Welcome letter from Dr. Kathy & suggested treatments

If you are a typical "newbie," you may be OVERWHELMED. That is the term
that most who join us use when referring to their feelings. Please know
that the more you read and inform yourself, the more that you will be
able to help your veterinarian. We dvm's "learn" at school and
lectures, that this is a doom and gloom disease; that couldn't be
farther from the truth in MANY cases, if we can find the right
management protocol, including meds, diet kind and consistency, etc.


You have probably already received, or will receive, tons of info from
the folks on the megaesophagus board, and it can be overwhelming. Give
yourself(selves) permission to take time to absorb as much info as you
can. Ask as many questions as you want on the board, as the folks there
have more experience w/ treating megaesophagus and myasthenia gravis
dogs, and probably aspiration pneumonia than most veterinarians. As a
veterinarian, I have learned an enormous amount about the management of
these dogs from the owners here. We work as a team/family.


Please do go to www.morrisvet.com website and get the information about
treating aspiration pneumonia w/ a nebulizer, albuterol and saline.
Quite a few dogs on this list need to receive treatments w/ the
nebulizer during their episodes w/ aspiration pnemonia, AND continue
afterwards to decrease the return of AP. If your go to
https://www.youtube.com/results?search_query=nebulizer+dog&search_type=&aq=f,
there are video's (9 separate ones - skip #1) on how to nebulize; also,
how to perform percussion therapy -
https://www.youtube.com/watch?v=hrTqco9_jiE


The more information that you provide, the better we can help. W/ your
signature, including your and your pet's name, the diagnosis, food, and
medications, with EVERY post, reminds all of us about who we are
discussing. There are so many pets that it is difficult to remember
them all. Following is a sample:


Jean w/ Robbie, 4year old, min.pin., w/ ME & MG, ID meatballs,
metoclopromide, Prilosec, recovering from AP (aspiration pneumonia),
neulizer treatments 2x/d.

I hope we can help you.

"It takes a village..."
Dr. Kathy
Dr. Kathy Morris-Stilwell
Redford, MI

On this board we are all learning and sharing ways in which to improve
the diagnosis and treatment of megaesophagus and it's associated
disorders (Aspiration Pneumonia - AP; Myasthenia Gravis - MG;
hypothyroidism; Addison's disease; Inflammatory Bowel Disease, etc). It
is with great appreciation that the members of this support group allow
my continued participation. The advise shared here is not meant to take
the place of routine and close veterinary care. No changes in
treatments should be started without discussion w/ your pet's
veterinarian. Veterinarians cannot offer medical advise unless a
patient-client relationship has been started; as I am not able to
examine your pet, all and any advise .
__________________________________________________________________
Megaesophagus fact sheet:
This is a fairly long information sheet, but, it covers a lot of information that will be helpful. More
information is located in the folders on the main megaesophagus board.

Megaesophagus fact sheet:

1) What is megaesophagus?

A NORMAL esophagus squeezes the food from the back of the throat, through the
chest, and into the stomach (see video at www.marvistavet.com, go to Library
and search for megaesophagus). With megaesophagus, part (focal) or all
(generalized) of the esophagus is paralyzed. It ends up being a flaccid tube
that just allows the food/liquid to sit within the esophagus, and not empty
into the stomach. These dogs usually have to be fed and maintained for 15-45
minutes in a VERTICAL position to take advantage of GRAVITY, to allow the food
and fluid to "fall" into the stomach. See the information on the Bailey chair
that you will receive upon joining. Also, look through the photos to see other
methods of feeding vertically (baby jumper, baby care seat, bucket stuffed w/
towels, Snugli, etc.). Most of these dogs require being held VERTICALLY
whenever drinking or eating anything, and then for 14-30 minutes after. Many
dogs fall asleep in the Bailey chair after having been fed. Most dogs do best
when being fed gruel or liquid food. Some can be fed food in a meatball form.
We want food to "slide down" the esophagus; nothing that can stick in the nooks
and crannies of the paralyzed esophagus.


