State_Veterinary_Association_MegaArticle
Greetings! I am writing to you to share an article I have written. I am offering it to you for potential journal or newsletter publishing, or to share directly with your constituency. This has been written in an effort to increase awareness about the impact that Megaesophagus (ME) is having on individual breeds and lives. I have also offered this article to each representative for the AKC sanctioned breeds. Though Megaesophagus is "in dogs" generally speaking, it is predominant in several breeds, as you may realize. I hope you will agree that It is only by sharing what is known that we can protect the future of our breeds.

My forward of comments which I hope you will elect to share with individual Veterinarians within your state follow as an introduction. When I incepted this article, I decided to feature my experience with my pup as she was severely affected. It was my intent to illustrate that reasonable quality of life is possible even in a dog with severe, frequent symptomology. As an anecdote before you read the article, I will share that many who are more moderately affected are easier to care for, yes. But even with severe symptoms, quality of life can be excellent, though there will be challenging times. Much like experiencing the worst symptoms from a common cold - the symptoms quell and life becomes normal again. Also to note, many parents of Megaesophagus dogs note that their ME affected dog is very high energy, often more so than their 'normal' dogs.  I hope that you will read this article with interest and that it will change how you view this topic.

Updated Request, 03 May 2008

Better training in diagnostics may be needed. One teaching University diagnosed a 6 month old female as having esophageal stricture and PRAA. The second teaching university, reviewing the same RADS found no PRAA or stricturing. This was later confirmed by their own diagnostics. I am aware that this is not an isolated occurrence.


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Dear Veterinarians and Technicians:
I have always been especially appreciative of the years of study, the hard work and diligence that each of you undoubtedly exercise on a daily basis. My concern, however, is that many cases of Mega go undiagnosed. Often the dx path is long - I have heard of instances of a dog regurgitating in front of an ACVIM specialist and the key signal was still missed. Further to that concern is the frequent frustration expressed by many "megaE parents" that the "doom and gloom" prognosis is often the only message they receive from their attending veterinarian.

One of my goals is to help us all focus on the possibilities for the future. I realize that in some cases it is best to let them go. However, I hope you will read Eva's story and take it to heart. Hers was one where success should not have ever been possible.. There are many other stories of success just like hers. Some are much better! Many are unknown...

We, the parents of affected pups are hoping and asking that, should you have a client where you believe Megaesophagus or ME complicated by any of the associative disorders is of concern, that you will remember to direct them to the Support Group at Yahoo (http://pets.groups.yahoo.com/group/megaesophagus/), and/or my website (http://www.caninemgaesophagus.org) for experienced support and knowledgeable help. Think of us as your assistants while you also guide their path to recovery. So many dogs are needlessly euthanized when good quality of life can be achieved through diligence, dedication, and a few  simple lifestyle changes. Often these dogs are more loved and better managed than you would have thought possible. Let your client and the dog surprise you! I know you will become a believer, just as I have in the possibilities for their quality of life. I too was once a disbeliever. It wasn't until I tried to explore the options, and with a little experience we met with success. It all became so much easier -- for her and for me!

It is at this juncture that I also wish to share I am in the process of launching a non-profit effort: "cmerp" - canine megaesophagus Education and Research project, and I hope I do so with your blessings as well as your interest. There can only be more cases each year, for what was once termed a 'rare disorder' -- it is becoming less rare, and I am sure of that. When I put the website together, I started watching traffic very carefully. It is frightening to me how many new visitors there are each and every day. Further, most of the traffic (remember, WWW), is US based -- currently 88.5 percent of visitors are in the US. My growing concern is that it is not only what we are breeding... but to some degree it might be what we are feeding as well (hormones, preservatives, etc.), as many Euro. countries have strict bands on hormones, etc. and very few visit from those countries.

Should you have personal interest in this disorder and might like to be involved in any capacity for the cmERp Advisory Committee as time permits, please contact me directly. The BOD is nearly complete, but I plan to have an Advisory Committee in place and which will serve the larger community well if I am successful.

Thank you for your time and consideration. It is with my blessings that you may use this article to best advantage on your personal clinic's websites or newsletters -- however you may deem fitting. Should you have any questions or comments, please do not hesitate to contact me.

