a 10-month - old domestic shorthair cat was evaluated for severe esophagitis and protracted vomiting and regurgitation secondary to a sliding ( type i ) hiatal hernia .
the hernia and concurrent upper airway obstruction ( nasopharyngeal polyp ) were diagnosed with a multi - modality approach , including thoracic and abdominal radiographs , abdominal ultrasound , computed tomography and endoscopy . following unsuccessful attempts at medical management ,
lower esophageal incompetence was successfully treated by employing a combination of surgical techniques , including herniorrhaphy , esophagopexy and modified ( floppy ) nissen fundoplication .
a multi - modality imaging approach was valuable in completely assessing the extent of this cat s disease . although an untraditional approach , the authors report herein the first clinical description of the use of combined surgical techniques with the floppy nissen fundoplication technique ( an antireflux procedure ) in a cat .
this procedure was used as a first - line surgical technique in this cat with severe lower esophageal incompetence , and may be a viable option for cases non - responsive to other therapeutic interventions . further investigation of this surgical technique is warranted .
hiatal hernia , defined as protrusion of abdominal contents through the esophageal hiatus into the thorax , is a complex entity in humans and animals , with a multifactorial etiology and pathophysiology .
the latter leads to decreased movement resistance of the gastric cardia from the abdomen to the thorax .
intrinsic and extrinsic components of the lower esophageal sphincter prevent regurgitation of gastric contents . disruption or displacement of the lower esophagus or gastroesophageal junction
a 10-month - old male intact , 1.4 kg , domestic shorthair cat was evaluated for chronic vomiting and poor body condition despite polyphagia .
clinical signs began at 10 weeks of age and included lethargy , fever , stunted growth and abdominal distention occurring within minutes of eating .
pyrexia and lethargy resolved with empirical treatment with augmented amoxicillin ( 14 mg / kg orally q12h ) .
famotidine ( 0.5 mg / kg orally q24h ) and metoclopramide ( 0.3 mg / kg orally q8h ) were added to the treatment plan .
results of a serum biochemistry analysis , complete blood count ( cbc ) , serum bile acids , fecal flotation and thyroid testing were normal .
in addition , a well - marginated , 2 cm  3 cm , soft tissue opacity , caudal esophageal mass was seen .
a mural , extramural or luminal caudal esophageal lesion was suspected , with preliminary differentials including esophageal foreign body , hiatal hernia , congenital megaesophagus and esophageal diverticulum .
upper gastrointestinal endoscopy revealed gastroesophageal mucosal hyperemia , distal esophageal dilation and severe esophageal reflux .
omeprazole ( 0.9 mg / kg orally q24h ) and small , frequent feedings were added to the treatment protocol .
the patient was referred for further diagnostic investigations after 6 months of poor response to medical management .
a body condition score of 3/9 , stunted growth and a body weight of 1.4 kg were noted on physical examination .
repeat serum bile acid concentrations were marginally increased at 15.7 mol / l ( reference interval [ ri ] 05 mol / l ) .
a cbc demonstrated a mature neutrophilic leukocytosis ( 42.2  10/l leukocytes , ri 4.215.6  10/l ; 34,943 
repeat orthogonal thoracic radiographs showed an intermittently present , large , 5 cm  2 cm  3 cm , well marginated , soft tissue opacity within the caudal esophagus with severe gastric distension ( of admixed gas / fluid opacity ) . during imaging the patient demonstrated signs of respiratory distress ( increased respiratory effort , rate and stertor ) , which resolved with discontinuation of applied manual restraint and supplementation of flow - by oxygenation .
the increased respiratory effort noted during thoracic imaging acquisition corresponded to a dynamic change in position of the mid- to caudal sternebral segments on the radiographs ( figure 1 ) .
thus , combined radiographic and clinical findings raised the suspicion of sliding hiatal herniation secondary to upper airway obstruction . given the propensity toward respiratory decline and the dynamic caudal esophageal mass effect , computed tomographic ( ct ) imaging was deemed the best - suited modality to evaluate the upper airway , esophagus and stomach .
note the presence of gas within the soft tissue mass at the level of the caudal esophagus and the dorsal displacement of the mid - to - caudal sternebral segments due to increased inspiratory effort and respiratory distress .
note how the patient s sternebral deformity and the mass at the level of the caudal esophagus resolve with assisted ventilation .
dynamic changes in the sternebral segments coupled with increased respiratory effort raised suspicion of an upper airway obstruction , which was likely exacerbated by the stress of restraint for thoracic imaging abdominal ultrasonography revealed a non - motile , fluid - filled stomach and normal pyloroduodenal junction .
