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MEGAESOPHAGUS

by Peg A. McIntyre

There I sat with my Gordon Setter, momentarily paralyzed, as our veterinarian explained the diagnosis, “your dog has Megaesophagus,” and “there is no cure.” In fact, the doctor continued, “we understand very little about this disorder”.  So began my mystifying discovery of and challenging attempt to resolve the symptoms of this little-known disorder, which, among others, also affects our beloved German Shepherd Dog breed.

The difficult-to-diagnose symptoms of canine Megaesophagus (Mega-E) can appear during any life stage. Megaesophagus literally means “enlarged esophagus,” but there may be other factors involved, such as foreign body blockage, strictures, dysmotility disorder, or Persistent Right Aortic Arch (PRAA).  At one time experts thought that congenital Mega-E only surfaced during weaning and could either affect only one pup or the entire litter.  Although true in severe cases, a mild case may not appear until months later as the disease progresses. Typically, doctors diagnose the idiopathic Mega-E in mid-to-senior years. Though the specific cause remains uncertain, it sometimes surfaces after an injury or exposure to toxic substances. Mild cases often take years to evolve and usually appear as the culmination of unmistakable symptoms. The key symptom is regurgitation. Food and/or water will roll back out of the mouth and was not able to reach the stomach. Sometimes a diagnosis occurs only after the discovery of aspiration pneumonia.

Damage or malformation of the sphincter muscle at the top of the stomach may cause regurgitation. When healthy, this sphincter quickly opens and closes during a swallow, and keeps the swallowed contents in the stomach. Peristalsis, the wavelike muscle contractions that propel food from the mouth to the stomach immediately following a swallow, might be malfunctioning. In either of these cases the food may sit in the esophagus for hours or even days. In some cases the enlarged esophagus may form a pouch that holds ingested food within the esophagus where it putrefies. Consequently the dog’s blood chemistry may change along with further organ damage; and the resulting malnutrition, loss of energy, and dehydration eventually inhibit the dog’s ability to thrive. Thus, a life-threatening case of aspiration pneumonia can quickly evolve, as food or water becomes aspirated into the windpipe and lungs where infection takes hold. One little cough often turns into an emergency and eventually a diagnosis of Mega-E.

What to look for?

A dog that always seems to be hungry, one who is not gaining weight and is rapidly growing thinner, and one who regurgitates (passive act, little if any stomach muscle involvement) minutes to hours after eating, may be afflicted. A regurgitated food bolus may be funnel-shaped (often a telltale sign).   Sometimes the dog may be able to hold food down but will regurgitate water along with a slimy mucous. The dog may seem to have difficulty swallowing, or you may detect a clicking noise as he moves.  Additionally, the dog may stretch his neck out as far as he can reach or elevate himself during rest and play, and his breathing patterns may seem unusual – such as puffing the cheeks upon expiration. These dogs do not sleep well because the lower esophageal sphincter loosens as the rest state begins, and stomach acids seep up, causing discomfort and a burning sensation from hydrochloric acids pooling within the esophagus – this is also how erosive esophagitis occurs. 

Living with Megaesophagus 

Some lifestyle changes such as those listed below can make many cases manageable: 

• Place the dog in a vertical (90-degree, not elevated) position for feeding and maintain this posture for at least 20 minutes after each meal. (This allows gravity to help the food flow.)

• Feed multiple, smaller portioned meals (four to six times daily).  In the majority of cases blended food with a more liquid consistency (like slurry) works best, but sometimes soft food formed into a small meatball-like shape manages to pop down and stay down more easily.

• Because many of the affected dogs have difficulty keeping water down and, thus, rarely drink water, offering solidified water (unflavored gelatin blocks) works as does providing small quantities of water apart from meals.  Do both to help prevent dehydration. 

• If possible encourage/teach the dog to sleep on an incline (as opposed to their normal instinct to curl up or lay very prone).  Often a bolster pillow or bed or very large stuffed toy can be used to accomplish this.  This will help alleviate the rest time regurgitation episodes/symptoms.

