Managing Gastrointestinal Stasis in Rabbits

ABVP 2017

Kristina Palmer, RVT, VTS

Introduction

Rabbits (Oryctolagus cuniculus) are popular small herbivorous pets that are prone to
gastrointestinal diseases. Gastrointestinal stasis (GI stasis) is a syndrome of rabbits and is a
common reason for presentation to veterinary hospitals. This syndrome can be life-threatening if
not treated immediately and appropriately. GI stasis can be a result of a number of disease
processes, as well as an inappropriate diet of high carbohydrate/low fiber, pain, dehydration, and
stress. Veterinary technicians working with rabbits need to be knowledgeable about the
appropriate rabbit diet, husbandry, and medical care benefiting the client, patient, and the clinic.
This article is intended to explore the normal rabbit diet, digestive anatomy and physiology,
clinical signs associated with GI stasis, and how to treat this life-threatening syndrome.

What is Hindgut Fermentation?

Rabbits utilize a digestive process called hindgut fermentation. This is a digestive process that
occurs in monogastric herbivores, including rabbits and horses, with a single-chambered
stomach. Cellulose is digested with the aid of symbiotic bacteria. Rabbits are sometimes
compared to horses since the anatomy, physiology, and gastric ileus syndromes are so similar.
Hindgut fermentation differs from foregut fermentation, which is the form of cellulose digestion
that occurs in a four-chambered ruminant stomach of cattle.

Appropriate Diet

Rabbits require a diet that is high in indigestible fiber and have a relatively high feed intake
requirement. A balanced rabbit diet contains adequate fiber (minimum 25%), minimal starch,
and moderate protein levels (12–16%). Insoluble fiber is the most important element in the diet
to maintain gastrointestinal health, as it stimulates gut motility, and this can be provided through
a hay-based diet. Simply put, hay is dried grass, legume, or other herbaceous plants that have
been cut and dried. There is a wide variety of hay types available, including western timothy,
orchard grass, botanical, bluegrass, and oat. Pellets also provide a source of fiber; however, the
strands are smaller in size and the pellet has been processed. Alfalfa hay and pellets are relatively
high in protein, calcium, and calories, and therefore is recommended only for young, pregnant,
or lactating animals. A diet consisting of alfalfa-based products can lead to obesity and other
medical problems such as urolithiasis and hypercalciuria in adult caged rabbits. Diets high in
starches result in extremely rapid microbial growth that potentially secretes toxins leading to
enteritis and possible death.

The appropriate diet for an adult companion rabbit would be composed of unlimited amounts of
grass hay, approximately 1 cup of fresh leafy greens, and about 1/8 cup of a grass-based pellet
per day. Examples of appropriate greens include kale, collards, beet tops, carrot tops, parsley,
dandelion greens, chicory, mustard greens, basil, mint, endive, wheat grass, cilantro, and Swiss
chard. A variety of greens is recommended. If leafy greens are new to the rabbit's diet, it is
essential to introduce them slowly.

Rabbits supplement their nutritional needs by practicing coprophagy, meaning the consumption
of stool. Coprophagy in rabbits is demonstrated by the ingestion of cecotrophs, or night feces.
Cecotrophs are protein and vitamin-rich droppings normally consumed directly from the rabbit's
anus.

