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Gastroesophageal Intussusception with Megaesophagus in a Hedgehog (Atelerix Albiventris)
AEMV FORUM GASTROESOPHAGEAL INTUSSUSCEPTION WITH MEGAESOPHAGUS IN A HEDGEHOG (ATELERIX ALBIVENTRIS) So-Young Lee, DVM, PhD, and Hee-Myung Park, DVM, MS, PhD
Abstract A 220-g, 3-month-old intact male hedgehog (Atelerix albiventris) was evaluated for a 3-day history of increased respiratory effort, vocalization, and salivation. Survey and positive-contrast radiographs suggested gastroesophageal intussusception and hiatal hernia as possible differential diagnoses. On endoscopic evaluation, a dilated distal esophagus and everted stomach with fluid regurgitation were observed. The intraesophageal portion of the stomach was returned to the normal anatomic position by the introduced endoscopic tip. The hedgehog died after an episode of severe vomiting 2 days after initial presentation. On necropsy, gross findings included megaesophagus and everted gastric cardia into the distal esophagus; the lower esophageal sphincter was located in the normal anatomic position. Histopathologic examination of the esophagus revealed diffuse ulcers with submucosal hemorrhage and severe inflammation, suggestive of reflux esophagitis. To the authors’ knowledge, this is the first case of gastroesophageal intussusception with megaesophagus reported in a hedgehog. Copyright 2012 Elsevier Inc. All rights reserved. Key words: Atelerix albiventris; gastroesophageal intussusception; hedgehog; megaesophagus
A
220-g, 3-month-old intact male hedgehog (Atelerix albiventris) was evaluated for a 3-day history of increased respiratory effort, vocalization, and salivation. The day before the initial presentation, the patient had an episode of regurgitation immediately after eating and became depressed and laterally recumbent. Preceding the regurgitation episode, the hedgehog had shown no signs of clinical illness and had no previous health problems. The patient was housed indoors and fed a commercial hedgehog diet (Hedgehog Food, Vitakraft, Bremen, Germany). The physical examination revealed severe dyspnea with an audible, high-pitched inspiratory stridor. Thoracic auscultation revealed expiratory and inspiratory wheezing in both lung fields. The tongue was pale, cyanotic, and cold, but the mucous membranes were normal. After stabilization in an oxygen cage, thoracic radiographs were obtained. Survey and positive-contrast radiographs were obtained in the conscious hedgehog with supplemental oxygen by facemask. The survey radiographs on right lateral (Fig 1A) and ventrodorsal (VD) (Fig 1B) views revealed soft tissue opacity striations cranial to the
diaphragm. A gas-dilated esophagus was evident. The gas opacity was contiguous with the distal stomach, and the gas-dilated duodenum was identified. Radiographic signs of aspiration pneumonia were not present. Based on the history, clinical presentation, and survey radiographic images, gastroesophageal intussusception (GEI) and hiatal hernia were considered the top differential diagnoses. A positive-contrast esophagram was performed with a 40% barium sulfate suspension (5 mL/kg by mouth, Raydix sol; Dong-in-dang Pharmaceutical, Co, South Korea). Right lateral and VD views were obtained at 5, 10,
From the Department of Veterinary Internal Medicine, College of Veterinary Medicine, Konkuk University, Seoul, South Korea Address correspondence to: Hee-Myung Park, DVM, MS, PhD, Department of Veterinary Internal Medicine, College of Veterinary Medicine, Konkuk University, #1 Hwayang-dong, Kwangjin-gu, Seoul 143-701, South Korea. E-mail: [email protected]. © 2012 Elsevier Inc. All rights reserved. 1557-5063/12/2102-$30.00 doi:10.1053/j.jepm.2012.02.005
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Journal of Exotic Pet Medicine 21 (2012), pp 168 –171
FIGURE 1. (A) Right lateral radiographic view of the thorax. Soft tissue opacity striations are cranial to the diaphragm (arrows) and the gas-dilated esophagus is observed cranial to the opacity. A distinct diaphragmatic line is also evident. The gas opacity is contiguous with the distal stomach and duodenum. (B) Ventrodorsal radiographic view of the thorax. The soft tissue opacity is located on the left side (arrows) and the cardiac margins are not well delineated.
