemithorax (white arrowheads). The soft tissue opacity suspected of being stomach and spleen (white arrows) is summated on the diaphragm and liver. Notice the lack of a gastric shadow in the abdominal cavity in both views.

Radiographic Findings and Interpretation On the lateral view, the intrathoracic esophagus is markedly distended with gas and fluid (Figure 2). An approximately 5-cm-diameter soft tissue opacity is seen within the caudal part of the esophagus adjacent to the diaphragm. The entire trachea is displaced ventrally, and the carina is narrowed from apparent compression by the esophagus. The cranial lung lobes are displaced ventrally, resulting in reduced lung volume with atelectasis or aspiration pneumonia or both. The cardiac silhouette is small and displaced ventrally. No lesions are seen involving the pleural space or pulmonary vasculature. On the ventrodorsal view, the esophagus is summated on the right hemithorax. The margins of the distended esophagus are less apparent than on the lateral view, but the thin-walled gas-distended stomach is evident. The soft tissue opacity is superimposed on the liver and diaphragm. On both views, a gastric shadow is not appreciated within the abdominal cavity. Serosal contrast is poor to absent within the abdominal cavity, which is a typical radiographic finding in young puppies. Collectively, radiographic findings are consistent with gastroesophageal intussusception.

Treatment and Outcome An exploratory laparotomy was performed. The partially invaginated stomach and the spleen were 894

found to be within the esophagus and with gentle retraction were removed from the esophageal hiatus and returned to the abdominal cavity. The esophageal hiatus appeared to be of normal size after retraction of the esophageal contents. A gastropexy was performed in the pyloric antrum. During surgery, a decreased tone of the gastric musculature was noted that could have been the result of gastroesophageal intussusception or a concurrent underlying neuromuscular disorder. Also, the stomach was partially gas filled, as observed on radiographic evaluation. No other abnormalities were found during surgery. Postoperative radiography revealed megaesophagus, a complication usually associated with gastroesophageal intussusception. Supportive care after surgery included the administration of antimicrobial, antacid, prokinetic, antiemetic, and analgesic drugs. The electrolyte imbalance was corrected with appropriate IV fluid therapy. The owner was advised to feed the patient a gruel diet, in an upright posture, such that the patient was standing on its pelvic limbs with the thorax elevated, causing the cervical and thoracic esophagus to be in a near vertical position. This position helps to reduce regurgitation and allows gravity-assisted passage of the food into the stomach.1 The owner was advised to hold this position of the patient for approximately 5 to 10 minutes after feeding to prevent esophageal regurgitation. The patient was able to ingest multiple small meals of a high-energy diet, in this manner, for a few days. One week after surgery, the patient declined in health because of persistent megaesophagus and was euthanized.

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Comments Gastroesophageal intussusception is the introversion of the gastric cardia into the caudal portion of the esophagus without displacement of the gastroesophageal junction.2 Additionally, gastroesophageal intussusception could be present with the involvement of other abdominal viscera such as spleen, duodenum, pancreas, and omentum.3 Gastroesophageal intussusception is most common in young animals and large breeds of dogs such as German Shepherd Dogs and Australian Shepherds.2,4,5 The most common clinical signs associated with gastroesophageal intussusception are acute onset of vomiting, regurgitation, increased respiratory effort, and abdominal discomfort. Gastroesophageal intussusception is a life-threatening situation, and immediate intervention is necessary. The etiology of gastroesophageal intussusception is not completely known but may include a neuromuscular motility disorder of the esophagus or incompetent gastroesophageal sphincter. The mortality rate with complicated cases or undiagnosed acute gastroesophageal intussusception is approximately 95%.2 Thoracic radiography is an important tool for diagnosing gastroesophageal intussusception and hence may improve the probability of survival with quick therapeutic intervention. Most common radiographic findings include the presence of a soft tissue opacity in the caudal portion of a distended esophagus (with or without gas), presence of pneumonia or pleural effusion, and a displaced gastric axis. Occasionally, gastric rugal folds may be visible on contrast studies along with presence of abdominal viscera such as the spleen. Computed tomography, contrast

radiography, or endoscopy may aid in the diagnosis of gastroesophageal intussusception; however, they may not always be needed or feasible to perform, especially in dyspneic patients. Megaesophagus may remain a common complication associated with gastroesophageal intussusception,6 leading to long-term management of megaesophagus in such patients. The prognosis with megaesophagus is generally poor, and the most common cause of death in such patients is aspiration pneumonia.1 In the case described in the present report, thoracic radiography was useful to identify gastroesophageal intussusception and helped us proceed to surgical exploration. With the aid of radiographic diagnostics, therapeutic surgery for gastroesophageal intussusception was performed.

References 1.

Jergens AE. Diseases of the esophagus. In: Ettinger SJ, Feldman EC, eds. Textbook of veterinary internal medicine. 7th ed. St Louis: Saunders, Elsevier, 2010;1493–1495. 2. von Werthern CJ, Montavon PM, Flückiger MA. Gastrooesophageal intussusception in a young German Shepherd Dog. J Small Anim Pract 1996;37:491–494. 3. Radlinsky MAG. Surgery of the digestive system. In: Fossum TW, ed. Small animal surgery. 4th ed. St Louis: Elsevier, Mosby, 2013;448–453. 4. Mathis KR, Nykamp SG, Ringwood BP, et al. What is your diagnosis? J Am Vet Med Assoc 2013;242:465–467. 5. Shibly S, Karl S, Hittmair KM, et al. Acute gastroesophageal intussusception in a juvenile Australian Shepherd dog: endoscopic treatment and long-term follow-up. BMC Vet Res 2014;10:109. 6. Murphy LA, Nakamura RK, Miller JM. Surgical correction of gastro-oesophageal intussusception with bilateral incisional gastropexy in three dogs. J Small Anim Pract 2015;56:630–632.

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What Is Your Diagnosis?

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