the portal vein to aortic ratio was normal ( 0.89 ; ri 0.81.0 ) , making a portosystemic shunt unlikely .
although the cat s episode of dyspnea was brief , it prompted a prioritized diagnostic evaluation of the upper airway with contrast - enhanced ct of the head .
given the intermittent radiographic mass lesion within the caudal thorax , ct of the thorax was also performed followed by a sedated examination of the oropharynx .
premedication , anesthetic induction and maintenance following intubation were maintained with butorphanol ( 0.1 mg / g i m ) , midazolam ( 0.2 mg / kg i m ) , propofol ( 2 mg / kg iv ) and an isoflurane  oxygen admixture , respectively .
contrast - enhanced ct demonstrated a non - enhancing , soft tissue density within a thickened and expansile left tympanic bulla ( figure 2 ) .
an obstructive , 1 cm diameter , similarly minimally enhancing , ovoid mass was identified within the nasopharynx .
ct abnormalities were consistent with a nasopharyngeal polyp extending from the left tympanic bulla / eustachian tube to the nasopharynx with secondary hiatal herniation . computed tomography of the head . ( a )
( b ) note the soft tissue density within the expansile left tympanic cavity with thickening of the osseus bulla .
note the soft tissue densities within the left tympanic cavity and the nasopharynx computed tomography of the thorax .
( a ) sagittal , ( b ) transverse and ( c ) dorsal , curved  planar reconstructed images demonstrating rugal folds within the thoracic esophagus just cranial to the hiatus . note also the diffuse gas distention of the intrathoracic esophagus on all images following imaging , the nasopharyngeal mass ( presumed to be a polyp ) was extracted via gentle traction and submitted for histopathologic confirmation .
the patient recovered without complication and was discharged with buprenorphine ( 0.015 mg / kg orally q46h ) , omeprazole ( 0.9 mg / kg orally q24h ) and cisapride ( 1.8 mg / kg orally q8h ) .
lower esophageal sphincter incompetence and complications secondary to a sliding hiatal hernia were suspected , with consideration given to esophageal hypotonia and reflux esophagitis .
surgical correction of the hiatal hernia was recommended given continued poor response to medical management .
thirty - three days following polyp removal , the cat was admitted for endoscopy , esophagoscopy , gastroscopy and hiatal hernia repair using a combined approach and employing an antireflux procedure .
premedication , anesthetic induction and maintenance following intubation were achieved with diazepam ( 0.5 mg / kg iv ) , buprenorphine ( 0.01 mg / kg i m ) , propofol ( 3 mg / kg iv ) and an isoflorane  oxygen admixture , respectively . lactated ringer s ( 10 ml / kg / h iv ) and a fentanyl continuous rate infusion ( 0.35 g / kg / min ) were administered
. endoscopy demonstrated severe esophagitis , scarring and erythema of the lower esophageal mucosa , and grossly normal gastric mucosa ( figure 4 ) .
( a , b ) note the severe esophagitis with irregularly marginated , multifocal erosions . a significant amount of bilious reflux was noted .
( d ) note the mural twist at the cardia just caudal to the diaphragm .
tented margins of the lower esophageal wall ventral midline celiotomy revealed a large , flaccid stomach and marked dilation of the esophageal hiatus .
blunt dissection of the esophagus , herniorrhaphy ( with 3 - 0 simple interrupted polypropylene simple interrupted diaphragmatic sutures ) and diaphragmatic esophagopexy ( with 4 - 0 polydiaxione simple interrupted sutures ) were performed followed by a floppy nissen fundoplication .
the size of the tube was such that it was able to distend the esophagus to some degree but able to be passed easily to the stomach , as per the previously described modified technique .
the gastric wall was mobilized 360 degrees dorsomedially around the intra - abdominal esophagus and sutured to itself without tension , using 3 - 0 polypropylene simple interrupted sutures .
the cat was kept in the hospital for observation and pain management for 48 h. a fentanyl continuous rate infusion ( 0.2 g / kg / min ) was administered for postoperative pain management .
two weeks postoperatively the cat was re - evaluated at the referral center for suture removal .
the owner reported three episodes of non - productive retching , but vomiting had resolved .
