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Megaesophagus in Dogs

Dr. Bari Spielman

Section: Overview
Megaesophagus is a condition where there is decreased or absent motility (movement, muscular contractions) of the esophagus. The esophagus is the tube that carries food and water from the throat to the stomach. With megaesophagus, passing food all the way to the stomach becomes difficult, and the food may be regurgitated back up into the throat. This reduced motility usually results in dilation of the esophagus.

Megaesophagus may be present at birth and become apparent shortly after weaning, or it can be acquired later in life. It can be secondary to a variety of diseases that cause neuromuscular dysfunction, or it can occur as a primary disorder for which the cause is unknown (idiopathic). It may be associated with esophageal obstruction due to a foreign object, stricture or narrowing, neoplasia (cancer), compression from adjacent masses in the chest, or compression from a vascular ring anomaly (a congenital defect of the blood vessels in front of the heart).

Affected animals may have difficulty maintaining adequate nutrition due to their inability to move food into the gastrointestinal tract. They may also develop pneumonia secondary to regurgitation and aspiration of foodstuffs into the lungs.

Megaesophagus is seen in both dogs and cats; however, it is much more common in dogs. It is hereditary in the wirehaired fox terrier and miniature schnauzer. Other breeds commonly affected include the German shepherd dog, Newfoundland, Great Dane, Irish setter, Chinese shar-pei, pug, and greyhound.

What to Watch For

Regurgitation of food and water

Fever

Cough

Nasal discharge

Salivation

Sometimes difficulty swallowing

Foul odor to the breath

Weight loss

Poor body condition

Respiratory distress with severe aspiration pneumonia

Diagnosis
A thorough description of the clinical signs is very important and can often be the key to the diagnosis. It is most important that your veterinarian understands exactly what signs your pet is exhibiting at home. Diagnostic tests are necessary to confirm a diagnosis of megaesophagus. They may include:

Complete blood count (CBC)

Biochemical profile

Urinalysis

Thoracic X-rays

Acetylcholine receptor antibody titer

Antinuclear antibody (ANA) titer for immune-mediated diseases

Hormonal testing, such a an adrenal stimulation test and thyroid function tests

Blood lead level

Treatment
Treatment for megaesophagus is directed at the underlying disease or associated conditions. In the event no underlying cause is identified, symptomatic and supportive measures are recommended:

Drugs that help increase gastrointestinal motility or movement

Antibiotic and fluid therapy in cases of pneumonia secondary to megaesophagus

Home Care and Prevention
Administer any prescribed medications and feed your dog according to the instructions given to you by your veterinarian. It is critical that you follow any special feeding instructions to reduce the risk of aspiration of food or vomitus into the lungs. It is important to maintain adequate nutrition if at all possible.

Most causes of megaesophagus cannot be prevented. However, megaesophagus associated with ingestion of certain types of foreign bodies or toxins may be prevented by closely monitoring your dog's environment.

Section: Information In-depth

Because the history, physical examination findings and overall presentation of animals with megaesophagus are variable, there are other illnesses that must be ruled out when establishing a definitive diagnosis. It is important to note that regurgitation, which is the effortless evacuation of fluid, mucus, and undigested food from the esophagus, is the most common clinical sign associated with megaesophagus. Regurgitation must be differentiated from vomiting, which is the forceful evacuation of digested food from the stomach.

The following are often associated with regurgitation:

Esophagitis – an inflammation of the esophagus

Foreign bodies that obstruct or block the esophagus

Esophageal neoplasia (cancer)

Hiatal hernia – an abnormality of the diaphragm that allows part of the stomach to be displaced into the thoracic (chest) cavity

Esophageal diverticula – a pouch-like dilatation or ballooning of the esophageal wall that can be present from birth or acquired secondary to esophageal weakness

Megaesophagus may occur as a component of several systemic diseases, such as:

Myasthenia gravis – an immune disorder that causes fatigue of the muscular system and weakness

Polymyositis – an inflammation of many different muscles in the body

Systemic lupus erythematosus – an immune disorder that affects multiple body systems

Botulism – a type of food poisoning

Tetanus – a bacterial infection causing severe muscle spasms

Dysautonomia – an inflammation and degeneration of certain components of the autonomic nervous system

Endocrine diseases, including hypothyroidism and hypoadrenocorticism

Toxicity caused by exposure to lead, thallium, and organophosphate insecticides

Thymoma – a tumor arising from the thymus organ in the chest

Section: Veterinary Care In-depth
Diagnosis In-depth
Certain diagnostic tests must be performed to make a definitive diagnosis of megaesophagus and exclude other disease processes that may cause similar symptoms. A complete history is especially important in these cases, as regurgitation, the most common clinical sign seen with megaesophagus is often referred to as vomiting by the pet owner.