Megaesophagus can also be recognized after an anesthetic procedure. If the
particular dog has GERD, a hiatal hernia, or an "opened" lower esophageal
sphincter, when they are anesthetized, some of the acid can reflux back into
the esophagus causing a sort of "burn." If the inflammation is not recognized
soon enough, a stricture can occur, which can then result in megaesophagus.
Most of the dogs on this board have idiopathic megae, or megae due to another
disorder.


Dogs can be born with it as "juvenile megaesophagus, " or have it due to a
malformation of blood vessels from the heart (they require surgery). The usual
"workup" for an adult dog who develops megae is to test for Myasthenia Gravis
(MG), Addison's and hypothyroidism, and, on occasion, lead toxicity. If no
causes are found, it is called "idiopathic" (cause unknown) megaesophagus.


2) There can also be a variety of co-existing conditions that can be associated
w/ megaesophagus

a) the sphincter between the esophagus and stomach
in megae dogs may be "lazy" and allow acidic stomach
fluids to reflux (leak back) into the esophagus. Acid
is NOT a friend to the esophagus, causing burns or ulcers.
If the stomach fluids can be made LESS acidic, it is less
likely to burn the inside of the esophagus (esophagitis).

In general, most dogs need to be tried on one of a
variety of "antacids." The most successful seems to be
Prilosec, Pepcid ADand Nexium. In people, these acid-meutralizers
are recommended to be given once daily. Twice daily seems to work
best in dogs. Chronic decreased acid, however, can cause a
Vitamin b12 and/or folic acid deficiency, so supplementation
w/ injectable b12 and/or b complex is suggested. Most owners
are taught to administer the injections.

b) Gastric motility may also be decreased. There is no
known treatment for this; however, minimizing the amount
of fat in the food, which stays in even a normal stomach,
for a longer time, may be helpful. Ie. stay away from
fatty foods, A/D, Maximum Calorie, etc. Metoclopromide,
cisapride or low dose erythromycin may help the stomach
empty more quickly. Bethenachol has also been used w/ some
success.

c) IBD - some of these dogs seem to have episodes of
IBD (Inflammatory Bowel Disorder), or, perhaps H. pylori,
which can only be diagnosed w/ endoscopy. However,
treatment w/ amoxicillin or metronidazole (or, other
antibiotic combos appropriate for these disorders) may
be considered, without endoscopy. This "syndrome" should
probably be called ANTIBIOTIC RESPONSIVE GASTRITIS/
ENTEROPATHY, as there is quite a bit of controversy about
the true involvement of the bacteria Helicobacter pylori.
- some of these dogs may also have dietary intolerances
and may be best served by being fed a hypoallergenic
diet. The most common ingredients (but, not the only ones
for dogs to be "allergic/intolerant of" are eggs, milk,
beef, chicken, soy, wheat and corn. There are few OTC
dog food that is free of all of those. Most dogs require
presciption diets; and, those are more balanced than homemade
recipes.

d) dysphagia/pharyngeal or cricopharyngeal
achalasia - Can cause difficulty/impossible swallowing of food/
fluids. If the throat is affected, some of these dogs have
a hard time swallowing fluids. Thickening agents such as
"Thicks It," or "Thick'n'Easy can be added to water, or liquid.

e) GERD - GastroEsophageal Reflux Disease and/or hiatal hernia
can be present. These dogs, in fact all megae dogs, probably
benefit from sleeping or laying slanted w/ their heads above
the bodies. A Pro-collar, which is sort of a like a human
cervical collar, which will hold the pets head more elevated,
which we believe minimizes the reflux of the acid into the
back of the throat, can be helpful.