and 30 minutes after administration of the contrast material. At 5 minutes, the contrast agent had filled the dilated thoracic esophagus and part of the stomach. Some filling defects with muscular striations were visible at the level of the esophageal hiatus. The rugal folds of stomach were evident within the caudal esophagus on the VD view (Fig 2A and B). At 30 minutes, all of the barium contrast had passed into the small intestine. Based on the survey positive-contrast esophagram, GEI was strongly suspected. The following day, an esophagoscopy was performed. The hedgehog was premedicated with atropine (0.02 mg/kg, subcutaneously; Je-il Pharmaceutical, Co, South Korea) and induced and maintained
under anesthesia via a facemask with isoflurane in oxygen. A 5-mm-diameter flexible endoscope (EB-250S System; Fuji Photo Optical, Co, Ltd., Saitama, Japan) was used to perform the procedure. A dilated distal esophagus and everted stomach with fluid regurgitation were observed. The intraesophageal portion of the stomach was returned to the normal anatomic position by the introduced endoscopic tip, but the lower esophageal sphincter (LES) remained opened. The hedgehog recovered uneventfully from anesthesia. After the procedure, the hedgehog was administered metoclopramide (0.5 mg/kg, subcutaneously,
FIGURE 2. A positive-contrast esophagram 5 minutes after barium administration. (A) Right lateral radiographic view of the thorax. The proximal 1/2 of the thoracic esophagus is dilated with contrast material as well as the stomach. Some filling defects are visible between the dilated thoracic esophagus and stomach. (B) Ventrodorsal radiographic view of the thorax. The filling defects in the rugal folds (arrows) are noted.
Lee and Park/Journal of Exotic Pet Medicine 21 (2012), pp 168 –171
1 6 9
FIGURE 3. Gross necropsy findings in a hedgehog. (A) The gastroesophageal opening is dilated because of the everted gastric cardia. (B) The lower esophageal sphincter is located in a normal anatomic position after reduction.
every 8 hours; Je-il Pharmaceutical, Co) and ranitidine (2 mg/kg, subcutaneously, every 12 hours; Hanall Pharmaceutical, Co, South Korea). Moist food was offered in an elevated position. Despite these efforts, the hedgehog died after an episode of severe vomiting 2 days after the initial presentation. Necropsy was performed with the client’s consent. On necropsy, gross findings included megaesophagus and everted gastric cardia into the distal esophagus, with the LES located in the
normal anatomic position (Fig 3A and B). Histopathologic examination of the esophagus revealed diffuse ulceration with submucosal hemorrhage and severe inflammation, suggestive of reflux esophagitis (Fig 4). DISCUSSION GEI is listed as one of the anatomically abnormal hiatal diseases, and results from the prolapse of all or
FIGURE 4. Esophagus of the hedgehog. A focally extensive area of ulceration (between the arrows) with submucosal hemorrhage and severe inflammation that extends to the underlying esophageal muscle (M) and serosa (S) are observed. The serosa is markedly expanded with inflammation and edema (hematoxylin and eosin, ⫻200).
