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Colic diagnostics

Zita MakraSZIU FVS Large Animal Clinic

makra.zita@aotk.szie.hu

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ColicColic = = abdominalabdominal painpainIleusIleus: : intestinalintestinal obstructionobstruction andand temporarytemporaryfailurefailure ofof peristalsisperistalsisPreventsPrevents aboralaboral movementsmovements →→stasisstasis++distentiondistentiontotaltotal//partialpartialRapid Rapid andand accurateaccurate diagnosisdiagnosisBroadlyBroadly classifiedclassified: : physicalphysical oror functionalfunctionalobstructionobstruction

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Classification of ileus (Gerber and Huskamp)

I. Mechanical disorders1. Inside the lumen

-impaction-obturation-stenosis-occlusion-invagination

∗small intestine∗ileum into caecum∗caecum into caecum∗caecum into large colon

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Classification according to Gerberand Huskamp

•• 2. 2. DisordersDisorders outsideoutside thethe lumenlumen2.1 2.1 incarcerationincarceration

2.1.12.1.1. . epiploicepiploic foramenforamen herniationherniation2.1.2. 2.1.2. inguinalinguinal herniahernia2.1.32.1.3. . herniahernia ofof diaphragmdiaphragm2.1.4. 2.1.4. nephrosplenicnephrosplenic entrapemententrapement2.1.5. 2.1.5. mesentericmesenteric teartear

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Classification according to Gerberand Huskamp

• II. Dynamic disorders1.Paralytic ileus:

1.1. primaer: grass sickness1.2. secunder: postoperative,

peritonitis, mechanical ileus

2.(Spasmodic colic): 2.1. After exercise or excitement2.2. Enteritis, parasitism, moldy feed

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PhysicalPhysical obstructionobstruction

-- nonstrangulatingnonstrangulating –– mesentericmesenteric bloodbloodsupplysupply intactintact butbut bowelbowel lumen lumen occludedoccluded

-- intraluminalintraluminal reductionreduction / / massmass-- intramuralintramural thickeningthickening oror extramuralextramural

compressioncompression-- strangulatingstrangulating –– luminalluminal occlusionocclusion andand

reductionreduction ofof mesenterialmesenterial bloodblood supplysupply ––((incarcerationincarceration, , intussusceptionintussusception, , torsiontorsion>>180180--degree)degree)

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FunctionalFunctional obstructionobstruction

DynamicDynamic, , paralyticparalytic ileusileus-- proximalproximal enteritisenteritis, , colitiscolitis-- plantplant poisoningpoisoning ((atropineatropine), ), postoppostop. .

paralyticparalytic ileusileus

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MechanismMechanism

ObstructionObstruction →→ preventsprevents aboralaboralmovementsmovements, , distentiondistention, , venousvenousdrainagedrainage↓↓, , congestedcongested-- edematicedematic mucosamucosa,,>24 >24 hourshours: : irreversibleirreversible mucosalmucosal ischemiaischemia

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InIn strangulatingstrangulating obstructionobstruction: : rapid rapid tissuetissue hypoxemiahypoxemia (4(4--6h)6h),,ischemiaischemia, , necrosisnecrosis ((rupturerupture)), , transmuraltransmural leakageleakage,,endotoxemiaendotoxemia, , hypovolemiahypovolemia

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How to get rapid and accurate diagnosis?

1. History2. Clinical observation and signs of pain3. Physical examination4. Nasogastric intubation5. Rectal examination6. Abdominocentesis7. Ultrasonography

The order can be changed if inicated.

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Diagnosis1. History

– Management- changes of diet- consumption of water- excercise level- stabling changes- dentistry- pregnancy- etc

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HistoryPresumptive diagnosis• Young racehorse orthopedic inj – impaction• Sex: stallion – inguinal hernia

mare – disease of the genital tract• Age: foal – meconium, NMS, inherited

problemsOlder, obese horse – lipomaold – tooth problem

• Breed: shetland pony: small colon obstructionthoroughbred and standardbred: inguinal

hernia

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HistoryPresumptive diagnosis• Geographic incidence of colics

appears uniform, but e.g. in Germany ilealimpaction more often than in other parts ofthe world

• Recently foaled mare – large colon volvulus• Adult horse recurrent colic passing mineral oil

– enterolith (arabian, QH)• Cribbers – epiploic foramen entrapement• Dewormed foals – ascaris impaction

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1. History

• Medical- any links to this episode of colic(deworming)- repetitive colic: previous abdom. surg.?