In parting, and please know I tried very hard not to share the next, but I feel it imperative to share. I have a friend who is recuperating from "E-ectomy" (esophagectomy) surgery after a lifelong struggle with Achalasia. She was telling her veterinarian about her surgery for her "megaesophagus" (putting it in vet. sci. language), and her veterinarian turned to her and said -- "We euthanize dogs for that - end of story." Do no harm? So many of these pups can and do have lives with quality. We need to re-educate ourselves a bit, and not immediately hand out a doom and gloom dx. Please! Be supportive and encouraging, even if the case seems impossible, loving parents do work miracles for these dogs each and every day. Sometimes successfully, sometimes not - but never with regret for having tried to manage the condition and enjoy their canine family member for as long as they can.

All my best to each of you,
Most sincerely,



Peg McIntyre
Founder, cmERp  - canine megaesophagus Education & Research project

PS) Also know that Dr. Jerold Bell, Geneticist @ Tufts has reviewed the article and his comments were simply that he found it to be 'both informative and factual."  Dr. Mike Willard (Texas A&M Gastroenterology Lab) also reviewed the article. He too found the material contained to be accurate, but encouraged me to make a stronger statement regarding the prognosis for *some* of the affected pups and dogs - that no matter what is tried, some will just not fare well, may expire quickly, or euthanization is ultimately the only favorable option.  I have also included a summation written by Dr. Kathy Morris-Stilwell. Dr. Kathy is a veterinarian who dedicates personal time to daily support of those who have just received dx, and we are very fortunate to have her. As she often states, we are all still learning about this disorder.

There is also a paragraph towards the end of the article that will appear to be breed specific. I want to bring this to your attention so that you might tailor the info to best fit for your community.
Letter to  DVMs, Students, Rescue Associates
March 2008
Megaesophagus
by Peg A. McIntyre









mystifying or challenging as what I was to encounter while trying to resolve the symptoms of Megaesophagus in my Gordon pup. The most heart-wrenching words any dog lover can hear are, “there is no cure” and “we understand very little about this disorder.” 

Symptoms of Megaesophagus may appear during any life stage. It was once thought that congenital “Mega-E” only surfaced during weaning, and this is true in pups that are severely affected. Congenital cases that are mild may not fully reveal themselves until months later as it is often a progressive disease process. Mega-E may affect only one pup or the whole litter. Idiopathic Mega-E is typically diagnosed during mid to senior years, and the specific cause often remains unknown. It can be due to an injury or exposure to toxic substances. Some believe idiopathic Megaesophagus, once toxic substance and injury are ruled out, may be a more mild case that took years to evolve and express itself in the culmination of unmistakable symptoms. Often Mega-E is not diagnosed until Aspiration Pneumonia is diagnosed, and it is at that point many have an ‘oh-yeah’ moment or two, realizing that they had been living with Mega-E all along but hadn’t recognized the symptoms.

Regurgitation is one of the key symptoms. Food or water will appear to roll out of the mouth, never having reached the stomach. Megaesophagus literally means “enlarged esophagus” but there may be other factors involved, such as foreign body blockage, strictures, dysmotility disorder, or PRAA, to name a few. Regurgitation may be attributable to damage or malformation of the sphincter muscle at the top of the stomach. This sphincter is meant to quickly open and close during a swallow, and holds the swallowed contents into the stomach. Peristalsis can also be ineffective, meaning there is a malfunction of the wavelike muscle contractions that should propel food from the mouth to the stomach immediately following a swallow, so the food may sit in the esophagus for hours or even days. In some cases the enlarged esophagus may form a pouch or strictures that hold ingested food within the esophagus where it putrefies. The pup may eventually become emaciated due to malnutrition, loss of energy, and a failure to thrive. Blood chemistry may change, and further organ damage can occur. A dire, life-threatening case of Aspiration Pneumonia can quickly evolve, as food or water are easily aspirated into the windpipe and lungs where infection will quickly take hold. One little cough often turns into an emergency.

