QUARTERLY BEAT / OCTOBER 2023 ///
/// QUARTERLY BEAT / OCTOBER 2023
STEP 3: LAVAGE (Note: this step is controversial and in many cases not necessary) • Create water column behind obstruction to soften and/or help advance into stomach • Requires mindful use of pump and adequate water (and water only!) while head is held down for safety • Pump until sufficient water goes in that it begins to flow back out nostrils
Diagnosis is generally relatively straightforward and involves consistent clinical signs and identification of an obstruction when attempting passage of a nasogastric tube. In more complicated cases, additional diagnostic modalities may be considered, including but not limited to endoscopy, ultrasound, radiographs +/- contrast, and ruling out other reasons for dysphagia (i.e., neurologic exam). Relieving the Obstruction STEP 1: PREPARATION • Key to success is appropriate preparation – of horse AND owner • Appropriate preparation of the horse involves adequate sedation and esophageal relaxation - Sedation key for patient tolerance of procedures (and thus client satisfaction), relaxation of the esophagus to facilitate bolus passage, and patient safety • Sedation with alpha-2 agonist of appropriate duration of action +/- opioid is preferred • No attempts to pass tube or relieve choke should be made prior to overt signs the horse is heavily sedated (i.e., nose close to ground, minimal response to stimuli, etc.)
IN THE HORSE Esophageal Obstruction
STEP 4: ATTEMPT TO PASS TUBE DURING LAVAGE • While pumping water in, gently use end of tube to advance obstruction • Continue until can advance into stomach (or STOP if no progress)
Clinical Assistant Professor, Large Animal Surgery and Emergency & Critical Care University of Georgia, College of Veterinary Medicine Naomi E. Crabtree DVM, MS, DACVS-LA, DACVECC-LA
STEP 5: REPASS THE TUBE • Once you think the obstruction has been relieved, repass to be sure • Sometimes, may have managed to push past it and then re-encounter obstruction on second pass STEP 6: CONSIDER POST-RESOLUTION CARE • Once obstruction is relieved, decide what (if anything) the horse needs; this may include: - Fluids - Antibiotics - Analgesics - Feeding plan (TIP: wait to feed and wait to house on bedding until back on feed) - Oral exam - Endoscopy? - Referral? When to Refer • Cases for which referral should be considered include: - Failure to resolve the obstruction - Concerns regarding the state of the esophagus - Concerns regarding the overall systemic picture of the patient • At the referral hospital, advanced management options include: - Repeated rounds of sedation/esophageal relaxation and lavage
LARGE ANIMAL WEBINAR
In this 1-hour, VETgirl large animal webinar, Naomi Crabtree, MS, DVM, DACVS-LA, DACVECC-LA reviews the clinical presentation, diagnosis, and treatment of equine esophageal obstruction. Tune in for tips and tricks for a successful outcome, a review of appropriate post-resolution care, and referral options for complicated cases!
WATCH FULL WEBINAR
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In addition, the use of other chemical means of esophageal relaxation can be of great help - May include things like: buscopan for smooth muscle relaxation; oxytocin for striated muscle relaxation (mechanism not well understood); or intra-esophageal lidocaine
ESOPHAGEAL OBSTRUCTION Esophageal obstruction can be divided into primary or secondary obstructions. Primary obstructions are what we typically think of when we think about choke: some kind of intraluminal obstruction – most commonly with feed. Intraluminal obstruction with things other than feed can occur, but this is uncommon. Common risk factors for primary obstruction include: • Poor dentition (reported in >90% of cases in one study) • Bolting of feed (especially dry cubed or pelleted feed, inadequately soaked beet pulp, carrots, or apples) • Recent sedation or anesthesia • Dehydration or debilitation • Refeeding too soon following resolution of choke (or NOT feeding but allowing access to bedding)
• Anatomical abnormalities, which may be: - Intramural (e.g., tumors, strictures, diverticula, cysts, etc.) - Extramural (e.g., neoplasia, vascular ring anomalies, abscess, etc.) • Functional abnormalities, such as: - Megaesophagus - Neurologic dysfunction CLINICAL PRESENTATION & DIAGNOSIS Clinical signs of choke include: • Stretching • Retching • Coughing • Feed or foamy nasal discharge • Hypersalivation • Palpable bolus in the cervical region (reported in as many as 88% of cases in one study) • Signs attributable to sequelae (e.g., dull demeanor, fever, respiratory signs) • Panic
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In addition to adequate preparation of the patient, preparing the owner is just as crucial for success - Before attending the emergency, prepare owner for how things are likely to go - Good time to explain you may not relieve the
obstruction right away, and that it may take additional rounds of sedation, muscle relaxation, and patience
STEP 2: PASS NASOGASTRIC TUBE • Have handler hold head as close to ground as possible (applying poll pressure can help) • Choose relatively firm, inflexible tube (can put it in cold water or fridge/freezer ahead of time if needed!) • Pass until encounter obstruction and stop • Gently use tube to palpate the bolus and get a feel for how “stuck” it is
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Webinar Highlights
Secondary obstruction is obstruction due to some other disease process. This can include:
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VETGIRL BEAT EMAGAZINE | VETGIRLONTHERUN.COM
VETGIRL BEAT EMAGAZINE | VETGIRLONTHERUN.COM
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