»adhesionsenterolithsingestion of sandlinear foreign body

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2. Clinical observation and signs of discomfort /acute abdominal pain in horses

Appreciate the level of discomfort:

restlessness, sweating, scratching, rolling, strange position, watching theflank region, kicking at their abdomen, (apathetic-indifferent)

Tachycardia, hypertension, dyspnoe, mydriasis, lack of appetite, musclefasciculation, shock (pain, hypovolaemia, endotoxaemia)

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Clinical observation (attitude)

• Level of discomfort>severity, duration, response

• Mild / moderate / severe not response toanalgesic (>surg)

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Grading system for colic

• 1. mild discomfort (gastric ulcer)• 2. getting up and down, looking at the

abdomen (obstipation)• 3. sweating, rolling (LDD)• 4. not controlable horse because of pain

(torsion of LC)• 5. apathy

– (foramen epiploicum hernia indolent phase)

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3. Physical examination((ToTo knowknow normalnormal rangerange ofof clinicalclinical datadata!!)!!)

CheckCheck cardiovascularcardiovascular+GI +GI tracttract!!!!!!

-T: 37,5-38,5°C (↔,↑peritonitis, enteritis; ↓ severeshock)

--HR: 28HR: 28--42 /min, 42 /min, pulsepulse qualityquality--RR: 14RR: 14--18/min18/min--SkinSkin turgorturgor, , mucousmucous membranemembrane, CRT: 1, CRT: 1--2 sec2 sec

venuosvenuos refillrefill--AbdominalAbdominal shapeshape ((distensiondistension))--AbdominalAbdominal auscultationauscultation ++ percussionpercussion--CheckCheck scrotumscrotum inin stallionsstallions!!

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PCV: 32PCV: 32--42 % (42 % (↑↑ splenicsplenic contractioncontraction, , dehydrationdehydration))

TPP: 6.0 TPP: 6.0 –– 7.5 g/dl (7.5 g/dl (↑↑ , , ↓↓ protprot. . lossloss intointo thethe lumen lumen ororperitonealperitoneal cavitycavity) )

BloodgasBloodgas analysisanalysis: : art.art.pH:pH: 7.35 7.35 -- 7.45 (7.45 (acidemiaacidemia))PaOPaO22 ((HgmmHgmm): 80 ): 80 -- 112112PaCOPaCO22 ((HgmmHgmm): 36 ): 36 –– 46 (46 (hypercapniahypercapnia))HCOHCO33 ((mEqmEq/l) : 22 /l) : 22 –– 29 (29 (basebase deficit) deficit) BaseBase excessexcess: : --1.7 1.7 -- +3.9+3.9

ElectroliteElectrolite determinationdetermination

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Clinical pathology

• EMERGENCY – minimal clinical pathology data• PCV, TPP – hydration status↓TPP and ↑PCV – protein loss, dehyd, poorprognosis

• Electolyte levels, blood gas status – guide fluid replacement

• WBC ↓: colitis, visceral rupture• CK: renal disease, dehydr.• GGT: liver disease, colonic displacement

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4. Nasogastric intubation

All horses!!

-gastric decompression↔primary/secondary distension- flushing of fluid – empty the stomach-if small-intestinal obstruction or enteritis is suspected(10-20 l reflux)- leave the tube in place to preventgastric rupture! (anesthesia!)

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5. Rectal examination

General statementsAlways should be done (pony, foal US!)Before paracentesisMay be an indication for surgery

TechniqueSedatives+spasmolytic iv.Twitch, in stocks, be careful!LubricationMucosa: lesions, bloodAs deep as possible

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5. Rectal examination

systematic examination!