A complete diagnostic evaluation is indicated in dogs with megaesophagus since an accurate diagnosis is important for both treatment and prognosis.

A complete blood count (CBC) is often within normal limits, although with certain infections, inflammatory disorders or toxins, characteristic changes may be noted.

A biochemical profile may show changes consistent with endocrine disorders.

A urinalysis is usually within normal limits.

Chest X-rays may show an esophagus dilated with gas, fluid, or food.

An esophagram may be indicated to confirm megaesophagus, especially when mild dilation may not be obvious on plain radiographs. It is a non-invasive barium contrast X-ray.

An acetylcholine receptor antibody titer (ARAT) is a blood test that is performed when myasthenia gravis is suspected. Although there are usually other systemic signs associated with myasthenia gravis, megaesophagus may be the only sign in certain cases. The incidence of myasthenia gravis appears to be higher in German shepherd dogs and golden retrievers.

Antinuclear antibody titers are sometimes run to confirm immune-mediated diseases like systemic lupus erythematosus.

An ACTH stimulation test evaluates adrenal gland function and confirms the diagnosis of hypoadrenocorticism.

Serum creatine kinase (CPK) is a blood test that may be elevated in certain muscle diseases.

Blood lead levels are measured, especially in cases where lead toxicity is suspected due to history, environment, or changes in the blood count.

Thyroid function tests may be run to rule out hypothyroidism.

Your veterinarian may recommend additional tests to exclude or diagnose other conditions, such as the following:

Esophagoscopy is the visual inspection of the esophagus with a rigid or flexible scope. It is not routinely done in all cases of megaesophagus; however, it may be useful in cases of suspected or confirmed esophageal foreign bodies, neoplasia, or esophagitis (inflammation of the esophagus).

Dynamic contrast fluoroscopy is a video X-ray that allows visual observation of the esophagus in motion. It helps assess the strength and coordination of esophageal contractions that propel the food down into the stomach. It often requires referral of your pet to a veterinary institution with the specialized instrumentation capable of performing video X-rays.

Toxicology assays may be indicated for suspected toxicities, such as thallium or organophosphates.

Electrodiagnostic tests such as electromyography (EMG) and nerve conduction velocity (NCV) help to rule out neuromuscular diseases.

A tensilon test is a special test used to diagnose myasthenia gravis.

Therapy In-depth
The primary goals in treating megaesophagus are to identify and treat the underlying cause, decrease the frequency of regurgitation, prevent over-distention of the esophagus, provide adequate nutrition, and treat complications such as aspiration pneumonia and esophagitis. In cases where a primary cause can be identified and treated, esophageal motility may improve with time. Treatment is symptomatic in animals in which an underlying cause cannot be identified.

Following appropriate feeding recommendations is of paramount importance, and although there is no single way that all animals should be fed, several general principals apply:

Elevated feedings allow gravity to aid movement of food through the esophagus. Medium and large dogs can be trained to eat with their front legs elevated on a table or rack. They should remain elevated at a 45-degree angle for 10 to 15 minutes after eating. Small dogs can be held upright (after eating) by their owners.

A diet must be formulated that provides adequate nutrition. Generally, a high calorie diet is fed in small amounts frequently over the course of the day. This regimen ensures adequate intake of nutrition and is less likely to cause over-distention of the esophagus.

Controversy still exists regarding the best-tolerated consistency of food. The diet consistency is tailored to each patient based on the diet that causes the fewest clinical signs. Some individuals do better with a more liquid diet, while others seem to tolerate more solid food. Using canned food rolled into small "meat balls" works well in many dogs.

Animals that cannot maintain an adequate nutritional balance may require tube feeding. Feeding tubes are usually placed surgically into the stomach, and may be left in place for several weeks.

Other treatment options include:
Drugs that improve movement of the gastrointestinal tract have been used with only limited success. Generally, these drugs are of benefit in cases where little esophageal distention exists.

There is no effective surgical treatment of megaesophagus; however, removal of a thymoma in the chest may be indicated.

Esophagitis is sometimes treated with drugs that decrease the acidity of the stomach contents. The regurgitated material from the stomach is therefore, less harmful to the lining of the esophagus. In addition, agents that coat and protect the esophagus may also be tried.

Animals with severe aspiration pneumonia require special attention and aggressive therapy.

Section: Follow-up
Optimal treatment for your pet requires a combination of home and professional veterinary care. There is no single therapy that is recommended for all animals with megaesophagus. Each case is unique, and specific recommendations are tailored for each patient.

It is important to administer all prescribed medications and follow feeding recommendations closely.

Observe your pet very closely and report any abnormalities to your veterinarian promptly.

Observe your pet closely for any signs of improvement or deterioration, and report these to your veterinarian.

