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EQUINE COLIC 11 Equine vet. J., Suppl. 32 (2000) 1 D4- 107

The medical management of eight horses with Grade 3 rectal tears

T. S. MAlR

Bell Equine Veterinary Clinic, Mereworth, Kent ME18 5GS, UK.

Keywords: horse; rectal tear; Smal colon; peritoneal cavity

Summary Eight horses with Grade 3b rectal tears of the peritoneal part of the rectum or small colon were treated by a combination of medical therapy and dietary manipulation. All of the horses developed septic peritonitis during the course of treatment. Medical therapy consisted of a combination of penicillin, gentamicin and flunixin meglumine administered parenterally, metronidazole administered orally and liquid paraftin administered by nasogastric tube. Some horses also received fluid and electrolyte therapy i.v., plasma and heparin i.v. All horses were maintained on a laxative diet. Six of the 8 horses recovered. Duration of therapy in the horses that survived was between 2 and 7 weeks. Three of the 6 horses that recovered developed a rectal diverticulum, which did not appear to cause any subsequent medical problems. In the 2 horses that died, the Grade 3 rectal tear progressed to a Grade 4 tear with subsequent faecal contamination of the abdomen. Manual evacuation of the cavity of the rectal tears during treatment and size of the tears were identified as possible causes for the progression of the disease in these 2 horses. Introduction
Horses with traumatic and obstructive diseases of the rectum and distal small colon are difficult to treat surgically because of limited access to these areas. Rectal tears are usually iatrogenic, occurring most commonly as a complication of manual palpation per rectum (Arnold et al. 1978; Stauffer 1981; Spensley et al. 1985; Sayegh e f al. 1996). They may also arise, less commonly, as a result of enema administration, especially in foals (Keller and Horner 1985), dystocia and breeding accidents (Arnold et (11. 1978; Guglick et al. 1996). Complications associated with rectal tears that occur caudal to the peritoneal reflection (i.e. in the retroperitoneal part of the rectum) include cellulitis, perianal fistulae and formation of a rectal diverticulum (Sayegh et al. 1996; Mazan 1997). Tears involving the intraperitoneal part of the rectum or small colon are potentially more serious and may result in septic peritonitis, which can be life-threatening. Rectal tears are classified according to the layers of the rectal wall that are disrupted (Arnold et (11. 1978). Grade 1 tears involve disruption of only the mucosa (with or without the submucosa). Grade 2 tears involve only the muscularis. Grade I and 2 tears usually heal with conservative treatment. Grade 3 tears involve the mucosa, submucosa and muscularis, and may result in the formation of a serosal diverticulum (Grade 3a), or they may

enter the dorsal mesentery (Grade 3b). The intact serma or mesorectum of Grade 3 tears prevents faeces from entering the peritoneal cavity, but bacterial contamination of the cavity occurs rapidly, resulting in septic peritonitis (Watkins et al. 1989).Tears that perforate all layers of the rectum and extend into the peritoneal cavity are classified as Grade 4. Grade 4 tears result in faecal contamination of the peritoneal cavity and death. Grade 3 tears may progress to Grade 4 due to rupture or necrosis of the Serosa or mesentery. Recommended treatments for horses with Grade 3 rectal tears include primary closure (Arnold and Meagher 1978; Speir:; e f al. 1980; Watkins et al. 1989; Stewart and Robertson 1990; Wilson and Stone 1990; Sayegh et al. 1996), implantation of a temporary indwelling rectal liner (Taylor et al. 1987; Watkins et al. 1989), temporary diversion of faeces via a loop or end colcstomy (Freeman et al. 1992a,b; Blikslager et al. 1995; Sayegh et al. 1996),or laparoscopic repair (Brugmans and Deegen 1998). Each of these surgical procedures has advantages and disadvantages. The prognosis for horses with Grade 3 rectal tears is guarded. In a report of 42 horses with Grade 3 or 4 tears, mortality rate was 64% (Arnold et al. 1978). Horses with Grade 3b rectal tears had a better prognosis for survival than did those with Grade 3a tears in this study. However, in another review of 35 horses affected by a rectal tear, horses with Grade 31, tears had a worse prognosis for recovery than did those with Grade 3a tears (Watkins et al. 1989). First aid measures undertaken at the time of initial diagnosis had a marked influence on the outcome in this study. This report reviews the case details and outcome of 8 horses with Grade 3b rectal tears that received medical treatment only.

