Chase-Lindsay-ppt2014

Report
Gastric and Esophageal
Diverticulum Rupture in a Friesian
Gelding
LINDSAY CHASE
M A Y 7 TH 2 0 1 4
CLINICAL ADVISOR: DR. KATHLEEN MULLEN
BASIC SCIENCE ADVISOR: DR. ELIZABETH BUCKLES
http://tinyurl.com/k4balp7
Signalment and History
 17 year old Friesian Gelding
 1 day history of inappetence and lethargy
 Approximately 8 hour history of colic and dyspnea
 rDVM Findings
 Tachycardic (80 bpm)
 Dyspneic
 Febrile (102.60F)
 Muddy mucous membranes – CRT 3 seconds
 Absent GI motility
 Normal rectal palpation
rDVM Therapy
 Flunixin meglumine, detomidine, ceftiofur
crystalline free acid
 Nasogastric tube
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No gastric reflux
Instilled water and mineral oil
Horse became uncomfortable during administration
 Referred to Cornell for suspected colitis
Physical Exam
 Vital Signs:
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T:101.7oF (99-101.5oF)
P: 86 bpm (28-44 bpm)
R: 52 bpm (8-16 bpm)
 Depressed
 BCS 7/9
 Small amount of malodorous nasal discharge
 Cardiovascular


Injected mucous membranes with a toxic line
CRT 3 seconds
 Gastrointestinal

Absent gut sounds in all quadrants
Diagnostics
 Blood work


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PCV: 62% (34-46)
TP: 6.3 g/dL (6.2-7.8)
Hypochloremic metabolic alkalosis
Cl 92 (100-110 mEq/L)
 pH 7.523 (7.32-7.44)
 BE 8
 HCO3 31 (25-30 mmol/L)

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Ionized Hypocalcemia
Hyperlactatemia
Elevated Creatinine
Elevated Troponin
Neutropenia
Lymphopenia
1.19
4.8
2.6
0.68
2.0
1.o
(1.25-1.78 mg/dL)
(0.3-1.5 mmol/L)
(0.4-2.2 mg/dL)
(0-0.06 ng/mL)
(3.0-7.0 thou/uL)
(1.8-5.0 thou/uL)
Additional Diagnostics
 Thoracic Ultrasound
 No pleural fluid or evidence of pleuritis
 Abdominal Ultrasound
 Stomach of normal size
 Thickened large colon and small intestinal walls
 Imaging was difficult because of BCS
 No appreciable peritoneal fluid
 Rectal Exam
 Thickened but compressible loops of small intestine
 Nasogastric Intubation
 Unable to pass tube beyond the cardia
Problem List
 Colic
 Thickened SI and colon
 Inability to pass NG tube into








stomach
Tachypnea
Endotoxemia
Dehydration
Hypoproteinemia
Hypochloremic metabolic
alkalosis
Hypocalcemia
Hyperlactatemia
Leukopenia
http://pad2.whstatic.com/images/b/ba/
Sickhorse.jpg
Differential Diagnoses for Colic
Colic
NonGastrointestinal
Gastrointestinal
Proximal GI
Gastric Impaction,
Gastric Ulcers,
Gastric Rupture,
Choke, Esophageal
Rupture
Small Intestine
Strangulating
Non-Strangulating
Lipomas,
Rents/Hernias
Enteritis, IBD, Ileal
Impaction
Large Intestine
Other
Genitourinary
Musculoskeletal
Large colon
volvulus, Colitis,
Displacements,
Impactions, Cecal
Disease, Enteroliths
Pleuropneumonia,
Hepatopathy,
Neuropathy
Urinary Calculi,
Uterine Artery
Rupture
Rhabdomyolysis,
Laminitis
Initial Stabilization and Treatment
 1L Hypertonic saline bolus
 20L Plasmalyte bolus
 Plasmalyte CRI with
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

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electrolyte supplementation
Hetastarch CRI
Lidocaine CRI
Antiendotoxic dose of
flunixin (0.25 mg/kg)
Cryotherapy
Offered 3L of water – after
drinking became
uncomfortable
Photo courtesy of Dr. Sally Ness
Re-evaluation
 No clinical improvement
 Thoracic ultrasound

Pleural fluid
 Abdominal ultrasound

Copious amounts of flocculant
peritoneal fluid
 Upper GI Endoscopy

Photo courtesy of Dr. Sally Ness
Impaction of feed material in distal
esophagus
 Abdominocentesis

Septic peritonitis consistent with GI
rupture
 Euthanasia was elected and a
necropsy was performed
Photo courtesy of Dr. Katie Mullen
Gross Findings
Photo courtesy of Dr. Kim Bonner
 Peritoneal cavity contained ~60 L of peritoneal effusion with
copious amounts of fibrin. No feed material was found in the fluid.
Gross Findings
Photos courtesy of Dr. Kim Bonner
 Left: 8 cm tear in impacted esophageal pulsion diverticulum caudal to the
diaphragm
 Right: Severe smooth muscle hypertrophy of caudal esophageal wall (1.7 cm
(normal thickness 0.5 +- 0.1 cm))
Esophageal Diverticula
 Types of Diverticula

Traction
Shallow body and wide opening
 Usually secondary to esophageal
injury
 Able to transmit peristalsis
 Not prone to impaction


Pulsion
Flask-like body and narrow opening
 Mucosa protrudes through a defect
in esophageal wall
 Prone to impaction
 Usually located in cervical region in
the horse