Patients should be re-examined if signs of aspiration pneumonia develop such as fever, cough, and nasal discharge.

In some cases, thoracic radiographs, an esophagram, and other diagnostics are recommended on a regular basis to monitor response to therapy.

Prognosis is often poor for patients with megaesophagus.Progressive emaciation and aspiration pneumonia are the two most common causes of death and are also common reasons pet owners elect euthanasia.

This article has been provided courtesy of PetPlace.com (www.petplace.com),
the definitive online source for pet news, health,and wellness information."

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Megaesophagus

From Wikipedia, the free encyclopedia

Megaesophagus is a condition in dogs where peristalsis fails to occur properly and the esophagus is enlarged. Normally, when the dog's esophagus is functioning properly, it acts as a muscle and pushes the food down the esophagus into the stomach. However, when a dog has megaesophagus, the esophagus stays enlarged and does not push the food down to the stomach. Therefore, the food fails to enter the stomach and often stays in the esophagus, and is eventually regurgitated.

In human pathology a condition known as achalasia may predispose a person to slowly develop megaesophagus. Achalasia is due to the loss of ganglion cells of the myenteric plexus. It occurs mostly in middle aged adults. There is a marked lack of contraction in the muscle contractions involving peristalsis with a constant contraction of the lower esophageal sphincter. Dilation of the esophagus results in difficulty swallowing. Retention of food bolus is also noted. Achalasia also predisposes to esophageal carcinoma.

Megaesophagus can also be a symptom of another disease in dogs called myasthenia gravis. Myasthenia gravis is a neuromuscular disease where the primary symptom is weakness in various body parts of the dog. However, when myasthenia gravis occurs in older dogs it is thought of as an immune-mediated disease. Often when myasthenia gravis is diagnosed in older dogs the first symptom the dog may manifest is megaesophagus.

Myasthenia gravis occurs when acetylcholine receptors (nicotinic acetylcholine receptors or AChRs) fail to function properly. Due to the inability of the nerve receptors to function appropriately, the muscles fail to have a stimulus that causes them to contract.

An important distinction in recognizing megaesophagus is the difference between when a dog regurgitates or vomits. Regurgitating is a common symptom of megaesophagus while vomiting is not necessarily associated with megaesophagus. When a dog regurgitates there is usually not as much effort involved as when a dog vomits. Often when regurgitating, the dog will tip its head down and the liquid and/or food will almost appear to "spill out" of its throat.

One of the primary dangers to a dog with megaesophagus is aspiration pneumonia. Because the food stays lodged in the throat, it can often be inhaled into the lungs causing aspiration pneumonia. One way to avoid this is to make sure that every time the dog eats or drinks anything, that the dog sits for at least 10 minutes afterwards or is held in a sitting up or begging position. This requires that all food and liquid intake be closely monitored and specifically administered to the dog in regular intervals (sometimes as often as 2-3 hours) in smaller quantities. Obviously, if smaller quantities of food and water are administered, one needs to take the necessary precaution to ensure the dog has a sufficient caloric and water intake. The prognosis for this condition is guarded.

Breeds Affected
Shar Pei
French Bulldog
German Shepherd Dog
Great Dane
Greyhound
Irish Setter
Miniature Schnauzer
Wire-haired fox terrier
Golden Retriever

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Megaesophagus:

What does this mean for my dog?
Janeen Klinkenborg

You have just been told your dog has mega esophagus (which you have never heard of), and you are probably feeling overwhelmed and scared. Your veterinarian explained what mega esophagus is, but where to go from here and how to help your dog maintain a good quality of life seems uncertain. Be assured that mega esophagus is not a death sentence and that your dog can lead a normal life with a few adaptations. Many others have been in the same place you are now. In fact there is a group of dog owners dealing with the same condition in their dogs and its members are available to assist you online. This group has knowledge about and experience with the follow-up care/daily management of dogs with mega esophagus. The purpose of this brochure is to share with you the valuable information that our group has learned through collective experience, helping you to provide the best daily care for your dog with mega esophagus.

We cannot stress enough the importance of partnering with your veterinarian and always discussing any changes to your dog’s care with him/her. After all, our veterinarians have medical knowledge that we do not and are familiar with our individual dogs and their unique needs. Below you will find answers to some of your initial questions about mega esophagus, and basic management recommendations from the group. We also encourage you to join the group where you can receive more individualized support and suggestions. By sharing what we have all learned through experience with our dogs, we hope to spread awareness and give peace of mind and hope to those who have just been told, “your dog has mega esophagus.”