f) Aspiration pneumonia - because of the potential for
reflux of stomach contents back up into the esophagus,
megae dogs can aspirate those fluids/acids into the
trachea and down into the lungs, resulting in aspiration
pneumonia (AP). The use of a nebulizer w/ albuterol and/or
saline is helpful for AP. Some owners feel, for those dogs
who are very prone to AP, or who have frequent attacks,
that daily nebulizer w/ albuterol treatments seem to minimize attacks.
This is not a "standard" use of nebulizer treatments, and
many dvm's, including specialists, seem to have a problem
accepting this modality. Go to http://www.morrisvet.com/
and view the "nebulizer" information sheet.

g) esophageal stricture or esophagitis - Megaesophagus can occur after
an anesthetic procedure. If the particular dog has GERD,
a hiatal hernia, or an "opened" lower esophageal sphincter,
when they are anesthetized, some of the acid can reflux
back into the esophagus causing a sort of "burn." If the
inflammation is not recognized soon enough, a stricture
can occur, which can then result in megaesophagus. Strictures
may be treated w/ bougenage (stretching of the esophagus
under anesthesia) and placement of a temporary or permanent
feeding tube. Esophagitis is treated w/ carafate liquid and acid-
inhibitors.

h) dogs w/ Myasthenia Gravis (MG), Addison's disease, or
hypothyroidism can be predisposed to megae. A rare cause
is lead toxicity.

i) Laryngeal Paralysis (LP) - please see information on the
main links page. Surgery for LP is usually not a good
idea in dogs w/ megae, as it results in a permanently opened
trachea, through which water and regurgitation/reflux can more
easily pass into the lungs. Doxepin, an anti-anxiety drug,
may help w/ some of the coughing in these dogs, per information
presented on the Veterinary Information Network (VIN).

j) Occasionally, we will receive a report that one of our
megae dogs having suffered from Gastric Dilatation/Torsion.
We don't know if megaesophagus predisposes dogs to "bloat,"
but, recognizing the symptoms is paramount. W/ bloat, the
dogs usually vomit, rather than just regurgitate. They
will retch, trying to "bring up" material, often just producing
"slime" and/or foam. This is an emergency, as if it is not corrected,
the dog will die.

Gastric Dilatation/Torsion is most common in large, deep chested
dogs like Danes, Dobes, GSD's, etc., but, deep-chested small dogs,
like dachsunds and Basset Hounds can also suffer from this disorder.

k) Nausea and/or vomiting antibiotics is quite common in all dogs,
not only those w/ megaesophagus. Administration of metoclopromide,
if it is tolerated, one-half hour before the antibiotics are taken
may minimize the nausea. Cerenia once daily for no more than 5
consecutive days, will usually also minimize the vomiting. If oral
or injectable anti-emetics (anti-vomit) medications do not help,
injectable antibiotics may be tried.

l) Gastroesophageal intussuception occurs when the stomach "telescopes" into
the esophagus through a weakened esophageal sphincter. Immediate surgical
repair is needed.

3) What are some medications that are used for treatment?
a) Sulcrate (carafate) - liquid or tabs - "bandage" for ulcers/erosions
in esophagus/stomach. MUST NOT BE GIVEN W/ ANYTHING EXCEPT WATER. MUST BE
GIVEN 1 HOUR B E F O R E FOOD OR MEDS, OR TWO HOURS A F T E R.
b) Acid neutralizer - Zantac (ranitidine), Pecid (famotidine ), Prilosec
(omeprazole), Nexium (esomeprazole) - Prilosec and Nexium work best if NOT
sprinkled on the food, but, given in the capsule (most listers have found it
to work either way). All but Nexium are available OTC - need to experiment w/
what works best for your dog. Tagamet (cimetidine) does not seem to work very
well, and must be given up to every 6 hours, so is rarely used. Tums are
useless.
c) Pro-motility drugs (help open up the sphincter between the stomach and
small intestines, allowing stomach contents to more quickly enter the small
intestines, so that it is less likely to reflux back up into the esophagus.
They do NOT improve the motility of the esophagus. Nothing will help esophageal
motility:
i. reglan (metoclopromide) - oral tabs & liquid - helps w/ nausea;
helps stomach empty - some megae dogs seem to be very sensitive to the
neurologic side effects (restlessness, panting, nervousness). It doesn't work
in every dog, and on occasion may even increase regurgitation.
ii. Cisapride (Propulsid) - helps with reflux (most specialists do
not believe it works/experience suggests that it does in many mega-e pets).
Currently only available through compound pharmacies
iii low-dose erythromycin - NOT used as an antibiotic


