Regurgitation in Dogs

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Regurgitation is the backward flow or effortless evacuation of fluid, mucus, or undigested food from the esophagus. Unlike vomiting, it is not accompanied by nausea and does not involve forceful abdominal contractions. It is a symptom of esophageal disease and not a disorder in itself.

The timing of regurgitation in relation to eating is determined by the location of esophageal dysfunction, degree of obstruction, and presence or absence of esophageal dilatation.

  • Regurgitation immediately after eating is most likely to occur with proximal esophageal lesions or esophageal obstruction.

  • Regurgitation may be unassociated with eating when the esophagus is dilated, because this provies a reservoir for food and fluid.

  • Selective retention of fluids over solid food is more likely with partial obstruction.

    There are many causes of regurgitation, including:

  • Esophageal Structural Disorders – which include foreign bodies, stricture and vascular ring anomaly
  • Esophageal motility disorders – which include megaesophagus

    What to Watch For

  • Weight loss
  • Coughing
  • Difficulty breathing
  • Lethargy

    Veterinary Care

    Care should start with a discussion with your veterinarian who will obtain a medical history about your pet. The initial differentiation between vomiting and regurgitation is important because, not only are different organs involved, but also different diagnostic techniques and therapeutics are warranted. Diagnostic tests and treatment should follow.

    Diagnosis

    Diagnostic tests are usually needed to determine the cause of regurgitation. A thorough medical history is of paramount importance, confirming that your pet is regurgitating and not vomiting. A thorough physical examination is always necessary as well.

    Diagnostic tests may include:

  • Complete blood count (CBC)

  • Biochemical profile

  • Urinalysis

  • Endocrine testing (ACTH stimulation, thyroid profile)

  • Thoracic (chest) radiographs (X-rays)

  • Acetylcholine receptor antibody test, antinuclear antibody testing

  • Electromyography and muscle biopsy

  • Esophagram (barium swallow)

  • Fluoroscopy

  • Esophagoscopy

  • Blood lead and/or organophosphate levels

    Treatment

    Treatment of the regurgitating patient can either be supportive or specific, where the latter can be instituted when a known underlying cause is identified.

    Supportive therapy may consist of the following:

  • Dietary modification

  • Gastrointestinal motility (movement) enhancing drugs

  • Acid blocking agents and esophageal/gastric coating agents in cases of suspect or associated esophagitis

  • Hospitalizing and restoring fluid and electrolyte balance and nutritional support in the severely ill patient

  • Antibiotic therapy in cases of pneumonia

    Home Care

    Home care recommendations depend on the underlying cause of the problem. The following general recommendations should be considered:

  • Administer all prescribed medications and practice the directed feeding instructions.

  • Watch very closely for signs that might suggest secondary pneumonia, which include labored breathing, coughing and/or general lethargy and a poor appetite.

  • Pay close attention to the body condition of your pet. Maintaining an appropriate nutritional plan can sometimes be difficult in these animals.

    • Barium study (x-ray with dye) of a dog with a persistent right aortic arch (PRAA) resulting in dilation of the esophagus.

    • Radiograph of a dog presented for persistent regurgitation due to an apple lodged in the esophagus.

    • Photograph of a megaesophagus on post mortem, after a dog was euthanized for chronic regurgitation.

    There are many causes of regurgitation. It is important to understand that although there are multiple diseases of the esophagus that cause regurgitation, there are other disorders that are considered systemic (involving the whole body), that have an effect on the esophagus, and regurgitation is only one of the symptoms being exhibited. The following are the most commonly reported disorders associated with regurgitation.

  • Megaesophagus (esophageal hypomotility) is the decreased/absent esophageal movement or peristalsis that often results in dilatation (stretching beyond normal size) of the esophagus. It may be congenital (existing from birth) or acquired (noninheritable trait that results later in life).

  • Esophageal inflammatory disease.

  • Esophagitis is an inflammation of the esophagus. It may be a primary entity or secondary to other disorders.

  • Myositis is an inflammatory/immune disorder that affects the muscles.

  • Intrathoracic extraluminal (in the chest cavity but outside of the esophagus) disease.

  • Vascular ring anomaly is a congenital disorder that causes an entrapment and compression of the esophagus and, in turn, a partial obstruction (blockage). Megaesophagus and regurgitation often occur secondary to this obstruction.

  • Intrathoracic (in the chest) tumors or masses may compress the esophagus from the outside, causing regurgitation.

  • A hiatal hernia is an abnormality of the diaphragm allowing part of the stomach to be displaced into the chest cavity. Regurgitation is one of the most common signs seen with this disorder.

  • Intraluminal (inside) esophageal obstruction.

  • An esophageal stricture is an abnormal narrowing of the esophagus, often secondary to either esophagitis or some inflammatory event, such as a foreign body.

  • Esophageal foreign bodies often cause regurgitation due to an associated esophagitis or physical blockage. Foreign bodies usually lodge at the narrowed areas if the esophagus, including the thoracic inlet, at the base of the heart, or at the hiatus of the diaphragm.

  • Tumors or masses can grow within the esophagus, causing obstruction and regurgitation.

  • An esophageal diverticulum is an out-pouching of the esophagus. It can be congenital or acquired.

  • Neuromuscular dysfunction resulting in megaesophagus.

  • Myasthenia gravis is a disorder affecting the neuromuscular (nerve and muscle)junctions often causing generalized weakness, in addition to megaesophagus/ regurgitation.

  • Polymyositis is a disorder associated with inflammation and weakness of the muscles, including the esophagus.