What is Mega esophagus in simplified terms?
Mega esophagus is basically an enlarged or stretched esophagus (tube that carries food from the mouth to the stomach). The muscles in the esophagus that are responsible for pushing food along do not work properly because the nerves that control them are partially or completely paralyzed. A dog’s esophagus runs parallel to the floor. Because the esophagus muscles are weak or non-functioning, whatever the dog eats or drinks can pool in the esophagus stretching the esophagus further and potentially creating pouches or pockets. These pockets collect food and water, where they will remain until the dog regurgitates them.

What is regurgitation? How is it different from vomiting?
Regurgitation is a passive occurrence. In other words, it tends to be a bit unexpected and often there is no warning that something is about to come out of the mouth. The dog may bark, and you’ll hear the ‘splat’ of something coming out. The dog may burp and something will come up. Sometimes a dog will exhibit signs before regurgitation such as: turning in a circle, getting a zoned-out look, hunching the back, looking uncomfortable or confused - like it is trying to work something out or its throat area may appear to contract. What comes out of the dog is often undigested food or water. Regurgitation is the body’s way of rejecting whatever did not make it to the stomach. This may be one or two pieces of food or a large quantity that has been sitting in the esophagus and may be accompanied by a fair amount of mucus (this is because the esophagus creates mucus as protection for itself).

Vomiting is an active occurrence. In other words, there is some forewarning that vomiting is about to occur. Dogs generally know this is about to happen and may even run to the door to go outside or to another room. Drooling sometimes precedes vomiting, which is usually an indication of nausea. The dog’s abdomen may quickly contract several times and you will hear the dog retch and gag. Then the entire contents of the stomach will be vomited. What comes out of the dog’s stomach may be either partially digested material, or bile (a yellowish substance). If your dog is vomiting there may well be a different or additional problem to consider.

Sometimes it is difficult to tell the difference between the two. But with time and careful observation of how your dog acts just beforehand, you can often tell which is happening. The difference may seem minor, but it is important to know which is happening. Regurgitation is a symptom of mega esophagus, vomiting is not (although dogs with mega esophagus can vomit).

Why is regurgitation a problem?
The pooling of materials in the esophagus may further damage the esophagus, and may even result in painful ulcers or esophagitis. It is important that whatever goes into the dog’s mouth gets to the stomach or it will sit in the esophagus until it comes back out (regurgitation). A dog cannot thrive unless food reaches its stomach to deliver nutrients. When regurgitation occurs there is also an increased risk that the dog will aspirate/inhale materials into the lungs (food, water, stomach acid, saliva, etc.). Aspirating anything into the lungs can cause life-threatening aspiration pneumonia (AP). Though your dog may never develop AP, it is a potential danger for every dog with mega esophagus, and one for which you must be vigilant. Each time a dog has AP, scar tissue may form in the lungs. With recurring bouts of AP, the space available for air may become more limited, making breathing more difficult. Preventing AP is very important; adapting your dog’s daily routine is crucial to prevention. If you suspect your dog has aspirated, immediate medical attention is recommended. Antibiotic administration is strongly encouraged if your dog is showing symptoms of AP because physical symptoms may precede x-ray abnormalities by 48 hours. Recognizing AP early, before the lung/s are weakened, is critical in dogs with mega esophagus. Loss of appetite or lethargy may be the first noticeable symptom.

How did my dog get this? Will it ever go away or be cured?
Those are the million dollar questions. Mega esophagus can affect any breed and size of dog. Mega esophagus may be congenital (inherited, possibly present at birth), or idiopathic (cause unknown). It may also be secondary to another condition. There are a variety of specific health disorders that may cause mega esophagus. Two of the more commonly seen conditions are myasthenia gravis (MG) and hypothyroidism. Having tests to rule underlying conditions in or out is recommended because many can be treated, and with treatment the esophagus may improve (or reverse). Your veterinarian will be able to help evaluate any other symptoms your dog is exhibiting and may suggest other tests as well. While the hope exists that your dog may be one of the lucky ones whose esophagus reverses completely, many dogs that have mega esophagus will have it for the remainder of their lives. Some puppies that are born with mega esophagus or develop it very early in life do outgrow it, but there are no guarantees.

What can I do for my dog?
A few changes to your dog’s routine will help compensate for the inability of the esophagus to move food and water to the stomach.

