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Y4 Equine - GI > Colic critical decision making and case management > Flashcards

Colic critical decision making and case management Flashcards

1
Q

Decisions

A

▪ What sort of treatment is required?
→ medical
→ surgical
→ euthanasia
▪ Where should treatment / management take place?
→ at home
→ at a veterinary clinic / surgical facility
▪ Decisions can be changed (apart from euthanasia)

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2
Q

Influencing Factors for decision making

A

▪ Cause / severity of colic
▪ Prognosis following treatment
▪ Finances / insurance cover
▪ Owner’s wishes
▪ Availability & ease of transport
▪ Intrinsic factors e.g. age, concurrent disease

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3
Q

Conditions that always require medical management

A
  • Spasmodic colic
  • Gaseous colic
  • Anterior enteritis
  • Colitis
  • Gastric ulceration
  • Grass sickness (ileus)
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4
Q

Conditions that are sometimes medical, sometimes surgical

A
  • Colon displacement
  • Colon impactions (ingesta/sand)
  • Peritonitis
  • Non-GI lesions (e.g. kidney dz)
  • SI simple obstruction
  • Parasites
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5
Q

Conditions that are require surgical tx (or euthanasia)

A
  • SI/small colon incarceration
  • SI/small colon volvulus
  • Colon torsion
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6
Q

How do we assess colic severity / achieve diagnosis?

A

1) History
2) Pain level and response to analgesia
3) Mucous membrane colour and capillary refill time – perfusion
4) Hydration status
5) Heart rate & pulse strength
6) Respiratory rate
7) Gut sounds
8) Abdominal distension
9) Temperature
10) Rectal findings
11) Volume of naso-gastric reflux
12) Abdominal fluid analysis
13) Ultrasound findings
14) Blood analysis

Not all diagnostic tests will be used in every case

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7
Q

History

A

▪ Signalment – age, breed, sex (stallion), pregnant, recently foaled?
▪ Normal management / feeding?
▪ Recent management / feeding changes?
▪Duration of signs?
▪ What behaviours have been occurring?
▪ Progression – improving / deteriorating?
▪ Previous colic incidence?
▪ Passed droppings today / last few days? Normal number & consistency?
▪ Concurrent disease?
▪ Recent medication (wormers)?

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8
Q

Signs of abdominal pain

A
  1. Standingquietly
  2. Reduced appetite
  3. Lip curling
  4. ‘Pained’ facial expression
  5. Restlessness
  6. Bruxism (teeth grinding)
  7. Pawing the ground
  8. Lookingatflanks
  9. Kicking at abdomen
  10. Repeatedly getting up and down **
    11.Lying flat out or on back**
  11. Rolling**

** = severe

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9
Q

Response to analgesia

A

▪ Response to analgesia is usually predictable.
– E.g. flunixin 1.1mg / kg should provide analgesia within 10 minutes and last about 12 hours.
▪ If colic signs do not improve following analgesia or return within a few hours something more significant is occurring.

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10
Q

Mucous membrane colour and capillary refill time

A

▪ Normal colour is ‘salmon pink’
▪ Normal capillary refill (CRT) is 1-2s
▪ Pale or dark injected membrane and prolonged CRT suggest poor peripheral perfusion
→ endotoxaemia? (esp if dark and injected)

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11
Q

Hydration Status

A

▪ Dry / tacky mucous membranes?
▪Prolonged CRT?
▪Prolonged skin tent?
▪ Not hugely accurate - a guide only
▪ Age affects skin tent
– Elasticity of skin decreases with age

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12
Q

Heart rate & pulse strength

A

▪ Elevated due to pain, toxic shock and dehydration
▪ Pulse may be weak and ‘thready’
– Facial artery pulse
▪ Transient heart murmur not uncommon with colic
– Due to flow disturbances in the CV system