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Lee and Park/Journal of Exotic Pet Medicine 21 (2012), pp 168 –171
parts of the stomach into the thoracic esophagus. Unlike axial or sliding hiatal hernias, the gastroesophageal junction does not displace cranially into the thorax.1 This condition is associated with the incompetency of the gastroesophageal sphincter, preexisting esophageal disease, especially megaesophagus, abnormal esophageal motility, or severe regurgitation or vomiting.1,2 GEI is uncommon in dogs and rare in cats; most cases are diagnosed in large breed dogs less than 3 months of age.1,3,4 German shepherd dogs are predisposed to GEI because of a higher incidence of megaesophagus and esophageal abnormalities.1,2 In cats, only 3 cases of GEI have been reported.3-5 The cat cases of GEI were identified concurrently with the presence of megaesophagus. Before this case report, GEI had not been reported in exotic small mammals and only a few cases of idiopathic megaesophagus have been reported in ferrets.6,7 The exact etiopathogenesis of GEI has not been determined, and mechanisms are likely multifactorial. In veterinary patients, most cases are linked to excessive dilation and retrograde motility of the esophagus induced by vomiting or retching, and/or associated with congenital or idiopathic megaesophagus.3,8 Other potential causes of megaesophagus include severe esophagitis and neurologic disease such as myasthenia gravis, polyneuropathy, and dysautonomia, all of which may induce esophageal motility disorders.2 The hedgehog in this report had severe esophagitis, determined through histopathologic examination, but no specific signs implying neurological disease. Age and lack of preexisting gastrointestinal signs suggest the patient’s megaesophagus may have been congenital in origin. In veterinary patients, most cases are linked to excessive dilation and retrograde motility of the esophagus induced by vomiting or retching, and/or associated with congenital or idiopathic megaesophagus. Severe esophagitis may have acted as a trigger for GEI in this hedgehog. Other possible contributors to GEI formation in this case include improper function of the LES and a large or lax esophageal hiatus.2 On endoscopic evaluation, a widened LES after restoration and recurrence of intussusception with abdominal pressure was observed. Clinical signs of GEI are associated with partial or complete esophageal obstruction, and include vomiting, regurgitation, dyspnea, and hematoemesis.1,3,4 Affected animals can die because of respiratory and/or cardiovascular compromise even after treatment.1,9 Published studies in dogs and cats describe a GEI mortality rate of 95% because of failure to recognize the condition and rapid deterioration of the affected animal’s health.5,8 Other sources concur that treatment success increases with
mild disease and early diagnosis.9 Unfortunately, the hedgehog in this case was not diagnosed until it was debilitated and in poor physical condition. In general, GEI is diagnosed through clinical signs and diagnostic imaging. Survey radiographic findings common to GEI include the displacement of the gastroesophageal junction and gastric rugal folds, and gas distension of the esophagus due to partial or complete obstruction.1,2,4,5 However, radiographic findings and clinical signs of GEI are similar to those of hiatal hernia. Therefore, contrast radiography or endoscopy is essential to making a definitive diagnosis. This case report described the diagnostic approach for GEI and megaesophagus in a hedgehog using survey radiographic films, a positive-contrast esophagram, and endoscopy. In general, GEI is diagnosed through clinical signs and diagnostic imaging. This article represents the first documented case of GEI and megaesophagus in the hedgehog. ACKNOWLEDGMENTS The authors would like to thank Drs. Javier Nevarez (Louisiana State University, Baton Rouge, LA USA) and Dae-young Kim (University of Missouri, Columbia, MO USA) for their help in reviewing this manuscript. This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Korea government (MEST) (No. 20100018275) REFERENCES 1. Guilford WG, Strombeck DR: Disease of swallowing, in Guilford DA (ed): Strombeck’s Small Animal Gastroenterology (ed 3). Philadelphia, PA, W.B. Saunders, pp 211-238, 1996 2. Jergens AE: Diseases of the esophagus, in Ettinger SJ (ed): Textbook of Veterinary Internal Medicine, vol 2 (ed 6). Philadelphia, PA, W.B. Saunders, pp 1298-1309, 2006 3. Geffen C, Saunders JH, Vandevelde B, et al: Idiopathic megaesophagus and intermittent gastro-oesophageal intussusceptions in a cat. J Small Anim Prac 47:471-475, 2006 4. Martínez NI, Cook W, Troy GC, et al: Intermittent gastroesophageal intussusception in a cat with idiopathic megaesophagus. J Am Anim Hosp Assoc 37:234-237, 2001 5. Van Camp S, Love NE, Kumaresan S: Radiographic diagnosis— gastroesophageal intussusception in a cat. Vet Radiol Ultrasound 39:190-192, 1998 6. Blanco MC, Fox JG, Rosenthal K, et al: Megaesophagus in nine ferrets. J Am Vet Med Assoc 205:444-447, 1994 7. Lennox AM: Gastrointestinal diseases of the ferret. Vet Clin North Am Exot Anim Pract 8:213-226, 2005 8. Leib MS, Blass CE: Gastroesophageal intussusceptions in the dog: a review of the literature and a case report. J Am Vet Med Assoc 20:783-790, 1984 9. Rasmussen L: Stomach, in Slatter D (ed): Textbook of Small Animal Surgery (3 ed). Philadelphia, PA, Elsevier/W.B. Saunders, pp 592-643, 2003