1) Feed (and water) your dog vertically. This means the spine should be straight up and down, with the dog seated in the “beg position” every time the dog receives anything by mouth (food, water, medication, treats). Feeding your dog elevated is not enough because the esophagus is still at an angle and food can still accumulate in pouches and pockets. There are a variety of ways to feed vertically. There is a specially designed chair called the Bailey Chair, which you can build for your dog. This is highly recommended and with the proper fit assures your dog is correctly positioned and supported (see the attached pictures and the link at the end of this document). You may also have your dog sit on a pillow in a corner, facing outward, with his/her front feet on your lap (while you are sitting in a chair in front of him/her). Smaller dogs can be held or even supported vertically in a bucket, mailbox or baby pack. Whatever you do, be sure your dog has the proper support for its spine. Use pillows, towels, whatever works to accomplish this. It is also important to feed your dog slowly and not allow gulping. The same vertical position is necessary for water. Allowing your dog to drink from a bowl on the floor is usually a problem. Many people add enough water to their dog’s food to avoid this potential problem. A dog generally needs 1 ounce of water per pound of body weight per day, more if it is very active. Some people use unflavored gelatin to make water cubes to help hydrate their dog if liquid alone causes problems.

2) Keep your dog vertical for a minimum of 15-20 minutes after each meal. Yes, this sounds like a hassle, but the difference it makes in your dog’s health and quality of life will be well worth it. The time spent vertical will allow gravity to empty anything in the esophagus into the stomach, which will in turn help minimize regurgitation. You will need to see what amount of time works best for your dog. In some cases 15 minutes is not long enough, and the time spent vertical must be increased. If your dog has orthopedic issues or other limitations that may make sitting in this position difficult, do the best you can to get as close to vertical as possible and discuss alternatives with your veterinarian.

3) Find the right food and consistency. Specialists recommend that dogs with mega esophagus eat a diet that is lower in proteins and fat, and higher in carbohydrates. Proteins and fat require more stomach acid for digestion. The increase in acid production can lead to acid reflux which can result in erosions or burns in the esophagus. Carbohydrates are milder on the system and also add calories, which will help your dog gain weight. Some dogs can only tolerate a very liquid consistency for their food, while others do best with rolled balls of food that are swallowed whole. There are also many dogs that fall somewhere in between. You will have to find what works best for your dog through trial and error. Generally you can start off with a milkshake consistency and then adjust from there. If the food is too sticky or is dry it can stick to the esophagus walls and cause problems. That doesn’t mean you can’t use kibble, but you will most likely have to grind, soak, mash, or blend it to get the right consistency.

4) Feed smaller, more frequent meals. Try to space your dog’s daily intake of food out into 3-4 feedings (or even more) throughout the day rather than 1-2. During your dog’s vertical time gravity is moving the food from the mouth to the stomach rather than the esophageal muscles, so things are moving at a much slower pace. Feeding smaller amounts of food and waiting two to three hours between meals will minimize pooling of materials in your dog’s esophagus and allow the body time for digestion.

5) Discuss medications with your veterinarian. While there is no drug that cures mega esophagus, many dogs do take some sort of medication. Your veterinarian may suggest a drug called Carafate/Sucralfate to prevent damage to the esophagus by coating it with a protective barrier. It will also ‘bandage’ existing ulcers and erosions in the esophagus and stomach to help them heal. It must be given an hour before or two hours after any other medication or food as it can bind with other medications preventing them from working properly or bind with food potentially causing a blockage. Acid inhibitors may also be helpful; many dogs in our group take one. Acid inhibitors suppress or block the production of stomach acid helping to prevent acid reflux which can burn the esophagus, create ulcers or be aspirated into the lungs. Acid inhibitors are not the same thing as antacids (such as Tums or Maalox). There are a variety of acid inhibitors and some work best given twice daily. Your veterinarian can help you decide if acid inhibitors are appropriate for your dog and which one is best. If your veterinarian feels an acid inhibitor may benefit your dog, regular testing for B-12 levels may be recommended. B vitamins require an acid environment for absorption. Long term use of acid inhibitors can alter the stomach chemistry potentially leading to a B vitamin deficiency. Motility drugs may help some dogs by moving the food out of the stomach more quickly, further minimizing reflux of stomach contents into the esophagus. Be aware that many medications can have side effects or interact negatively with other medications. It is imperative that you always talk to your veterinarian before giving your dog any medication.

6) Try to get your dog to sleep with his/her shoulders and head elevated. Many dogs have more trouble at night, or very early morning. This is because dogs often lay flat with their upper bodies level to their stomachs, which may promote reflux. If you can, get your dog to lay with shoulders and head on a pillow. Or if your dog is crated, put something under one end of the kennel and encourage your dog to sleep with his/her head at the raised end. This will help keep stomach acid, food and water from flowing back into the esophagus.

This is a great deal of information to digest, so be sure you are sitting completely vertical to let it all settle. :) While each case can be different, the experience of the group is that these daily care modifications will give dogs with mega esophagus the best possible chance to live happy, healthy lives. Please discuss any and all changes with your veterinarian. Mega esophagus can be managed. It is not a death sentence for your dog. With diligence and a few adaptations, your dog can live a fairly normal life. You can do this and your dog will be grateful for the chance at an improved quality of life. We are here to help.