Materials and methods

The case details of 8 mature horses with iatrogenic rectal tears that were treated by medical therapy only were reviewed. These horses were examined by the author over a 12 year period (1986-1997). During this period a further 6 horses with other forms of rectal tears were diagnosed; these included 4 with Grade I rectal tears (all recovered following medical treatment) and 2 with Grade 4 rectal tears (both died). The location and severity of the rectal tears were determined in each case by careful digital palpation per rectum with an ungloved and well-lubricated hand, with the horse sedated and after administration of epidural anaesthesia. In 3 horses (Cases 5, 6 and 8) the tear was also evaluated by fibreoptic endoscopy. All horses had samples of peritoneal fluid obtained for cytology on

T.S . Mair
TABLE 1: Clinical features of 8 horses with Grade 3b rectal tears Duration of injury (hours) 2 6 20 18 3 24 6 24

105

Case 1
2

Age (years) 14

Breed

Sex G G F G M F G F

Approximate distance Approximate length Treatments prior of tear from anus (cm) of tear (cm) to examination 25 25 35 30 25 20 15 25 5 14 6 8 5 13 10 9 Antibiotics Nil Nil Nil Antibiotics Nil Nil Nil

10
18 21 7 15 19 7

P
T P A A P C

3 4 5 6 7 8

Breed: P = Pony; T = Thoroughbred; A =Arab; C = Cob. Sex: G = gelding; M = stallion, F = mare. TABLE 2: Clinical and clinical pathology details of 8 horses with Grade 3b rectal tears Heart rate (beatdmin) 44 60 48 46 40 48 38
80

Case
1 2

Rectal temperature ("C) 38.0 38.8 37.5 38.0 37.5 38.8 38.0 39.0

Gross appearance of peritoneal fluid Yellow. Slightly turbid Yellow. Turbid Orange. Turbid Serosanguinous Yellow. Turbid Orange. Turbid. Yellow. Clear Orange. Turbid

Total nucleated cell count (x 109/1)in peritoneal fluid 5.0 21.5 89.0 37.5 6.0 112.0 3.0 89.0

Bacterial culture of peritoneal fluid NR No growth E.coli Strep. zooepidemicus NR NR Clostridium spp E.coli Clostridium spp Staphylococcusspp Bacteroides spp

4
5 6 7

NR = not recorded.

admission and at varying time periods during the course of treatment. Bacterial culture of peritoneal fluid under both aerobic and anaerobic conditions was performed in every horse on at least one occasion. All horses received the following medication at the time of admission: 1. Antimicrobial therapy: Sodium benzyl penicillin (Crystapen for Injection)' 22000 i u k g bwt i.v. every 6 h Gentamicin (Pangram 5%)* 2.2 mgkg bwt i.v. every 8 h or 6.6 mgkg bwt i.v. every 24 h Metronidazole (Metronex for horse^)^ 15-20 mgkg bwtper 0s every 12 h

Heparin (M~ltiparin)~, 40-80 idkg bwt subcutaneously every 8 h (Cases 7 and 8 ) Manual removal of faeces from the rectum and the tear was carried out daily in Cases I, 2, 4 , 5 and 6. This procedure was performed after sedation and epidural anaesthesia.

