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CE

ARTICLE #1

Gastrointestinal and esophageal


CE articles help RVTs earn
foreign bodies in the dog and cat
credits toward their RVT By Jinelle Webb, DVM, DVSc, Diplomate ACVIM
certification. Internal Medicine Dept, Mississauga-Oakville Veterinary Emergency Hospital and Referral Group
Correctly answer the quiz Adjunct Professor, Ontario Veterinary College
associated with this article
to earn one CE credit.

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However much we try, our dogs and cats like no previous history of foreign body ingestion, most commonly in the distal esophagus or at
to eat things that they should not. In some and yet imaging locates a foreign body within the level of the carina. The esophagus
cases, even items that they are given, such as the gastrointestinal tract. Foreign body proximal to the foreign object is typically
a rawhide or chew, can get stuck somewhere ingestion should always be a differential dilated with air and sometimes fluid or food.
along the gastrointestinal tract. Dogs and cats diagnosis in the acutely vomiting or inappetent The upper esophageal sphincter is often visible
with gastrointestinal foreign bodies most pet, regardless of age and history. on radiographs and can be mistaken for an
commonly present with vomiting and esophageal foreign body; it should be noted
Common clinical signs associated with
decreased appetite, although some may that esophageal foreign bodies are uncommon
esophageal foreign bodies include retching,
present with lethargy and abdominal pain. in this region. In equivocal cases, a contrast
regurgitation of food and water, ptyalism,
Esophageal foreign bodies often cause agent can be administered, however there is
anorexia, restlessness and cervical pain.2,3
regurgitation, cervical discomfort, and in some a relatively high risk of aspiration of the
Less common presenting complaints include
cases, respiratory distress. If not removed contrast medium if an esophageal foreign body
dyspnea, cough, and lethargy.2,3 Clinical signs
rapidly, foreign bodies of the esophagus and is present. 2,3 It is therefore safer to perform
of gastrointestinal foreign bodies may be less
intestine are associated with a high morbidity esophagoscopy if there is a suspicion of an
pronounced than with esophageal foreign
and mortality. Gastric foreign bodies are best esophageal foreign body. Ultrasonography is
bodies, and may be intermittent. Clinical signs
removed quickly, to avoid entrance into the rarely useful in cases of esophageal foreign
can include vomiting, hematemesis, anorexia,
small intestine and possible obstruction. bodies.
lethargy, abdominal pain, or the foreign body
Diagnosis can be made via physical
may be an incidental finding.2,3 Physical Gastric foreign bodies (other than metallic) can
examination, radiography, ultrasonography,
examination may reveal ptyalism and cervical be challenging to definitively diagnose on both
and/or exploratory laparotomy. Objects can be
discomfort in pets with an esophageal foreign radiographs and ultrasound examination, as
removed endoscopically or surgically.
body. Gastrointestinal foreign bodies may have there is often gas and food material present in
a normal abdominal palpation, or there may be the stomach that can cause shadowing and
a suspicious region felt or painful area noted.3
Diagnosis masking of objects by overlying opacities.
Electrolyte abnormalities are common with Barium administration can outline some
Commonly ingested foreign bodies in dogs gastrointestinal foreign bodies, including, in gastric foreign bodies, but often does not
include bones, rawhide, toys and balls, order of most to least common, hypochloremia, provide a definitive diagnosis. However, both
greenies, fish hooks, coins, towels, socks, metabolic alkalosis, hypokalemia, and radiographs and ultrasound can strongly
underwear and nylons.1,2,3 Commonly ingested hyponatremia; hyperlactatemia is also suggest the presence of a gastric foreign body.
foreign bodies in cats include needles, string, common.2,3,4 If food and/or gas are present, then imaging
toys, elastics, plastic and hair.1,2,3 In many can be repeated after a period of fasting,
cases, the owner has witnessed ingestion of however owners should be counselled that
the foreign material, or has returned home to Diagnostic Imaging this could allow a potential object to enter the
find last night’s garbage strewn all over the small intestine.
Radiography can be suggestive or diagnostic
kitchen. However, sometimes the pet has
in many cases of esophageal and Radiography can be useful in some cases of
ingested something out on a walk, or eaten
gastrointestinal foreign bodies, especially if small intestinal foreign bodies. Plain
something in the house that is not noticed as
metallic. Esophageal foreign bodies are radiographs can reveal a suggestive gas
missing. Occasionally, foreign body ingestion
usually visible on plain thoracic radiographs.2,3 pattern indicating obstruction, and bunching of
is not witnessed by an owner in an animal with
An opacity is noted within the esophagus, intestines can be noted in linear foreign bodies

