1. Gastric and Esophageal Diverticulum Rupture in a Friesian Gelding
Lindsay Chase
May 7th 2014
Clinical advisor: Dr. Kathleen mullen
Basic science advisor: dr. Elizabeth buckles

2. 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

3. rDVM Therapy
Flunixin meglumine, detomidine, ceftiofur crystalline free acid
Nasogastric tube
No gastric reflux
Instilled water and mineral oil
Horse became uncomfortable during administration
Referred to Cornell for suspected colitis

4. Physical Exam Vital Signs: Depressed BCS 7/9
T:101.7oF ( oF)
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

5. Diagnostics Blood work PCV: 62% (34-46) TP: 6.3 g/dL (6.2-7.8)
Hypochloremic metabolic alkalosis
Cl 92 ( mEq/L)
pH ( )
BE 8
HCO3 31 (25-30 mmol/L)
Ionized Hypocalcemia ( mg/dL)
Hyperlactatemia ( mmol/L)
Elevated Creatinine ( mg/dL)
Elevated Troponin ( ng/mL)
Neutropenia ( thou/uL)
Lymphopenia 1.o ( thou/uL)

6. 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

7. Problem List Colic Thickened SI and colon
Inability to pass NG tube into stomach
Tachypnea
Endotoxemia
Dehydration
Hypoproteinemia
Hypochloremic metabolic alkalosis
Hypocalcemia
Hyperlactatemia
Leukopenia

8. Differential Diagnoses for Colic
Gastrointestinal
Proximal GI
Gastric Impaction, Gastric Ulcers, Gastric Rupture, Choke, Esophageal Rupture
Small Intestine
Strangulating
Lipomas, Rents/Hernias
Non-Strangulating
Enteritis, IBD, Ileal Impaction
Large Intestine
Large colon volvulus, Colitis, Displacements, Impactions, Cecal Disease, Enteroliths
Non-Gastrointestinal
Other
Pleuropneumonia, Hepatopathy,
Neuropathy
Genitourinary
Urinary Calculi, Uterine Artery Rupture
Musculoskeletal
Rhabdomyolysis, Laminitis

9. Initial Stabilization and Treatment
1L Hypertonic saline bolus
20L Plasmalyte bolus
Plasmalyte CRI with 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

10. Re-evaluation No clinical improvement Thoracic ultrasound
Pleural fluid
Abdominal ultrasound
Copious amounts of flocculant peritoneal fluid
Upper GI Endoscopy
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. Sally Ness
Photo courtesy of Dr. Katie Mullen

11. Photo courtesy of Dr. Kim Bonner
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.

12. Photos courtesy of Dr. Kim Bonner
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 cm))

13. 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

14. Photos courtesy of Dr. Kim Bonner
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

15. Regional Anatomy Esophagus Stomach Diaphragm Liver Left Dorsal Colon
Left Ventral Colon 3 1 2 4 5 6
Color Atlas of Veterinary Anatomy, Volume 2, The Horse. Vol. 2: Elsevier Health Sciences, Print.

16. Photo courtesy of Dr. Elizabeth Buckles
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

17. History of the Breed
Developed in the Friesland province of the Netherlands
1879 – Studbook was founded
1913 – Only 3 approved stallions
1928 – 8 approved stallions bred 358 mares
Currently 45,000 registered Friesians

18. 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 Oldruitenborgh-Oosterbaan. "The Friesian Horse Breed: A Clinical Challenge to the Equine Veterinarian?" Equine Veterinary Education 24.2 (2012): Web.

19. 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
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

20. Current Research Aortic Rupture Dwarfism
Study published in April 2014 showed specific histological changes
Accumulation of mucoid material
Disorganization and fragmentation of elastic laminae
Smooth muscle hypertrophy
Medial necrosis
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

21. 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
Rescue assistance
Necropsy assistance
Health assistance
Genetic assistance
Educational assistance
Continuing Care Assistance Upon Incapacitation Or Death

22. 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:
Hydrocephalus
Dwarfism
Aortic rupture
Megaesophagus
Detailed necropsy guidelines and sample information found at:

23. Final Cost Emergency Colic Work-up Medications, Fluids and Supplies
$768
Medications, Fluids and Supplies
$852.23
Diagnostics
$393.19
Necropsy
$214.40
Total: $
- Reimbursement from Fenway Foundation

24. References
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): 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): Web.
Fenway Foundation for Friesian Horses. N.p., n.d. Web. <
"Friesian Timeline." Friesian Horse Association of North America. N.p., Web. 01 May <
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 <
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 <
Yamout, S. Z., K. G. Magdesian, and D. A. Tokarz. "Intrathoracic Pulsion Diverticulum in a Horse." Canadian Veterinary Journal 53 (2012): Web.

25. Questions? Thank you to: My advisors Class of 2014! Dr. Buckles
Dr. Mullen
Class of 2014!