Results
All horses were diagnosed as having Grade 3b rectal tears following careful digital examination of the defect. Details of the horses, the duration of the injury at the time of examination by the author, the location and size of the tears, and therapy prior to examination by the author are shown in Table 1. Four of the horses had unrelated chronic medical problems (Cushing's disease in Cases 4 and 7; squamous cell carcinoma of the penis in Case 1; recurrent diarrhoea in Case 3). Details of the clinical findings at initial examination (heart rate, rectal temperature), gross appearance of peritoneal fluid samples, total nucleated cell counts in peritoneal fluid and results of bacterial culture are shown in Table 2. All 8 horses developed septic peritonitis (peritoneal fluid total nucleated cell count > 10.0 x 109/l; peritoneal fluid total protein > 20 g/l; bacteria visible) by the time of the initial examination or during the course of treatment. The duration of therapy and outcome of the cases are shown in Table 3. Six of the 8 horses recovered from the peritonitis and their tears healed by secondary intention. Rectal examination at the cessation of treatment revealed a fully healed rectum in 3 horses. In 3 other horses, a rectal diverticulum at the site of the tear was palpable (Cases 1, 3 and 8). The diverticula had not resulted in any subsequent overt clinical problems at the time of writing ( 1 4 years after initial treatment). Two horses (Cases 2

2. Flunixin meglumine (Finadyne Solution)' 0.5-1.0 mgkg bwt i.v. followed by 0.25 mgkg bwt i.v. every 6-8 h
The above treatments were maintained in 5 horses for the duration of therapy. In 3 cases (Cases 3, 4 and 7), procaine penicillin (N~rocillin)~ (22000 iukg bwt i.m. every 12-24 h) was substituted for the sodium benzylpenicillin after 3-10 days. All 8 horses were given liquid paraffin (2-4 1) by nasogastric tube daily for 2-5 days at the start of treatment. This was repeated as necessary during the course of treatment to maintain soft faeces. All horses were also fed a diet of grass and bran mashes. Other treatments administered to some of the horses included Fluid therapy i.v. with saline or Hartmann's solution (Cases 2, 3,5, 6 and 8) Plasma therapy i.v. (Cases 6 and 8)

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Medical management of Grade 3 rectd tears

TABLE 3: Duration of therapy and outcome of 8 horses with Grade 3b rectal tears

Case

Duration of therapy (weeks)

4 1 2 5 7 0.5 7 6

Outcome Survived Euthanasia Survived Survived Survived

Euthanasia
Survived Survived

and 6) were destroyed on humane grounds due to progressive clinical deterioration and the identification of faecal particulate material in peritoneal fluid samples. A postmortem examination was performed in one horse (Case 2), which revealed necrosis of the mesorectum and the progression of the Grade 3 tear to a Grade 4 tear.

Discussion
Surgical treatment to achieve either primary closure of the rectal tear and/or to divert faeces away from the rectal tear is recommended for all horses with a Grade 3 tear into the peritoneal region of the rectum (Arnold and Meagher 1978; Watkins et al. 1989; Freeman et al. 1992a.b). The aims of surgical therapy are to promote healing of the tear and to prevent the progression of the tear from Grade 3 to Grade 4 . Grade 4 tears usually result in contamination of the peritoneal cavity by particulate faecal material and the prognosis for affected horses is usually hopeless (Watkins et al. 1989). Primary closure of Grade 3 rectal tears may result in the formation of dead space within the intestinal wall, thereby predisposing to abscess formation (Herthel 1975). Furthermore, attempts to repair the tear may cause the tear to enlarge or even perforate (Arnold and Meagher 1978; Sayegh et al. 1996) and, for these reasons, primary closure of Grade 3 rectal tears is considered contraindicated by some surgeons. However, successful primary suture closure of Grade 3 tears has been reported (Watkins et al. 1989). If the tear is close to the anus, it may be sutured per rectum in the standing or anaesthetised horse using either a one-handed suturing technique or via an adjustable speculum (Speirs et al. 1980; Spensley er al. 1985; Sayegh et al. 1996). Surgical access to more proximally-sited tears has been achieved by intussuscepting and exteriorising the rectum thereby permitting suture or staple repair of the defect (Arnold and Meagher 1978; Stewart and Robertson 1990). However, intussusception of the rectum may result in tearing or thrombosis of the vessels in the mesocolon and mesorectum. Intussusception and exteriorisation of the damaged segment of rectum may also be difficult to achieve, except in young and thin horses, due to the large amount of mesenteric and retroperitoneal fat (Stewart and Robertson 1990). Surgical access to Grade 3 or 4 rectal tears through a laparotomy (celiotomy) is, in most cases, extremely limited. The ability to see and repair the tear by direct suturing from the abdomen depends on the distance of the tear from the anus (Arnold and Meagher 1978). In mares, a midline prepubic incision between the mammary glands may provide exposure to tears more than 25 cm from the anus. Exposing tears of male horses is more difficult. In addition, if the tear extends into the dorsal mesentery (i.e. Grade 3b tears), suture repair through a midline laparotomy (celiotomy) is difficult and likely to be unsuccessful. Surgical access to dorsal tears can be improved in some cases by creating an enterotomy in the antimesenteric taenia of the small colon or

