What about ME?

I can’t stop thinking about him: the big, beautiful cream puff on Petfinder.com that looks to have a very old soul.  Animals are resilient – strong and adaptable.  They say our animals pick up on our emotions, and, if this is true, Kodi is a young dog that, at less than a year old, has a season pass at the roller-coaster theme-park.

Kodi was recently diagnosed with megaesophagus (ME) – a condition that baffles most people, and apparently, also a large percentage of the veterinary profession.  Kodi’s parents found the prognosis, or lack thereof, overwhelming and made the decision to have him euthanized.  Thankfully, his vet was in the minority of this profession, knew the symptoms, and tested Kodi early on.  Having convinced the couple to care for him until a foster or new forever home could be found, his veterinarian outlined a new feeding regimen, which included a special diet of pureed food with added supplements, along with feeding Kodi in an upright, begging position.  Kodi would need to stay upright for a period of up to one-half hour after eating to allow food to fall into his stomach.  Early diagnosis is crucial and may severely impact the lifespan of megaesophagus dogs.

As a volunteer at various shelters, I had heard of this condition only once before and knew it had something to do with the esophagus and the digestion of food.  I thought, perhaps it is because my heart went out to Kodi, that I noticed this condition coming up more often during the last six to eight months.  After speaking with members of Megaesophagus Support Groups, I have learned a great deal about the condition, and I certainly do understand how overwhelming this condition, with possible underlying conditions and varying degrees of severity and symptoms, can be.  megaesophagus is more apparent now, as groups like the Yahoo Megaesophagus Group, the Facebook Canine Megaesophagus Support Group, the Facebook Mega E Babies Group, and medical research facilities are spreading the word that megaesophagus can be managed and dogs can lead fairly normal lives with ME.  People are going to their veterinarians armed with this information.

This is a condition that continues to be misdiagnosed, however, and sadly, timing can be everything.  I certainly don’t mean to say that all doctors of veterinary medicine have not studied this condition and learned what the symptoms are.  In fact, Margaret, a member of the Facebook support group, took her beloved Sparky to his vet, and she was asked the following questions:

1. Is he throwing up or is it regurgitation?  Not sure. (See note on regurgitation vs. vomit below)
2. How often is this happening? Several times a day.
3. Is it after meals?  He free feeds (his food is left down all the time)
4. What does the vomit look like?  Is it foamy and long, like a tube?  Yes

It sounded very much like Megaesophagus and the vet theorized that Sparky was born with either Primary Megaesophagus or a condition called PRAA (Persistent Right Aortic Arch).  A barium swallow test was recommended to figure it out.  Sparky had the barium swallow, followed by an x-ray.  No PRAA; it was Primary Megaesophagus.

Margaret says, ‘He gave us 2 options: put him down or return him to the breeder.  My husband and I both said at the same time, “OR???”  The vet said we could try feeding 4 to 6 meals a day and holding him upright afterwards. We figured out the right calorie intake and held him up for 30 minutes in a baby snuggy after each meal.  He had at least 50 bouts of AP.  He lived to be 13 years and 10 months old!  He sure did beat the odds and had a fairly normal and super happy life.’

Lillie was one of three in her litter.  At approximately five weeks old, Lillie started eating soaked kibble and water, which she would “throw up” every once in awhile.  Thinking perhaps she was eating too much or too fast, Lillie’s mom didn’t think any more of it.  When the pups were taken for their first vaccination, it was mentioned to the veterinarian.  Considering a possible allergy or digestive issue, the vet sent Lillie home with a new diet.  The problem continued and Lillie returned to the clinic and saw a different doctor as her regular vet had a full schedule.  Lillie was taken for x-rays, which showed irregularities.  Megaesophagus was mentioned, but the vet wasn’t absolutely sure, so a barium x-ray was performed.  It was then confirmed; Lillie had megaesophagus caused by a vascular ring around the bottom of her esophagus or PRAA (Persistent Right Aortic Arch).  As the vet continued to explain about the effect on the heart and how the food would stop at the bottom of the esophagus, Lillie’s mom went blank, hearing only bits and pieces of what she was being told and thinking to herself that Lillie was going to starve to death.  Upon realizing the doctor had stopped speaking, she asked him, “What do I do?  Will I have to have her put to sleep?”  Thankfully, he said no.  Lillie’s mom was given advice on how to feed her, testing different consistencies of pureed food and water.  It would be “trial and error.”  They discussed surgery and decided it was not the best option in her case.

Sadly, a large number of veterinarians believe megaesophagus to be a guaranteed death sentence [Dr. Kathy Morris-Stilwell, DVM states “That is still being taught in many veterinary schools”], the average DVM may not see many cases in her or his practice and may not  have the day to day hands on experience to know of how many successes  there are.  Thankfully, Margaret and her husband refused to believe this was the best option, and Lillie was diagnosed by an optimistic veterinarian.  Both Sparky and Lillie left their clinics and went home with their people.