6 The RVT Journal


Gastrointestinal and esophageal foreign bodies
in the dog and cat...continued

resulting in intestinal plication.3 Abdominal the dorsal colonic wall difficult to visualize. Removal of Foreign
ultrasonography remains the most useful non- However, abdominal ultrasound is useful to Bodies
invasive method for diagnosis of small rule out colonic perforation leading to septic
The decision on whether to remove the foreign
intestinal foreign bodies.3.5 In most cases, a peritonitis.
body depends on location, clinical signs, time
shadowing object is noted within the small
The administration of contrast material in since ingestion of the item, and size, shape
intestine, typically causing some degree of
cases of suspected esophageal and and nature of the foreign body.3 Esophageal
intestinal dilation at the site of obstruction.
gastrointestinal foreign bodies is often foreign bodies require immediate removal in
The small intestine proximal to the obstruction
contemplated. As mentioned earlier, this all cases, whereas gastrointestinal foreign
is usually dilated with fluid, and this can
carries the risk of aspiration of contrast bodies may pass through the entire
extend to a markedly fluid-distended stomach
material due to the presence of gastrointestinal tract without issue.3
if the obstruction is in the upper small
regurgitation/vomiting. If aspirated, barium is Immediate removal is indicated for large
intestine. The small intestine distal to the
objects, objects with sharp points or sharp
obstruction should appear normal. In cases of
Gastric foreign bodies (other than metallic) surfaces, irregular objects, and caustic-
linear foreign bodies, the small intestine can
can be challenging to definitively diagnose containing material such as batteries or
plicate or bunch around the echogenic foreign
on both radiographs and ultrasound pennies. A discussion about the pros and cons
material. If a small intestinal foreign body is
examination, as there is often gas and food of removal of smaller objects should be
present for more than a short period, the
material present in the stomach that can performed in all cases, so that owners can
associated mesentery may be hyperechoic, cause shadowing and masking of objects by make educated decisions about whether to
and associated lymph nodes may be enlarged. overlying opacities. pursue removal.3
If free abdominal fluid is present, this may
indicate perforation, and a sample should be
obtained for cytology and bacterial culture.2,5
much better tolerated than iodine-based Esophageal foreign bodies
The presence of free abdominal air on
contrast agents, however both can have long-
radiographs or ultrasound indicates All esophageal foreign bodies are an
term consequences if aspirated. If esophageal
gastrointestinal perforation, the need for emergency requiring immediate removal.3
perforation is suspected, iodine contrast
immediate surgical intervention, and a Delay of even a few hours can greatly increase
agents are safer than barium.2,3 Contrast
guarded prognosis. the chance of esophageal stricture following
administration creates shadowing artifact in
removal. Foreign material present for an
Colonic foreign bodies are extremely rare due the stomach and small intestine (and colon) on
extended time in the esophagus, foreign
to the increased diameter of the colonic lumen, abdominal ultrasound, and will therefore
bodies that have sharp points, and foreign
and the fecal material present. Pins or other reduce the ability of this modality to accurately
bodies that expand resulting in pressure
sharp objects that have managed to traverse diagnose a gastrointestinal foreign body. It can
necrosis, are all at increased risk of
the entire small intestinal tract can become create complications at surgical removal of a
esophageal perforation. Greenies are an
lodged within the colonic wall or rectum. foreign body, as well. If abdominal ultrasound
example of a substance that expands and is at
Animals may display no symptoms, or have is available, this imaging modality is preferred
high risk of pressure necrosis, although recent
hematochezia, tenesmus, etc.2 As almost all over contrast administration.3,5 Contrast
changes to their composition have reduced
colonic foreign bodies requiring intervention administration also limits the ability to
this risk.6 Esophageal perforation, and
are metallic, they are easily visualized on visualize objects endoscopically, and can
requirement for thoracotomy to address an
radiography, although often several views will damage the endoscope when suctioned.
esophageal foreign body, both result in a much
be required to definitively determine if they are Attempting to feed animals with suspected
higher morbidity, mortality and complication
in the colon or small intestine. Abdominal foreign bodies should not be performed if
rate.7 However, most esophageal foreign
ultrasound can be useful to visualize the radiography, ultrasonography, endoscopy, or
bodies can be removed endoscopically.2 There
foreign object, although fecal material can surgery is likely.
are a variety of endoscopic grasping forceps,
create shadowing that makes objects within
nets and snares that can be used to remove

