Endoscopic removal of esophageal and ruminal foreign bodies in 5 Holstein calves

Abstract

Endoscopic removal of esophageal and ruminal foreign bodies was successfully performed in 5 Holstein-Friesian calves under sedation or general anesthesia by using an electrocautery snare or a wire-guided Dormi basket. This report describes the endoscopic manipulations, treatment, and outcomes of esophageal foreign body removal in these calves.

Esophageal and ruminal foreign body obstructions in calves are uncommon. Administration of medicinal bolus or ingestion of corncobs, potatoes, apples, carrots, stones, or wood fragments are associated with esophageal obstructions in cattle (1–3). In humans, flexible endoscopy is the mainstay of foreign body removal mainly because it permits direct visual evaluation of foreign objects and allows assessment of esophageal integrity (4). This report describes 5 calves that were presented for evaluation of esophageal and ruminal foreign bodies which were removed using endoscopic guidance.

Case description

Endoscopic removal of esophageal foreign bodies

History and physical examination

Calf 1 was referred for evaluation of severe respiratory distress and epistaxis. Approximately 2 h before presentation an esophageal feeder (Figure 1A) broke off within the lumen of the calf’s esophagus, while the calf was being fed milk. The owner attempted to force the tube from the esophagus into the pharynx by external manipulation of the jugular furrow; however, this resulted in epistaxis and the calf was referred to the teaching hospital. On presentation, the calf’s vital parameters were within normal limits (Table 1) but she appeared mildly dehydrated and moderate epistaxis and hemoptysis were evident. Palpation of the proximal left jugular furrow revealed the presence of a rigid tubular structure that was suspected to be the fragment of the esophageal feeder. Auscultation of the thorax revealed crackles and wheezes bilaterally in the cranioventral lung. Thoracic radiographs were compatible with severe aspiration pneumonia. In case 2, an esophageal feeder tube broke off in the calf’s esophagus approximately 3 d prior to presentation and during this time the calf continued to be fed milk replacer using another esophageal feeding tube. In case 3, 1 h prior to presentation, an esophageal feeder broke off while 3 L of colostrum were being administered. Calves 2 and 3 were bright, alert, and responsive but calf 2 was mildly tachypneic (Table 1). Palpation of the distal left jugular furrow revealed the presence of a rigid tubular structure that was suspected to be the esophageal feeder. In both cases the foreign bodies extended beyond the thoracic inlet; therefore, the length of the fragment could not be determined. Auscultation of the thorax was unremarkable in both cases and no other abnormalities were detected.

Figure 1.

Esophageal feeder (A) and balling gun (B).

Table 1.

Demographic and physical examination data from 5 female calves admitted for the presence of an esophageal or ruminal foreign body

Calf	1	2	3	4	5	Reference range (19)
Age (days)	2	5	1	6	2	NA
Weight (kg)	42	46	43	36	44	NA
Temperature (°C)	39.3	38.1	38.3	39.1	38.7	38–9.3
Heart rate (bpm)	96	72	108	142	148	80–140
Respiratory rate (rpm)	46	60	36	32	36	30–60
Admitting hospital	OVC	OVC	CHUV	CHUV	CHUV	NA

bpm — beats/min; rpm — respirations/min; OVC — Ontario Veterinary College Teaching Hospital; CHUV — Centre hospitalier universitaire vétérinaire, Université de Montréal, Saint-Hyacinthe, NA — not applicable.

Endoscopic removal procedure

An esophageal endoscopic examination was performed under sedation with 5 mg of diazepam (Diazepam INJ USP; Sandoz Canada, Boucherville, Quebec) IV in calf 1 and under general anesthesia in case 2. Calf 2 was premedicated with diazepam (Sandoz Canada), 5 mg and butorphanol (Torbugesic Tartrate Injection USP; Wyeth, St-Laurent, Quebec), 2.5 mg, both IV. Ketamine (Vetalar; ketamine hydrochloride injection USB; Bioniche Animal Health Canada, Belleville, Ontario), 150 mg IV, was used for induction, and anesthesia was maintained with isoflurane and oxygen through nasotracheal intubation. Calf 3 was sedated with xylazine (Rompun, Bayer Health Care, Toronto, Ontario), 5 mg and diazepam (Sandoz Canada), 5 mg.