Palpable intraabdominal structures:

-caudal border of the spleen-nephrosplenic ligament-caudal pole of the left kidney-mesenteric root-ventral cecal band-cecal base (head)-small colon containing discinct fecal balls-pelvic flexure-examine: internal inguinal rings, bladder, reproductive tract

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Abnormal rectal findings:-distended small intestine, cecum, large/small colon

-marked intramural/mesenteric edema

-bowel malposition, displacement

-herniation

-impaction

-intussusception

-intraabdominal space-occupying mass(abscess/hematoma/tumor)

-enterolithiasis

-volvulus of the mesenteric root, urogenital abnormality

-free abdominal gas/ingesta (visc. rupture)

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6. AbdominocentesisMost dependent part18G, 7,5 cm, Collect into serum tube – TP

EDTA – cytology, cell countRISK: bowel laceration, enterocentesis,amniocentesis – US helps, kick

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6. Abdominocentesis

• Clear-transparent, pale yellow• Normal: WBC < 3000-5000/µl

TP< 2,5 g/dl• Presence of bacteria!• Exploratory celiotomy, castration, laparoscopy: ↑ TP, WBC

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6. Abdominocentesis

Strangulating ileusReduced iv. volume:- ↓perif. perfusion, HR↑, PCV↑,

mucous membranesShock: inadequate tissue oxygenationPoor periferal tissue perfusion+anaerob metabolism⇒Lactate↑Lactate indicates endotoxic mitochondrial hypoxiaHorses are suseptible for endotoxins (have a lot ofreceptors on WBC)Preop. Lactate measurement!:

- how suseptible for endotoxins- how hypoxic=assessment of perfusion

Blood lactate<2mmol/lPeritoneal lactate > 5-6 mmol/l⇒strang. Ileus (LC volvulus)Peritoneal>blood lactate⇒strang. Ileus, prognosis

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6. Abdominocentesis

Blood-tinged fluid⇒intestinal necrosis=99% surgeryHb↑- Strangulating ileus

Hypocalcemia in the bloodCa2+↓ in colic casesEndotoxemia⇒PTH release in serum⇒ Ca2+↓Intracellular Ca overload⇒inflammatory enzymes

activatedHypocalcemia: severity of disease (cellular injury!),prognosisHR- phrenic n. transmission-diaphragm-abd. wall tremor

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7. Ultrasonography

• Becoming routine part• Sprayed with alcohol• From the line of diaphragmatic reflection down to

the ventral midline• 2-3,5 MHz• Gastric distention (fluid, carcinoma), 8-15 ICS• SI: movements, thickness <3mm,(>5mm-incarc)

dilatation >5cm• Intussusceptions, inguinal hernia• Lesions involving the caecum• LC: <5mm (>9mm–torsion)

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7. Ultrasonography

• Intraabdominal fluid, masses• Foal: instead of rectal exam• By rectal tears• Postop: to control peristaltic• Thickness of intestinal wall (hypertrophy-

oedem)• Intestinal content (gas, fluid, sand etc.)• Incarceration (oedem+fluid in the lumen)• Invagination (snail-like pattern)

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7. Radiography

• Enteroliths (Us) • sand accumulation – ventral abdomen, low

power• Diaphragmatic hernias• FOAL, small horses: conventional/contrast

(30% BaSO4 orally or rectally)- meconium, segmental atresia

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What to do?

Pain reliefStabilization of cardivascular + metabolic statusMinimizing the deleterious effects of endotoxemiaEstablishing a patent and fuctional intestine:

analgesic th.fluid therapy+cardiovascular supportdecompression of stomach, cecum, large colonlaxativesantiendotoxin th.th. for ischemia-reperfusion injuryantimicrobial th.nutritional supportsurgical intervention

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Diagnosis:

Immediate surgical management or euthanasia

Medical management with further monitoring andpossible surgery

Medical management

Decision can be based on the available information

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Indications for exploratory celiotomy in horses:

-persistent or recurrent, unrelating abdominal pain-refractory to analgesics-increased HR-progressive abdominal distention-abscence of borborygmi-large quantities of gastric reflux-abnormal rectal examination-serosanguineous abdominal fluid with ↑TP and

nucleated cell count

Early surgical intervention, even if it unnecessary is lessdangerous to the horse with colic than delayed surgicalintervention that results in visceral rupture!

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Indication of surgery

- distended edematous SI without motility by Us- presence of enterolith on X-ray- physiologic deterioration despite medical

therapy, IV fluids and supportivetreatment=failure of conservative treatent

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Ancillary diagnostic aids

• Endoscopy (eosophagus, stomach, duodenum, rectum distal small colon) (3m)

• Laparoscopy: acute and chronic- trauma after foaling, abdominal cavity trauma,

splenic disease, adhesions, large colon displacements, visceral rupture, abdominalneoplasia

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Status presens• Circulation: conservative / surgical

• Pulse <80/min <100/min• Mucosa pink – red livid - cyanotic• Body surface OK cold• PCV - TPP < 50 ; 6-7.5 g/dl >50 ; >7.5g/dl