7 The RVT Journal


Gastrointestinal and esophageal foreign bodies
in the dog and cat...continued

foreign objects, and ideally several different object can be sheathed in a protective covering circumferential pressure necrosis (such as a
types should be available. Occasionally, a for endoscopic removal (baby bottle liner corn cob), In these cases, there may be areas
urinary catheter with an expandable balloon technique). If a very large object, or an object of intestine with substantial damage from
can be endoscopically-placed beyond the with a very smooth, round surface (such as a pressure necrosis or excessive plication, which
foreign object, at which point the balloon can smooth rock), is present, then gastrotomy may may require resection and anastomosis.
be expanded and then used to pull the foreign be indicated. If an object is anchored in the Complications are uncommon after
body rostrally out of the esophagus. stomach but extends beyond the proximal enterotomies and resection/anastomosis, but
Approximately 10% of esophageal foreign duodenum, then endoscopic removal may not include dehiscence and septic peritonitis.1 If a
bodies cannot be removed orally and are be indicated. As for esophageal foreign bodies, large amount of small intestine is removed,
pushed into the stomach; the material can having a large number of different endoscopic then small bowel syndrome can develop. As
either be digested and passed, or removed via removal devices will increase the chance of with gastrotomies, once the foreign material
gastrotomy or endoscopic removal from the removal. Most gastric foreign bodies can be is removed, the entire gastrointestinal tract
stomach.2,3 removed rapidly and without complication. should be evaluated for additional foreign
material.
Difficulty ventilating a patient post removal Gastrotomy is a relatively simple procedure to
may indicate esophageal perforation and remove foreign material. The stomach should
pneumothorax. This is a medical emergency, be packed off, and stay sutures used to elevate
Colonic foreign bodies
and immediate thoracocentesis is required the stomach. Once all material is removed,
once the condition is diagnosed gloves should be changed prior to closure of Colonoscopy remains the most effective and
radiographically. After removal, if a perforation the stomach. The small intestine should be least invasive method of removal for colonic
is suspected based on the endoscopic thoroughly evaluated in case there are foreign bodies. Colonotomy is avoided if at all
appearance of the esophagus, or due to the additional foreign bodies present. possible due to the potential for contamination
nature of the foreign object (i.e., a sharp point), Complications associated with a gastrotomy of the abdominal cavity. However, if
then thoracic radiographs should be performed performed to remove a foreign object are radiography or abdominal ultrasound
prior to recovery. Esophageal perforation uncommon but can include dehiscence and evaluation suggests complete perforation of
requires immediate thoracotomy and surgical septic peritonitis.[Hayes]1 the colonic wall, or septic peritonitis, then
intervention, and the prognosis for recovery is exploratory laparotomy is indicated.
guarded.
Small intestinal foreign bodies
Post-procedure recovery
Enterotomy is indicated when a small
Gastric foreign bodies Esophageal foreign bodies
intestinal foreign body has been diagnosed.
The majority of gastric foreign bodies can be [Tams, Washabau]2,3 Endoscopic removal of Immediately after removal of the esophageal
removed endoscopically. However, there are small intestinal foreign bodies is rarely foreign body, the esophagus should be
specific indications for gastrotomy. If a large successful and therefore very rarely indicated. evaluated for damage. Stricture formation is
number of foreign objects are present, then [Washabau]3 For a single, focal small intestinal most likely if substantial circumferential
endoscopic removal will require a longer foreign body, one enterotomy can be damage is present.3 Even deep ulcers, if
anesthetic time, and there could be damage to performed, which is typically a relatively quick present in only a focal region, will likely heal
the esophagus with a large number of objects procedure. However, many cases will present without stricture formation. Percutaneous
being removed individually, therefore with multiple foreign bodies, which require endoscopically-placed gastrotomy tubes (PEG
gastrotomy is indicated. If an object has a very several enterotomies. Linear foreign bodies tubes) are rarely indicated after removal of an
sharp surface (such as a razor blade) or sharp often require multiple enterotomies to remove esophageal foreign body, and there is
point (such as a fish hook), endoscopic removal them safely. Some cases may present with anecdotal evidence that the passage of food
may pose too high a risk to removal through longer standing foreign bodies, linear foreign through the site of the previous esophageal
the esophagus. In some cases, the sharp bodies, or foreign bodies that result in