(Links and Pictures can be found in the Yahoo group files)

Disclaimer: The information provided in this document is based on the experience and collective knowledge of the mega esophagus group members. It is offered as a service to the veterinary profession and the public for the purpose of improving the lives of dogs with mega esophagus and their caregivers. It was not intended that any of it be plagiarism or misrepresentation of any medical information. It is also not intended to be a treatment plan for your pet. Your veterinarian’s involvement is crucial to your success.

Permission granted to copy this document in its entirety & distribute responsibly, provided the document is not altered in it’s language or content and that the pamphlet is not sold for profit.

Compiled by: Janeen Klinkenborg, 2006 (PIPER’S MOM)

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Megaesophagus

by Peg A. McIntyre

pets.groups.yahoo.com/group/megaesophagus/
support group of dedicated volunteers who work round the clock to offer knowledge and comfort to the newly diagnosed. Volunteer Veterinarian also 'on staff.'

It is my hope to educate readers about Megaesophagus, a disorder which many breed enthusiasts have undoubtedly never heard of. After a decade of being involved in rescue efforts and experiencing a wide range of disorders and diseases during that course of time, apparently I was still short on experiencing sadness and challenge, as not one of those disorders was ever as mystifying or challenging as what I was to encounter while trying to resolve the symptoms of Megaesophagus in my Gordon pup. The most heart-wrenching words any dog lover can hear are, “there is no cure” and “we understand very little about this disorder.”

Symptoms of Megaesophagus may appear during any life stage. It was once thought that congenital “Mega-E” only surfaced during weaning, and this is true in pups that are severely affected. Congenital cases that are mild may not fully reveal themselves until months later as it is often a progressive disease process. Mega-E may affect only one pup or the whole litter. Idiopathic Mega-E is typically diagnosed during mid to senior years, and the specific cause often remains unknown. It can be due to an injury or exposure to toxic substances. Some believe idiopathic Megaesophagus, once toxic substance and injury are ruled out, may be a more mild case that took years to evolve and express itself in the culmination of unmistakable symptoms. Often Mega-E is not diagnosed until Aspiration Pneumonia is diagnosed, and it is at that point many have an ‘oh-yeah’ moment or two, realizing that they had been living with Mega-E all along but hadn’t recognized the symptoms.

Regurgitation is one of the key symptoms. Food or water will appear to roll out of the mouth, never having reached the stomach. Megaesophagus literally means “enlarged esophagus” but there may be other factors involved, such as foreign body blockage, strictures, or PRAA, to name a few. Regurgitation may be attributable to damage or malformation of the sphincter muscle at the top of the stomach. This sphincter is meant to quickly open and close during a swallow, and holds the swallowed contents into the stomach. Peristalsis can also be ineffective, meaning there is a malfunction of the wavelike muscle contractions that should propel food from the mouth to the stomach immediately following a swallow, so the food may sit in the esophagus for hours or even days. In some cases the enlarged esophagus may form a pouch or strictures that hold ingested food within the esophagus where it putrefies. The pup may eventually become emaciated due to malnutrition, loss of energy, and a failure to thrive. Blood chemistry may change, and further organ damage can occur. A dire, life-threatening case of Aspiration Pneumonia can quickly evolve, as food or water are easily aspirated into the windpipe and lungs where infection will quickly take hold. One little cough often turns into an emergency.

The good news is that many cases are manageable through lifestyle changes. The pup must be fed in vertical (90 degree, not elevated) position. This allows gravity to work a little magic. Maintaining the elevated posture for 20 minutes or longer after each meal is also key. The food that seems to work best in the majority of cases is a slurried consistency. Others seem to do better by being fed soft food formed into a meatball that is then popped down the hatch. Feeding multiple meals, 4-6 meals per day, with small quantity offered at each meal is also mandatory. Many of the affected dogs will have difficulty keeping water down. Offering solidified water, “Knox Blocks” (unflavored gelatin) as we sentimentally refer to them, is often helpful, as is ensuring that water is given in small quantities as far away as possible from meals. Many dogs prefer not to drink any water, having made the connection that it causes them grave difficulty, so dehydration can be a daily concern.


Bailey in his Infamous Bailey Chair Bailey Chair Info: http://www.geocities.com/bailey_chair/	This is Bailey's birthday celebration last year. He turned eight - eight years post dx.

Often the symptoms, frequency or severity will change course on an unknown whim, so keeping a strict schedule and daily journal to record events can be quite helpful. Even though the disease can become progressive in nature, the progression and symptom frequency are unique to each dog. Mildly affected dogs may have extended life spans with a much greater prospect for quality and duration of life with appropriate treatment and lifestyle changes. There are increasing numbers of dogs who live 3-8 years after diagnosis, a direct result of lifestyle changes.