The upper airway and the esophagus were endoscopically examined using an Olympus 2.5 m video-endoscope (Olympus Gastroscope SIF-140; Olympus Canada, Markham, Ontario) in all 3 cases. A 60-mL syringe case with the end cut off and edges rounded was used as a mouth speculum and the endoscope was advanced through the speculum. In case 1, severe swelling and hemorrhage of the pharynx and larynx was observed. The esophageal feeder was identified 10 cm distal to the upper esophageal sphincter. An endoscopic electrocautery snare with a duck-bill shaped loop (Acusnare Polypectomy Snare; Wilson Cook Medical, Winston-Salem, North Carolina, USA) (Figure 2A) was passed through the biopsy scope canal and the loop was used to grasp the body of the tube. The portion of the broken esophageal feeder was subsequently removed by simultaneously insufflating the esophagus and slowly retracting the endoscope. The total time of the procedure was 33 min.

Figure 2.

Electrocautery snare with a duck-bill shaped loop (A) and wire-guided Dormi basket (B).

In case 2, the feeder tube was identified 35 cm distal to the upper esophageal sphincter and the snare loop of an endoscopic electrocautery snare with a duck-bill shaped loop (Acusnare Polypectomy Snare) (Figure 2A) was used to grasp the tube. The fragment was removed by slowly retracting the endoscope and snare as the esophagus was insufflated. Manipulation of the tube was difficult when this was retracted into the pharyngeal recess. A bronchoesophageal forceps was passed via the nasal passage and used to force the beveled free end of the feeding tube into the pharynx for retrieval. The total time of the procedure was 40 min.

A 20-cm piece of esophageal feeding tube was identified 25 cm distal to the upper esophageal sphincter in calf 3. An endoscopic wire-guided Dormi basket (Olympus Retrieval basket; Olympus Canada, Markham, Ontario) (Figure 2B) was passed through the biopsy scope canal. Significant insufflation of the esophagus was crucial to allow better visualization of the tube fragment. The tube was grasped 1 cm distal to the beveled free end of the feeding tube and it was subsequently removed by slowly retracting the endoscope and basket as the esophagus was continuously insufflated. Manipulation of the tube was difficult as the tube was retracted into the pharyngeal region. Instillation of lidocaine (Lurocaine; Vetoquinol, Lavaltrie, Quebec) in the pharynx and extension of the neck facilitated the retrieval. The total time of the procedure was 35 min.

Endoscopic examination was repeated to assess esophageal integrity. No abnormalities were found in case 1. In case 2, a 1 cm × 1 cm rounded, non-circumferential ulcer, which appeared to involve only the mucosa, was observed 35 cm distal to the upper esophageal sphincter. A superficial ulcer of the mucosa of the esophagus measuring 0.5 cm × 1.5 cm was observed 25 cm distal to the upper esophageal sphincter in calf 3.

Treatment, outcome, and follow-up

Medical therapy was initiated with intravenous lactated Ringer’s solution (Baxter Healthcare, Irvine, California, USA) 100 mL/kg body weight (BW), q24h, trimethoprim sulfadoxine (Borgal; Merck Animal Health, Kirkland, Quebec), 30 mg/kg BW, IV, q12h, and flunixin meglumine (Flunixin Injection; Wyeth Animal Health, Wyeth Canada, Guelph, Ontario), 1.1 mg/kg BW, IV, q24h in calves 1 and 2. Calf 1 improved the following day; however, due to the anticipated cost associated with intensive monitoring and treatment of aspiration pneumonia the owner elected euthanasia. The postmortem examination confirmed the diagnosis of aspiration pneumonia which affected approximately 30% of the total lung volume. In case 2, endoscopic reevaluation 6 days after retrieval revealed complete healing of the esophageal ulceration and no evidence of stricture formation. In case 3, antimicrobial and analgesic therapies consisted of procaine penicillin (Duplocillin LA; Merck Animal Health, Intervet Canada, Kirkland, Quebec) 30 000 IU/kg BW, IM, q12h, for 3 d and a single dose of flunixin meglumine (Banamine sterile solution injectable; Intervet/Schering-Plough, Animal Health, Quebec, Canada), 1.1 mg/kg BW, IV. Calves 2 and 3 were reported to be healthy 1 and 4 y later, respectively.