Gastrointestinal Anatomy and Physiology

The abdominal cavity of rabbits is large, and the gastrointestinal tract is relatively long. It
consists of a simple, non-compartmentalized stomach, small intestine (duodenum, jejunum), and
a large hindgut (cecum and colon). Rabbits have a simple stomach that is thin-walled, located on
the left side of the abdomen, and serves as the reservoir for ingesta. Due to the positioning and
well-developed nature of the cardiac sphincter of the stomach, rabbits are unable to vomit or
eructate. Rabbits normally produce a large amount of saliva and gastric secretions. The small
intestine is relatively short and comprises only 12% of the gastrointestinal tract. This is the site
of digestion and absorption of sugars, proteins, vitamins, and fatty acids. The duodenum lies at
an acute angle to the liver and can be compressed in cases of hepatomegaly. The jejunum is
slightly less thick and has a decreased vascular supply in comparison to the duodenum. Motilin is
secreted by the endocrine cells of the duodenum and jejunum and helps to stimulate
gastrointestinal motility in the small intestine, colon, and rectum. High-carbohydrate diets inhibit
its secretion and can lead to gastrointestinal stasis syndrome. The terminal ileum goes through
the weak ileocecal valve and enlarges into a dilatation called the sacculus rotundus, a structure
that is unique to the rabbit.

The cecum of the rabbit represents 40% of the intestinal tract. It is thin-walled and coils on itself
into three gyral folds before ending in a blind-ended, thick-walled tube called the vermiform
appendix. The cecum is adapted for microbial hindgut fermentation, breaking down cellulose and
proteins into volatile fatty acids (VFAs). Some VFAs are absorbed directly into the bloodstream
and some are stored in cecotrophs. There is a symbiotic microbial population of the hindgut that
consists primarily of Bacteroides spp.

Rabbits utilize a mechanism for the selective secretion of fiber and retention of small particles
and complex carbohydrates for fermentation in the cecum. Intestinal contents enter the hindgut at
the ileocecal-colonic junction and uniformly disperse in the cecum and colon. The different
breakdown products of ingesta simultaneously move in opposite directions. Contraction of the
cecum moves large fiber particles into the proximal colon where peristaltic action moves these
indigestible components through the colon to be voided as hard fecal pellets. Contractions of the
haustrae of the proximal colon move the smaller particles and fluids backward into the cecum
where fermentation occurs.

The fusus coli is an anatomical structure that is unique to rabbits, and it controls the separation of
hard and soft feces. Located in the proximal colon, it is a thickened circular muscle that is
heavily supplied with ganglion cells and is under the influence of aldosterone and prostaglandins.
During periods of stress - such as pain associated with surgery, dental disease, trauma, and diet
changes - it can induce increases in adrenaline that can inhibit gastrointestinal motility and lead
to cecal stasis and abnormal cecotrophs.

Cecotropes and Coprophagy

The term cecotrophy is the practice of consuming cecotropes. Coprophagy and cecotrophy are
often used interchangeably, and their practice is considered an important part of the digestive
process in rabbits. Cecotropes, also known as "soft feces" or "night feces," are usually formed by
microbial hindgut fermentation breaking down cellulose and proteins into VFAs within the
cecum. These nutritious cecotropes are normally consumed by the rabbit directly from the anus.
Cecotropes are usually passed in small clusters that are soft, sweet-smelling, and have an outer
mucoid membrane. The mucoid membrane protects the cecotrope for up to 6 hours in the
stomach. The semiliquid cecal ingesta contain high levels of vitamins B and K, as well as twice
the protein and half the fiber of hard feces. Cecotrophy is a form of recycling nutrients, which
allows rabbits to ingest protein and vitamins that were not absorbed in the first pass through the
rabbit's rapidly moving gut.

Gastrointestinal Stasis Syndrome

Gastrointestinal disorders in rabbits may be caused by anything that disrupts normal

gastrointestinal motility, the pH of the cecum or the stomach, or the fluid content of the ingesta,
particularly in the hindgut. Multiple factors are usually involved including low dietary fiber, high
dietary starch or protein, inadequate water intake, inactivity, stress, pain, and/or dehydration
secondary to underlying medical conditions. When a rabbit becomes dehydrated, water is pulled
from the gastrointestinal tract to keep the rest of the body hydrated, resulting in dry or doughy
gastric and cecal contents.