4) Antibiotics frequently used for aspiration pneumonia (AP) -
a. Baytril - pills & injectable
b. Clavamox - pills and oral liquid (frequently cause nausea) - can give
metoclopromide one half hour prior, to "settle stomach"
c. Azithromycin (Zithromax) - capsules and oral liquid -
give for 5-10 days, but, has activity for 10-14 additional days.
Usually saved for severe cases, or ones that may have been treated w/ other
antibiotics and for which a resistance may have developed.
d. cephalexin (Keflex)
e. amikacin or gentocin can be administered via nebulizer. Can also be
administered intravenously, but, these antibiotics are very toxic to the
kidneys, and daily testing should be performed while using these drugs.
f. in patients who do not seem to be responding to empirical (educated
guess) antibiotics, material may be recovered directly from the lungs for a
culture.

5) When these dogs become dehydrated, they can deteriorate quickly. Upon
joining the group, we will send you information on how hydration can be
maintained. And,that information is on the front boards folder "dehydration...."


6) What is the life expentancy of our dogs?
It depends on the extent of the megae, and if there are related conditions
present. Are there other causes (hypothyroidism, Myasthenia Gravis (MG), lead
toxicity, trauma, chemical damage, etc.)? Are there other health issues -
stomach or bowel disease such as Helicobacter pylori (HP), inflammatory bowel
disease (IBD) ), etc? How often does the pet develop aspiration pneumonia? How
"intense" the treatment must be - ie. some (RARELY seen on this board) dogs
require only elevated feedings; others require 4-7 small vertical feedings
daily and then require being kept vertical for 10-45 minutes. So, with many of
the dogs, especially those belonging to the owners who frequent this board, it
depends on how much time the pet owner has to devote to the pet's care. Please
remember that the owners of dogs who are EASILY managed, only participate in
this board occasionally, because they don't need as much advise.


You will find dogs on this board who have lived a pretty normal length of
years. Hobbs, a Wire Haired Fox Terrier, was lost at about 15 years old, from a
brain tumor. Bailey, who belongs to Donna and Joe Koch (developers of the
Bailey chair), was diagnosed as a puppy and is now 10 years old, (as of 5/09)
and pretty much runs the household with the rest of the "herd."

7) Why do symptoms seem to worsen when they sleep? Many occurrences 0D
happen at night. Is there anything we can do to help? When the dog is lying
down, fluid refluxes back into the esophagus and then can leak into the
trachea, resulting in severe irritation not only of the esophagus, but of the
trachea and/or lungs. This is were treatment w/ antacids, pro-motility drugs,
and/or carafate (an esophagus "bandage") is helpful. Doses can be given during
the day, but, most find it best to give a dose of each prior to bedtime
(Carafate must be given an hour prior to,or 2 hours after any other meds or
feeding, to be effective). Many on the board teach their dogs to sleep w/ their
front end elevated (again, perusing the photos can give you some ideas). If the
dog sleeps in a crate, one end can be elevated 6-8 inches, and they can be
encouraged to sleep w/ their head at the elevated end.