The good news is that many cases are manageable through lifestyle changes. The pup must be fed in vertical (90 degree, not elevated) position. This allows gravity to work a little magic.  Maintaining the elevated posture for 20 minutes or longer after each meal is also key. The food that seems to work best in the majority of cases is a slurried consistency. Others seem to do better by being fed soft food formed into a meatball that is then popped down the hatch. Feeding multiple meals, 4-6 meals per day, with small quantity offered at each meal is also mandatory. Many of the affected dogs will have difficulty keeping water down. Offering solidified water, “Knox Blocks” (unflavored gelatin) as we sentimentally refer to them, is often helpful, as is ensuring that water is given in small quantities as far away as possible from meals. Many dogs prefer not to drink any water, having made the connection that it causes them grave difficulty, so dehydration can be a daily concern. Drinking exercise should be officiated while the dog is in elevated position. Click on the photo below to view a video that demonstrates method as well as symptom. 





























Often the symptoms, frequency or severity will change course on an unknown whim, so keeping a strict schedule and daily journal to record events can be quite helpful. Even though the disease can become progressive in nature, the progression and symptom frequency are unique to each dog. Mildly affected dogs may have extended life spans with a much greater prospect for quality and duration of life with appropriate treatment and lifestyle changes. There are increasing numbers of dogs who live 3-8 years after diagnosis, a direct result of lifestyle changes.

Many Megaesophagus dogs seem to also suffer from food allergies and may have trouble digesting certain types of proteins, carbohydrates or fats. Grasses, grains and saturated fats seem to be of a particular concern. In others, high fiber content may be a problem. Offering high quality, pharmaceutical grade omegas via Salmon oil can be quite beneficial if the dog can tolerate the addition in his/her nutrition plan. It is my hope that more veterinarians will refer clients to nutritionists for evaluation as well as allergy testing, even in situations where it does not seem to fit the case. If I had tested sooner, I would have realized better results for my puppy. It wasn't until we learned just what nutritional components were giving her problems that all the pieces of the puzzle fit together, and she was granted increased relief from her symptoms. She never had any telltale symptoms that would point to allergies, with the exception of the runny nose and worsening of regurgitation every spring. Who would have thought a small quantity of green peas buried in holistic-brand kibble would tip the scale, causing a resurgence of these symptoms?

What to look for?
A dog that always seems to be hungry, one who is not gaining weight and is rapidly growing thinner. One who regurgitates (passive act, little if any stomach muscle involvement) minutes to hours after eating. A regurgitated food bolus may be funnel-shaped in formation, and this is a certain giveaway. At other times the dog may be able to hold food down but will regurgitate water along with a slimy mucous. The pup may seem to have difficulty swallowing. You may detect a clicking noise as he moves about. He may stretch his neck out as far as he can reach. Or he may elevate himself during rest and play, having made the connection that he feels better when he is up. Breathing patterns may seem unusual. A subtle key is puffing of cheeks upon expiration (breathing out). These pups do not sleep well. The lower esophageal sphincter will loosen as the rest state begins. This allows stomach acids to seep up into the esophagus, causing much discomfort as a burning sensation from the hydrochloric acids pooling within the esophagus, and thus erosive esophagitis sets up shop.

I can’t tell you how frequently I was awakened by a brisk step as my pup came to me for comfort and a split-second later having the effects of regurge splashed on my face. Initially we both slept elevated: trying to teach a pup to sleep on an incline can take a little adjustment  positive reinforcements it is instinct to curl up in a ball or lay very prone. So, my pup slept propped up on my chest so that I could quickly move her muzzle away, and into a cookie-toss pan that was always there for regurges should they occur. Eventually we slept well and nighttime regurge episodes became a symptom of the past. Eventually I was able to condition her to sleep on a huge stuffed toy. Oh, what a joy it was to actually be able to sleep without multiple changes of bed linens per night. EvaDiva insisted that her 'woobie baby', twice the size that she was, accompany us everywhere we went -- she carried it out the door and into our vehicle herself, as well as up and down the stairs each day and night! My house was lined with plastic, and the carpet cleaner was hardly put away before it was needed again. The laundry was never ending, but thank goodness for inexpensive towels – I threw many away without feeling guilty. Sometimes the slimy phlegm is impossible to wash away. Scheduling life around the multiple feeding schedule, ‘burping’ (coupage), and rest times could be a daunting challenge.

