rectum opposite the site of the tear (Wilson and Stone 1990). Surgical access to the dorsal surface of the rectum or small colon may be more easily achieved by laparoscopy. The laparoscopic repair of experimentally produced rectal teax has been evaluated (Brugmans and Deegen 1998), and this technique offers promise of an easier and more effective way to repair these tears directly. However, the technique needs to be assessed in clinical cases. Temporary indwelling rectal liners have been used to divert faecal material away from Grade 3 or 4 rectal tears to permit healing by secondary intention (Taylor et ul. 1987; Watkins et al. 1989). The liner is sutured in place via a midline laparotomy (celiotomy). The liner requires continuous postoperative maintenance to prevent impaction of the ring with faeces. Po1.ential complications include separation of the prosthesis from the rectal wall before the tear has healed and insufficient length of the rectal liner. However, this technique has a major advantage over a diverting colostomy in that only one surgical procedure is required. The ring and encircling ligature slough spontaneously 9 to 12 days after placement, and surgical removal is, therefore, unnecessary. Colostomy can be used to divert faeces temporarily or permanently away from the damaged rectum to allow the rectal tear to heal by secondary intention. Both loop and end colostomy procedures have been described (Stashak and Knight 1978; Freeman et al. 1992a,b; Blikslager et al. 1995; Freeman 1996; Sayegh et al. 1996). Both techniques require 2 surgical procedures, one to create the stoma and the other to restore continuity of the small colon after the tear has healed. Potential complications of colostomies include dehiscence, stoma1 prolapse, peristomal herniation, disuse atrophy of the distal portion of the small colon, rupture of mesenteric vessels, adhesions, and impaction at the anastomosis (Blikslager et al. 1995). The choice of method for definitive treatment of a rectal tear can be influenced by cost and by the surgeons preference (Baird and Freeman 1997). In the treatment of horses with Grade 3 rectal tears, combined survival rates from two studies with loop colostomy were 60% (9 of 15 horses) (Freeman et al. 1992b; Blikslager et al. 1995), compared to 40% (6 of 15 horses) where a rectal liner was used (Taylor et al. 1987). The 75% survival rate following medical therapy in the current series conipares very favourably with the reported results of surgical therapies. However, too many factors play a part in the outcome O F such cases to allow direct comparison between different studies (Baird and Freeman 1997). In the 8 horses described in this report, primary closure of the rectal tear via the anus was not considered feasible due to the location of the tears and their distance from the anus. The owners of all of these horses were reluctant to have general anaeFthesia or surgery performed. All of the horses were mature ( 5 of the 8 being age 14 years or older) and of limited financial value, and 4 of them had other unrelated medical problems. Althcugh a diverting colostomy would have been the authors treatment of choice in all of the cases, this option was rejected by the cwners who chose medical therapy only. Although it is well recognised that horses with Grade 3 rectal tears can make full and uneventful recoveries without surgical treatment (Baird and Freeman 1997; Katz and Ragle 1997), few such cases have been documented. Successful medical management of a full thickness tear of the retroperitoneal portion of the rectum in a 30-year-old horse affected by hyperadrenocorticism was reported by Mazan (1997 1, and healing by secondary intention of a near circumferential retroperitoneal rectal tear in a 13-year-old pony was reported by Embertson et al. (1986). Katz and Ragle (1997) described the

T. S. Mair

107
'Virbac Ltd., Cambridge, Cambridgeshire, UK. 3Cheminex Laboratories Ltd., Corby, Northants, UK. 4Norbrook Laboratories Ltd., Carlisle, Cumbria, UK. 'CP Pharmaceuticals Ltd.. Milton Keynes, UK.