Endoscopic removal of ruminal foreign bodies History and physical examination

In case 4, the calf was reluctant to drink from the automatic feeder therefore it was tube-fed and the rigid portion of the feeding tube (Figure 1A) broke off approximately 12 h prior to presentation. In case 5, a portion of a plastic balling gun (Figure 1B) broke off while a bolus was being administered approximately 24 h before presentation. Calves 4 and 5 were bright, alert, and responsive but were mildly tachycardic (Table 1). Auscultation of the thorax was unremarkable and no other abnormalities were detected.

Endoscopic removal procedure

Calves 4 and 5 were sedated with xylazine (Rompun; Bayer Health Care), 5 mg and diazepam (Sandoz Canada), 5 mg and esophageal endoscopic examination was performed. A modified 60-mL plastic syringe case was also used as a speculum to pass an Olympus 2.5 m video-endoscope (Olympus Gastroscope SIF-140; Olympus Canada) through the mouth. The upper esophageal sphincter was identified, and the scope was introduced into the esophagus, which was continuously insufflated with air.

A 15-cm portion of an esophageal feeding tube was identified in the ventral sac of the rumen partially obscured by milk-like fluid in calf 4. Part of the balling gun (15 cm) was found in the ventral sac of the rumen in calf 5.

An endoscopic wire-guided Dormi basket (calf 4) (Olympus Retrieval basket; Olympus Canada) and an endoscopic electrocautery snare with a duck-bill shaped loop (calf 5) (Olympus Polypectomy Snare; Olympus Canada) were passed through the biopsy scope canal.

In case 4, the tube was grabbed by its beveled free end and passed through the lower esophageal sphincter and retracted into the oropharynx as the insufflation of the esophagus continued, then the tube was manually retrieved. Total time of the procedure was 45 min.

In case 5, the beveled free end of the balling gun was located caudally. It was grasped and turned to have the beveled end orientated rostrally. The fragment was successfully retrieved into the lower esophageal sphincter. As the tube was retracted into the pharyngeal region it was manually retrieved. The total time of the procedure was 15 min.

Endoscopic examination was repeated after the foreign bodies were removed to assess esophageal and ruminal integrity; no abnormalities were observed.

Treatment, outcome, and follow-up

Antimicrobial and analgesic therapies consisted of sodium ceftiofur (Excenel Sterile Powder; Pfizer Canada, Kirkland, Quebec), 1 mg/kg BW, IM, q24h for 3 d (calf 4), and a single dose of flunixin meglumine (Banamine sterile solution injectable, Intervet/Schering-Plough), 1.1 mg/kg BW, IV (calves 4, 5). Calf 4 was 8 mo pregnant 2 y after discharge and calf 5 was growing well 6 mo after removal of the object.

Discussion

Various approaches have been proposed for treatment of esophageal and ruminal foreign bodies in cattle, either by surgical extraction via esophagotomy or rumenotomy or extraction by oral retraction (5–10). Esophagotomy has been recommended when the foreign body is embedded within the cervical esophagus (7). The primary indication for esophageal surgery in large animals is to relieve esophageal obstructions (choke) that have not been responsive to conservative treatment (7). In all 3 cases reported here with esophageal foreign bodies, esophagostomy was not considered as a treatment alternative. Complications of esophagostomy include strictures, leakage from the surgical wound, and fistula formation. A previous report suggested the use of Thygesen’s extractor with a cutting loop to relieve a sugar beet choke in cattle; 46 cattle were treated for beet choke, with a success rate of approximately 90% without complications (5). Despite such a high rate of success, the authors of the present article do not recommend this technique due to the high risk of laceration and/or perforation of the esophagus (9,10). Rumenotomy can be used to remove ruminal or reticular foreign bodies such as balling guns, Frick’s speculums, or broken or chewed off esophageal tubes (6). In a recent report, an esophageal feeding tube embedded in the cervical esophagus of a 2-day-old calf was removed by rumenotomy without complications (8); the complication rate associated with rumenotomy appears to be < 5%, with peritonitis being the most common complication. However, animals undergoing rumenotomy can develop incision infections, seromas, and abscesses (6). In all 5 cases reported here, endoscopic retrieval was used because of the availability of the equipment and the increased cost, recovery time, and relative invasiveness of a rumenotomy. In addition, removal of most esophageal and ruminal foreign bodies can be accomplished with sedation only which decreased the risk associated with general anesthesia, the recovey time, and cost of the procedure. General anesthesia was used in Case 2 because the duration of the obstruction (3 d) and owner attempts to continue feeding the calf in the presence of an obstruction raised concerns about the integrity of the esophageal mucosa. In humans, foreign bodies usually are pushed from the esophagus into the stomach and removed surgically when the risk of esophageal perforation is present (11). In Case 2, general anesthesia was used as it would have facilitated advancement to ruminotomy, if required. The authors of this article emphasize that ruminotomy procedure can be the treatment choice to retrieve esophageal and ruminal foreign bodies when endoscopy equipment is not available.