Managing the Disease
Acid inhibitor medications may be helpful, but they will not reverse the condition. I eventually accepted that western medicine would only throw PPIs at the problem, along with heavy doses of broad-spectrum, triple antibiotic therapies lasting a month or longer should there be even a hint of Aspiration Pneumonia. For day-to-day maintenance I elected to provide fresh wholesome nutrition, studied nutritive herbs, and used traditional chiropractic, VOM, and massage therapies.  Others are reporting good results with acupuncture or acupressure. Multiple daily sessions of coupage -- "burping"  became a way of life. Coupage is rhythmic tapping of the chest cavity on each side for about ten minutes every hour or so, and specifically during/after meals to loosen phlegm or food particles that could be lodged. This helped thump it all downward, or so I hoped.

In some cases an underlying cause may be at play, so it is imperative that a specialist examine your pup and perform a thorough diagnostic workup. Diagnostics to rule in/out the clinical side conditions can be a bit pricey. There are well over 40 different disorders that can contribute to a case of Megaesophagus. Following is the short list of contributing conditions thought to be the most frequent or prevalent:  Addisons, Myasthenia Gravis, Gastroenteritis, IBD, Bloat (GDV), Laryngeal Paralysis, Pancreatic Insufficiency, Polyneuropathies, and PRAA (Persistent Right Aortic Arch).  There is supposition that Addison’s disease may be just as prevalent as Myasthenia, the first disorder most specialists feel important to rule out. Though more rare, Hiatal and Diaphragmatic Herniations often may be missed in the diagnosis, especially if simple radiographs were the only diagnostic tool. These disorders will certainly contribute to the severity of symptoms. Fortunately, surgeries are possible in these instances and fortunately for us (?), both were involved in my pup’s case. Her Megaesophagus symptoms became increasingly mild and less frequent post-operatively. I do believe that each of the management techniques is equally important for success (i.e. vertical feeding is equally as important as elevated sleeping; food consistency and nutrients are equally as important as coupage; getting the medications, dosage and administration times right is equally as important as all of the other techniques). CAM therapies should be given equal consideration to traditional medicine, and once the correct combination is realized for that particular dog, symptom response will realize heightened possibilities. Tube feeding should be considered to rest the esophagus as needed. Many are reporting increased success by implementing nebulizer treatments. It all goes hand-in-hand for these dogs!




















Heritability
Over the past decade, there has been growing scientific evidence that genetics and breed predilection play an important factor in the frequency and severity of the disorder. Often breeders believe if they cull the one apparently affected pup, and the rest appear non-symptomatic, they are not affected. Unfortunately, there is a ‘silent carrier’ aspect to this disorder. A dog may not appear to be affected and, in fact will never express any recognizable symptoms for its entire lifespan, yet can carry defective DNA. It has been theorized that some young dogs may outgrow the ailment, and as they mature the immature musculature and neurons that control peristalsis also mature and strengthen. Others will only progressively worsen no matter what modality or combination of modalities are tried.

Currently, there is no definitive genetic test to identify afflicted dogs, carrier dogs or dogs that are clear of the disease. Because of this, most vets tell their clients that they believe the illness to be genetic or congenital in origin, but they cannot categorically state that it is so. However, because of previous experience and knowledge of the numbers affected in other breeds demonstrating genetic predilection, most vets will tell clients that future breedings of parents or siblings should not be done.

Because of our experiences it has become my mission to educate the dog community about this disorder. During conversation with a specialist at Texas A&M, I was told that it would take 40-50 affected Gordon Setters and an equal number of unaffected dogs in order to study the genetics within the breed. I pray there will never be that many affected! However, progress will never be made if we turn a blind eye and foolishly believe Megaesophagus is not a factor or potential threat to the health of our breed.

At this time I would like to ask for blood samples to be donated to the Gordon Setter CHIC DNA Repository. If DNA samples are not collected and stored, research cannot happen. Please visit http://ww.caninehealthinfo.org for further information. There is also Gordon Setter specific information on the TarTan Gordon Setter website, http://www.tartangsc.org/health-chic-dna.html.

It is my hope that this article will reach into your hearts, and reach far and wide within the dog community. I have spoken with many people from other breeds, and unfortunately, Megaesophagus is making a strong, expressive statement with increased frequency. It is heart-wrenching that so much damage can be done to in just a generation or two.