the referring veterinarian provided a 6 week postoperative follow - up report . at that visit
the cat weighed 2.1 kg , having gained an additional 0.4 kg , and the owner noted marked improvement in activity levels at home . although the owner reported overall improvement of regurgitation , episodes with retching and production of small amounts of brown , frothy fluid persisted and were noted five times weekly , usually within 3 h of consuming a meal . the cat progressively continued to thrive at home and gain weight , with reports from the owner of once - daily non - productive retching in the 616 week interim following surgery . between this time period ,
the referring veterinarian provided wellness maintenance with an unchanged regimen of prokinetics and proton pump inhibitors . at the 16 week follow - up at the referral center , the cat s physical examination was normal .
this weight gain was attributed to the surgical intervention given that the cat s body weight had nearly doubled in the 16 week postoperative period .
thoracic radiographs showed a persistent , mild increase in soft tissue opacity in the region of the caudal esophagus ( figure 5 ) .
endoscopy revealed resolved esophagitis with mild reflux within the caudal esophagus and no gross esophageal or gastric mucosal abnormalities .
irregularity of the lower esophagus was considered related to the surgery ( figure 4 ) .
note the decreased size of the thoracic cavity compared with figure 1 ( a ) .
note the lack of gas within the esophagus and the resolution of the previously described soft tissue mass at the level of the caudal esophagus .
mild , normal volume of mixed gas  fluid opacity is present within the fundus .
note also the normal contour of the ventral thoracic body wall with the more normally positioned sternebral segments due to resolved respiratory distress .
note the poorly defined increase in soft tissue opacity just dorsal to the caudal vena cava and cranial to the diaphragm .
gas opacity persistent within the fundus and the normal mixed gas  fluid opacity within the pylorus .
findings are consistent with the surgically induced malposition of the stomach follow - up by email occurred bi - monthly for 24 months postoperatively , then every 6 months up to 48 months postoperatively . over that time
the owner reported that the cat had non - productive retching of gradually decreasing frequency ( episodes stabilized to 23 times weekly rather than after every meal ) .
reduction of prokinetic therapy ( cisapride 1.8 mg / kg ) from every 8 h to once daily , as per the referral veterinarian , had no effect on retching frequency .
the patient s retching frequency continued to slowly decrease ; by 48 months following surgery no retching episodes were noted and the cat was thriving .
a multi - modality imaging approach and combined surgical techniques were used in the juvenile cat of this report in order to diagnose and treat a sliding hiatal hernia .
even though respiratory issues were not a primary complaint , restraint for radiographic imaging precipitated a respiratory episode .
congenital or acquired hiatal herniations were the primary differentials for the soft tissue opaque mass in the caudodorsal thorax seen on the same study .
ct was supportive of this clinical suspicion , revealing a large obstructive mass in the nasopharnynx .
upper airway obstruction has been reported in cases of dogs with hiatal hernia , where it is speculated that increased intraesophageal and intrapleural pressure can pull the esophagus and stomach into the thorax .
further evaluation of the upper and lower airway is indicated in patients with suspected respiratory disease . in the patient of this report
, ct provided details regarding the inappropriate presence of mixed soft tissue and gas densities with rugal fold architecture at the hiatus .
the diagnosis of hiatal hernia typically relies heavily on signalment , history , clinical signs and diagnostic imaging . widely available
modalities such as radiographs , contrast esophagraphy , fluoroscopy and ct can aid in the diagnosis of the sliding hernia .
barium esophagraphy can be especially useful in assessing esophageal motility and caudal esophageal sphincter function . as was the case with the cat of this report , endoscopic evaluation was helpful in evaluating the degree of mucosal changes associated with secondary reflux esophagitis , as well as aiding in medical and presurgical treatment planning . although not a traditional approach , ct was instrumental in a rapid diagnosis for both the cause of the upper airway obstruction and the displaced gastric anatomy through the hiatus .
abdominal ultrasonography demonstrated gastric dilation and functionally reduced gastric motility , while ruling out other causes of persistent regurgitation in young cats ( such as pyloric stenosis ) .
endoscopy confirmed the presence of esophagitis , gastritis and gastric flaccidity , and also prescreened the patient for the presence of contraindicated disease for the employment of the modified nissen fundoplication technique .
repeat endoscopy was valuable in documenting resolved esophagitis . in the private practice setting , this degree of imaging may not be economically or technically feasible . at a minimum ,
we recommend survey thoracic and abdominal radiographs , and a sedated oropharyngeal exam prior to referral for advanced imaging and surgical intervention of cats with suspected hiatal hernias . in addition , we recommend endoscopy and/or dynamic fluoroscopic evaluation of esophageal motility for cats with evidence of chronic reflux esophagitis and poor response to medical management .