Lee and Park/Journal of Exotic Pet Medicine 21 (2012), p 168 –171
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Abstract A 220-g, 3-month-old intact male hedgehog (Atelerix albiventris) was evaluated for a 3-day history of increased respiratory effort, vocalization, and salivation. Survey and positive-contrast radiographs suggested gastroesophageal intussusception and hiatal hernia as possible differential diagnoses. On endoscopic evaluation, a dilated distal esophagus and everted stomach with fluid regurgitation were observed. The intraesophageal portion of the stomach was returned to the normal anatomic position by the introduced endoscopic tip. The hedgehog died after an episode of severe vomiting 2 days after initial presentation. On necropsy, gross findings included megaesophagus and everted gastric cardia into the distal esophagus; the lower esophageal sphincter was located in the normal anatomic position. Histopathologic examination of the esophagus revealed diffuse ulcers with submucosal hemorrhage and severe inflammation, suggestive of reflux esophagitis. To the authors’ knowledge, this is the first case of gastroesophageal intussusception with megaesophagus reported in a hedgehog. Copyright 2012 Elsevier Inc. All rights reserved. Key words: Atelerix albiventris; gastroesophageal intussusception; hedgehog; megaesophagus
A
220-g, 3-month-old intact male hedgehog (Atelerix albiventris) was evaluated for a 3-day history of increased respiratory effort, vocalization, and salivation. The day before the initial presentation, the patient had an episode of regurgitation immediately after eating and became depressed and laterally recumbent. Preceding the regurgitation episode, the hedgehog had shown no signs of clinical illness and had no previous health problems. The patient was housed indoors and fed a commercial hedgehog diet (Hedgehog Food, Vitakraft, Bremen, Germany). The physical examination revealed severe dyspnea with an audible, high-pitched inspiratory stridor. Thoracic auscultation revealed expiratory and inspiratory wheezing in both lung fields. The tongue was pale, cyanotic, and cold, but the mucous membranes were normal. After stabilization in an oxygen cage, thoracic radiographs were obtained. Survey and positive-contrast radiographs were obtained in the conscious hedgehog with supplemental oxygen by facemask. The survey radiographs on right lateral (Fig 1A) and ventrodorsal (VD) (Fig 1B) views revealed soft tissue opacity striations cranial to the
diaphragm. A gas-dilated esophagus was evident. The gas opacity was contiguous with the distal stomach, and the gas-dilated duodenum was identified. Radiographic signs of aspiration pneumonia were not present. Based on the history, clinical presentation, and survey radiographic images, gastroesophageal intussusception (GEI) and hiatal hernia were considered the top differential diagnoses. A positive-contrast esophagram was performed with a 40% barium sulfate suspension (5 mL/kg by mouth, Raydix sol; Dong-in-dang Pharmaceutical, Co, South Korea). Right lateral and VD views were obtained at 5, 10,
From the Department of Veterinary Internal Medicine, College of Veterinary Medicine, Konkuk University, Seoul, South Korea Address correspondence to: Hee-Myung Park, DVM, MS, PhD, Department of Veterinary Internal Medicine, College of Veterinary Medicine, Konkuk University, #1 Hwayang-dong, Kwangjin-gu, Seoul 143-701, South Korea. E-mail: [email protected]. © 2012 Elsevier Inc. All rights reserved. 1557-5063/12/2102-$30.00 doi:10.1053/j.jepm.2012.02.005
1 6 8
Journal of Exotic Pet Medicine 21 (2012), pp 168 –171
FIGURE 1. (A) Right lateral radiographic view of the thorax. Soft tissue opacity striations are cranial to the diaphragm (arrows) and the gas-dilated esophagus is observed cranial to the opacity. A distinct diaphragmatic line is also evident. The gas opacity is contiguous with the distal stomach and duodenum. (B) Ventrodorsal radiographic view of the thorax. The soft tissue opacity is located on the left side (arrows) and the cardiac margins are not well delineated.