A thorough history, including a detailed dietary history, can provide invaluable clues to the
underlying cause of GI stasis. Patients with GI stasis commonly present for lethargy, anorexia,
decreased or no stool production, a distended abdomen, and signs of pain such as a hunched
posture or bruxism. Physical examination findings often include depression, hypothermia,
doughy stomach and cecum on palpation, and gas-filled intestinal loops. Auscultation of the GI
tract may reveal normal or hyperactive gut sounds early in the disease process, but later gut
sounds are reduced or absent.

Gastrointestinal Obstructions

Gastrointestinal obstructions are rarer than intestinal ileus. Obstruction of gastric outflow may
often be caused by a small mass of dehydrated ingesta or hair-filled cecal pellets. Less
commonly a trichobezoar, mass lesion, or an ingested foreign body may cause an obstruction.
The distal duodenum and ileocecal junction are the most common sites of obstructions. The
result is gastric distention or bloat that can quickly become life threatening if left untreated.
Since rabbits cannot vomit or eructate, obstruction of gastric outflow quickly leads to distension
of the stomach and, in some cases, places excess pressure on the diaphragm, which compromises
the rabbit's lung volume. Patients often respond to supportive therapy, but surgical intervention
may be necessary if the condition does not resolve. As a general rule, rabbits do not tolerate
surgery of the gastrointestinal tract as well as other species, and aggressive medical management
is often the first option for treatment.

Gastric Trichobezoars

The condition commonly referred to as "gastric trichobezoars" or "hairballs" is a problem that is

primarily related to dehydration and chronic gastric hypomotility. Over time, this results in an
impacted, dehydrated food ball that cannot pass through the GI tract. Rabbits are fastidious
groomers and will always have some hair in the GI tract, but when they are fed an inappropriate
low-fiber diet and become dehydrated, these rabbits can develop gastric trichobezoars. If rabbits
are fed an appropriate diet and consuming enough water, ingested hair is passed regularly in the
fecal pellets.

Enteritis and Dysbiosis

Enteritis is caused by an overgrowth of bacteria in the cecum, typically Clostridium spiroforme.

The causes are inappropriate diet, stress, gastrointestinal tract dysfunction, and in some cases,
inappropriate antibiotic usage. Dysbiosis commonly occurs when the rabbit consumes a diet rich
in sugars and other simple carbohydrates such as whole or cracked corn, fruits, seeds, crackers,
cereals, or yogurt treats. The carbohydrate overload is thought to be a predisposing factor in the
development of yeast overgrowth and an imbalance of bacterial flora. Signs range from soft
stools and diarrhea to enterotoxemia, sepsis, and death.

Dysbiosis is best addressed with supportive care as indicated by the patient's clinical status along
with strict diet changes. Eliminate all simple carbohydrates and encourage the rabbit to consume
coarse fiber primarily in the form of hay along with modest amount of leafy greens.

Antibiotics that may predispose a rabbit to dysbiosis are: lincomycin, ampicillin, amoxicillin,
amoxicillin-clavulanic acid, cephalosporins, clindamycin, penicillins, and erythromycin.
Antibiotics that are commonly used to treat bacterial infections in rabbits are: chloramphenicol,
ciprofloxacin, enrofloxacin, metronidazole, penicillin (SC), silver sulfadiazine (topically), and
trimethoprim sulfadimethoxine.

Diagnostics

A diagnostic workup of the patient should include a thorough history and physical examination,
a complete blood count, biochemistry profile, and survey radiographs. Abdominal radiographs
may help distinguish between gastrointestinal ileus and obstruction. Whole-body right lateral and
ventrodorsal are the standard diagnostic radiographs. A rabbit with GI stasis may have a stomach
filled with gas and/or fluid and food, and may have large amounts of gas in the intestinal loops
and cecum. An obstruction can look very similar; however, the loops of intestine proximal to the
site of the obstruction may appear dilated. An abdominal ultrasound may also be pursued to
evaluate the motility of the intestines as well as evaluate the intestinal tract for signs of an
obstructive process.
Supportive Therapy