The science:

Megaesophagus is often overlooked and misdiagnosed as it can be secondary to other conditions such as Myasthenia Gravis, Hypothyroidism, Addison’s disease and other neurological disorders.  Varying medications can be prescribed for frequent associated symptoms such as acid reflux, lack of motility of the stomach and/or intestines, and nausea.  Surgery may be an option for PRAA – which, causes a compression from entrapment.  This is best done while the dog is a young puppy.  If the esophagus has not been damaged too much, the megaesophagus may resolve.  In other cases, the dog still needs to be fed upright but will do much better having had the stricture removed.  Medical therapy is used in the majority of all megaesophagus cases.  Dogs vary in which medications work best for them and which ones they need.  Pro-motility drugs, such as Cisapride, Reglan (metoclopramide) and Bethanechol, are frequently used.  The drug Cisapride (Propulsid), was taken off of the market for humans, but not for animals.  It doesn’t work the same in animals as it does in people so there isn’t the same risk involved (it can induce cardiac arrhythmias in humans – and although very rarely reported in dogs, Dr. Kathy Morris-Stilwell, DVM confirms it is a possibility).  Here’s a description of the action of metoclopramide from Wedgewoodpetrx: Metoclopramide is used in veterinary medicine to stimulate the motility of the upper GI tract. It has minimal effect on the lower GI tract and colon. Metoclopramide increases peristalsis of the small intestine and increases tone and strength of contractions in the stomach while causing relaxation of the pyloric sphincter. Consequently, metoclopramide speeds gastric emptying and, possibly, intestinal transit times.  Dr. Kathy Morris-Stilwell (DVM and member of the Yahoo support group) simplifies, stating “metoclopramide is used to empty the stomach of the previous meal to make it ready for the next meal.  It’s given 30 minutes before feeding the dog to perform this function.”  Here is information from the same web site on cisapride:  Cisapride is a drug that is used to stimulate the smooth muscle that lines the digestive tract, causing the contents to move further along through the esophagus, stomach and the intestines. It is used in dogs to reduce vomiting associated with mega esophagus, or other conditions that slow the emptying of the stomach. Like many other drugs in veterinary medicine, Cisapride is not FDA approved for use in animals; however, it may be compounded by a specialty pharmacy for your pet. Cisapride is considered accepted practice within veterinary medicine.  Other medications that are commonly used for treating the various symptoms and issues associated with megaesophagus:  Bethanechol (another pro-motility drug), Prilosec, Pepcid, Cerenia, Sucralfate/carafate.  Some people use natural and alternative therapies in addition to these medications, but there aren’t any natural remedies that can completely replace the traditional medicines.  Some natural therapies include slippery elm to soothe the esophagus and aid in digestion, and coconut milk and oat bran to add calories.  As is the case with conventional medications however, several different approaches may need to be attempted before finding the best solution to the problem

Acupuncture may be helpful in treating pets with megaesophagus in an attempt to stimulate normal esophageal motility. Additionally, chiropractic manipulation can also be tried in an attempt to remove any blockages that could disrupt nerve supply to the esophagus.  Dr. Kathy Morris-Stilwell, DVM has reported that according to some literature research there are specific pressure points for acupuncture that help, although reports of its success, or lack thereof, from Yahoo support group members are inconclusive.

Various herbal, homeopathic, and nutritional supplements might be effective and are certainly worth trying in affected pets.  Dr. Shawn Messonier writes “I have had some success combining acupuncture with supplements including homeopathic and whole food supplements.”  Pam Giles (member of both groups) says “every dog is different in terms of their symptoms, severity of symptoms and what drugs they need and can tolerate.  If a dog’s megaesophagus is mild, they may not need any drugs and may be fine with just upright feeding, such as my dog, Piper.  If symptons of their megaesophagus is severe, traditional medicines are usually necessary to control these and can be supplemented with natural remedies.  Preventing the dog from getting aspiration pneumonia and allowing the dog to be able to live and thrive are the main goals of all of these protocols.”  Donna Koch agrees “for some, slippery elm, properly  prepared and administered, may be sufficient.  For yet others, the full  host of medications and the addition of Carafate to provide a liquid  bandage within the esophageal lining, is needed to protect and/or to  heal inflammation and erosion.”

In more detail; the condition is caused by a loss of muscle tone in the esophagus.  The esophagus runs from the mouth to the stomach.  In healthy dogs, the muscle contracts, pushing food down the tube (esophagus) to the stomach.  Megaesophagus is the condition of a weak and enlarged esophagus because of lack of enervation.”   This is a problem of certain nerves no longer communicating with the organ, which has lost the ability to function.  It’s like a balloon that has been inflated several times and then hangs limp.

Megaesophagus dogs will regurgitate food and water unless they are positioned in an upright position allowing gravity to do the work of transporting nutrients to the stomach.  Reflux of this material into the esophagus and into the back of the throat, can result in aspiration pneumonia (AP) which can happen within hours and is life threatening.  It is VERY important to note the difference between vomit which comes from the stomach, and regurgitus from the esophagus or back of the throat.  This could mean the difference between a timely or delayed diagnosis.

