50 | How to successfully manage oesophageal foreign bodies in cats and dogs

PodcastGastroenterology
Written By Laura Jones

Today, we’re talking about one of the most challenging oesophageal disorders to manage - oesophageal foreign bodies.

 

Patients with oesophageal foreign bodies can vary from being well at the time of presentation to ones with significant, chronic obstructions where patients are significantly unwell at the time of presentation. 

Removal is risky, and complications like pneumothorax are very real, but by understanding the primary considerations for these patients, we can start preparing for them, minimising complications, and giving even better care.

What is an oesophageal foreign body, and what objects cause the most significant issues?

An oesophageal foreign body is any ingested item that fails to pass into the stomach after it is swallowed. Usually, this is a bone, but any large piece of food, apple cores, hairballs, treats such as rawhide chews, and sharp objects such as needles and fish hooks can also become lodged in the oesophagus.

These items usually lodge in the areas of the oesophagus that distend the least—at the level of the thoracic inlet (near the heart) or just cranial to the diaphragm.

Oesophageal foreign bodies can be seen in dogs and cats, though the disease is much more common in dogs, as they are far more likely to eat anything!

What problems do these foreign bodies cause?

The severity of our patient’s condition depends on a few things:

  • Whether the patient has a partial or complete obstruction

  • How long the obstruction has been present

  • Whether the obstruction has caused oesophageal perforation.

Patients with oesophageal foreign bodies are often painful and unable to keep down food and sometimes also water, meaning they are at risk of significant fluid and electrolyte abnormalities at presentation - especially if the obstruction has been present for several days.

Removing these foreign bodies also risks oesophageal perforation - risking complications like pneumomediastinum and pneumothorax, pyothorax, pleuritis and mediastinitis.

Secondary oesophageal inflammation also results from the mechanical irritation of the foreign body on the oesophageal mucosa, and as this heals, these patients can develop oesophageal strictures.

Just like our megaoesophagus patients from episode 49, any regurgitating patient risks aspiration pneumonia - this too is a considerable complication in patients with oesophageal foreign bodies, and we’re often left managing not just the foreign body but secondary aspiration pneumonia, too.

So, what signs do we see in our oesophageal FB patients?

Sometimes, our clients will be immediately aware that their animal has eaten something inappropriate, and we will see these patients shortly after ingestion - which carries a much better prognosis, as there has been less time for oesophageal damage and fluid/electrolyte abnormalities.

However, in most cases, our patients present hours or days after foreign body ingestion, with signs such as:

  • Lethargy,

  • Oesophageal pain,

  • Low head carriage,

  • Repeated gulping or excessive swallowing,

  • Regurgitation,

  • Anorexia,

  • Hypersalivation.

If the patient has secondary aspiration pneumonia, they might also present with coughing, tachypnoea, dyspnoea, and pyrexia.

And how do we diagnose them?

Radiography is the primary way we identify oesophageal foreign bodies. 

Most foreign bodies are radiopaque and can be seen easily on plain radiographs, but contrast can be used if a radiolucent object is suspected.

In these cases, we avoid using barium for several reasons. 

Firstly, there is a risk of oesophageal perforation, and if that is the case, we want to use a sterile, water-based contrast agent like iohexol. 

Secondly, we’ll need to perform an endoscopy to remove the foreign body - and barium hates endoscopes. It causes endoscope damage and obscures the endoscopist’s view. Therefore, we tend to wait 24 hours after performing a barium study before performing any gastrointestinal endoscopy. In a foreign body patient, we don’t have 24 hours to wait - meaning we need to reach for an endoscope-safe contrast agent. 

Lastly, these patients also have regurgitation and an increased aspiration risk - and the last thing we want is for them to aspirate barium.

Aside from identifying the foreign body, thoracic radiographs can also document perforation and associated inflammation or infection and document evidence of aspiration pneumonia.

The foreign body from our patient’s X-ray visualised with endoscopy.