  • Endocrine disorders (hypothyroidism, hypoadrenocorticism) can be associated with regurgitation.

  • Certain toxicities (lead, organophosphate) can affect the esophagus and cause megaesophagus and regurgitation.

  • Systemic lupus erythematosis is an immune disorder affecting multiple systems, occasionally causing megaesophagus and regurgitation.

  • Polyneuritis is a disorder associated with the inflammation of multiple nerves, occasionally causing megaesophagus and
    regurgitation.

  • Idiopathic (unknown cause) megaesophagus is one of the most common causes of regurgitation. This is generally a diagnosis of exclusion, after all of the above diseases have been ruled out with appropriate diagnostics.

  • One of the most important considerations when managing these patients is to accurately differentiate regurgitation from vomiting. Regurgitation is one of the most commonly misinterpreted signs in veterinary medicine. Obtaining a thorough history is of paramount importance when differentiating the two.

    Not only are different organs involved, but also different diagnostic techniques and therapeutics are warranted. Regurgitation can be associated with a multitude of different disease processes, therefore, establishing the underlying cause is essential. Your pet may be very mildly affected, with infrequent and/or subtle signs, or very severely affected, with signs that warrant hospitalization for support and a more aggressive work-up.



    Diagnosis In-depth

  • A complete blood count (CBC) is most often within normal limits, however with severe inflammation/infection or anemia, one may expect to see an elevation in the white blood cell count or decrease in the red blood cell count, respectively.

  • A biochemical profile is needed to rule out other systemic disorders (liver, kidney disease) that may predispose to certain diseases associated with regurgitation.

  • A urinalysis is part of any complete baseline work-up.

  • Endocrine testing (ACTH stimulation test and thyroid assays) should be performed to rule out regurgitation associated with hypoadrenocorticism or hypothyroidism.

  • Antinuclear antibody (ANA) titers are performed to help rule out immune-mediated diseases (such as systemic lupus erythematosis) associated with regurgitation.

  • Thoracic (chest) radiographs (X-rays) are needed to evaluate the size/shape of the esophagus, assess for the presence of a foreign body, growth or megaesophagus and assess the lungs for the possibility of secondary pneumonia.

  • An acetylcholine receptor antibody test is a simple blood test performed on individuals with regurgitation secondary to megaesophagus to rule out myasthenia gravis. Although most often there are additional systemic signs associated with myasthenia, megaesophagus and regurgitation may be the only manifestations in certain cases.

  • Blood lead and/or organophosphate levels are run on patients who we suspect toxicities as underlying causes of regurgitation.

  • Electromyography (EMG) and muscle biopsies are recommended when a myopathy (muscle disorder) is suspected. These necessitate anesthesia, and are, therefore, associated with more risk than many of the other diagnostics described. An EMG is most often performed in a specialty hospital as specialized equipment and expertise are necessary.

  • An esophagram (barium contrast radiograph) may be indicated to rule out structural changes, such as a foreign body, growth, stricture.

  • Fluoroscopy helps assess the function of the esophagus. It evaluates the movement of solids and liquids through the esophagus. It is often necessary to have the procedure performed in a specialty facility as it requires expertise and special instrumentation.

  • Esophagoscopy (direct visual inspection of the inside of the esophagus) is a very helpful tool in diagnosing certain diseases that can cause regurgitation. Examples include esophagitis, foreign body and growths. This procedure necessitates anesthesia and is associated with more risk than some of the previously mentioned diagnostics. Most often a specialist is involved as experience and special instrumentation is needed.

    Therapy In-depth

    The following nonspecific (symptomatic) treatments may be applicable to some, but not all pets with regurgitation. These treatments may reduce severity of symptoms or provide relief for your pet. However, nonspecific therapy is not a substitute for definitive treatment of the underlying disease responsible for your pet's condition.

  • Dietary modification should include small frequent feedings of an easily digestible product. The specific disease should be addressed with the appropriate feeding regime. In particular, individuals with megaesophagus need very special attention. Generally, elevated feedings tend to be tolerated best. It is recommended to try different consistency foods, ranging from liquid/gruel to solids/kibble.

  • Motility modifying drugs (drugs that promote movement through the gastrointestinal tract), such as metoclopramide (Reglan®), can be used to stimulate movement within the esophagus and promote gastric emptying.

  • Gastric (stomach) acid inhibitors (blocking agents) are recommended to block acid secretion, therefore diminish the volume of acid that is refluxed (leaked backward) into the esophagus. Since esophagitis is often a component (cause or effect) of regurgitation, their use is generally recommended for symptomatic relief. Examples include a group called H2 receptor antagonists (cimetidine Tagamet®, ranitidine Zantac®, famotidine Pepcid®) or another group of drugs (proton pump inhibitors) that include omeprazole (Prilosec®).

  • Sucralfate(Carafate®) suspension (liquid) helps sooth and coat an inflamed esophagus, which is often associated with regurgitation.

  • Hospitalization may be indicated symptomatically/supportively for those patients who are extremely ill. Fluid and electrolyte replacement and/or nutritional supplementation may be indicated for certain individuals. Placing a gastrotomy (stomach) tube endoscopically or surgically may be helpful in bypassing a diseased esophagus to deliver adequate nutrition to the regurgitating patient. Alternatively, instituting parenteral (intravenous) nutrition for a period of time, while trying to identify and treat the underlying cause, might be the safer choice for the compromised patient that might be at risk having to undergo an anesthetic procedure.

  • Antibiotic therapy may be recommended in cases where secondary pneumonia is suspected, specifically if a regurgitating patient begins to cough, has difficulty or a change in breathing or becomes febrile.

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