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Gastric and Esophageal Diverticulum Rupture in a Friesian Gelding

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Presentation on theme: "Gastric and Esophageal Diverticulum Rupture in a Friesian Gelding"— Presentation transcript:

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. <http://www.fenwayfoundation.com/index.html>. "Friesian Timeline." Friesian Horse Association of North America. N.p., Web. 01 May <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 <http://vet.sagepub.com/content/early/2013/11/13/ >. 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 <http://vet.sagepub.com/content/early/2014/04/16/ >. 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!


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