• Multiple daily sessions of coupage (burping) can be effective. Coupage is rhythmic tapping of the chest cavity on each side for about ten minutes every hour or so, and specifically during/after meals, to loosen phlegm or food particles that could be lodged and help move the food down into the stomach.

• Keep a consistent schedule and daily journal. 

The disease can become progressive in nature; the progression and symptom frequency vary.  Mildly affected dogs may have extended life spans with a much greater quality and duration of life after implementing appropriate treatment and lifestyle changes.  Scheduling life around the multiple feeding schedule, “burping” (coupage), and rest times could be a daunting challenge, but it is now common knowledge that many of the dogs are now living three to eight years post diagnosis as a direct result of these regimens.

Medication Options

Many Mega-E dogs seem to also suffer from food allergies and may have trouble digesting certain types of proteins, carbohydrates or fats.  In some, grasses, grains and saturated fats seem to be of a particular concern. In others, high fiber content may be a problem. Offering high quality, pharmaceutical grade omegas (such as salmon oil) can be beneficial if the dog can tolerate the addition in his/her nutrition plan. 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.

Acid inhibitor medications may be helpful, but they will not reverse the condition. Other than heavy doses of broad-spectrum, triple antibiotic therapies lasting a month or longer should there be even a hint of aspiration pneumonia, I eventually accepted that western medicine could only provide temporary solutions. 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. CAM** therapies should be given equal consideration to traditional medicine, and once the correct combination is established for a 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. Nebulization is used during any bout with Aspiration Pneumonia, should it occur. Interestingly, many are realizing that daily nebulization helps to keep AP totally at bay.

In some cases an underlying cause may be at play, so it is imperative that a specialist examine your dog and perform a thorough diagnostic workup. Over forty different disorders can contribute to a case of Mega-E. The most common contributing conditions seem to be:  Addison’s disease, Myasthenia Gravis, Gastroenteritis, IBD (Inflammatory Bowel Disease), bloat (GDV)***, Laryngeal Paralysis, Pancreatic Insufficiency, Polyneuropathies, and PRAA.  Hiatal and Diaphragmatic Herniations, though rare, often may be missed in the diagnosis, especially if simple radiographs were the only diagnostic tool. These disorders can contribute to the severity of symptoms. Fortunately, surgeries are possible in these instances and often the Mega-E symptoms become increasingly mild post surgery. 

Heritability

Over the past decade, growing scientific evidence suggests 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 a dog that may not appear to be affected; and, in fact, never shows any recognizable symptoms, can carry defective DNA. Some theorize that some young dogs may outgrow the ailment; and as they mature the immature, musculature and neurons that control peristalsis also mature and strengthen. While this might be true, others will progressively worsen no matter what modality or combination of modalities is tried.

Currently, no definitive genetic test exists to identify afflicted dogs, carrier dogs or even dogs without the disease, but most experts believe the illness to be genetic or congenital in origin. Because of their previous experience with and knowledge of the numbers affected in other breeds demonstrating genetic predilection, most veterinarians discourage future breeding of parents or siblings of the afflicted dogs.

Because of my experiences, it has become my mission to educate the dog community about this disorder. A specialist at Texas A&M told me they would need forty to fifty 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, but, progress will never be made if we foolishly believe Mega-E is not a potential threat to the health of the breed. Research cannot happen without the collection and storing of DNA samples, and, therefore, the Gordon Setter CHIC DNA Repository is actively seeking blood sample donations. Please visit http://www.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.

I hope this article will touch 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 our beloved breed in just a generation or two.

 * VOM Veterinary Orthopedic Manipulation 
** CAM Complementary Alternative Medicine                 
*** GDV  Gastric Dilatation & Volvulus Syndrome

 

A Summation, by Dr. Kathy Morris-Stilwell

Depending on the cause and the concomitant disorders present, canine megaesophagus can be a very manageable disease. Diagnostic limitations often limit veterinarians in their ability to completely evaluate each case as thoroughly as possible.  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 implementing vertical feeding. Since many of these dogs are prone to aspiration pneumonia, prevention (by feeding vertically, and encouraging the dog to sleep with its 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 much more. 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.