and 30 minutes after administration of the contrast material. At 5 minutes, the contrast agent had filled the dilated thoracic esophagus and part of the stomach. Some filling defects with muscular striations were visible at the level of the esophageal hiatus. The rugal folds of stomach were evident within the caudal esophagus on the VD view (Fig 2A and B). At 30 minutes, all of the barium contrast had passed into the small intestine. Based on the survey positive-contrast esophagram, GEI was strongly suspected. The following day, an esophagoscopy was performed. The hedgehog was premedicated with atropine (0.02 mg/kg, subcutaneously; Je-il Pharmaceutical, Co, South Korea) and induced and maintained
under anesthesia via a facemask with isoflurane in oxygen. A 5-mm-diameter flexible endoscope (EB-250S System; Fuji Photo Optical, Co, Ltd., Saitama, Japan) was used to perform the procedure. A dilated distal esophagus and everted stomach with fluid regurgitation were observed. The intraesophageal portion of the stomach was returned to the normal anatomic position by the introduced endoscopic tip, but the lower esophageal sphincter (LES) remained opened. The hedgehog recovered uneventfully from anesthesia. After the procedure, the hedgehog was administered metoclopramide (0.5 mg/kg, subcutaneously,
FIGURE 2. A positive-contrast esophagram 5 minutes after barium administration. (A) Right lateral radiographic view of the thorax. The proximal 1/2 of the thoracic esophagus is dilated with contrast material as well as the stomach. Some filling defects are visible between the dilated thoracic esophagus and stomach. (B) Ventrodorsal radiographic view of the thorax. The filling defects in the rugal folds (arrows) are noted.
Lee and Park/Journal of Exotic Pet Medicine 21 (2012), pp 168 –171
1 6 9
FIGURE 3. Gross necropsy findings in a hedgehog. (A) The gastroesophageal opening is dilated because of the everted gastric cardia. (B) The lower esophageal sphincter is located in a normal anatomic position after reduction.
every 8 hours; Je-il Pharmaceutical, Co) and ranitidine (2 mg/kg, subcutaneously, every 12 hours; Hanall Pharmaceutical, Co, South Korea). Moist food was offered in an elevated position. Despite these efforts, the hedgehog died after an episode of severe vomiting 2 days after the initial presentation. Necropsy was performed with the client’s consent. On necropsy, gross findings included megaesophagus and everted gastric cardia into the distal esophagus, with the LES located in the
normal anatomic position (Fig 3A and B). Histopathologic examination of the esophagus revealed diffuse ulceration with submucosal hemorrhage and severe inflammation, suggestive of reflux esophagitis (Fig 4). DISCUSSION GEI is listed as one of the anatomically abnormal hiatal diseases, and results from the prolapse of all or
FIGURE 4. Esophagus of the hedgehog. A focally extensive area of ulceration (between the arrows) with submucosal hemorrhage and severe inflammation that extends to the underlying esophageal muscle (M) and serosa (S) are observed. The serosa is markedly expanded with inflammation and edema (hematoxylin and eosin, ⫻200).
1 7 0
Lee and Park/Journal of Exotic Pet Medicine 21 (2012), pp 168 –171
parts of the stomach into the thoracic esophagus. Unlike axial or sliding hiatal hernias, the gastroesophageal junction does not displace cranially into the thorax.1 This condition is associated with the incompetency of the gastroesophageal sphincter, preexisting esophageal disease, especially megaesophagus, abnormal esophageal motility, or severe regurgitation or vomiting.1,2 GEI is uncommon in dogs and rare in cats; most cases are diagnosed in large breed dogs less than 3 months of age.1,3,4 German shepherd dogs are predisposed to GEI because of a higher incidence of megaesophagus and esophageal abnormalities.1,2 In cats, only 3 cases of GEI have been reported.3-5 The cat cases of GEI were identified concurrently with the presence of megaesophagus. Before this case report, GEI had not been reported in exotic small mammals and only a few cases of idiopathic megaesophagus have been reported in ferrets.6,7 The exact etiopathogenesis of GEI has not been determined, and mechanisms are likely multifactorial. In veterinary patients, most cases are linked to excessive dilation and retrograde motility of the esophagus