Through the scope balloon dilatation of post-traumatic esophageal stricture in dog – case report


Author Emil Ofner

Emil Ofner DVM, Only sky’s the limit

Emil Ofner DVM, Veterinary Clinic More

Authors : Emil Ofner, DVM
Davor Crnogaća, DVM
Ivica Ukić, DVM
Silvijo Tarasić, Eng; OLYMPUS d.o.o. Zagreb

Small Animal Veterinary Clinic More, Šibenik, Croatia
Key words : esophageal stricture, balloon dilatation, regurgitation

Abstract :

Many diseases can cause esophageal stricture formation. Strictures in dogs are most frequently caused by foreign objects trapped in esophagus. The easiest way to diagnose and treat esophageal strictures is with flexible gastroscopes. Although there are lots of ways to dilate stricture, through the scope method, using esophageal balloon catheter is simple and safe method enabling direct visualisation of whole procedure.

Introduction :

Table 1

table 1

Post-traumatic esophageal strictures in small animals are relatively rare problems. Most common cause of post – traumatic esophageal strictures is foreign body entrapment in the esophagus. Also, post – traumatic endoluminal strictures can be caused by caustic material ingestion or as a complication of esophageal surgery. In all of these situations damage of esophageal wall layers causes local inflammation with production of fibrous connective tissue. Local fibrosis or scar formation causes reduction of esophageal diameter thus causing stricture. Common symptoms of esophageal strictures are : regurgitation, salivation, dysphagia and ptyalism. Treatment is usually dilatation with balloon catheters or different types of cylindrical tubes called bogies (Table 1).

Case presentation :

Picture 1

Picture 1. Olympus BE – 6 esophageal balloon catheter and hand held saline pump

Female, 9 years old West Highland White Terrier was brought to our clinic because of chronic regurgitation that lasted for four weeks. Prior to this, dog ingested bones and vomited them after five days. She could drink water and take liquid food. Solid food was regurgitated immediately after ingestion. Rectal temperature was normal but she lost 0.84 kg of body weight. Complete blood count and biochemistry values were normal. Radiographic examination didn’t reveal any cause of regurgitation. At this point we decided to do a flexible endoscopy examination of esophagus, which revealed 4 mm diameter stricture in distal part of thoracic esophagus.

Management and Outcome :

Picture 2

Picture 2. Esophageal stricture

Picture 3

Picture 3. Through the scope method of introducing balloon catheter into stricture

Dog was put under general anesthesia and intubated. Olympus GIF Q10 flexible gastroscope with 2.8 mm working channel was introduced into esophagus. After this, Olympus SWIFT balloon catheter (model BE – 6 ) was introduced through the working channel into the stricture ( through the scope method ). To generate force for stricture dilatation, catheter was expanded using saline and hand held Swift pump, two times for duration of two minutes. Steroid ( tramcinolone 40 mg / ml ) diluted with saline 1 : 2 was injected submucosally in three places around the stricture ( Pictures 1 to 5 ). After procedure, we prescribed omeprazole ( 1 mg / kg PO q24h ) for 7 days. After three weeks whole procedure was repeated. On next check-up dog regained normal body weight and was eating solid food without any problems.

Discussion :

Picture 4

Picture 4. Expanding balloon catheter with saline

Picture 5

Picture 5. Triamcinolone application

From a biomechanical perspective, all types of dilators ( balloons and bougies ) generate two types of forces on esophageal wall, radial stretch force which is responsible for dilatation and unwanted longitudinal shear force which can cause esophageal perforation ( Table 1 ).
Through the scope balloon dilatation of esophageal strictures is an easy and relatively safe procedure. Stricture dilatation occurs because saline filled balloon transfers radial stretch force on esophageal wall. Complications like esophageal preforation rarely occur when using balloon catheters because of low longitudinal shear force. Mean shear force of balloon catheters is 1,44 N. Low shear force of balloon catheters is associated with significantly lower risk for perforation.
When using other types of dilators like bougies, in theory perforations are more likely to occur because of strong radial and shear forces.Bougies involve passing long rigid instrument ( rigid cylindrical tube ) through the stricture blindly or by endoscopic guidance. Advancing bougie through stricture generates radial force which causes dilatation of stricture, but it also generates strong shear force which can cause perforation. Mean shear force when using bougies is 16,92 N for Maloney type and 6,92 N for Savary – Gilliard bougie.
Steroid injection prior or after dilatation improves outcome because it’s decreasing scar formation and need for repeated dilatations. Most cases will need repeated procedure in three weeks. If the dog is eating normally after 3-4 weeks it probably wont need new dilatation procedure.
After procedure, anti-acids are prescribed to reduce potentially negative effect of gastric acid on new scar formation. Use of proton pump inhibitors like omeprazole is recommended because of better effect than H2 receptor antagonists ( ranitidine, famotidine ).

