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Acute Abdomen Louise L. Southwood, BVSc, PhD, Dipl ACVS, Dipl ACVECC Colic is the most
Acute Abdomen Louise L. Southwood, BVSc, PhD, Dipl ACVS, Dipl ACVECC Colic is the most

Acute Abdomen

Louise L. Southwood, BVSc, PhD, Dipl ACVS, Dipl ACVECC

Colic is the most common problem necessitating emergency care of horses. Obtaining a thorough history and performing a meticulous physical examination is critical when exam- ining a horse with colic. Ancillary tests, such as hematology and serum biochemistry, peritoneal fluid analysis, ultrasonography, and radiography, can be used to obtain a more specific diagnosis, determine the need for exploratory celiotomy, and estimate prognosis. While the causes of colic are numerous and in some cases life-threatening, the majority of horses showing signs of colic respond to basic medical management. The prognosis for horses with more serious causes of colic has improved dramatically over the past 10 years, predominantly because of early referral and surgical intervention. Future epidemiological studies investigating the causes of colic and novel treatment methods for horses with strangulating lesions are necessary for continued improvement in survival rates of the colic patient. Clin Tech Equine Pract 5:112-126 © 2006 Elsevier Inc. All rights reserved.

KEYWORDS equine, colic, gastrointestinal disease, impaction, large colon displacement, nephrosplenic entrapment, large colon volvulus, colitis, epiploic foramen entrapment, strangulating lipoma

C olic is the most common reason for equine emergency treatment. The cause can vary from mild gas or spas-

modic colic to life-threatening large colon (LC) strangulation. Obtaining a detailed history and performing a meticulous physical examination is the cornerstone for an accurate as- sessment of a horse with colic. Basic treatment consists of analgesia, as well as oral, and occasionally intravenous (IV), fluid therapy. More recently, with the introduction of Busco- pan (N -butyl-scopolammonium bromide; Boehringer In- gelheim, St Joseph, MO) to the United States, spasmolytics are used as part of the initial management of horses with colic. In severe cases, management of shock is necessary and involves IV fluid therapy with crystalloids and colloids, elec- trolyte correction, and antiendotoxin treatment. The use of inotropes and pressors, such as dopamine, dobutamine, epi- nephrine, and vasopressin, has not gained widespread use in horses with colic because of the possible adverse effect of thes e drugs o n gastrointestinal trac t (GI ) perfusion 1 ; these

drugs may become an important part of future treatment regimens to manage critically ill horses with GI disease. Colic is an important cause of morbidity and mortality in the equine population. The annual national incidence of colic in the U.S. horse population was estimated to be 4.2 colic events/100 horses per year at an estimated annual cost of

Department of Clinical Studies, New Bolton Center, University of Pennsyl- vania, Kennett Square, PA. Address reprint requests to: Louise L. Southwood, BVSc, PhD, DACVS, DACVECC, University of Pennsylvania, Department of Clinical Studies, New Bolton Center, 382 W. Street Rd, Kennett Square, PA 19348. E- mail: southwoo@vet.upenn.edu

112 1534-7516/06/$-see front matter © 2006 Elsevier Inc. All rights reserved.

doi:10.1053/j.ctep.2006.03.005

$115.3 millio n t o th e equin e industry. 2 Th e fatalit y rate was 11% , an d 1.4 % o f coli c event s resulte d i n surgery. 2 Risk factors for colic identified in epidemiological studies are out- line d i n Tabl e 1. 3- 6 Recognitio n o f an d managemen t changes to avoid these predisposing factors is important for prevent- ing colic. Early referral and surgical intervention is the key to a suc- cessful outcome with an improved prognosis during the past 10 years attributed to early, appropriate treatment and the evolution of the specialty of equine emergency and critical care. Th e Glass Hors e (www.3dglasshorse.com ; Figs. 1 t o 3) and the American College of Veterinary Surgeon’s (ACVS) Web site (www.acvs.org) are new resources available to cli- ents and veterinarians to enhance the understanding of GI disease.

Signalment and History

The signalment (age, breed, and gender) is important in

forming a differential diagnosis. For example, geriatric horses

( 16 years old) commonly suffer from strangulation of the

smal l intestin e (SI ) b y a pedunculate d lipoma. 7 Th e mea n age

of horses with a strangulating lipoma (19.2 years) was signif- icantly higher than that of horses with entrapment of the SI in the epiploic foramen (EFE, 9.6 years) and other SI lesions (7.7 years), and the proportion of horses with a strangulating lipom a increase d wit h increasin g age. 7 Geriatric horses also appear to be predisposed to impaction, possibly as a result of poor dentition and altered intestinal motility. Right dorsal displacement of the LC (RDD) was more likely to occur in

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Table 1 Risk Factors for Colic 35 and Colonic Obstruction and Distention 6 That Were Identified in Epidemiological Studies in Texas and the United Kingdom

Location

Risk Factor

Texas 35

Change in diet, type or batch of hay, type of grain or concentrate fed Less exposure to pasture Feeding > 2.7 kg of oats per day, hay from round bales, Coastal Bermuda grass hay Change in housing or weather Thoroughbred and Arabian breeds Aged > 8 or 10 years Having had a previous episode of colic or having undergone an exploratory celiotomy for colic Recent (< 7 days previously) administration of an anthelmintic [note: Regular anthelmintic administration reduces the risk of colic.] Hours spent in a stable Residing at the present stable for < 6 months Change in exercise regimen Travel within the preceding 24 hours Having had a previous episode of colic Absence of administration of an ivermectin or moxidectin anthelmintic within the previous 12 months Infrequent teeth checks Aerophagia (crib-biting, wind-sucking)