Gross Findings
Photos courtesy of Dr. Kim Bonner
 Left: Full thickness gastric tear (5.5 cm) located within a 10
cm partial tear (separation of tunica muscularis) along the
lesser curvature
 Right: Severe edema in pyloric gastric wall
Regional Anatomy
1.
2.
3
1
3.
4.
2
5.
4
6.
5
6
Color Atlas of Veterinary Anatomy, Volume 2, The Horse. Vol. 2: Elsevier Health Sciences, 2012. 160. Print.
Esophagus
Stomach
Diaphragm
Liver
Left Dorsal
Colon
Left Ventral
Colon
Histopathology
 Distal Esophagus
 Thickened tunica muscularis
 No underlying condition was found that would have
predisposed to either the gastric or esophageal
lesions
Photo courtesy of Dr. Elizabeth Buckles
History of the Breed
 1500-1600 - Developed in the Friesland province of
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the Netherlands
1879 – Studbook was founded
1913 – Only 3 approved stallions
1928 – 8 approved stallions bred 358 mares
Currently 45,000 registered Friesians
http://tinyurl.com/lcyvxcl
http://tinyurl.com/ophacvb
Common Anomalies and Diseases
 Dwarfism
 Hydrocephalus
 Retained placenta
 Chronic Proliferating
Lymphangitis
 Megaesophagus
 Aortic rupture
 Aortopulmonary fistulas
All photographs: Boerma, S., W. Back, and M. M. Sloet Van OldruitenborghOosterbaan. "The Friesian Horse Breed: A Clinical Challenge to the Equine
Veterinarian?" Equine Veterinary Education 24.2 (2012): 66-71. Web.
Current Research
 Retrospective study conducted in 2013
 852 horse necropsies over 6 years at Michigan State
University
 42 horses had gross esophageal lesions, 10 were severe
 35.3% of Friesians submitted had severe esophageal
lesions compared to 0.5% of other breeds
 Most common lesion was caudal esophageal smooth
muscle hypertropy
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
Prevalence in Friesians: 35% and all other breeds <3%
Usually an incidental idiopathic finding in older horses
 Megaesophagus was present in 6 Friesian horses, 5/6
had severe muscular hypertrophy
Current Research
 Aortic Rupture
 Study published in April 2014 showed specific histological
changes
Accumulation of mucoid material
 Disorganization and fragmentation of elastic laminae
 Smooth muscle hypertrophy
 Medial necrosis
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
Hypothesized to be a genetic connective tissue disorder of
elastin or collagen
 Dwarfism
 Tendons of dwarf Friesians and non-dwarf Friesians have been
shown to have more elastic properties compared to control
ponies
Fenway Foundation for Friesian Horses
 Mission Statement

“The Fenway Foundation for Friesian Horses is a not for profit
corporation created to preserve and enhance the longevity and
quality of life of Friesian horses by accruing pertinent equine, more
specifically Friesian, information to educate the public and offering
assistance regarding Friesian horses and their owners throughout
North America.”
 Services
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Rescue assistance
Necropsy assistance
Health assistance
Genetic assistance
http://www.fenwayfoundation.com/index.html
Educational assistance
Continuing Care Assistance Upon Incapacitation Or Death
Necropsy Assistance
 The foundation will reimburse for necropsies on
Friesians 17 years old and younger
 Work in conjunction with Dr. Back at Utrecht
University on the following:
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
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Hydrocephalus
Dwarfism
Aortic rupture
Megaesophagus
 Detailed necropsy guidelines and sample
information found at:

http://www.fenwayfoundation.com/services.html
Final Cost
 Emergency Colic Work-up
 $768
 Medications, Fluids and Supplies
 $852.23
 Diagnostics
 $393.19
 Necropsy
 $214.40
http://www.kimballstock.com/pix/HOR/01/HOR_01_MB0134_01_P.
JPG
 Total: $2227.82
 - Reimbursement from Fenway Foundation
References
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Benders, N. A., J. B. Veldhuis Kroeze, and J. H. Van Der Kolk. "Idiopathic Muscular
Hypertrophy of the Oesophagus in the Horse: A Retrospective Study of 31
Cases." Equine Veterinary Journal 36.1 (2004): 46-50. Web.
Boerma, S., W. Back, and M. M. Sloet Van Oldruitenborgh-Oosterbaan. "The
Friesian Horse Breed: A Clinical Challenge to the Equine Veterinarian?" Equine
Veterinary Education 24.2 (2012): 66-71. Web.
Fenway Foundation for Friesian Horses. N.p., n.d. Web.
<http://www.fenwayfoundation.com/index.html>.
"Friesian Timeline." Friesian Horse Association of North America. N.p., 2014. Web.
01 May 2014. <http://www.fhana.com/timeline/>.
Komine, M., I. M. Langohr, and M. Kiupel. "Megaesophagus in Friesian Horses
Associated
With Muscular Hypertrophy of the Caudal Esophagus." Veterinary Pathology
Online (2013): n. pag. Sage Publications. Web. 1 Apr. 2014.
<http://vet.sagepub.com/content/early/2013/11/13/0300985813511126>.
Ploeg, M., V. Saey, C. Delesalle, et. al. "Thoracic Aortic Rupture and Aortopulmonary
Fistulation in the Friesian Horse: Histomorphologic Characterization." Veterinary
Pathology Online (2014): n. pag. Sage Publications. Web. 25 Apr. 2014.
<http://vet.sagepub.com/content/early/2014/04/16/0300985814528219>.
Yamout, S. Z., K. G. Magdesian, and D. A. Tokarz. "Intrathoracic Pulsion Diverticulum in a
Horse." Canadian Veterinary Journal 53 (2012): 408-11. Web.
Questions?
 Thank you to:
 My advisors
 Dr. Buckles
 Dr. Mullen
 Class of 2014!
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