History
A 3-year-old sexually intact male Dogue de Bordeaux was evaluated because of respiratory distress. The patient had been admitted earlier at the referral clinic because of vomiting and regurgitation with subsequent development of dyspnea and cyanosis. The dog had a history of megaesophagus and renal disease, which had been diagnosed at 10 weeks of age. On initial evaluation, the dog was laterally recumbent. Physical examination revealed hypothermia, mild cyanosis, tacky mucous membranes with prolonged capillary refill time, and labored breathing. The lungs could be auscultated in all lung fields, and findings on abdominal palpation were unremarkable. Blood gas analysis revealed severe metabolic acidosis and a high lactate concentration. Measurements of PCV and serum total protein, blood glucose, and BUN concentrations revealed high serum total protein and BUN concentrations (PCV and blood glucose concentration were within reference ranges). Radiography of the thorax was performed (Figure 1).
Right lateral (A) and ventrodorsal (B) radiographic views of the thorax of a 3-year-old dog with acute vomiting, regurgitation, and subsequent dyspnea and cyanosis. The lateral image was acquired before death and the ventrodorsal image was acquired after death.
Citation: Journal of the American Veterinary Medical Association 244, 3; 10.2460/javma.244.3.279
Right lateral (A) and ventrodorsal (B) radiographic views of the thorax of a 3-year-old dog with acute vomiting, regurgitation, and subsequent dyspnea and cyanosis. The lateral image was acquired before death and the ventrodorsal image was acquired after death.
Citation: Journal of the American Veterinary Medical Association 244, 3; 10.2460/javma.244.3.279
Right lateral (A) and ventrodorsal (B) radiographic views of the thorax of a 3-year-old dog with acute vomiting, regurgitation, and subsequent dyspnea and cyanosis. The lateral image was acquired before death and the ventrodorsal image was acquired after death.
Citation: Journal of the American Veterinary Medical Association 244, 3; 10.2460/javma.244.3.279
Determine whether additional imaging studies are required, or make your diagnosis from Figure 1—then turn the page →
Radiographic Findings and Interpretation
A right lateral radiographic image of the thorax was acquired before death, and the ventrodorsal projection was acquired after death. In the lateral view, there is marked esophageal dilation with a large soft tissue opacity mass that results in ventral deviation of the trachea and cardiac silhouette. The cranial margin of the mass is rounded, and the stomach is not evident in its normal location within the abdomen (Figure 2). These findings are consistent with a gastroesophageal intussusception. In the postmortem ventrodorsal radiograph, the diffuse alveolar pattern is more intense, consistent with lack of aeration, and the gastroesophageal intussusception persists.
Same radiographic images as in Figure 1. The esophagus appears to be markedly dilated and contains a large soft tissue opacity. Ventral deviation of the trachea and cardiac silhouette by the large soft tissue opacity is evident. The cranial margin of the mass is rounded (large arrows). Notice the diffuse alveolar pattern of the lungs (small arrow) in the antemortem lateral image, which is more intense in the postmortem ventrodorsal image and consistent with lack of aeration.
Citation: Journal of the American Veterinary Medical Association 244, 3; 10.2460/javma.244.3.279
Same radiographic images as in Figure 1. The esophagus appears to be markedly dilated and contains a large soft tissue opacity. Ventral deviation of the trachea and cardiac silhouette by the large soft tissue opacity is evident. The cranial margin of the mass is rounded (large arrows). Notice the diffuse alveolar pattern of the lungs (small arrow) in the antemortem lateral image, which is more intense in the postmortem ventrodorsal image and consistent with lack of aeration.
Citation: Journal of the American Veterinary Medical Association 244, 3; 10.2460/javma.244.3.279
Same radiographic images as in Figure 1. The esophagus appears to be markedly dilated and contains a large soft tissue opacity. Ventral deviation of the trachea and cardiac silhouette by the large soft tissue opacity is evident. The cranial margin of the mass is rounded (large arrows). Notice the diffuse alveolar pattern of the lungs (small arrow) in the antemortem lateral image, which is more intense in the postmortem ventrodorsal image and consistent with lack of aeration.
Citation: Journal of the American Veterinary Medical Association 244, 3; 10.2460/javma.244.3.279
Treatment and Outcome
The patient had developed cardiac arrest during radiography and was resuscitated twice. The owners elected euthanasia. A necropsy was performed. The caudal two-thirds of the thorax were occupied by a distended esophagus, which contained the entire inverted stomach. This distension was approximately 25 cm long and 12 cm wide. The lungs were compressed, and the right middle lung lobe was displaced medially. There was pulmonary congestion and hemorrhage in all lung lobes. The aorta was stretched over the left side of the esophagus and collapsed. The gastric mucosa was dark red and edematous. The esophageal hiatus in the diaphragm, through which the stomach had passed, was approximately 5 cm in diameter. The cranial portion of the esophagus was distended to about 8 cm in diameter and atonic. The omental attachment of the spleen was drawn into the distal portion of the esophagus, causing cranial displacement and malpositioning of the spleen.
Comments
Gastroesophageal intussusception is the invagination of the gastric cardia into the distal aspect of the esophagus with or without the spleen, duodenum, pancreas, and omentum. Although the exact etiology of gastroesophageal intussusception is not well understood, the active, retrograde motility initiated during vomiting as well as the presence of underlying conditions, such as megaesophagus or abnormal esophageal motility, may predispose dogs to this type of intussusception.1 Most cases of gastroesophageal intussusception occur in dogs < 3 months of age, with a higher percentage of cases occurring in German Shepherd Dogs.2 The higher occurrence rate in German Shepherd Dogs may be related to the increased incidence of megaesophagus in this breed.3
Immediate surgical intervention is the preferred treatment for gastroesophageal intussusception. Unfortunately, by the time a dog is evaluated for treatment and a radiographic diagnosis of gastroesophageal intussusception is determined, irreversible changes leading to vascular compromise, gastric and intestinal ischemia, and circulatory, endotoxic, and cardiogenic shock have often developed.4
Gastroesophageal intussusception should be suspected in any large-breed dog with signs of dyspnea, regurgitation, and rapid clinical deterioration. Gastroesophageal intussusception may be suspected on the basis of acute onset of clinical signs, previous history, signalment, and radiographic findings. Owners of German Shepherd Dogs and dogs with previously diagnosed megaesophagus should be made aware of this disease.
1. Pietra M, Gentilini F, Pinna S, et al. Intermittent gastroesophageal intussusception in a dog: clinical features, radiographic and endoscopic findings, and surgical management. Vet Res Commun 2003; 27 (suppl 1): 783–786.
2. Applewhite A, Cornell KK, Selcer BA. Diagnosis and treatment of intussusceptions in dogs. Compend Contin Educ Pract Vet 2002; 24: 110–127.
3. von Werthern CJ, Montavon PM, Flückiger MA. Gastro-oesophageal intussusception in a young German Shepherd Dog. J Small Anim Pract 1996; 37: 491–494.
4. Fossum TW. Gastroesophageal intussusception. St Louis: Mosby Elsevier, 2007;400–401.