United Kingdom 6

horses 4 to 10 years of age compared with a hospital- and colic-contro l population. 8 Th e most commo n cause s o f colic in neonates were uroperitoneum, meconium impaction, in- tussusception , an d enterocoliti s i n olde r foals. 9 Horses of different breeds and gender are predisposed to different causes of colic. For example, RDD was more com- mon in wide-body horses, such as Quarter Horses, compared wit h th e hospital - an d colic-contro l population. 8 Miniature breeds are predisposed to small colon (SC) obstruction with a fecalith. 1 0 Broodmare s ar e commonl y affecte d b y L C volvu- lus (LCV) 1 1 1 to 3 month s postfoaling ; however , an LC V can also occur peripartum. In a retrospective study of horses with LCV referred to Colorado State University (CSU), 22.6% (74 of 327) of all horses and 40.9% (74 of 181) of female horses were reported to be either pregnant or had recently foaled wit h a the media n duratio n o f tim e postpartu m o f 3 7 days. 12 A complete history should be obtained for all horses with coli c ( Fig . 4 ) . Pertinen t historica l findings includ e geographic regio n i n whic h th e hors e live s o r ha s live d an d exposure to predisposin g factors 3-6 ( Tabl e 1 ) . Th e geographica l regio n the horse has lived in is important; for example, horses from Californi a ar e predispose d t o enterolithiasis 13 ; horse s from sandy regions, such as California, Arizona, Colorado, Mich- igan, Florida, and New Jersey, often have colic as a result of sand accumulatio n o r impaction 14,15 ; an d ilea l impactions occur in horses in the south eastern United States where

Coasta l Bermuda grass ha y is fed. 1 6 Th e owne r o r caretaker should be asked about the duration, character, consistency, and severity of clinical signs. The recent history of defecation (amount and consistency), appetite, water consumption, and urination should be obtained. Aerophagia (“cribbing” or “wind-sucking” ) ha s been identified as a ris k facto r for colic 6 and more recently with entrapment of the ileum and/or jeju- nu m i n th e epiploi c foramen. 1 7 Whe n horse s wit h strangu- lating SI lesions were evaluated retrospectively, horses with a history of aerophagia were 34.7 times (University of Illinois) and 8.2 times (University of London) at increased risk of havin g a n EF E tha n horse s wit h n o histor y o f aerophagia. 17

Physical Examination

Physical examination begins with observing the horse for signs of pain, abdominal distention, sweating, and any injuries that occurred when the horse was painful. Heart rate, respiratory rate, rectal temperature, oral mucous membrane color and moistness, capillary refill time, and auscultation of borborygmi are part of the initial examination. Changes in physical exami- nation findings over a period of time are often more useful than physical examination findings at a particular moment in time. Heart rate is important to assess pain and the cardiovascular status of the horse, and is a useful prognostic indicator for sev- eral causes of colic (see below). A nasogastric tube is passed immediately in any horse showing signs of colic and tachycardia (heart rate 60 beats/min) to prevent gastric rupture. Respira- tory rate varies, and observing nostril flare and depth of respira- tion can be a useful indicator of the degree of pain (Fig. 5). Rectal temperature can be useful for differentiating horses with an in- flammatory or infectious condition (enteritis or colitis) from a horse with a surgical colic; however, horses with surgical lesions may have a fever associated with the systemic inflammatory response syndrome (SIRS; Table 2) or an unrelated disease (for example, respiratory tract infection). Signs of endotoxemia, SIRS, or hyperdynamic shock include hyperemic (injected, bright pink) oral mucous membranes as a result of peripheral vasodilation (Fig. 6a), and signs of hypodynamic or terminal shock include dark or cyanotic membranes as a result of poor peripheral perfusion. Dry oral mucous membranes (and pro- longed skin tent) is a sign of dehydration, which is a loss of total body water, particularly from the subcutaneous tissue. Clinical signs of dehydration can be detected when fluid loss is 5% of the body weight (ie, 22.5 L in a 450-kg horse) and the horse will be moribund when the fluid loss is 12% of the body weight (ie, 54

L in a 450-kg horse). A prolonged capillary refill time (and slow

jugular refill time) is a sign of hypovolemia or loss of water from the intravascular space (Fig. 6b). Perfusion can also be assessed

by palpating the skin temperature of the extremities; cool ex- tremities are associated with poor peripheral perfusion. Auscul- tation of borborygmi is best classified as present or absent and increasing or decreasing compared with that observed on pre- vious auscultation. Palpation per rectum requires adequate restraint (halter and lead rope, nose twitch, stocks, sedation), copious lubri- cation with or without lidocaine, and a gentle technique to prevent a rectal tear and injury to the examining veterinarian.

If gas distention is present, the anatomical location of the gas

distention (SI, LC, cecum, SC) is determined based on the size, structural features, and location of the distended vis-

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114 L.L. Southwood Figure 1 Right dorsal displacement of the large colon. (A) Left lateral and

Figure 1 Right dorsal displacement of the large colon. (A) Left lateral and (B) right caudolateral views. The large co- lon is displaced between the cecum and the right body wall. Image pro- vided courtesy of The Glass Horse (www.3dglasshorse.com) and the University of Georgia. (Color version of figure is available online.)

cus. 2 2 I f a n intra-abdominal mas s i s palpated , th e consistency (ie, fecal material consistent with an impaction versus an abscess or tumor) should be assessed. If a firm fecal impac- tion is palpable, its anatomical location (pelvic flexure/ven- tral colon, cecum, SC) should be evaluated based on the size, structura l features , an d th e locatio n o f th e impacted viscus. 22

Ancillary Tests

Laboratory Data

Hematocrit, total protein, as well as total leukocyte and dif- ferential count can be used to further assess the systemic

condition of the horse as well as the severity and type of disease. Hematocrit can be used to evaluate the degree of hemoconcentration/hypovolemia; however, is not the most reliable measurement because other factors, such as splenic contraction and blood loss, can contribute to the final hemat- ocrit. The hematocrit may be severely increased compared with normal ( 55%) in horses with SIRS because of the alteration in vascular endothelial function and subsequent water leakage from the intravascular space. Large volumes of fluid can also be lost from the intravascular space into the GI lumen and/or wall. Hypoproteinemia is common in horses with SIRS as a result of a loss of albumin from the intravas-

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Figure 2 Left dorsal displacement of the large colon or entrapment of the colon over the nephrosplenic liga- ment. (A) Left lateral and (B) caudal views. Image provided courtesy of The Glass Horse (www.3dglasshorse. com) and the University of Georgia. (Color version of figure is available online.)