induced by vomiting or retching, and/or associated with congenital or idiopathic megaesophagus.3,8 Other potential causes of megaesophagus include severe esophagitis and neurologic disease such as myasthenia gravis, polyneuropathy, and dysautonomia, all of which may induce esophageal motility disorders.2 The hedgehog in this report had severe esophagitis, determined through histopathologic examination, but no specific signs implying neurological disease. Age and lack of preexisting gastrointestinal signs suggest the patient’s megaesophagus may have been congenital in origin. In veterinary patients, most cases are linked to excessive dilation and retrograde motility of the esophagus induced by vomiting or retching, and/or associated with congenital or idiopathic megaesophagus. Severe esophagitis may have acted as a trigger for GEI in this hedgehog. Other possible contributors to GEI formation in this case include improper function of the LES and a large or lax esophageal hiatus.2 On endoscopic evaluation, a widened LES after restoration and recurrence of intussusception with abdominal pressure was observed. Clinical signs of GEI are associated with partial or complete esophageal obstruction, and include vomiting, regurgitation, dyspnea, and hematoemesis.1,3,4 Affected animals can die because of respiratory and/or cardiovascular compromise even after treatment.1,9 Published studies in dogs and cats describe a GEI mortality rate of 95% because of failure to recognize the condition and rapid deterioration of the affected animal’s health.5,8 Other sources concur that treatment success increases with
mild disease and early diagnosis.9 Unfortunately, the hedgehog in this case was not diagnosed until it was debilitated and in poor physical condition. In general, GEI is diagnosed through clinical signs and diagnostic imaging. Survey radiographic findings common to GEI include the displacement of the gastroesophageal junction and gastric rugal folds, and gas distension of the esophagus due to partial or complete obstruction.1,2,4,5 However, radiographic findings and clinical signs of GEI are similar to those of hiatal hernia. Therefore, contrast radiography or endoscopy is essential to making a definitive diagnosis. This case report described the diagnostic approach for GEI and megaesophagus in a hedgehog using survey radiographic films, a positive-contrast esophagram, and endoscopy. In general, GEI is diagnosed through clinical signs and diagnostic imaging. This article represents the first documented case of GEI and megaesophagus in the hedgehog. ACKNOWLEDGMENTS The authors would like to thank Drs. Javier Nevarez (Louisiana State University, Baton Rouge, LA USA) and Dae-young Kim (University of Missouri, Columbia, MO USA) for their help in reviewing this manuscript. This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Korea government (MEST) (No. 20100018275) REFERENCES 1. Guilford WG, Strombeck DR: Disease of swallowing, in Guilford DA (ed): Strombeck’s Small Animal Gastroenterology (ed 3). Philadelphia, PA, W.B. Saunders, pp 211-238, 1996 2. Jergens AE: Diseases of the esophagus, in Ettinger SJ (ed): Textbook of Veterinary Internal Medicine, vol 2 (ed 6). Philadelphia, PA, W.B. Saunders, pp 1298-1309, 2006 3. Geffen C, Saunders JH, Vandevelde B, et al: Idiopathic megaesophagus and intermittent gastro-oesophageal intussusceptions in a cat. J Small Anim Prac 47:471-475, 2006 4. Martínez NI, Cook W, Troy GC, et al: Intermittent gastroesophageal intussusception in a cat with idiopathic megaesophagus. J Am Anim Hosp Assoc 37:234-237, 2001 5. Van Camp S, Love NE, Kumaresan S: Radiographic diagnosis— gastroesophageal intussusception in a cat. Vet Radiol Ultrasound 39:190-192, 1998 6. Blanco MC, Fox JG, Rosenthal K, et al: Megaesophagus in nine ferrets. J Am Vet Med Assoc 205:444-447, 1994 7. Lennox AM: Gastrointestinal diseases of the ferret. Vet Clin North Am Exot Anim Pract 8:213-226, 2005 8. Leib MS, Blass CE: Gastroesophageal intussusceptions in the dog: a review of the literature and a case report. J Am Vet Med Assoc 20:783-790, 1984 9. Rasmussen L: Stomach, in Slatter D (ed): Textbook of Small Animal Surgery (3 ed). Philadelphia, PA, Elsevier/W.B. Saunders, pp 592-643, 2003
Lee and Park/Journal of Exotic Pet Medicine 21 (2012), p 168 –171
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