ENDOSCOPY or Looking Inside

By Dr. Eugene Gorodetsky, DVM

Endoscopy translated from Greek means looking inside. Basically it involves advancing a video camera either into a natural orifice or into an opening made specifically for that purpose. Endoscopes come in many different sizes and varieties. In my practice I commonly use multiple endoscopes ranging in size from 2.5 mm to 13 mm in diameter (as my patients range in size from a couple hundred grams to a couple hundred kilograms plus).

In human medicine endoscopes have been in use for over a 100 years. In the veterinary world it's become relatively widely available over the past 30 years or so. Veterinary endoscopy is well utilized in specialty practices and teaching institutions as well as in many general practices. However, it is still not as commonplace as it deserves to be: when a pet has swallowed a fish hook or part of a tennis ball, the knee-jerk-reflex for many practitioners is to perform surgery rather than look for a less invasive solution. The cavities that I examine most commonly include upper gastro-intestinal tract/GIT (oesophagus, stomach and the adjacent portion of the small intestine), lower GIT (rectum, colon +/-ileum), nasopharynx, nasal turbinates +/-sinuses, trachea and bronchi. Endoscopy allows for collection of samples such as brushing for cytology and/or culture, broncho-alveolar lavage under direct visualization, collection of biopsies for histopathology. In some situations polyps can also be removed through the scope. Different instruments can be passed through the instrument channel of the scope in order to retrieve foreign bodies or to obtain samples such as biopsies.

X-ray showing a fish hook!

This American Bulldog had quite a history with foreign bodies: in the past she had both endoscopic and surgical removal. This time the owners were at the end of their rope: if endoscopy did not work, they'd consider euthanasia. In other words, no pressure. Fortunately for all involved, I was able to retrieve an intact pair of pantyhose as well as the remnants of a T-shirt.

Foreign bodies are certainly the most entertaining aspect of endoscopy. Over the years I have removed hundreds (and likely by now thousands) of foreign objects from dogs, cats, ferrets, birds, lizards, turtles, horses, pigs, and even from a lion. Cats usually ingest predictable things such as needles, thread, hair ties, condoms, ear plugs; occasionally you get something more exciting such as a toy mouse. In dogs, however, the sky is truly the limit as to what they can and will eat. The most common foreign bodies include rocks, coins, balls, fish hooks, plastic of various kinds, socks, different types of underwear and hygienic products. Dogs with greater imagination prefer beer bottle cups, leashes, collars, meat skewers, gloves or Christmas ornaments. And the true gourmands go for diamond rings, brooches, tips of garden hoses, door knobs, rubber duckies, intact Christmas tree light bulbs, seven feet of poop bags, Mr. Potato Head’s tongue or a toupee. Just in case you are wondering, this list is not a product of my lively imagination; this is a sampler of what I have personally removed endoscopically.

A ball is a true staple of endoscopic foreign body removal.

Some of the exotic patients have also supplied me with memorable stories. In the past I’ve removed a little bell from a Chinese Water Dragon (a small lizard). The cool thing about that case was that you could actually hear the bell when the lizard moved. A Bearded Dragon ingested a penny. A piglet managed to get an oesophageal obstruction (blocked food pipe) with a dried apricot. A 10 day old miniature horse (a whooping 35 lb equine) got a blockage after ingesting wood shavings. A Monitor lizard with fabric in his stomach. A lion that was given a water hose as an enrichment tool in her enclosure, and promptly started vomiting pieces of the hose. And the list goes on.

This was a 10 day old miniature horse (35 lb) that managed to ingest a large amount of wood shavings and got herself an oesophageal obstruction.

One’s ability to remove different types of foreign objects comes down to experience, common sense and the availability of proper instruments. There are numerous instruments such as snares, baskets, graspers, and nets commercially available. Their use requires some experience, but it definitely is not rocket science. Can any foreign body be removed from the stomach using endoscopy? Just about. My success rate is about 99% with gastric (stomach) foreign objects. Basically, if it did go down, it must be able to come back up as long as proper tools are readily available. Some exceptions apply, but they are few and far between. These exceptions are usually of two types: things that change in the stomach, and things that form in the stomach. Some examples of objects changing on prolonged contact with gastric acid would be a rubber ducky (it becomes hard as a rock after spending a couple of weeks in the stomach) or rubber gloves (those turn hard, brittle and black). Things that form in the stomach can be hairballs or other aggregations of material such as fabric, etc. Not infrequently they form around some kind of centre such as a piece of plastic.