Acknowledgments :

We are thankful to Mr. Silvijo Tarasić and Olympus d.o.o. Zagreb who provided technical expertise that greatly assisted us in implementing new technology improvements in our practice.

References :
1. Adamama-Moraitou KK, Rallis TS, Prassinos NN, Galatos AD. Benign esophageal stricture in the dog and cat: A retrospective study of 20 cases. Can J Vet Res. 2002 Jan;66(1):55-9.
2. Leib MS, Dinnel H, Ward DL, Reimer ME, Towell TL, Monroe WE. Endoscopic balloon dilation of benign esophageal strictures in dogs and cats. J Vet Intern Med. 2001 Nov-Dec;15(6):547-52.
3. Harai BH, Johnson SE, Sherding RG. Endoscopically guided balloon dilatation of benign esophageal strictures in 6 cats and 7 dogs. J Vet Intern Med. 1995 Sep-Oct;9(5):332-5.
4. McLean GK, LeVeen RF. Shear stress in the performance of esophageal dilation: comparison of balloon dilation and bougienage Radiology. 1989 Sep;172(3 Pt 2):983-6.
5. ASGE Technology Committee, Siddiqui UD, Banerjee S, Barth B, Chauhan SS, Gottlieb KT, Konda V, Maple JT, Murad FM, Pfau PR, Pleskow DK, Tokar JL, Wang A, Rodriguez SA. Tools for endoscopic stricture dilation. Gastrointest Endosc. 2013 Sep;78(3):391-404. doi: 10.1016/j.gie.2013.04.170.



The gastro-esophageal intussusception


Dr Constantin Ifteme

Constantin Ifteme , DVM

Small Animal Veterinary Clinic Blue Vets in Bucharest , Romania


The gastro-esophageal intussusception

The gastro-esophageal intussusception is an acute pathological state, caring a grave prognostic. It appears as an intussusception of a part or the whole stomach in the distal esophageal area.
The causes and mechanisms are not well known, but it appears that the main predisposing factors involved are: the laxity of the esophageal hiatus, esophageal hipomotility and megaesophagus.

Clinical case


Endoscopy view

I will try to be as thorough as possible in these few lines. The case had more than one medical complaints, rarely encountered and diagnosed in veterinary medicine, but fairly interesting for us, surgeons.

Kino is a 5 year old Berger Blanc Suisse patient known for his gastro-esophageal pathology. He was diagnosed at the age of 6 months with congenital megaesophagus. A few months later he was diagnosed endoscopically with ulcerative gastritis cause by Helicobacter (diagnosed on cytology). He suffered three interventional endoscopies – one for removing a foreign body and the other two for dilating the hypertrophic cardiac sphincter with an achalasia balloon.
From when he was first diagnosed with megaesophagus, Kino received antisecretory, antiemetic and prokinetic treatment, and he was fed blended food from a vertical surface.
At this time, Kino’s clinical signs were far worse than all the other appointments in the clinic. The owner complained he had been vomiting and regurgitating after drinking water for no less than 40 times in the past 12 hours.

Clinical signs
• Poor general state
• Mild dyspnea
• Lethargy
• Purulent nasal discharge
• Hypersalivation
• Mild hyperemia of the mucous membranes
• Halitosis

• CRT > 5sec
• Severe dehydration 10%
• Crackles on pulmonary auscultation
• Weak pulse
• BP 8/5
• Body temperature 38,7

Abdominal palpation was unrewarding. The patient was cachectic, weighing 25kg (low under the breed standard bodyweight of 40kg).
We drew bloods for a complete blood count, biochemistry and a electrolyte count and set up a peripheral iv line for fluids and symptomatic medication.

The blood work showed:


Blood test


Blood test


Dog Kino

• Slightly decreased HCO3 due to the hypovolemic shock
• Blood pH level 7,46
• Mild increase of BUN and Creatinine levels due to dehydration
• Mild hypoalbuminemia due to the esophageal pathology
• Leukocytosis with high Neutrophil, Monocyte and Basophil counts
• Mildly increased platelet counts

Based on the clinical signs and the results of the blood work we suspected an acute inflammatory / septic process, but we couldn’t figure out the primary cause of these severe symptoms.
We then recommended an ultrasound examination and x-rays. The A-FAST abdominal ultrasound we couldn’t see the stomach and spleen.
The x-rays showed an increased opacity in the thoracic segment of the esophagus (most likely food content). Furthermore, another increased, oval, well defined opacity was noticed in the caudal area, next to the cardiac sphincter. The measurement was 179mm/89mm. The lungs also presented an increased interstitial pattern.

Recommendations: endoscopy.



Kino’s x-ray


Kino’s x-ray

During this time Kino was on CRI with: Ringer fluid and Duphalyte and received antiemetic and antisecretory medication (maropitant and pantoprazole). He also received antibiotic therapy with ceftriaxone.