What are the signs of Aspiration Pneumonia (AP), so we know what to watch
for? Sometimes the ONLY signs are lethargy and decreased appetite. If one of
these dogs refuses just a FEW meals, or acts lethargic for more than a few
hours, it is very advisable to have them evaluated. Coughing, wheezing,
increased respiratory rate, lethargy, and, sometimes (but, not always) are the
more common symptoms. Unfortunately, the only way to CERTAINLY rule AP in or
out, is with an x-ray. A dvm cannot always HEAR infection within the lungs.
Owners may want to request 3 x-rays of the lungs - one w/ the dog on it's
stomach or back, and one w/ the dog laying on the Left then Right sides. If
only 1-2 views is collected, a minor lesion can be missed. A lot of dogs w/
pneumonia cough, or, their breathing sounds "rough," or, gurgly. Nebulizer
administration of drugs, as well as oral antibiotics, etc. are usually used for
treatment. Some of the antibiotics (clavamox, especially) can cause nausea,
loss of appetite, or vomiting. Those dogs with chronic or recurring AP can be
treated using medications administered using a nebulizer. We have found here
that the nebulizer, used w/ albuterol, may be helpful in preventing AP.


Are there any other complications we should be on the look out for?
The health of these dogs can be very fragile, so if there are any symptoms that
you see that suggest that the pet isn't acting "quite right," evaluation by a
dvm is strongly urged. It is a good idea to become familiar w/ the emergency
rooms in your area so that you aren't walking in with no knowledge of the the
experience or knowledge of the staff. Even though some of these dogs ARE
fragile, many of them lead happy, busy, joyful lives.


Many folks copy info from these boards and ask their veterinarian to take a
look. Some dvm's welcome the info; some may resent it - tough! YOU are your
pet's advocate; the dvm is his quarterback, taking all info and putting it
together for what is best for his/her patient.


9) What should we consider an emergency or urgent?
- bloody or persistent vomit or diarrhea
- pale or blue-tinged gums or conjunctiva (eye membranes - should be pink)
- stumbling, incoordination, weakness
- continuous coughing for more than 1/2 hour, or breathing with head
extended (hard time getting oxygen)
- foam coming from mouth or nose


IF FOR ANY REASON YOU ARE CONCERNED ABOUT ANY SYMPTOMS THAT YOUR DOG IS
SHOWING, PLEASE RUSH TO YOUR DVM OR TO AN EMERGENCY ROOM. THE HEALTH OF THESE
DOGS IS VERY FRAGILE. THE SOONER TREATMENT COMMENCES, THE BETTER. BETTER A
WASTED TRIP, THAN A SEVERELY ILL DOG. Once you become familiar w/ the symptoms
of AP, you may ask you dvm for a supple of antibiotics to start w/ the first
signs. They mustn't be given for only for a few days, but, usually for 4-6
weeks. Giving them for too short of a time may result in resistance.
_________________________________________________________________________

Here is a "typical" (but, not the ONLY) protocol for megae dogs:
1) Feed 4-5 times daily w/ the dog's body perpendicular to the floor so food
"falls" through the esophagus into the stomach (consider using a Bailey chair
or other method of feeding the dog in a VERTICAL position during and after
2) administer a dose of metoclopromide (or, cisapride) 15-30 minutes prior
to eating
3) administer acid neutralizer w/ the meal (once daily if prilosec or nexium -
at night; 2-3 times daily if zantac or pepcid w/ one of the feedings)
4) administer carafate ("bandage" for ulcers or erosions in esophagus or
stomach) 2 hours prior to bedtime
5) administer antacid right before bed to minimize acid in stomach, so if
reflux from the esophagus occurs from the stomach while the dog is laying down,
it is not as acid. Antacids are SUPPOSED to be given on an empty stomach, but,
most owners report help even if given WITH food.

Kathy Morris-Stilwell, DVM
Univ. of Illinois 1974
Redford, MI

(I have not examined your pet, therefore there is no patient-veterinarian
relationship. Any suggestions mentioned are meant for you to share with your
veterinarian, and as a way of opening a dialogue for continued successful
treatment of your pet. Please do not change medications without consulting with
your dog's veterinarian. If there are any concerns about the welfare of your
pet, please consult with your dvm or an emergency room, as these patients can
very quickly deteriorate).




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