The name of the pig was (and hopefully still is) U-u. The piglet (a young mini-pig only weighing 3.5 kg) was suddenly unable to eat and was drooling. On x-rays there was a suspicion of an oesophageal foreign body. On endoscopic exam I found and removed a rather peculiar obstruction - a dried apricot. What kind of self-respecting pig would get obstructed with an apricot? Well, stranger things have happened...

When the object has moved past the stomach into the small intestine, in many cases I can still get it, but it is not nearly as straightforward as it is with the gastric ones. With intestinal foreign bodies cats typically have a considerably higher chance of successful removal. The reason for that is twofold: they like to eat soft things such as earplugs, pieces of yoga mat or erasers AND the majority of these objects get stuck in the part of the small intestine adjacent to the stomach. So, the soft foreign body does not cause a lot of damage to the intestinal wall, AND I can usually reach it and remove it.

Yes, I did take all this material out of this American Bulldog's stomach. Even more amazingly, he managed to ingest it all in one sitting: owners left for the evening, and while they were gone, the bulldog went to town. Most of the stuff ingested consisted of yarn (green and white), but there also were some shoelaces, a bra, some undergarments, etc.

Growing up, this pup must have dreamed about being a sword swallower. Decided to try with one conspicuously long treat. Got it lodged. Got it removed. Lived happily ever after.

Another invaluable application of endoscopy is oesophageal obstruction (blocked food pipe). I have removed about 500 foreign bodies from oesophagi of various creatures. Most of them happen in dogs. Bones are the most common, followed by rawhide chews, but occasionally one can find an apple core, piece of watermelon rind, a toy or even a large piece of kibble. Whereas the stomach can usually be accessed by open surgery, no surgeon will touch the oesophagus with a ten foot pole if they can help it. That is why endoscopic removal is by far the best and safest option available. The sooner the oesophageal obstruction is addressed (hours rather than days), the less likely the patient is to experience severe complications. The saying goes that the sun should never set on an oesophageal obstruction.

Some foreign body retrievals take literally a few minutes. Others can be very challenging technically and extremely time consuming. For example, recently I treated a 14 year old Golden with a stomach completely filled with artificial moss (soft plastic). It took me about a hundred trips into the stomach to remove it piece by piece. In total, there was about five litres of this material. Needless to say, that took more than a few minutes; more like an hour and a half plus. But, to me it is still a preferable option, especially for a senior dog: the day after the procedure the patient was eating and active. And there is no big painful incision to heal.

14 year old Golden stomach filled with...ARTIFICIAL MOSS!

This five week old kitten was born with a genetic defect - a cleft palate. As a result, he was unable to eat normally, so he was fed through a tube delivering the milk straight into the oesophagus (and thus bypassing the mouth). Somehow the little tube (a red linear structure next to the kitten in the picture) was lost in the oesophagus. I had to get it out using one of the smaller scopes (he weighed less than one pound). The kitten did well.

One of the objects I have never removed before was a shuttlecock (colloquially known as birdie).

Not uncommonly I encounter foreign bodies in the nasal cavity — either in the nostrils or in the nasopharynx: usually they are blades of grass, pieces of tree bark, pine needles, occasionally you can find a peanut. Once I found a tooth that was in the nose as a result of previous trauma. Rarely one can find a tracheal foreign body. I have only seen about a dozen of them: a small rock, a nut, a piece of pine cone, a few twigs, a cherry pit, a few blades of grass.

Occasionally I get to remove foreign bodies from shall we say more unusual locations. I’ve seen a couple of socks that were swallowed and then passed along all the way to the colon. Then somehow they got caught around the ileo-colic junction (an area where the small intestine goes into the large intestine). I went in with a scope rectally and was easily able to dislodge and remove the foreign object. I have also removed a few objects (usually plant matter such as fox tails, etc) from the ears, many of them puncturing the ear drums. Another foxtail was removed from a dog’s vagina; it was sitting quite deep, close to the cervix.

Foreign bodies are fun, but the most common use of endoscopy should be for diagnosis of chronic conditions — chronic gastro-intestinal cases, chronic noses, chronic lungs. I am sure every one of us working with small animals can think of a persistently vomiting dog, a cat with chronic nasal discharge or a coughing dog that just does not respond well to symptomatic treatment. For any of those scenarios as well as for many others endoscopy can offer direct examination of the affected area as well as collection of samples for further pathological examination and diagnosis.

Endoscopy is not a solution to all problems, but in many cases it is an effective and less invasive alternative to surgery. For those of us who have personally lived through any kind of surgical procedure, the memories of pain associated with healing are enough to try and avoid any future surgeries unless absolutely necessary. I am happy to provide my patients with that alternative.