removal of the nasopharyngeal polyp was prioritized to alleviate the risk of respiratory decompensation . following a poor response to medical management and protracted episodes of retching and regurgitation , lower esophageal sphincter incompetence due to chronic esophageal reflux
was highly suspected and confirmed with presurgical endoscopic evaluation of the lower esophagus . surgical correction of the sliding hiatal hernia with an antireflux procedure , a modified ( floppy ) nissen fundoplication , was then performed .
floppy nissen fundoplication successfully reduced clinical signs ( vomiting and weight loss ) in this cat in the short term ; in the long term , the cat s clinical signs completely resolved .
a sliding hiatal hernia , also called a type i hernia or axial hernia , is described as cranial displacement of the abdominal esophagus , esophageal junction and , sometimes , a portion of the stomach into the thoracic cavity .
congenital sliding hiatal hernias in young patients and acquired sliding hiatal hernias in adults are the most common forms seen . when sliding hiatal hernias occur in young animals between the ages of 2 and 4 months , they are usually described as congenital . however , hiatal herniation is a complex entity in humans and animals with an incompletely understood , multifactoral etiology and pathophysiology .
given the large obstructive nasopharyngeal mass in the patient of this report , an acquired sliding hiatal hernia was suspected , despite the patient s young age .
congenital hiatal herniation was also considered , and coincidental occurrence of the polyp could not be ruled out .
patients with sliding ( type i ) hiatal herniation usually present for emesis and regurgitation .
other clinical signs can include ptyalism , nasal discharge , coughing , dysphagia and hematemesis .
stunted growth , recurrent gastric dilations , and clinical signs referable to esophagitis and gastroesophageal reflux , such as regurgitation with or without blood , aerophagia , anorexia and weight loss , are often reported .
disruption or displacement of the position of the esophagus , gastroesophageal junction and lower esophageal sphincter contribute to sphincter incompetence , leading to gastroesophageal reflux and esophagitis .
experimentally , the production of esophageal reflux in cats has been shown to lower gastroesophageal sphincter pressure , resulting in a chronic cycle of reflux and esophagitis .
hiatal herniation may be associated with , or exacerbated by , respiratory disease , neuromuscular compromise , megaesophagus , esophageal motility disorders and obesity .
as with the cat described in this report , respiratory difficulty and obstruction can be a predisposing factor in the occurrence of hiatal hernia both in dogs and cats .
entrapment of gastric fluid orad to the hiatus and loosening of the phrenoesophageal attachment may also contribute to movement of the intrinsic component of the lower esophageal sphincter .
patients with subclinical sliding hiatal hernia may not require medical or surgical intervention . in patients with clinical signs ,
medical management of gastroesophageal reflux should be attempted for a minimum of 30 days when reasonable , but is often unsuccessful .
small - volume , frequent feedings of a low - fat diet may aid in gastric emptying and decreased acid production .
changing the consistency of the food and feeding from an elevated position may also contribute to esophageal clearing .
drug therapy aims to decrease acid production , increase gastric emptying and increase the tone of the esophageal gastric junction .
frequently employed pharmaceuticals include sucralfate , antacids , h2 blockers , prokinetic agents and proton pump inhibitors .
surgical intervention is recommended if clinical signs ( especially regurgitation and high - volume reflux ) persist despite medical management .
the occurrence and severity of reflux in patients with hiatal hernia is multifactorial . in immature animals , as with the cat of this report , reflux may be significantly increased because of an immature or poorly developed lower esophageal sphincter
. reduction of the hiatus alone rarely results in complete resolution of the clinical signs .
antireflux procedures are considered superior in patients with gastroesophageal reflux and may obviate the inconvenience and expense of lifelong medical management . as the majority of clinical signs associated with sliding hiatal hernias are related to gastroesophageal reflux , a procedure that is effective in reducing or eliminating reflux has merit .
techniques for repairing hiatal hernias in animals vary and there is much debate in the veterinary community regarding which techniques , or combination thereof , are best depending on the type of hernia .
described techniques include herniorrhaphy , gastropexy , esophagopexy , antireflux procedures and feeding tubes , or a combination thereof .
corrective surgical techniques have been described and include different methods of maintenance of hernia reduction and manipulation of the gastroesophageal sphincter .