During my research, and from speaking with megaesophagus parents from around the world, I found this disease can affect any breed and is not age specific (it can be present at birth (congenital) or acquired later in life).  There are some breeds, such as German Shepherd Dogs, in which megaesophagus occurs more frequently.  One thing is certain and I can’t stress enough – the delay in accurately diagnosing megaesophagus and starting  treatment, including vertical feeding, often results in aspiration  pneumonia or other severe symptoms, such as failure to thrive, severe  weight loss, etc.  (Many dogs are not diagnosed until their dog has  aspiration pneumonia, either because missed at first by the DVM, or  because the owner did not go to the DVM).

If undiagnosed, many dogs that continue to eat normally may inhale food, water and saliva into the windpipe and lungs resulting in “Aspiration” and possibly pneumonia.  In some instances the dog will show signs of aspiration pneumonia (i.e. lethargy, lack of appetite, cough, laboured breathing, and fever) despite the owners never having seen evidence of regurgitation. This is because the dog may regurgitate the material into its mouth and then swallow it or inhale it without ever having the material leave its mouth. If only small amounts of material are aspirated into the trachea, cough will be the most obvious problem. This cough may be moist or dry.  Nasal discharge can occur when material is pushed into the back of the nose during regurgitation.  If larger amounts are inhaled and the material reaches the lungs, severe pneumonia may result, causing the above symptoms, which can lead quickly to death.  Aspiration pneumonia is the main cause of death in megaesophagus dogs.  Dr. Kathy Morris-Stilwell, DVM says “Unfortunately, sometimes the only signs of aspiration pneumonia are lethargy and/or increased frequency of regurgitation. Aspiration pneumonia, if left untreated, may be life-threatening and can result in death within hours. Rapid recognition is of paramount importance.”

The use of a specially designed “Bailey chair” (co-designed by Donna and Joe Koch for their ME dog Bailey) is the choice of most megaesophagus parents, in which their canine companions will sit to consume a meal of fortified and blended food or meatballs.  The chair makes it easier to keep the dog in an upright position while eating and for a period of fifteen minutes to half an hour afterwards while the food makes its way to the stomach.  The chair (instructions for which are generously supplied by the creators – visit the Yahoo support group), works well for most, however, the method of elevation and digestion time may vary in each case.  For example, smaller dogs may be held and Great Danes may be more comfortable standing with their front feet on an elevated surface.  Some megaesophagus parents opt for ‘feeding tubes’ which, sometimes  are much easier for the owner and for the dog, in cases where ‘gravity feeding’  does not empty the esophagus enough to avoid significant regurgitation.

Although Sparky’s people were relieved and gained a sense of hope at having an answer, others become overwhelmed at the prospect of huge vet bills and the inconvenience a new routine will have on their lives.  Sadly, the lifetime commitment is too much and the diagnosis for some of these “beloved family members,” results in immediate euthanasia.  Other “special needs” dogs like Murphy may spend their whole lives in foster care.  The number of megaesophagus and other special needs dogs listed on rescue sites such as Petfinder.com is increasing; however, those considering adopting a new family member are afraid of the unknown and overwhelmed at the inconsistent information provided on this subject.  

Foster care is certainly a better option than a shelter for animals that require close monitoring, rehabilitation or have specific meal and/or medical requirements (diabetes and megaesophagus, for example).  Most rescue organizations offer foster care; however, there are not enough homes for the number of animals that need them.  As a volunteer, I have come to learn of the great lengths to which the wonderful people who work at the shelters go in order to shuffle these poor animals around to make room and save them from being “PTS” (an acronym for “Put To Sleep,” which is used far too often).

As yet, there is no cure for megaesophagus.  Research is currently being conducted at Clemson University to determine the genetic basis for megaesophagus.  In cases in which the megaesophagus is a result of another condition, such as Myasthenia Gravis, the megaesophagus may go into remission once the other condition goes into remission.  In the most severe cases, megaesophagus can be life threatening because of the risk of aspiration pneumonia.  Education is the key.  This subject is discussed at great lengths among members of support groups with ME – parents from around the world joining almost daily, sharing their experiences:  the tears, the triumphs and some very comical moments.  They answer, to the best of their knowledge, questions from anxious and emotionally stressed members, new and long-standing.  Rescue organizations, volunteers and a growing number of doctor’s in the veterinarian world are also learning and talking about this condition.  The common goal: generate awareness, allowing for early diagnosis and consistent treatment in order to prolong the lives of our animal companions and those in the foster system waiting for a second chance at a home and family.

If you have room in your home and your heart for someone in need, please contact your local shelter or rescue organization to find out how you can make a huge difference.  Offering a safe place for just one animal could mean the difference between life and death to many.

References:

http://pets.groups.yahoo.com/group/megaesophagus/

http://www.facebook.com/groups/4329632343/

http://www.baileychair.blogspot.com

www.petfriendlytravel.com

http://www.petcarenaturally.com/articles/megaesophagus.php

http://www.caninemegaesophagus.org/

http://vetneuromuscular.ucsd.edu/publications/Megaesophagus%20Brochure-1.pdf

http://www.marvistavet.com/html/body_megaesophagus.html

http://www.petforums.co.uk/dog-health-nutrition/119654-megaesophagus-dogs.html