of Georgia. (Color version of figure is available online.) cular space because of altered endothelial function.

cular space because of altered endothelial function. Protein can also be lost into the damaged GI lumen. A high hemato- crit and low total protein has been associated with a less favorable prognosis for horses with many causes of colic (see following discussion). Fibrinogen can be used to assess the inflammatory response and as an early indicator of a coagu- lopathy. Hyperfibrinogenemia ( 400 g/dL) is uncommon in horses with colic and should alert the clinician to the pres- ence of an underlying or unrelated inflammatory process. Hypofibrinogenemia is also uncommon and is most likely to be observed in horses with severe systemic disease and early signs of disseminated intravascular coagulopathy (DIC) and

multipl e orga n dysfunction syndrom e (MODS ; Tabl e 2 ) . If hypofibrinogenemia is observed, a coagulation profile should be performed. Leukocyte count can be used to help differen- tiate an inflammatory disease (enteritis or colitis) from a non- inflammatory disease. While leukopenia, neutropenia, and a high number of immature (band) neutrophils are often asso- ciated with enteritis or colitis, it is imperative to remember that horses with severe compromise to GI integrity or with SIRS can become leukopenic as a result of leukocyte margin- ation associated with leukocyte and endothelial cell activa- tion. Azotemia (high serum creatinine concentration, 2 mg/

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116 L.L. Southwood Figure 3 A counterclockwise or ven- tromedial-dorsolateral large colon volvulus at the base

Figure 3 A counterclockwise or ven- tromedial-dorsolateral large colon volvulus at the base of the large colon as viewed from the right side of the abdomen. Image provided courtesy of The Glass Horse (www.3dglasshorse. com) and the University of Georgia. (Color version of figure is available online.)

dL), hyperlactatemia ( 2 mmol/L), and low venous oxygen tension (PvO 2 45 mm Hg) or saturation (SvO 2 65%) are indications o f poo r tissu e perfusio n i n horse s wit h colic. 23 However, serum creatinine can also be high in horses with renal failure and hyperlactatemia can occur as a result of other factors, such as high epinephrine concentration and poor hepatic clearance of lactate. Persistent azotemia follow- ing fluid therapy warrants further assessment of renal func- tion. Electrolytes should be measured and any abnormalities corrected in horses with colic. Preoperative total and ionized magnesium concentrations were low in 17% and 54% and total and ionized calcium concentrations were low in 57% and 86% of horses undergoing abdominal surgery, respec- tively, and ionized calcium and magnesium concentrations were lower in horses with strangulating compared with non- strangulatin g lesions. 2 4 Similarly, i n a retrospectiv e stud y of horses with LCV, we found that 69% of horses were hypocal- cemic (total calcium), 23% were hyponaturemic, 54% were hypochloremic , an d 3 % were hypokalemi c preoperatively . 12 Liver enzymes are often high in horses with colic; however, there has been no association with prognosis in horses with primar y GI disease. 12,25 Abdominocentesis is generally not performed in cases that are managed medically in the field but rather when the horse has been referred for further assessment and more intensive treatment. Abdominocentesis can be per- formed by usin ga1½ -inch 20-gauge needle or a teat cannula to the right of midline at the most dependent part o f th e ventra l abdomen. 2 6 Whil e peritonea l flui d analysis can be useful, abdominocentesis carries with it the risk of enterocentesis (which has a low rate of adverse sequelae) and omental herniation in foals when a teat cannula is used (which can be corrected by transecting the herniated omentum and apposing the skin). The gross appearance of the fluid (clear yellow [normal], opaque yellow [peritoni- tis], serosanguinous [severely damaged intestine]) is im-

portant. The published normal value for peritoneal fluid nucleated cell count is 5000 to 10,000 cells/ L, and fo r th e tota l protei n concentratio n 2. 5 g/dL. 2 6 Peritoneal fluid analysis can be used to assess intestinal viability (gross appearance, total protein concentration) as well as the presence of peritonitis or neoplasia (cytology). In horses with strangulating lesions, total protein concentra- tion and nucleated cell count will gradually increase com- pared with normal. Horses with enteritis or colitis will often have a high total protein concentration ( 4 g/dL) with a normal nucleated cell count. Horses with a stran- gulating ischemic intestinal obstruction had a higher peri- toneal lactate concentration (8.45 mmol/L) compared with horses with a nonstrangulating obstruction (2.09 mmol/L). 2 7 Becaus e o f a n overal l lac k o f specificit y and sensitivity of routine peritoneal fluid assessment for diag- nosing strangulating intestinal lesions, the use of markers for assessing intestinal viability has also been investigated. Fo r example , Niet o an d coworkers 2 8 reporte d tha t the equine intestinal fatty acid binding protein concentration in serum and peritoneal fluid was useful for predicting survival and the need for abdominal surgery in horses with colic.

Imaging Techniques

Radiology is not often used as a diagnostic modality for adult horses with colic. However, radiography can be use- fu l fo r diagnosin g th e presenc e o f enterolith s 2 9 ( Fig . 7 ) and sand 3 0 ( Fig . 8 ) i n adul t horses . A bariu m contras t enema and radiography can be used to determine the location of an aboral obstruction in foals with colic. Ultrasonography can be a useful ancillary test for assessing a horse with colic. 31,3 2 Ultrasonograph y i s mor e sensitiv e tha n palp a - tion per rectum for identifying SI distention and can be used to assess the degree of distention, wall thickness,

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Figure 4 An example of a history sheet for horses with abdominal pain used at Colorado State University. A for- matted history sheet facilitates obtain- ing a thorough history and in part can be completed by the client at the time of admission. (A) Front page and (B) back page.

at the time of admission. (A) Front page and (B) back page. luminal contents, and motility.

luminal contents, and motility. Ultrasonographic identifi- cation of distended, thickened, amotile SI was 100% sen- sitive and 100% specific for the presence of a strangulating lesion. 3 3 Specifi c cause s o f coli c wher e ultrasonography has been used to help with obtaining a more definitive diagnosis include nephrosplenic ligament entrapment (NLE), 3 4 RDD, 3 5 LCV, 3 6 intussusception, 3 5 an d peritoni - tis. 31