8 The RVT Journal


Gastrointestinal and esophageal foreign bodies
in the dog and cat...continued

foreign body may reduce the formation of a Gastric and colonic foreign bodies Gastrointestinal foreign bodies removed
stricture. Typical medical therapy includes a removed endoscopically surgically
histamine-2 antagonist or proton-pump
Immediately after removal of the gastric or Post gastrotomy or enterotomy, pets should
inhibitor, sucralfate, and feeding
colonic foreign body, the stomach or colon receive adequate analgesia, appropriate
gastrointestinal canned dog food as soon as
should be evaluated for additional foreign antibiotic therapy (cefazolin or similar), a
possible after retrieval. If there is deep
material and damage. All air and fluid should histamine-2 antagonist or proton-pump
ulceration present, delaying feeding for
be suctioned prior to completion. Typical inhibitor, sucralfate if indicated, and be fed a
24 hours is recommended. Medical therapy is
medical therapy for gastric foreign bodies gastrointestinal canned dog food. Feeding
continued for typically for 3-7 days, depending
includes a histamine-2 antagonist or proton- should be delayed at least 12-24 hours after
on the degree of damage noted. Most cases
pump inhibitor and sucralfate; a special diet is gastrotomy or enterotomy. Medical therapy is
can be discharged the same day or next day.
not usually required. If there is deep ulceration continued for typically for 7-10 days. Most
In cases with a potential for stricture
present, delaying feeding for 24 hours is often cases can be discharged 1-2 days after
formation, or any cases that present with
recommended. Medical therapy is continued surgery. Pets should be monitored closely for
regurgitation, ptyalism, or cervical discomfort
for typically for 3-7 days, depending on the evidence of pain, fever, vomiting and
after esophageal foreign body removal, repeat
degree of damage noted. There is no specific inappetence, and should be seen immediately
endoscopy is recommended approximately
medical therapy for colonic foreign bodies post if any of these symptoms develop.
5-7 days after removal to assess for
endoscopic removal; occasionally antibiotic
esophageal stricture formation.
therapy may be pursued if deep penetration of
the colonic wall is suspected. Most cases of
gastric or colonic foreign body can be
discharged the same day.

Esophageal foreign bodies require immediate removal in all cases, whereas gastrointestinal foreign bodies may pass through the entire
gastrointestinal tract without issue.

Figure 1a ■ Lateral thoracic radiograph revealing a gastroesophageal foreign Figure 1b ■ The foreign body (Figure 1a)
body (bone) in a Shih Tzu. visualized in the esophagus endoscopically.
The foreign body was removed with a snare
via flexible endoscope.

9 The RVT Journal


Gastrointestinal and esophageal foreign bodies
in the dog and cat...continued

Figure 2a ■ Lateral thoracic radiograph showing a large Figure 2b ■ Lateral abdominal radiograph revealing a foreign body (large
esophageal foreign body (bone). hairball) in a cat, causing vomiting and anorexia.

Figure 3a ■ Ultrasound examination Figure 3b ■ Ultrasound examination Figure 4a ■ Mild, patchy but circumferential
showing a large, shadowing foreign object showing a shadowing foreign body (sock) in erosion after removal of a distal esophageal
in the stomach of a Doberman puppy. The the small intestine of a mature Standard foreign body.
dog had been seen ingesting the foam pad Poodle; the small intestine distal to the
used to support his ear post-cropping; the foreign body (right side of image) returns
object was retrieved endoscopically. abruptly to normal.

Figure 4b ■ Deep, focal ulceration after removal


Dr. Jinelle Webb of a sharp, bony esophageal foreign body.
Dr. Jinelle Webb completed her Small Animal Internal Medicine
Residency and DVSc in 2005 at the Ontario Veterinary College, and
obtained board certification with the American College of Veterinary
Internal Medicine that year. In 2006, Dr. Webb started the Internal
Medicine Service at the Mississauga-Oakville Veterinary Emergency
Hospital. Dr. Webb has also spearheaded the rotating internship and
Internal Medicine residency programs at this practice. She is an Adjunct
Professor at the OVC.
Dr. Webb's main clinical research interests include: investigating the use of laboratory
testing and non-invasive imaging modalities in healthy dogs and cats, developing novel
approaches to internal medicine procedures and investigating ways to reduce the
invasiveness of procedures. She is a published author and speaker.

Full references for this publication are available at


www.oavt.org.

10 The RVT Journal

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