Esophagoscopy/ruminoscopy is indicated particularly in those cases in which the clinical examination does not provide a definitive diagnosis and location of the foreign body (12). In such cases, endoscopy allows for the rapid exclusion or verification of the esophagus and rumen as the affected organs (4,13). In all 5 cases herein, endoscopic examination was useful to confirm the location of the foreign bodies. In calf 1, endoscopy also revealed severe pharyngeal and laryngeal trauma, presumably due to the tube traumatizing the upper airway when removal was attempted by the owner. Furthermore, in calves 2 and 3 esophagoscopy permitted good assessment of the extent and severity of the esophageal laceration after the feeding tube was removed, allowing direction of further treatment or re-assessment as necessary. In calves 4 and 5, endoscopic examination showed that the foreign bodies were in the rumen and immediate endoscopic removal was performed. Removal of ruminal foreign bodies may not be necessary as they may remain in the ventral sac of the rumen without consequences as the animal grows, though this speculation remains to be proven.

The value of endoscopic foreign body removal is emphasized in several studies in humans, dogs, cats, and horses, but little information is available in cattle. In humans, fiber optic-endoscopic management of esophageal obstruction of the upper gastrointestinal tract is successful in 92% of food impactions and 76% of true foreign bodies (4,14). The success rates for endoscopic removal or dislodgement of esophageal foreign bodies in dogs range from 26% to 85% (15–17). A previous report described successful removal of a nasogastric tube fragment from the stomach of a horse under standing sedation using an endoscopic foreign body removal technique (18). In all 5 cases reported here, the technique used to remove the foreign bodies was successful and no endoscopic removal-induced lesions occurred. Use of duck-billed loop snares or Dormi baskets enabled easier placement around objects located to the side of the scope. Placement of the snare or basket was facilitated due to the short length of the calves’ esophagus. In addition, optimal visualization of the esophagus and rumen was important for these procedures (18). In the cases of this report, visualization was greatly increased by the use of insufflation to expand the esophagus and rumen with air. A significant difficulty manipulating the snare or the Dormi basket was noted once the fragment was retracted into the pharyngeal region. Use of bronchoesophageal forceps or manual manipulation of the end of the tube to retract the feeding tube into the pharynx seems to be helpful when this difficulty occurs. This prevents pharyngeal trauma and facilitates extraction.

The complication rate of esophagoscopic foreign body removal in dogs varies between authors and methods of retrieval, ranging from 8% to 38% (15–17) with esophageal perforation being the most common complication (17). The authors of the aforementioned study concluded that rupture could be attributed to the foreign body itself rather than the endoscopic removal (17). Damage to the esophagus is influenced by the foreign body type, size, shape, and duration of obstruction (19). The mucosal ulceration visualized in calves 2 and 3 could be associated with the longer duration of foreign body-induced pressure on the esophageal wall and the presence of shaper edges which may have applied more pressure on the tissue, as opposed to an association with endoscopic removal. Esophageal strictures occur commonly as sequelae to intraluminal obstruction and maximal reduction of the lumen occurs within 4 weeks after obstruction (1). Further endoscopic evaluation of the esophagus in cases 2 and 3 could have been indicated to determine the presence of stricture. However, the magnitude and shape (non-circumferential) of the esophageal ulceration did not suggest a high risk for development of stricture (1).

Aspiration pneumonia was suspected in all cases (except case 5) as a result of the presence foreign body. In calf 1 aspiration pneumonia was confirmed on postmortem examination. Although the diagnosis of aspiration pneumonia was not established in the other cases, empirical antimicrobial therapy was prescribed. Broad-spectrum antibiotics are recommended in every case of esophageal obstruction in horses (20). Further investigation is required to determine if this recommendation may be extrapolated to cattle.

In conclusion, this report illustrates the usefulness of esophageal and ruminal endoscopic foreign body removal as a non-invasive, successful, and economic method for treatment of esophageal obstruction and foreign bodies in calves, with a low rate of complication.