Gastrointestinal Lesions

Gas or Spasmodic Colic

Gas or spasmodic colic is probably the most common caus e o f coli c i n horses. 4 I t i s ofte n a presumptiv e diagno - sis based on spontaneous resolution of pain or resolution of pain following administration of analgesia and oral flu- ids. Horses generally show mild to moderate pain; how- ever, occasionally horses can be severely painful and dis- tended. Surgical intervention is rarely necessary. Typically horses are treated with flunixin meglumine (1 mg/kg IV), followed by xylazine (0.2 to 0.5 mg/kg IV) and butorpha-

nol (0.01 to 0.02 mg/kg IV) if the pain is persistent. It is important to administer flunixin meglumine IV and not intramuscularly, because intramuscular injection has been associate d wit h a n ofte n fatal Clostridium sp p myositis. 37 The amount of flunixin meglumine administered should not exceed 1 mg/kg every 12 hours and the horse should be well hydrated, because of complications such as renal papillary necrosis and GI ulceration. Referral for further assessment and treatment is indicated in any horse that is persistently painful following treatment with a dose of flunixin meglumine as well as a dose of the xylazine-bu- torphanol combination. Since its introduction to the United States Buscopan (Boehringer Ingelheim), a spas- molytic drug, has been used by some practitioners for managing horses with gas or spasmodic colic. While the results of clinical studies from Europe showed favorable results, 3 8 ther e hav e bee n n o prospective , randomized controlled studies on the use of Buscopan for treatment of gas or spasmodic colic. High doses of Buscopan caused intestina l stasi s an d colic, 3 9 an d whil e th e author s reported that lower doses (100 mg every 2 hours [q2 hour]) were

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118 L.L. Southwood Figure 4 (Continued) safe, caution should be used when giving this type of

Figure 4 (Continued)

safe, caution should be used when giving this type of drug to horses with GI disease. It is important to note that the product marketed as Buscopan in the United States does not contain dipyrone.

Impactions

Impactions of the pelvic flexure (left ventral colon), right dorsal colon, and SC occur commonly. Horses show signs of mild to moderate colic and become progressively more dis- tended if the impaction is not resolved. A pelvic flexure or SC impaction can often be diagnosed by using palpation per

rectum. Impactions can occur with ingesta or sand and the LC or SC can become obstructed with concretion formation aroun d a foreig n bod y o r a n enterolith . A RD D ( Fig. 1 ) can occur secondarily to a pelvic flexure impaction and this should be considered in a horse with a pelvic flexure impac- tion that does not respond to medical management, becomes more painful and distended, or if the findings on palpation per rectum change. While there are several oral water and electrolyte solutions, laxatives, lubricants, and cathartics that hav e bee n used, Lopes an d coworkers 4 0 recently demon- strated that an oral balanced water and electrolyte solution

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Figure 5 Nostril flare can be an impor- tant sign indicating pain, particularly in a stoic horse. (Color version of fig- ure is available online.)

horse. (Color version of fig- ure is available online.) was efficacious for hydrating the right dorsal

was efficacious for hydrating the right dorsal colon contents and feces and was more efficacious than magnesium sulfate, water, or IV polyionic isotonic fluids in normal fistulated horses. The balanced electrolyte solution caused fewer sys- temic electrolyte alterations particularly when compared wit h oral wate r alon e an d sodiu m sulfate. 4 0 Th e balanced water and electrolyte solution was 5.27 g NaCl, 0.37 g KCl, and 3.78 g NaHCO 3 in 1 L of water administered orally at a rat e o f 5 L per hou r a t a constan t rat e infusion. 4 0 Surger y is indicated for horses with a LC or SC impaction that do not respond to medical treatment and are persistently or severely painful, have moderate to severe or progressively increasing abdominal distention, are not defecating, and have worsen- ing tachycardia. Surgery involves a pelvic flexure enterotomy for horses with a LC impaction and a high enema or SC enterotomy for horses with an SC impaction. Heart rate, re- spiratory rate, blood leukocyte count, blood lactate concen- tration, and peritoneal fluid total protein concentration at admission were significantly associated with outcome in horse s wit h an L C impaction. 4 1 Th e surviva l fo r horses with an L C o r S C impaction i s good 41,4 2 ( Tabl e 3 ) . Interestingly, 43% (16/24) of horses with an SC impaction that were man- aged surgicall y had Salmonella spp . isolate d fro m thei r feces 42 and particular attention to biosecurity and isolation proce- dures should be followed when managing horses with an SC impaction. Cecal impactions are a particularly serious form of large intestinal obstruction. While some horses with a cecal impac- tion may respond to medical management with IV fluids as well as oral fluids and laxatives, the risk of, and fatality asso- ciated with, cecal perforation leads to many clinicians being reluctant to pursue medical therapy for longer than 12 to 24 hours unless there is major clinical improvement. Surgery is also indicated for any horse suspected of having a cecal im- paction that is persistently painful and nonresponsive to an- algesic drugs. Cecal impaction can usually be diagnosed

based on palpation per rectum. Many of these horses do not show obvious signs of colic, and inappetence, lack of fecal production, and mild intermittent pain may be the only clin- ical findings. It is especially important to monitor horses following unrelated surgery, such as orthopedic procedures, for these signs. Complete cecal bypass (jejuno- or ileocolos- tomy) and/or typhlotomy are the two most common surgical procedures performed to treat horses with a cecal impaction. In the past, surgeons have recommended performing a com- plete cecal bypass if the cecum appeared to have a functional problem at surgery (ie, the cecum was large, fluid-filled, in- flamed). More recently, however, success with performing a typhlotomy only for surgical treatment of horses with a cecal impaction has been reported anecdotally and also pub- lished. 4 3 Nin e o f 10 horses undergoin g typhlotomy-only for a cecal impaction thought to be associated with a dysfunctional cecu m survived an averag e o f 43 months. 4 3 Anthelmintic treatment (pyrantel pamoate) was recommended as Anoplo- cephala perfoliata was recovered in severa l cases. 4 3 Slo w rein- troduction of good quality, low-residue feed is critical to prevent reimpaction in the early postoperative period.