successful management of 4 horses with Grade 3b rectal tears by a combination of medical therapy (administration of antibiotics and nonsteroidal anti-inflammatory drugs) and repeated manual evacuation of the rectum and cavity of the tear. The results of the present study confirm that Grade 36 tears in the peritoneal part of the rectum or small colon can heal satisfactorily if aggressive medical management of the peritonitis is initiated early in the course of the disease. The high survival rate in the present series as compared to survival rates in previously published series of Grade 3 rectal tears where surgical treatments were used is, almost certainly, primarily due to the prompt initiation of therapy and the short time between the occurrence of the rectal tear and diagnosis (less than 24 h in every case). An improved prognosis has been noted in previous studies where appropriate first aid measures were undertaken and where definitive treatment was started soon after the tear occurred (Watkins et al. 1989; Freeman et al. 1992a; Baird and Freeman 1997; Katz and Ragle 1997). The major component of the therapy applied to these horses was the treatment of septic peritonitis. The same antimicrobial regime (i.e. penicillin, gentamicin and metronidazole) was used in each case regardless of whether or not a positive bacterial culture was obtained from samples of peritoneal fluid. This antimicrobial combination provided good broad-spectrum bactericidal activity, and is commonly recommended for the treatment of horses with septic peritonitis (Bowman 1990; Semrad 1992). All horses were also treated with flunixin for its antiendotoxic effects. Treatment was continued until such time as the rectal tear was filled by granulation tissue and the cytological appearance of the peritoneal fluid was normal. It took between 2 and 7 weeks for the peritoneal fluid cell counts to return to normal in the 6 horses that recovered. Other standard treatments for septic peritonitis, such as i.v. fluid therapy, plasma therapy and heparin, were also used as deemed necessary. Peritoneal lavage (Bowman 1990; Semrad 1992) could also have been used, but was not employed in the treatment of any of these horses. Liquid paraffin was administered to all cases to prevent the production of formed faeces while the tears were healing. This therapy was considered important in preventing impaction of the tears, migration of faeces further into the mesorectum, and rupture of the mesorectum (i.e. progression from Grade 3b to Grade 4 tears). An alternative approach might be to withold food completely for up to a week following the development of the rectal tear. Manual removal of faeces from the rectum and the cavity of the tear was carried out daily in 5 horses. This technique was previously described by Katz and Ragle (1997) who successfully treated 4 horses with Grade 3b rectal tears. In the present study, 2 of the horses that had manual evacuation of the rectum and tear were subsequently destroyed due to faecal contamination of the abdomen. It was not clear whether this complication was a direct result of the manipulation of the tear; both of these horses had relatively large tears and would have been more at risk of impaction by faeces and pressure necrosis of the mesorectum. However, in view of these findings, the author recommends that manual cleansing of a tear only be undertaken if the tear is felt to be impacted with faecal material. It may be preferable to evacuate the rectum manually more frequently than once daily; Katz and Ragle (1997) recommended manual evacuation every 1 or 2 h during the first few days of therapy, which should be more effective at preventing impaction of the defect by faeces. Any manipulation of a tear should be undertaken with extreme caution and with the use of epidural anaesthesia.

Acknowledgements
The author is grateful to colleagues at the University of Bristol, School of Veterinary Science and at the Bell Equine Veterinary Clinic for help with the management of these cases.