• Alimentary tract• Palpation abdomen not tight +; ++; +++• Peristaltic OK, hyperactive -• Rectal exam. Normal pathological

finding• Nasogastric tube no reflux reflux• Abdominocentesis clear, transp., turbid, reddish• Ultrasonographic examination

• Pain, faces, sweating

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Nonintestinal colic disorders

• Cardiovascular (a. iliaca thrombus, pericarditis)

• airways (pleuritis, pleuropneumonie)• abdominal cavity (tumor, abscess,

peritonitis, haematome)• liver (cholelithiasis, cholangiohepatitis)• spleen (abscess, splenomegalie)• urogenital tract (nephrolits, pyelonephritis,

cystitis, ruptured bladder)

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Basic equipment for colicexamination in the praxis• stetoscope• twitch• Nasogastric tube• Rectal gloves, gel• PCV centrifuge, refractometer• Caecum trocar, instruments for surg.

Preparation, iv. catether• Drugs

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Transabdominal caecum punctionaseptic surg. preparation, ab,trocar with mandrine

Large colon transrectal decompression

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Pain control

• Disguises colic!• Flunixine-meglumine (0,5-1 mg/kg) –

endotoxemia! (mask signs!)• Xylazine (0,2-0,5 mg/kg) potent analgesic,

short duration• Butorphanol tartrate (0,01-0,02 mg/kg IV)• Detomidine: longer acting

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Treatment•• 1. 1. AnalgeticsAnalgetics::

-- decompressiondecompression -- nasogastricnasogastric tubetube, , -- caecumcaecum headhead/LC /LC trocarisationtrocarisation

-- DetomidineDetomidine, , XylazineXylazine-- ButorphanolButorphanol (0,1mg/kg)(0,1mg/kg)-- NovaminoNovamino –– SulfonSulfon: : VetalginVetalgin, , NovalginNovalgin-- MetamizolMetamizol--NaNa: : BuscopanBuscopan, , ChosalganChosalgan-- FlunixinFlunixin megluminmeglumin: : FinadyneFinadyne

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Treatment•• 2. 2. SedativeSedative:: XylazinXylazin, , DetomidinDetomidin reduce propulsive

motility in caecum and LC, promote transit of ingesta injejunum

•• 3. Fluid 3. Fluid theraphytheraphy::-- ReduceReduce hypovolhypovol::KristalloidKristalloid: 20: 20--40 ml / kg / h ~1040 ml / kg / h ~10--20 l/h20 l/h

hypertonichypertonic salinesaline 4ml/kg=2 l4ml/kg=2 lKolloid: Kolloid: FrozenFrozen plasmaplasma, HAES 10ml/kg, , HAES 10ml/kg, DextranDextran infinf..

•• 4. 4. AntiendotoxinesAntiendotoxines::FrozenFrozen plazma, plazma, flunixinflunixin, OTC, , OTC, doxycyclindoxycyclin,,activatedactivated charcoalcharcoal, paraffin , paraffin oiloil

•• 5. 5. LaxativesLaxativesparaffin, paraffin, linseedlinseed

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Treatment•• 6. 6. TheraphyTheraphy forfor ischemiaischemia--reperfusionreperfusion injuryinjury

absorption of endotoxin across ischaemic-injuredmucosa, flunixin retards mucosal repair, syst. lidocainhas anti-inflammatory effects, improve mucosal recovery

•• 7. 7. CholinergicCholinergic stimulatesstimulates::-- cisapridecisapride ((PropulsidePropulside) 0,1mg/kg ) 0,1mg/kg -- smallsmall andand largelarge

colon colon propulsivepropulsive effecteffect-- metoclopramidemetoclopramide ((CerucalCerucal))-- pilocarpinpilocarpin hydrochloridhydrochlorid--atropineatropine poisoningpoisoning

•• 8. 8. AnticholineseteraseAnticholineseterase::-- NeostigmineNeostigmine: : stimulatesstimulates largelarge colon, colon, butbut increaseincreasesmallsmall intestinalintestinal secretionsecretion ((KonstigminKonstigmin))

•• 9. 9. ColicColic surgerysurgery

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Referencees

• Auer & Stick: Equine Surgery 3rd edition• Orsini and Drivers: Manual of equine

emergencyes• www.glasshorse.com

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Thank You for Your attention!