Large Colon Displacements

Displacements of the LC include RDD and left dorsal dis- placement (LDD) or NLE. Other displacements, such as pel- vic flexure retroflexion, can also occur and are likely a form of the more commonly reported displacements. Horses gener- ally present with signs of mild to moderate colic and abdom- inal distention. Horses may be mild to moderately dehy- drated and hemoconcentrated. An LC displacement can be diagnosed based on palpation per rectum. RDD involves the LC becoming displaced between the cecum and the right body wall. The pelvic flexure can move in a counterclockwise (most common) or clockwise (less common) direction around the cecum as viewed from the

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Table 2 Nomenclature for Systemic Conditions Affecting Horses With Colic Based on Information From Human and Veterinary Critical Care 18 21

Nomenclature (Acronym)

Clinical Signs

Endotoxemia

Endotoxin (lipopolysaccharide from Gram-negative bacteria cell

Systemic inflammatory response syndrome (SIRS)

wall) circulating in the blood; endotoxin can stimulate a systemic inflammatory response (SIRS) Systemic inflammatory response to severe clinical disease with

Multiple organ dysfunction syndrome (MODS)

2 or more of the following: (1) fever or hypothermia, (2) tachycardia, (3) tachypnea or hypocapnia, and (4) leukopenia, leukocytosis, or a high number of circulating immature (band) neutrophils Functional abnormality of more than 1 vital organ system

Sepsis

including lungs, kidneys, cardiovascular, central and peripheral nervous systems, coagulation, gastrointestinal tract, liver, adrenal glands, and skeletal muscle SIRS plus infection

Severe sepsis

Sepsis plus MODS, hypoperfusion, or hypotension

Septic shock

Sepsis-induced hypotension despite adequate fluid

Hyperdynamic shock

resuscitation plus perfusion abnormalities (lactic acidosis, oliguria, altered mentation) Tachycardia, tachypnea, hyperemic mucous membranes, rapid

Hypodynamic shock

capillary refill time, decreased borborygmi compared to normal, muscle fasciculations, and dullness; hyperdynamic shock is characterized by a high cardiac output and low peripheral vascular resistance Tachycardia, tachypnea (rapid, shallow respiration), prolonged

Disseminated intravascular coagulopathy (DIC)

capillary and jugular refill times, dry and purple to pale mucous membranes, weak peripheral pulses, cool extremities, and hypothermia; hypodynamic shock is characterized by low cardiac output, high peripheral vascular resistance, and systemic hypotension; MODS often follows signs of hypodynamic shock Abnormality in 3 of 5 of the following categories:

thrombocytopenia, hypofibrinogenemia, prolonged clotting time tests (prothrombin time [PT], partial thromboplastin time [PTT], activated clotting time [ACT]), decreased antithrombin III (ATIII) activity compared to normal, high fibrin (fibrinogen) degradation products (FDP)

ventra l abdome n ( Fig . 1 ) . I n a stud y o f 168 horses wit h RDD diagnosed at surgery or necropsy, 71 (43%) were Quarter Horses, the median age was 9 years (range 6 months to 21 years), 82 (49%) were female, 71 (43%) were castrated males , and 1 4 (8% ) wer e intac t males. 1 2 Mos t o f th e cases occurred in the summer (June to August, 39% [63 of 160]), followe d b y th e fall , an d the n spring. 1 2 Forty-thre e percent (55 of 128) of the horses were reported to have had at least one previou s episod e o f colic. 1 2 Tachycardi a (hear t rat e 48 beats/min ) wa s reporte d i n approximatel y hal f th e horses. 12 Reflux following passage of a nasogastric tube was obtained

i n 17 % (13 o f 78 ) o f horses. 1 2 Hematolog y wa s unremarkable in most ( 70%) horses. The most notable abnormalities on seru m biochemistry ar e show n i n Fig. 9 . Recently , Gardner an d coworkers 2 5 have also reporte d hig h seru m gamm a glu- tamyl transferase (GGT; 49% [18 of 37] of horses) and bili- rubin (33% [8 of 24] of horses) in horses with RDD, but not in horses with LDD or NLE, and proposed that this was caused by transient extrahepatic bile duct obstruction sec- ondary to the RDD. Most important, high liver enzymes were not associated with a poor prognosis or with persistent signs

o f live r diseas e i n horse s with RDD i n eithe r study. 12,25 While some horses with RDD may respond to medical management

(withholding feed, IV polyionic isotonic fluids), surgery is indicated in most cases. Surgical correction involves colonic decompression and repositioning of the colon. The prognosis followin g surgical correctio n o f RD D i s excellent 1 2 ( Table 4 ). Duration of colic, heart rate, and peritoneal fluid total protein concentration were associated with short-term survival 12 (Fig. 10). Long-term follow-up results are shown in Table 4. 12 While the actual recurrence rate of RDD was not obtained, horses that had experienced an episode of colic before the episode necessi- tating surgery were significantly more likely to show signs of colic after surgery compared with horses that had not experi- enced a previous episode of colic (P 0.01). 12 LDD or NLE occurs when the LC becomes displaced between the spleen and the left body wall or entrapped ove r th e nephrospleni c ligamen t ( Fig . 2 ) . I n a recen t ret- rospective study of 161 horses diagnosed with 174 epi- sodes of NLE, the median age of horses was 5 years (9 months to 24 years). Interestingly, nasogastric reflux ( 2 L ) wa s obtaine d i n 28 % (3 2 o f 113 ) o f horses. 4 4 Treatment options for horses with NLE include IV phenylephrine combined with light exercise, rolling under general anes- thesia, and surgery. Phenylephrine is an alpha-adrenergic receptor agonist that can be administered at a dose rate of

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Figure 6 (A) Hyperemic (injected, bright pink) oral mu- cous membranes. (B) Prolonged capillary refill time. Courtesy of Dr. Josie Traub-Dargatz, Colorado State University.