Many Mega E dogs seem to also suffer from food allergies and may have trouble digesting certain types of proteins, carbohydrates or fats. Grasses, grains and saturated fats seem to be of a particular concern. In others, high fiber content may be a problem. Omega oils seem to be of benefit. It is my hope that more veterinarians will refer clients to nutritionists for evaluation as well as allergy testing, even in situations where it does not seem to fit the case. If I had tested sooner, I would have realized better results for my puppy. It wasn't until we learned just what nutritional components were giving her problems that all the pieces of the puzzle fit together, and she was granted increased relief from her symptoms. She never had any telltale symptoms that would point to allergies, with the exception of the runny nose and worsening of regurgitation every spring. Who would have thought a small quantity of green peas buried in holistic-brand kibble would tip the scale, causing a resurgence of these symptoms?

What to look for?
A dog that always seems to be hungry, one who is not gaining weight and is rapidly growing thinner. One who regurgitates (passive act, little if any stomach muscle involvement) minutes to hours after eating. A regurgitated food bolus may be funnel-shaped in formation, and this is a certain giveaway. At other times the dog may be able to hold food down but will regurgitate water along with a slimy mucous. The pup may seem to have difficulty swallowing. You may detect a clicking noise as he moves about. He may stretch his neck out as far as he can reach, or he may elevate himself during rest and play, having made the connection that he feels better when he is up. Breathing patterns may seem unusual. A subtle key is puffing of cheeks upon expiration (breathing out). These pups do not sleep well. The lower esophageal sphincter will loosen as the rest state begins. This allows stomach acids to seep up into the esophagus, causing much discomfort as a burning sensation from the hydrochloric acids pooling within the esophagus, and thus erosive esophagitis sets up shop.

I can’t tell you how frequently I was awakened by a brisk step as my pup came to me for comfort and a split-second later having the effects of regurge splashed on my face. Initially we both slept elevated, trying to teach a pup to sleep on an incline. She slept propped up on my chest so that I could quickly move her muzzle away, and into a cookie-toss pan that was always there for regurges. Eventually I conditioned her to sleep on a huge stuffed toy. Oh, what a joy it was to actually be able to sleep without multiple changes of bed linens per night. My house was lined with plastic, and the carpet cleaner was hardly put away before it was needed again. The laundry was never ending, but thank goodness for inexpensive towels – I threw many away without feeling guilty. Sometimes the slimy phlegm is impossible to wash away. Scheduling life around the multiple feeding schedule, ‘burping’ and rest times was a daunting challenge.


Some of the dogs do get a bit 'antsy' during post-meal hold sessions. This creative mums strolls with her pup to make the time pass more quickly. What a lucky pup!		Planning for growth stages: This creative mom used a highchair for her pup.When the pup is fully mature, a Bailey Chair will be built.

Managing the Disease
Acid inhibitor medications may be helpful, but they will not reverse the condition. I eventually accepted that western medicine would only throw PPIs at the problem, along with heavy doses of broad-spectrum, triple antibiotic therapies lasting a month or longer should there be even a hint of Aspiration Pneumonia. For day-to-day maintenance I elected to provide fresh wholesome nutrition, studied nutritive herbs, and used traditional chiropractic, VOM, and massage therapies. Others are reporting good results with acupuncture or acupressure. Multiple daily sessions of coupage became a way of life -- rhythmic tapping of her sides every hour or so, and specifically during/after meals to loosen phlegm or food particles that could be lodged. This helped thump it all downward, or so I hoped.

In some cases an underlying cause may be at play, so it is imperative that a specialist examines your pup and performs a thorough diagnostic workup. Diagnostics to rule in/out the clinical side conditions can be a bit pricey. There are well over 40 different disorders that can contribute to a case of Mega-E. Following is the short list of contributing conditions thought to be the most frequent or prevalent: Addisons, Myasthenia Gravis, Gastroenteritis, IBD, Bloat (GDV), Laryngeal Paralysis, Pancreatic Insufficiency, Polyneuropathies, and PRAA (Persistent Right Aortic Arch). There is supposition that Addison’s disease may be just as prevalent as Myasthenia, the first disorder most specialists feel important to rule out. Though more rare, Hiatal and Diaphragmatic Herniations often may be missed in the diagnosis, especially if simple radiographs were the only diagnostic tool. These disorders will certainly contribute to the severity of symptoms. Fortunately, surgeries are possible in these instances and fortunately for us (?), both were involved in my pup’s case. Her Megaesophagus symptoms became increasingly mild and less frequent post-operatively. I do believe that each of the management techniques is equally important for success (i.e. vertical feeding is equally as important as elevated sleeping; food consistency and nutrients are equally as important as coupage; getting the medications, dosage and administration times right is equally as important as all of the other techniques). CAM therapies should be given equal consideration to traditional medicine, and once the correct combination is realized for that particular dog, symptom response will realize heightened possibilities. Tube feeding should be considered to rest the esophagus as needed. Many are reporting increased success by implementing nebulizer treatments. It all goes hand-in-hand for these dogs!