the nissen fundoplication was developed to treat reflux in humans . in pediatric patients , the modified fundoplication used in conjunction with a gastrostomy tube
is commonly used to treat esophageal achalasia or hiatal hernia with severe gastroesophageal reflux . an antireflux procedure combined with herniorrhaphy and esophagopexy
were chosen in this patient in an attempt to prevent further reflux , which was causing the clinical signs . in cats , modified nissen fundoplication has experimentally been the most effective procedure in restoring lower esophageal pressure to normal , and the only procedure that helped prevent reflux .
the other developed severe necrotizing gastritis in the immediate postoperative period but recovered with medical management .
antireflux procedures in small animals have previously been challenged , with opponents arguing that primary lower esophageal sphincter incompetence , the main indication for an antireflux procedure in humans , does not occur in small animals .
however , lower esophageal sphincter incompetence is thought to be secondary rather than primary in humans .
some authors propose that these techniques are surgically demanding , lend themselves to higher complication rates , and that the rationale for pursuing sphincter enhancement techniques is a failure of response to previous repositioning efforts . given the low number of cases , there is a lack of evidence clearly demonstrating that repositioning techniques lead to irreversible hiatal attenuation and prevention of reflux in the long term .
additionally , performance of techniques such as gastropexy could potentially compromise performance of a subsequent antireflux procedure .
antireflux procedures have not been reported following failure of repositioning techniques in the veterinary literature . in humans
, studies have shown that some patients having no reflux preoperatively developed reflux postoperatively when antireflux procedures were not performed . in these cases ,
the development of reflux may have been attributable to dissection of the gastroesophageal junction , reduction of the stomach or insufficient crural repair .
complete evaluation for a functional esophageal motility disorder was not performed prior to or after surgery with dynamic , fluoroscopic , positive contrast esophagography . in patients with esophageal motility disorders , however , an excellent outcome can be achieved with modified nissen fundoplication , regardless of etiology .
the procedure should be avoided in cases with aperistalsis , tight fibrous strictures and  short esophagus syndrome. one previous study suggested that the absence of megaesophagus on survey radiography is consistent with a functional esophagus , while other studies emphasize the importance of evaluating for functional motility disorders with a barium esophagram or dynamic fluoroscopic esophagography .
additional limitations of this report include lack of esophageal and gastric histopathology and full gastrointestinal panel serum analysis ( b12/folate ) .
although this cat was quite young , the possibility of primary inflammatory bowel disease as a contributing factor was considered .
advanced imaging was an invaluable tool in the diagnosis , management and employment of combined surgical techniques , which provided an excellent outcome in a young cat with a sliding hiatal hernia , severe lower esophageal incompetence and concurrent reflux esophagitis .
although presumed to be secondary to upper airway obstruction , the sliding hiatal herniation may have been congenital in nature .
failure of response to medical management , degree of reflux noted on endoscopy , lack of a functional lower esophageal sphincter , suspicion of gastric hypomotility and questionable esophageal functional motility prompted the consideration of combined surgical techniques to include an antireflux procedure . surgical correction consisted of herniorrhaphy , esophagopexy and modified ( floppy ) nissen fundoplication .
regardless of the underlying etiology , advanced imaging and a multi - modality approach can assist in evaluation of candidacy for antireflux procedures .
further studies are needed to investigate short- and long - term outcomes of the floppy nissen fundoplication antireflux procedure and combined herniorrhaphy / organopexy in feline and canine cases of sliding hiatal hernia .
 case summarya 10-month - old domestic shorthair cat was evaluated for severe esophagitis and protracted vomiting and regurgitation secondary to a sliding ( type i ) hiatal hernia . 
 the hernia and concurrent upper airway obstruction ( nasopharyngeal polyp ) were diagnosed with a multi - modality approach , including thoracic and abdominal radiographs , abdominal ultrasound , computed tomography and endoscopy . following unsuccessful attempts at medical management , 
 lower esophageal incompetence was successfully treated by employing a combination of surgical techniques , including herniorrhaphy , esophagopexy and modified ( floppy ) nissen fundoplication.relevance and novel informationa multi - modality imaging approach was valuable in completely assessing the extent of this cat s disease . 
 although an untraditional approach , the authors report herein the first clinical description of the use of combined surgical techniques with the floppy nissen fundoplication technique ( an antireflux procedure ) in a cat . 
 this procedure was used as a first - line surgical technique in this cat with severe lower esophageal incompetence , and may be a viable option for cases non - responsive to other therapeutic interventions . further investigation of this surgical technique is warranted . 
Case summary
Relevance and novel information
Introduction
Case description
Discussion
Conclusions