of Dr. Josie Traub-Dargatz, Colorado State University. 3 g/kg/min for 15 minutes. At this dose the

3 g/kg/min for 15 minutes. At this dose the splenic area reduce s t o 28 % o f baselin e measurements. 4 5 Phenyleph - rine causes vasoconstriction and a reflex bradycardia and horses should be monitored closely during phenylephrine administration. The horse can be exercised (walking and light trotting) for a very short time (5 to 10 minutes) immediately following phenylephrine administration. Ex- cessive or prolonged exercise may result in colonic rup- ture. While the success of treating horses with NLE with phenylephrin e i s reporte d t o b e hig h ( 5 o f 5) , 4 4 obtaining a definitive diagnosis of NLE is difficult and it is possible that some horses that “respond” to treatment with phen-

ylephrine may not have had an NLE. If the horse does not respond to treatment with phenylephrine, rolling under general anesthesia and/or surgery is necessary to correct the NLE. Recently, we have reported the successful man- agemen t o f a hors e wit h NL E usin g laparoscopy. 4 6 The horse of this report had minimal signs of colic or colonic distention and had been treated several times with phen- ylephrine. Laparoscopy was useful for confirming the di- agnosis of NLE and repositioning the colon. The recur- renc e rat e o f NL E wa s reporte d t o b e 8 % (1 3 o f 161) . 44 Laparoscopic ablation of the nephrosplenic space by using a suturing technique has been reported to successfully

Table 3 Prognosis for Survival for Horses With an Impaction of the Large or Small Colon

Impaction Site

Duration of Follow-Up (Treatment)

Survival, % (Surviving Horses/Total Horses)

Large

colon 41

Short-term (overall)

94.6% (139/147)

 

Long-term (medical)

95.1% (78/82)

Long-term (surgical)

57.8% (11/19)

Small

colon 42

Short-term (medical)

87.0% (41/47)

 

Short-term (surgical)

86.0% (32/37)

Long-term (medical)

72.7% (24/33)

Long-term (surgical)

75.0% (21/28)

122

L.L. Southwood

122 L.L. Southwood Figure 7 Abdominal radiograph that was used to diagnose enterolithiasis (arrow). Courtesy of

Figure 7 Abdominal radiograph that was used to diagnose enterolithiasis (arrow). Courtesy of Dr. Josie Traub- Dargatz, Colorado State University. (Color version of figure is available online.)

preven t th e recurrenc e o f NLE. 4 7 Laparoscopi c ablatio n of the nephrosplenic space by using a mesh that is tacked to the kidney and spleen may be a technically simpler lapa- roscopic alternative to the previously reported suturing technique (K. Epstein and E.J. Parente, unpublished data).

Large Colon Volvulus

LCV is a rapidly life-threatening lesion and requires the most immediate attention for a favorable outcome. The LC is usu- ally rotated in a counterclockwise (ventromedial-dorsolat- eral) direction at the base of the colon or adjacent to the cecocoli c ligamen t ( Fig. 3 ) . Immediate surgical intervention is necessary and involves colonic decompression and derota- tion. In some cases, a pelvic flexure enterotomy to empty the contents of the LC and administer intraluminal treatment, such as di-tri-octahedral smectite (Biosponge; Platinum Per- formance, Buellton, CA) and psyllium, or an LC resection is performed. There has been recent anecdotal evidence that an extensive LC resection can lower the morbidity and mortality

for horses with an LCV by reducing the absorption of inflam- matory mediators and toxins and creating a smaller surface are a over whic h th e mucos a need s t o regenerate. 4 8 Horses with an LCV often require intensive postoperative monitor- in g an d treatment. 4 9 Th e prognosi s fo r horses wit h a n LCV remain s fair 1 2 ( Tabl e 4 ) . Th e overal l short-ter m survival rate for horses with an LCV was higher in 1999 (68%) compared wit h 198 7 t o 198 9 (25%). 1 2 Recently , Embertso n an d co- workers 1 1 reported a surviva l rat e o f 83 % (16 9 o f 204 ) for horses with an LCV. The high success rate in this study em- phasizes the importance of early surgical intervention for attaining a successful outcome. Duration of colic, heart rate, hematocrit, blood glucose concentration, serum creatinine concentration, serum chloride concentration, anion gap, peritoneal fluid total protein, and mean arterial pressure un- der general anesthesia were associated with short-term out- come. 12,49 Interestingly , live r enzymes wer e high in 60 % to 80% of horses; however, there was no association between hig h live r enzym e concentratio n an d a poo r outcome . 49

Figure 8 Abdominal radiograph showing the presence of sand in the large colon. Courtesy of Dr. Josie Traub-Dar- gatz, Colorado State University. (Color version of figure is available online.)

colon. Courtesy of Dr. Josie Traub-Dar- gatz, Colorado State University. (Color version of figure is available

Acute abdomen

123

100 90 80 70 60 50 40 30 20 10 0 GLY AZO CA SDH
100
90
80
70
60
50
40
30
20
10
0
GLY
AZO
CA
SDH
GGT
BILI
AST
CK
% of horses

Serum biochemistry measurement

Figure 9 Serum biochemistry abnormalities in horses with a right dorsal displacement of the large colon. The percentage of horses with an abnormal value is shown on the y axis and the serum biochemistry measurement is shown on the x axis. GLY, hypergly- cemia (serum glucose 110 g/dL, 89 of 129 horses); AZO, azotemia (serum creatinine concentration 2.1 g/dL, 16 of 145 horses), CA, hypocalcemia (total calcium concentration 11 g/dL, 80 of 142 horses); SDH, high serum sorbitol dehydrogenase ( 12 g/dL, 53 of 95 horses); GGT, high serum gamma glutamyl transferase ( 22

g/dL, 29 of 103 horses); BILI, high serum bilirubin concentration

( 2.1 g/dL, 78 of 125 horses); AST, high serum aspartate transam-

inase ( 375 g/dL, 77 of 117 horses); CK, high serum creatinine kinase ( 470 g/dL, 49 of 125 horses). (Color version of figure is available online.)