Online Resources:

UC DAVIS

www.upei.ca/cidd/Diseases/GI%20disorders/megaesophagus.htm

Dr. Diane Shelton - Myasthenia/Megaesophagus

Dr. Shelton includes a photo of the Bailey chair during a case presentation of Myasthenia complicated by Megaesophagus. Please visit her URL: http://vetneuromuscular.ucsd.edu/cases/2005/may05.html

Support Group - Megaesophagus

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.'

Eva’s Website - Megaesophagus (Daily Care, Clinical Side Conditions, Genetic Heritability)

http://www.caninemegaesophagus.org/

 

An active dog rescue volunteer, Peg McIntyre, founded Golden Beginnings Golden Retriever Rescue. As she walked the shelters, and her eyes met those of so many abandoned German Shepherd Dogs; Peg became one of the volunteers instrumental in restoring the GSD rescue program in the Houston, Texas area. She fostered many GSDs, but now knowing the GSD to be one breed most affected by Mega-E, she is amazed never to have encountered it before she brought a show quality Gordon Setter pup, and Mega-E hit home. Passionate about the need for research, interest and education to prevent future suffering, Peg has designed 'cmERp' - canine megaesophagus Education & Research project. Non-profit status will be finalized in the near future.

 

OSU Laboratory First to Discover a Virus in United States - OADDL Identifies A New Canine Parvovirus

A team of Oklahoma State University (OSU) veterinarians, virologists and pathologists at the Oklahoma Animal Disease Diagnostic Laboratory (OADDL) recently published a paper in the Journal of Clinical Microbiology on their findings from a Canine parvovirus (CPV) study. Led by Dr. Sanjay Kapil, the group is the first to describe the CPV type 2c variant in the United States. “We were quite fortunate to discover this variant,” explains Kapil. “It has been known for six years in Italy but nobody paid attention to it here until we found it last year.” Shortly after Kapil joined the OSU Center for Veterinary Health Sciences, he received a case at the OADDL. The adult dog had been vaccinated multiple times and still became sick with Parvovirus. “This was very unusual and we were totally surprised that it was CPV type 2c, which had not been found in the U.S. until then,” says Kapil. “What was so interesting was that after we described this disease, we ended up with samples from other locations here in the U.S.” A patent has been filed on the characteristics of the U.S. CPV-2c. The team reports that 500 samples were submitted from locations in south California to south Florida. The published paper has been presented at national level meetings and internationally in Italy and Melbourne, Australia. However, their work is not done. “The team work was most important. Sometimes we received ten dead puppies a day. We are working with several veterinarians and are receiving samples from cases with a history of vaccine failure,” continues Kapil. “Diagnostic laboratories need to be involved to identify CPV-2c. The disease now exists in all countries except Australia because of its geographical isolation.” According to Kapil, the disease presentation is different in that normally parvovirus does not affect adult dogs only puppies. However, since publishing their findings, the OADDL has received samples from adult dogs in Minnesota. “Veterinarians are confused because the in office diagnostic tests come up negative,” explains Kapil. “Clinically it looks like parvovirus so they send it to us. The OADDL tests it and it is parvovirus. Now world-wide (except for Australia), this particular variant can attack the heart and intestines.” He goes on to say that the mortality has been quite heavy. One breeder lost 600 puppies in one night. Without further testing, it is not known if the cause was simply this virus or if other factors were involved. “We will continue to study CPV-2c. Through collaborations with others we will search for more effective vaccines,” he promises. Of 80 cases tested by the OADDL, 26 were from Oklahoma puppies/dogs.  Of those 26, 15 tested positive for CPV-2c.  For more information on the Oklahoma State University Center for Veterinary Health Sciences, visit http://www.cvhs.okstate.edu.

Last Updated ( Monday, 14 January 2008 )