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Case Report: Oesophageal Stricture in a Jack Russell Terrier

Vomiting, regurgitation or possibly both?

 Signalment and history

A ten year old, male entire, Jack Russell Terrier was referred with a history of vomiting and weight loss. Six weeks previously he had run into a barbed wire fence and had suffered caudal abdominal trauma. A lacerated penis and bladder rupture had been successfully repaired and marked azotaemia had resolved following fluid therapy. However, one week later he suffered acute onset vomiting of undigested food following every meal. The owner described many of these events as true vomiting with abdominal effort and retching. However, some occurred so closely following feeding that some passive regurgitation was also suspected. There had been no diarrhoea and the dog had remained bright with a good appetite. Over the last month he had only been able to tolerate liquid feeding and his bodyweight had fallen from 12.8kg to 11.3kg.

Examination and initial investigations

fig.1 - endoscopic view of caudal oesophagus reveals narrowing of the lumen with a stricture present distally

On presentation the dog was bright and alert but with a poor body condition score (2/5). Clinical examination was unremarkable apart from some abdominal guarding. Serum biochemistry, routine haematology and urinalysis were also unremarkable as was survey radiography and abdominal ultrasonography. Endoscopy revealed the presence of an oesophageal stricture at the level of the cardia (figures 1 & 2).

fig.2 close-up endoscopic view of stricture

There was no active oesophageal ulceration but, since the stricture was so narrow, it was not possible to examine the stomach (our smallest scope with a diameter of only 3.6mm could not be passed).

Treatment

Endoscope guided balloon dilation was performed to stretch the oesophageal stricture, facilitating visualisation of the stomach and small intestine. The duodenal mucosa appeared diffusely pale and patchy with a rough, cobble stone appearance (fig. 3). Multiple gastric and duodenal pinch biopsies were taken. The dog was then managed with frequent and elevated feeding along with a course of sucralfate and omeprazole. An exclusion diet was used and a five-day course of high dose fenbendazole was also given. Following balloon dilation, anti-inflammatory doses of prednisolone are often given in an attempt to reduce the chance of repeat stricture formation. However, in this case steroid therapy was delayed pending the histopathology results. 

Outcome

fig.3 - Endoscopic views showing abnormal duodenal mucosa with an irregular and heterogenous appearance. The mucosa is pale and patchy with adherent mucous strands.

Over the next few days the dog tolerated feeding reasonably well with only occasional vomiting. However, the following week he started to required sloppier food in order to prevent regurgitation, suggesting recurrence of the stricture. This was confirmed on endoscopy and balloon dilation was repeated. Histopathology of the gut biopsies revealed a marked cellular infiltrate consistent with lymphocytic-plasmacytic enteritis. Since occasional vomiting had persisted, prednisolone therapy was now started. Over the next few weeks the vomiting gradually resolved and the dog regained his previous body weight.

Discussion

Although balloon dilation of oesophageal strictures can achieve excellent outcomes, many patients require multiple dilation procedures and some will continue to re-stricture regardless of intervention. Resolution following only two dilation procedures was therefore a good outcome in this case. The initial cause remains uncertain; it may simply have arisen as a post-anaesthetic complication following the recent surgery. Another possibility is that it may have stemmed from acid reflux subsequent to vomiting; either as a result of transient uraemic gastritis at the time of the initial trauma or alternatively stemming from the ongoing enteritis. This was an unusual case since a combination of regurgitation and active vomiting were present simultaneously, making interpretation of the clinical signs rather challenging. However, it highlights how endoscopy can be an extremely useful tool for both the diagnosis and treatment of gastrointestinal disorders.