Long-term follow-up results on horses discharged following surgica l treatmen t o f a n LC V ar e show n i n Tabl e 4 . 1 2 Horses that had experienced an episode of colic before the episode necessitating surgery were significantly more likely to have an episode of colic after surgery compared with horses that had not experience d a previou s colic episod e (P 0.03). 12

Enteritis and Colitis

Enteritis (duodenitis-proximal jejunitis, DPJ) and colitis refer

t o inflammatio n o f the S I an d LC , respectively. 5 0 Whil e in

many cases the cause is unknown, infection with Clostridium spp and Salmonella spp has been reported in cases of both DP J and colitis. 5 0 Recently, Arroy o an d coworkers 5 1 reported

that toxigenic strains of Clostridium difficile were cultured from 100% (5 of 5) of horses with DPJ and from none of the horses with other causes of nasogastric reflux (0 of 6). Early disease recognition and appropriate treatment is critical for a favorable outcome. Horses may show signs of severe colic initially, but then become dull. Horses with DPJ are often tachycardic, have distended SI on palpation per rectum and ultrasound examination, and large volumes of reflux follow- ing passage of a nasogastric tube. Horses with colitis are also tachycardic, may have abdominal distention, hypermotile to amotile borborygmi, and on palpation per rectum or abdom- inal ultrasound examination may have a fluid-filled LC. The challenge is differentiating a horse with DPJ or colitis from a horse with a surgical lesion. While there is no definitive di- agnostic test to differentiate between these types of lesions; anecdotally, dullness, fever, leukopenia, and yellow-to-or- ange peritoneal fluid with a very a high total protein concen- tration ( 4 g/dL) and a normal nucleated cell count are more likely associated with DPJ or colitis than with a surgical le- sion. Recently, it was reported that horses with DPJ were more likely to have hepatic injury, indicated by a high GGT, serum aspartate transaminase (AST), and alkaline phospha- tase (ALP), than horses with a strangulating lesion and that the mechanism of hepatic injury in horses with DJP was possibly ascending infection from the common bile duct, absorption of endotoxin or inflammatory mediators from the portal circulation, or hepatic hypoxia associated with SIRS and shock. 5 2 Treatmen t fo r horses with DPJ o r colitis involves aggressive fluid and electrolyte therapy with crystalloids and colloids, analgesia, anti-inflammatory drugs, antiendotoxin therapy , and laminiti s prevention. 5 0 Motilit y stimulatio n may also be useful for horses with DPJ. While an exploratory celiotomy is expensive and associated with infrequent but inherent complications with general anesthesia and surgery, it is useful for obtaining a definitive diagnosis. Decompress- ing the SI in cases of DPJ may be beneficial and an enterotomy may be useful for emptying the contents of the LC in cases of colitis . Seahor n an d coworkers 5 3 reporte d a n overall survival of horses with DPJ of 66% (50 of 75), with 88% (66 of 75) of the horses in the study being managed medically, and 12% (9 of 75) of the horses undergoing surgery. Anion gap, abdom-

Table 4 Survival Rate for Horses With a Right Dorsal Displacement of the Large Colon (RDD) or a Large Colon Volvulus (LCV)*

Lesion

Duration of Follow-Up (Classification)

Survival, % (Surviving Horses/Total Horses)

RDD

Short-term (overall) Short-term (operated) Short-term (recovered from general anesthesia) Long-term (alive & no subsequent colic episodes) Long-term (alive & > 1 subsequent colic episodes) Long-term (died from colic) Short-term (overall) Short-term (operated) Short-term (recovered from general anesthesia) Long-term (alive & no subsequent colic episodes) Long-term (alive & > 1 subsequent colic episodes) Long-term (died from colic)

80% (134/168)

86% (133/155)

93% (133/143)

52% (14/27)

48% (13/27)

15% (4/27)

LCV

35% (144/327)

51% (105/206)

78% (105/135)

63% (29/46)

22% (10/46)

13% (6/46)

Short-term, discharged from the hospital; long-term, longer than 6 months after surgery and the survival rate reported is for horses that were discharged from the hospital for which follow-up was available; overall, survival rate for all horses that were admitted with a definitive diagnosis of RDD or LCV; recovered from general anesthesia, survival rate for the horses that were recovered from general anesthesia. *The results are from horses admitted to Colorado State University between 1987 and 1999. 12

124

L.L. Southwood

A 100 B Table 90 Postop 80 Discharge 70 60 50 40 30 20 10
A
100
B
Table
90
Postop
80
Discharge
70
60
50
40
30
20
10
0
% of horses
% of horses
<1 2 to 3 3 to 4 >4 Duration of colic (days) C 100 Table
<1
2 to 3
3 to 4
>4
Duration of colic (days)
C
100
Table
90
Postop
80
Discharge
70
60
50
40
30
20
10
0
<2.5
2.5 to 3
3 to 4
>4
% of horses

Peritoneal fluid total protein (g/dL)

inal fluid total protein concentration, and volume of reflux obtained when a nasogastric tube was passed during the first 24 hours were associated with short-term survival out- come. 5 3 Th e prognosi s fo r horse s with coliti s (acut e diarrhea) to survive short-term was 74.6% (91 of 122) and a history of antimicrobial treatment for an unrelated disease, azotemia (serum creatinine concentration 2.0 g/dL), hemoconcen- tration (hematocrit 45%), tachycardia (heart rate 60 beats/min), and low serum total protein concentration were associate d wit h a failur e t o survive. 54

Strangulating Small Intestinal Lesions

There are several causes of SI strangulation. Strangulating lipoma and EFE are two of the most common causes. Early referral and surgical intervention are essential for a favor- able outcome. Surgical treatment involves transection of the mesenteric pedicle associated with the lipoma and removal of the jejunum or ileum from the epiploic fora- men in cases of strangulating lipoma and EFE, respec- tively. Visual assessment of intestinal viability is per- formed and the decision made with regard to the necessity for a resection and anastomosis. Nonviable intestine is resected and a jejunojejunostomy or jejunocecostomy is completed. In many cases where surgical intervention oc- curs early, resection and anastomosis is not necessary. In a recent retrospective study, it was reported that all horses with a strangulating lipoma not requiring a resection and anastomosi s survive d mor e tha n 1 year. 5 5 Postoperative