Intensive supportive care is required to rehydrate the patient and the stomach contents, and
stimulate gastric motility. Treatment often requires analgesia, fluid therapy, assisted feedings,
encouraging exercise, and prudent use of gastrointestinal motility agents. Fluid therapy:
appropriate fluid therapy with crystalloid fluids such as lactated Ringer's solution (LRS) or
normal saline administered subcutaneously, intravenously, or intraosseously depending on the
condition of the patient and the severity of the disease. Fluid rates of 100–150 ml/kg/day may be
needed to rehydrate a critically ill rabbit. Analgesia: buprenorphine 0.03–0.05 mg/kg IM or SQ q
6–8 h, meloxicam 0.3–0.5 mg/kg SC, PO q 12 h, tramadol 10–15 mg/kg PO q 12 h. Other
medications: famotidine 0.5 mg/kg SC, BID, a histamine H2 blocker that inhibits stomach acid
production.

Practical Feeding Strategies

Rabbits with GI stasis can rapidly develop hepatic lipidosis, and the ingesta can become
dehydrated and compacted. Unless the rabbit is suspected of having a foreign body obstruction
of the GI tract, it is important to provide immediate nutritional support. The goals are to
rehydrate the ingesta, provide high indigestible fiber to encourage peristalsis, provide some
carbohydrates to return the patient to a positive energy balance, and correct any fluid deficits.
The patient should have free access to hay, leafy greens, and fresh water. In addition, the patient
should be syringe-fed high-fiber gruel such as ground-up timothy-based pellets or hay, or
premanufactured formulations such as Oxbow Critical Care®. Regular syringe-feeding intervals,
varying from 30–50 ml PO up to 3–4 times per day.

Nasogastric Feeding Tube Placement

Nasogastric feeding tubes can be placed in patients that are critically ill and too weak for oral
syringe feeding. The formulations that are ultra-fine can't stimulate GI motility as effectively as
the fiber in very small pieces. The technique for placing these is similar to that in cats. After
passing the tube to the stomach, secure the tube by applying a piece of tape around the tube and
suture the tape to the top of the rabbit's head. Tube placement can be verified through performing
a lateral radiograph of the thorax. An Elizabethan collar can be used to prevent the rabbit from
pulling the tube out with its feet. Rabbits may not eat with an E-collar in place.

Decompression

Decompressing a gas-filled stomach is sometimes necessary. If the patient is stable enough to be

heavily sedated or anesthetized, place the patient in sternal recumbency, premeasure a gastric
tube (12 Fr red rubber catheter) by placing it against the rabbit and estimating the position of the
stomach, and mark the spot on the tube where it should exit the mouth. Place an oral speculum in
the mouth, apply a small amount of lubricant on the tube, and pass the tube into the stomach.
Remove as much fluid and gas as possible. Monitor the patient closely and provide additional
analgesia and supportive therapy as necessary.

Summary
Rabbits are prone to gastrointestinal disease, and it is a common presentation. This is life-
threatening if not treated immediately and appropriately. This condition is often multifactorial.
Aggressive supportive care is necessary, and it is important to try to identify the underlying
cause. Management relies on analgesia, fluid therapy, and assisted feedings. An appropriate diet
that is high in fiber and low in simple carbohydrates is the most important factor for maintaining
normal gastrointestinal health. Veterinary technicians working with these unique pets must
understand the normal anatomy and physiology of the rabbit in order to effectively treat a rabbit
that presents with GI stasis.

References

1.  Quesenberry KE, Carpenter JW. Ferrets, Rabbits and Rodents Clinical Medicine and
Surgery. Saunders; 2006.

2.  Mitchell MA, Tully TN. Manual of Exotic Pet Practice. Elsevier; 2009.

3.  O'Malley B. Clinical Anatomy and Physiology of Exotic Species. Germany: Elsevier

Saunders; 2005.

4.  Carpenter JW, Mashima TY, Rupiper DJ. Exotic Animal Formulary. 2nd ed. WB Saunders
Company; 2001.