Heritability
Over the past decade, there has been growing scientific evidence that genetics and breed predilection play an important factor in the frequency and severity of the disorder. Often breeders believe if they cull the one apparently affected pup, and the rest appear non-symptomatic, they are not affected. Unfortunately, there is a ‘silent carrier’ aspect to this disorder. A dog may not appear to be affected and, in fact will never express any recognizable symptoms for its entire lifespan, yet can carry defective DNA. It has been theorized that some young dogs may outgrow the ailment, and as they mature the immature musculature and neurons that control peristalsis also mature and strengthen. Others will only progressively worsen no matter what modality or combination of modalities is tried.

Currently, there is no definitive genetic test to identify afflicted dogs, carrier dogs or dogs that are clear of the disease. Because of this, most vets tell their clients that they believe the illness to be genetic or congenital in origin, but they cannot categorically state that it is so. However, because of previous experience and knowledge of the numbers affected in other breeds demonstrating genetic predilection, most vets will tell clients that future breedings of parents or siblings should not be done.

Because of our experiences it has become my mission to educate the dog community about this disorder. During conversation with a specialist at Texas A&M, I was told that it would take 40-50 affected Gordon Setters and an equal number of unaffected dogs in order to study the genetics within the breed. I pray there will never be that many affected! However, progress will never be made if we turn a blind eye and foolishly believe Megaesophagus is not a factor or potential threat to the health of our breed.

At this time I would like to ask for blood samples to be donated to the Gordon Setter CHIC DNA Repository. If DNA samples are not collected and stored, research cannot happen. Please visit http://ww.caninehealthinfo.org for further information. There is also Gordon Setter specific information on the TarTan Gordon Setter website, http://www.tartangsc.org/health-chic-dna.html.

It is my hope that this article will reach into your hearts, and reach far and wide within the dog community. I have spoken with many people from other breeds, and unfortunately, Megaesophagus is making a strong, expressive statement with increased frequency. It is heart-wrenching that so much damage can be done to in just a generation or two.

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A Summation, by Dr. Kathy Morris-Stillwell
Canine megaesophagus can be a very manageable disease in many dogs, depending on the cause, and on the concomitant disorders that are present. Veterinarians are often limited in their ability to completely evaluate each case as thoroughly as they would like, due to diagnostic limitations. The usual diagnostics are laboratory tests, x-rays, with and without barium, endoscopy, and occasionally, fluoroscopy. It would be helpful if we could also evaluate each of these patients for how well their upper and lower esophageal sphincters function, as well as if they have concurrent poor motility of their stomachs, or other co-existing bowel disorders such as IBD (Inflammatory Bowel Disease). As it is, once a patient is diagnosed with megaesophagus, whether congenital or acquired, and depending on if it is idiopathic, or caused by Myasthenia Gravis, hypothyroidism, etc., we are left with helping the owners develop a feeding and management protocol that works for that particular dog. This includes, but is not limited to, experimenting with food consistency, trying a variety of pro-motility drugs, using acid inhibitors to reduce esophagitis which occurs due to reflux of food from the stomach into the esophagus, preventing and treating esophagitis and aspiration pneumonia, and vertical feeding. Since many of these dogs are prone to aspiration pneumonia, prevention (by feeding vertically, and encouraging the dog to sleep with it's front end elevated) and treatment can be accomplished by the administration of albuterol and/or saline using a nebulizer. Ultimately, some of these dogs require minimal management, while others need a lot. The success depends on the dedication of the owner, as well as the willingness of the veterinarian to keep an opened mind and to not give a dismal prognosis to all cases.

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Dog Anatomy Pictures	Megaesophagus Info Source Portal	Megaesophagus Secondary to PRAA	Dilation of the Esophagus
Esophagram	Efficiency of Gastrointestinal Drugs	Pets regurgitation May Signal Weak Esophagus	Accupuncture
The Bailey Chair	Aspiration Pneumonia	Canine Idiopathic Megaesophagus:Pathogenesis, Diagnosis and Therapy	Elevated Feeders
Feeding and Nutrition Tips	Feeding Tubes	Canine Megaesophagus Education and Research Project	Coupage
Nutritional Challenges and Rewards

Canine Megaesophagus (Oesophageal Dilation)

Megaesophagus in Dogs

Megaesophagus

What is megaesophagus?

Achalasia

Megaesophagus:

Megaesophagus