Chase-Lindsay-ppt2014
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Transcript Chase-Lindsay-ppt2014
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
No gastric reflux
Instilled water and mineral oil
Horse became uncomfortable during administration
Referred to Cornell for suspected colitis
Physical Exam
Vital Signs:
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
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)
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
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
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
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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
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
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
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:
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
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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