References
Arnold, J.S. and Meagher, D.M. (1978) Management of rectal tears in the horse. J. equine med. Surg. 2, 64-71. Arnold, J.S., Meagher, D.M. and Lohse, C.L. (1978) Rectal tears in the horse. J. equine med. Surg. 2, 55-61. Baird, A.N. and Freeman, D.E. (1997) Management of rectal tears. Vef. Clin. N. Am.: Equine Pracf. 13, 377-392. Blikslager. A.T., Bristol, D.G., Bowman, K.F. and Engelbert, T.A. (1995) Loop colostomy for treatment of grade 3 rectal tears in horses: seven cases (19831994). J. Am. vef. med.Ass. 207, 1201-1205. Bowman, K.F. (1990) Peritonitis and peritoneal drainage. In: Current Prucfice of Equine Surgery, Eds: N.A. White and J.N. Moore, J.B. Lippincott Co., Philadelphia. pp 377-384. Brugmans, F. and Deegen, E. (1998) A new laparoscopic method to repair rectal tears in horses. 6th Equine Colic Research Symposium, University of Georgia. p 23. (Abstract). Embertson, R.M., Hodge, R.J. and Vachon, A.M. (1986) Near circumferential retroperitoneal rectal tear in a pony. J. Am. vef. med. Ass. 188, 738-739. Freeman, D.E. (1996) Comments on loop colostomy in horses. J. Am. vef. med. AS^. 208,336-337. Freeman, D.E., Richardson, D.W., Tulleners, E.P., Orsini, J.A., Donawick, W.J., Madison, J.B., Ross, M.W. and Beroza, CLA. (1992a) Loop colostomy for management of rectal tears and small colon injuries in the horse: 10 cases (1976-1989). J. Am. vet. med. Ass. 200, 1365-1371. Freeman, D.E., Robertson, J.T., Richardson, D.W., Donawick, W.J., Tulleners, E.P., Orsini, J.A. and Beroza, G.A. (1992b) Loop colostomy for management of rectal and small colon injuries in horses. Pmc. Am. Ass. equine Pracmrs. 38, 133-149. Guglick, M.A., MacAllister, C.G., Ewing, P.J. and Confer,A.W. (1996)Thrombosis resulting in rectal perforation in a horse. J. Am. vef. med. Ass. 209, 1125-1127. Herthel, D.J. (1975) Colostomy in the mare. Pmc. Am. Ass. equine Procfnrs. 21, 187-191. Katz, L.M. and Ragle, C.A. (1997) Rectal tears: treatment by repeated manual evacuation. Pmc. Am. Ass. equine Prucfnrs. 43, 154-1575, Keller, S.D. and Homer, ED. (1985) Diseases of the equine small colon. Comp. conf. Educ. pracf. Vet. 7, S113-SI20. Mazan, M.R. (1997) Medical management of a full-thickness tear of the retroperitoneal portion of the rectum in a horse with hyperadrenocorticism. J. Am. vet. med. Ass. 210, 665-667. Sayegh, A.I., Adams, S.B., Peter, A.T. and Wilson, D.G. (1996) Equine rectal tears: causes and management. Comp. conf. Educ. pracf. Vet. 18, 1131-1143. Semrad, S.D. (1992) Peritonitis. In: Current Therupy in Equine Medicine, 3rd edn, Ed: N.E. Robinson, W.B. Saunders Co., Philadelphia. pp 236-244. Speirs, V.C., Christie, B.A. and van Veenendaal, J.C. (1980) The management of rectal tears in horses. Ausf. vef.J. 56, 313-317. Spensley, M.S., Meagher, D.M. and Hughes. J.P. (1985) Instrumentation to facilitate surgical repair of rectal tears in the horse: a preliminary report. Pmc. Am. Ass. equine Pracmrs. 31, 553-563. Stashak, T.S. and Knight, A.P. (1978) Temporary diverting colostomy for the management of small colon tears in the horse: a case report. J. equine med. Surg. 2, 192-200. Stauffer, V.D. (1981) Equine rectal tears - a malpractice problem. J. Am. vef. med. ASS. 178, 798-799. Stewart, R.H. and Robertson, J.T. (1990) Surgical stapling for repair of a rectal tear. J. Am. vef. med. Ass. 197, 746-748. Taylor, T.S., Watkins, J.P. and Schumacher, J. (1987) Temporary indwelling rectal liner for use in horses with rectal tears. J. Ant. vet. med. Ass. 191, 677-680. Watkins, J.P., Taylor, T.S., Schumacher, J., Taylor, J.R. and Gillis, J.P. (1989) Rectal tears in the horse: an analysis of 35 cases. Equine vef.J. 21, 186-188. Wilson, D.G. and Stone, W.C. (1990) Antimesenteric enterotomy for repair of a dorsal rectal tear in a mare. Cun. vef. J. 31. 705-707.

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