His clinical signs did not improve whatsoever during the first 12-15 hours since admission in the clinic. Moreover, he was now vomiting blood.
The clinical signs and the tests results pointed out a presumptive diagnosis of gastro-esophageal intussusception and aspiration pneumonia.

Once the owners signed the consent form, we had the patient sedated with butorphanol and midazolam for the surgical preparation.

On complete sedation, the patient was gently aspired with the surgical vacuum to prevent the worsening of the preexisting clinical signs (aspiration pneumonia)
We induced the patient with propophol and preceded the endoscopic examination with a large caliber Olympus video-endoscope, commonly used for digestive tract procedures. We found large quantities of liquid and purulent discharge in the respiratory tract (larynx, trachea and bronchi), which we completely aspired. We then had the patient intubated and anesthetized with isoflurane.

The next step was the endoscopic examination of the esophagus where we vacuumed a mixed liquid and food content, found in large quantities. In the lumen of the distal esophageal area we could see the gastric mucosa.
The gastric mucosa presented with hyperemia and small ischemic areas. We tried to endoscopically reposition the stomach in the abdominal cavity, but with no results.
The third step of the procedure was the exploratory laparatomy with diagnostic and curative intend. Upon examination we noticed the mispositioning of the stomach and partly the spleen.


Dog Kino



We repositioned the stomach and the spleen by gently pulling the duodenum until we saw the antral area and continued with gentle pulling of the stomach until we achieved continuity of all the digestive segments.
The cardiac and the fundic areas of the stomach showed inflammation and the gastric mucosa was hypertrophic. No ischemic lesions were noticed due to prolonged stasis. We also assessed this finding during the post-interventional endoscopy. The spleen was partly torsed in a small region, near the splenic head.



We continued exploring the abdominal cavity and found a lax area near the diaphragmatic hiatus, which had contributed significantly to the “herniation” of the stomach in the mediastinum and ultimately in the esophagus – therefore Kino was also diagnosed with hiatal hernia.

We reduced the hernia by placing resorbable sutures near the diaphragmatic pillars. During this procedure, we placed a large caliber oral-gastric tube (12mm) in the lumen of the esophagus to prevent any potential strictures.

We continued the surgery with a gastropexy, placing sutures from the gastric antrum area to the right abdominal wall, next to and including the 12th rib.
Finally, at the end of the laparatomy, we “washed” the abdominal cavity with saline at body temperature (38 degrees C) and then aspirated the content with the surgical vacuum.
We ended the procedure with a tracheobronhical lavage and aspiration with saline at body temperature.
The final endoscopic examination of the superior digestive tract, esophagus and stomach showed that the pathological changes had been reversed and the prognosis in this case is favorable.


Dog Kino

 During anesthesia, the patient’s vitals were:
• spontaneous breathing: 8-10 rpm
• sinusal cardiac rhythm
• heart rate 90 bpm
• blood pressure 11/8
• Oxygen saturation 98%-100%
• Rectal temperature at the end of the surgery: 36,50C
Postoperative the patient received:
• Pain medication – fentanyl
• NSAIDs – meloxicam
• Antibiotics – a triad with ceftriaxone, enrofloxacine and metronidazole
• IV fluids: with isotonic solutions and duphalyte
• Parenteral feeding with peripheral kabiven
• Antisecretory medication – pantoprazole and ranitidine
• Injectable multivitamins
Postoperatively we restricted food for 48 hours, followed by prebiotics administration and highly protein canned food. We will remove the sutures 10-12 days following surgery.

The following exams will be necessary following surgery:
• Complete blood count, serum biochemistry and electrolyte count
• Thoracic X-rays
• Barium X-rays


Dog Kino

• Endoscopic examination of the: bronchi (taking samples for cytology, bacteriology and mycology) and the digestive tract.

The gastro-esophageal intussusception is a major surgical emergency, having severe clinical signs, irreversible with conservative therapy and caring a grave prognosis.
The endoscopic examination and the x-rays are the most important tests for a definitive diagnosis.
If the simple x-rays are inconclusive, barium x-rays will show a esophageal obstruction.
The treatment is surgical and it requires repositioning the stomach in the abdominal cavity, gastropexy and rectifying the hiatal hernia. The endoscope can also be used curatively in the treatment of small gastro-esophageal intussusceptions by blowing air in the esophagus.
Possible complications:

• Esophagitis
• Gastric wall necrosis
• Splenic torsion
• Peritonitis
• Septicemia
• Circulatory collapse


Thank you for sharing! It is Vets on the Balkans !

Authors- DVM Constantin Ifteme – The Veterinary Endoscopic and Digestive Tract Surgery Center, Bucharest
Associate Professor Cristian Daniel M.D.,Ph.D. – UMF Carol Davila Bucharest
Blue Vets team – The Veterinary Endoscopic and Digestive Tract Surgery Center, Bucharest