What about endoscopy?

You can also visualise your foreign body endoscopically - we tend to do this at the time of removal, but if you’re unsure if a foreign body is present or not based on radiography, we can examine the oesophagus endoscopically.

Alongside identifying the foreign body and facilitating its removal, we can examine the oesophagus for signs of severe inflammation, focal necrosis or perforation.

The foreign body from our patient’s X-ray visualised with endoscopy.

So, we’ve found our foreign body. What are we going to do next?

Any foreign body, once identified, needs emergency removal. The best way to do this is determined based on the patient’s condition, the specific foreign body, the obstruction duration, and the available facilities.

Let’s talk stabilisation.

Before we anaesthetise our patient and remove their foreign body, we need to stabilise them. This means addressing dehydration and electrolyte imbalances and providing appropriate analgesia as these patients are often painful.

Anti-emetics may also be given to minimise opioid-associated nausea or vomiting, and antacids such as omeprazole may also be given to minimise further oesophageal injury from reflux of the acidic stomach content into the oesophagus.

Once these pre-anaesthetic considerations have been addressed, we can think about removal.

And how will we remove the foreign body?

In most cases, we can remove the foreign body per os using a flexible endoscope and retrieval forceps. However, when the foreign body cannot be safely pulled out, we may push the oesophageal foreign body into the stomach instead. 

From here, the foreign body can either be removed surgically or left for the body to break down, depending on what the foreign body is. Many food items, for example, can be left for the GI tract to break down.

Endoscopic foreign body removal carries a risk of oesophageal perforation and subsequent pneumothorax. So, monitor these patients closely during removal, and always have thoracocentesis equipment on hand throughout the procedure.

If endoscopic retrieval or advancement is unsuccessful or there is a high chance of oesophageal rupture, a surgical approach may be used.
However, an oesophagotomy is a challenging procedure, especially if the thoracic oesophagus is affected since these patients will require a thoracotomy.

Once the foreign body has been removed, we must examine the oesophagus and assess the degree of inflammation and necrosis. If severe, a PEG tube may be placed to allow nutrition to be administered whilst bypassing the damaged area. However, this is a controversial topic, as many clinicians prefer to keep the oesophagus open and prevent strictures via oral feeding.

How will we manage the patient after their foreign body is removed?

After removal, we must continue supportive medical management, including fluid therapy, antiemetics and antacids, and appropriate analgesia.

Gastroprotectant medications like sucralfate are also used - these need to be administered by mouth since they sit over the inflamed oesophagus and act as a barrier, protecting the mucosa whilst it heals.

Nutritional support is also vital. We’ll feed these patients by mouth or via a PEG tube, depending on the individual patient and the clinician’s preference. Like any other medical patient, we’ll calculate their energy requirements and adjust this for the duration of any anorexia present.

If feeding orally, we’ll hold the patient up for 15-20 minutes after feeding, just like we would do a megaoesophagus patient.

Medical management and supportive care are continued until the patient is well enough to be discharged. Complications like stricture formation are common, so clients should be advised to monitor for ongoing regurgitation. We often repeat endoscopy around 2 weeks after foreign body removal to examine for signs of stricture formation. If our patient has had a PEG tube placed, we can remove it simultaneously (if it is no longer needed).


So there you have it - my guide to managing patients with oesophageal foreign bodies. We see these relatively commonly, especially in dogs, and they do best with prompt diagnosis and emergency removal. After removal, careful nursing management, especially considering analgesia, fluid balance and nutrition, is needed, alongside monitoring for any ongoing complications.

Did you enjoy this episode? If so, I’d love to hear what you think. Take a screenshot and tag me on Instagram (@vetinternalmedicinenursing) so I can give you a shout-out and share it with a colleague who’d find it helpful!

Thanks for learning with me this week, and I’ll see you next time!

References and Further Reading

Laura Jones
Next

49 | How to easily care for patients with megaoesophagus as a vet nurse