A Summation, by Dr. Kathy Morris-Stilwell

Canine megaesophagus can be a very manageable disease in many dogs, depending on the cause, and on the concomitant disorders that are present. Veterinarians are often limited in their ability to completely evaluate each case as thoroughly as they would like, due to diagnostic limitations. The usual diagnostics are laboratory tests, x-rays, with and without barium, endoscopy, and occasionally, fluoroscopy. It would be helpful if we could also evaluate each of these patients for how well their upper and lower esophageal sphincters function, as well as if they have concurrent poor motility of their stomachs, or other co-existing bowel disorders such as IBD (Inflammatory Bowel Disease). As it is, once a patient is diagnosed with megaesophagus, whether congenital or acquired, and depending on if it is idiopathic, or caused by Myasthenia Gravis, hypothyroidism, etc., we are left with helping the owners develop a feeding and management protocol that works for that particular dog. This includes, but is not limited to, experimenting with food consistency, trying a variety of pro-motility drugs, using acid inhibitors to reduce esophagitis which occurs due to reflux of food from the stomach into the esophagus, preventing and treating esophagitis and aspiration pneumonia, and vertical feeding. Since many of these dogs are prone to aspiration pneumonia, prevention (by feeding vertically, and encouraging the dog to sleep with it's front end elevated) and treatment can be accomplished by the administration of albuterol and/or saline using a nebulizer. Ultimately, some of these dogs require minimal management, while others need a lot. The success depends on the dedication of the owner, as well as the willingness of the veterinarian to keep an opened mind and to not give a dismal prognosis to all cases.


Online Resources:
UC DAVIS
www.upei.ca/cidd/Diseases/GI%20disorders/megaesophagus.htm

Dr. Diane Shelton - Myasthenia/Megaesophagus
Dr. Shelton includes a photo of the Bailey chair during a case presentation of Myasthenia complicated by Megaesophagus. Please visit her URL: http://vetneuromuscular.ucsd.edu/cases/2005/may05.html

Wikipedia - Megaesophagus
en.wikipedia.org/wiki/Megaesophagus

Support Group - Megaesophagus
pets.groups.yahoo.com/group/megaesophagus/ -- support group of dedicated volunteers who work round the clock to offer knowledge and comfort to the newly diagnosed. Volunteer Veterinarian also 'on staff.'

Eva’s Website - Megaesophagus (Daily Care, Clinical Side Conditions, Genetic Heritability)
http://www.caninemegaesophagus.org/


Below is a  photo collage of just a few of the dogs whose humans belong to the Megaesophagus Support Group
Membership is currently (3/25/08) over 2,440 - membership which unfortunately grows by the day. When I started this Letter Campaign, February 17th, the membership had just reached 2,350. This is a wonderful support group. Please visit and don't forget to share about the support group with your clients. It will bring them much comfort in understanding the disorder, and help to get their dog's case turned to a positive direction.
DVM Staff
Placing this poster on your clinic's bulletin board will help increase awareness. Friends of dogs who may be affected could recognize the symptoms, and take the info to the pet owner who is in need of your educated services.
We want to be
Mega special, too!
Eva wore a little smock to keep food & regurge off her coat. It also helped to provide a little support to her throat region during swallows.
Planning for growth stages:
This creative mom used a highchair for her pup. When
the pup is fully mature, a Bailey Chair will be built.
Some of the dogs do get a bit 'antsy' during
post-meal hold sessions. This creative mums
strolls with her pup to make the time pass
more quickly. What a lucky pup!
Photo Credit:  Marilyn Lentini, Rosie's mums.
Brochure - please select your format:
Harry asks that you

It is my hope to educate readers about Megaesophagus,
a disorder which many breed enthusiasts have undoubtedly never heard. After a decade of being involved in rescue efforts and experiencing a wide range of disorders and diseases during that course of time, apparently I was still short on experiencing sadness and challenge, as not one of those disorders was ever as
It is better to light one candle . . .                                    . . .  than to curse the darkness.
                                                                            

Health Enthusiasts
We hope you will help the cause by taking a poster and letter to your vet clinic. Thank you!
Assisted Drinking in Vertical Position

Click to view & hear sounds that many
of the dogs make while drinking.
'Rare' (megaesophagus) dogs leading very normal, active lives.
Help find a home for Marina, Dash, Eve, Tululua, & Woof!
Copyright ©2008 cmERp -  canine megaesophagus Education & Research project.  All rights reserved.
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