100

90

80

70

60

50

40

30

20

10

0

Table Postop Discharge <50 50 to 70 70 to 90 90 to 100 >100
Table
Postop
Discharge
<50
50 to 70
70 to 90
90 to 100
>100

Heart rate (beats per minute)

Figure 10 The association between short-term survival of horses with a right dorsal displacement and the duration of colic (A), heart rate (B), and peritoneal fluid total protein (C). The percent- age of horses is shown on the y axis and the category for duration of colic (days), heart rate (beats per minute), and peritoneal fluid total protein (g/dL) is shown on the x axis. Table, euthanized or died on the surgical table under general anesthesia; Postop, eu- thanized or died following recovery from general anesthesia be- fore discharge from the hospital; Discharge, discharged from the hospital (short-term survival). (Color version of figure is avail- able online.)

ileus and adhesion formation are the most challenging complications following SI surgery in horses, and while there are many motility modifying drugs and published adhesion prevention strategies, early surgical intervention and meticulous surgical technique are critical for prevent- ing these postoperative complications. The 2-week and 1-year survival rates for horses with a strangulating lipoma that required a jejunojejunostomy were 84% (27 of 32) and 69% (22 of 32), respectively, and for horses requiring a jejunocecostomy 68% (19 of 28) and 43% (12 of 28), respectively. 5 5 Undergoin g surger y befor e 1992 , hear t rate 80 beats/min, abnormal peritoneal fluid color, pale oral mucous membranes, the necessity for an intestinal resec- tion, and an inability to maintain a mean arterial blood pressure of 100 mm Hg or higher under general anesthesia wa s associate d wit h a poo r surviva l rate. 5 5 A les s favorable prognosis for horses with EFE compared with horses with othe r cause s o f S I strangulatio n ha s bee n reported . 5 6 Free - man and Schaeffer 57 recently reported a survival rate of 95% (20 of 21) for horses with EFE that underwent sur- gical correction ( resection and anastomosis) and recov- ere d fro m genera l anesthesia, 5 7 whic h wa s significantly higher than the prognosis for horses with a strangulating lipoma (84%, 32 of 38) and miscellaneous causes of SI strangulatio n (91% , 4 9 o f 54). 5 6 Th e authors 5 7 concluded that prompt diagnosis of EFE is essential for a favorable outcome, and that improved jejunocecostomy and viabil- ity assessment (to avoid intestinal resection) techniques

Acute abdomen

125

are important for improving the survival rate of horses with EFE.

Decision Making for Referral and Surgical Intervention

The decision of when to refer a horse to a secondary or tertiary surgical facility and when surgical intervention is necessary can be challenging. The inherent complication rate associated with equine general anesthesia and surgery has decreased to being low to negligible at most hospitals with experienced surgeons and anesthesiologists. However, the expense associated with abdominal surgery is the major drawback to surgical intervention in a case in which it may not be necessary. Early referral to a surgical facility is recommended for a horse with colic that is severely painful or that has been treated with flunixin meglumine as well as xylazine and bu- torphanol and remains painful. In addition to persistent or severe pain, abdominal distention, tachycardia (heart rate 60 beats/min), absence of borborygmi, nasogastric reflux, or abnormal findings on palpation per rectum are indications for referral. The owner should be informed of the dire con- sequences of delayed referral and provided with an estimate of the cost, prognosis, and expectations regarding further evaluation and treatment at the referral hospital. It is important to remember that abdominal exploration is diagnostic and therapeutic. Surgery is indicated in any horse with severe or persistent colic. The decision for surgery can be challenging in horses showing very mild signs of pain that are responsive to analgesia. In addition to pain, worsening tachycardia and abdominal distention, abnormal findings on palpation per rectum, absence of borborygmi or fecal pro- duction, and abnormal peritoneal fluid are indications for abdomina l surgery . I n a recen t surve y o f veterinarians, 5 8 the findings on initial examination of a horse with colic that were associated with the need for surgery were moderate, severe, or persistent pain, return of pain after treatment, repeated pain treatments, and decreased or absent borborygmi. Ab- normal findings on palpation per rectum on the initial exam- inatio n wer e no t associate d with th e nee d fo r surgery, 5 8 em- phasizing the importance of repeat patient evaluation and assessing the change in physical examination findings over time.

Prognosis and Future Directions

While the short-term survival has improved for horses un- dergoing surgical treatment, there are still concerns among owners regarding the long-term prognosis for survival and athletic activity. Horses that had undergone operation for colic in France between 1999 and 2000 were followed long- term. 5 9 Two-third s o f th e horse s wer e reported t o hav e re- sumed activity identical to that before surgery; 26% had short-term complications (ie, most commonly wound infec- tion, hernia, and edema) and half of the horses had at least on e additiona l episod e o f colic. 5 9 Horse s with S I lesion s took longer to recover and had fewer postoperative complications compared with horses with LC problems. Similarly, Santschi

an d coworkers 6 0 reporte d tha t youn g Thoroughbred s were significantly less likely to race (63%) following a celiotomy compared with unaffected siblings (82%); age at the time of surger y was associated wit h th e abilit y t o race. 6 0 Affected foals that were able to race won as much money, raced as often , wit h a s man y start s as thei r siblings. 6 0 Th e authors concluded that while colic surgery may have a negative im- pact on future racing, the majority of foals discharged from th e hospita l wer e able t o perfor m athleticall y a s adults. 60 Future research directed toward improving the long-term prognosis and usefulness of horses with colic is necessary. Epidemiological studies are needed to improve our under- standing of the causes of GI disturbances, particularly recur- rent colic, to lower the incidence of colic in horses. Intense laboratory and clinical research is ongoing with the goal of improving our understanding of intestinal healing, patho- physiology of SIRS and shock in horses, and to study novel treatments to improve the prognosis for horses with strangu- lating intestinal lesions and horses undergoing major abdom- inal surgery.

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