HR 20-44 = normal
HR 44-60 = mild
HR 60-80 = moderate
HR >80 = severe

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13
Q

Respiratory rate

A

▪ Elevated due to pain or concurrent respiratory disease

RR 8-12 = normal
RR 12-20 = mild
RR 20-30 = moderate
RR >30 = severe

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14
Q

Gut sounds

A

▪ Gut sounds (borborygmi) occur constantly
→ Low grade constant grumbling – peristalsis in S.I. and colon
→ Caecal emptying 1-3x / minute – sounds like a toilet flushing
– Listen to RHS
▪ During colic, sounds may be normal, decreased or increased
▪ Listen in all 4 quadrants and grade separately
▪ Abnormal sounds may also be heard e.g. sand

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15
Q

Interpretation of normal gut sounds

A
  • doesn’t mean the horse doesn’t have colic
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16
Q

Interpretation of increased gut sounds

A
  • Guts are hypermobile, e.g. spasmodic colic
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17
Q

Interpretation of decreased gut sounds

A
  • Guts are hypomobile e.g. colon impaction
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18
Q

Interpretation of absent gut sounds

A
  • Guts are non-motile, e.g. SI incarceration
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19
Q

Abdominal distension

A

▪ Difficult for us to tell between fat / distended– ask owner
▪ May expand between examinations
▪ May get a ‘ping’ following abdominal percussion
▪ Indicates gas distension with large intestinal lumen
→ excess gas production or blockage passage of gas?
→ usually large intestine

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20
Q

Rectal temp of >37C (interpretation, relevance)

A
  • hypothermic
  • suggests CV compromise/shock
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21
Q

Rectal temp of 37-37.5C (interpretation, relevance)

A
  • mildly hypothermic
  • important in foals
  • probably irrelevant in adults
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22
Q

Rectal temp of 37.5-38.5C (interpretation, relevance)

A
  • normal
  • doesn’t rule out colic
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23
Q

Rectal temp of 38.5-39C (interpretation, relevance)

A
  • mildly hyperthermic
  • may be due to pain
24
Q

Rectal temp of >39C (interpretation, relevance)

A
  • significantly hyperthermic
  • suggests infectious/inflammatory condition
25
Q

Rectal findings

A

▪ Normal rectal is soft and without tension or distension
▪ Abnormal findings include hard ingesta, gas distended intestines, abnormally
located structures and tight taenial bands.
▪Can palpate small intestine, caecum, large colon, spleen, ovaries, uterus, bladder.

26
Q

Naso-gastric reflux (normal stomach content, max volume, what large volumes suggest)

A

▪ The stomach normally holds 2-3L of green non- malodourous fluid and will empty quickly after drinking.
▪ Larger volumes of fluid in stomach suggest S.I. obstruction
→ fluid backs up behind a blocked pipe.
▪ Maximum volume of horse stomach is 8-15L.
▪ Large volumes (>7-12L) foul smelling gastric fluid can be retrieved in small intestine is obstructed

27
Q

Normal abdominal fluid analysis

A

Colour:
- Yellow

Clarity:
- Clear

Volume:
- Small

WBCc:
- <5000cells/µl

Total protein:
- <30g/L

Lactate:
- <2.5mmol/L

28
Q

Compromised intestine abdominal fluid analysis

A

Colour:
- Pink/brown (serosanguinous)

Clarity:
- Opaque

Volume:
- Slightly increased

WBCc:
- Slightly elevated

Total protein:
- Slightly elevated

Lactate:
- Elevated

29
Q

Ruptured intestine abdominal fluid analysis

A

Colour:
- Green/brown (ingesta)

Clarity:
- Opaque (can see food particles)

Volume:
- Large

WBCc:
- Elevated

Total protein:
- Elevated

Lactate:
- Elevated

30
Q

Peritonitis abdominal fluid analysis

A

Colour:
- White/yellow

Clarity:
- Turbid

Volume:
- Large

WBCc:
- Elevated

Total protein:
- Elevated

Lactate:
- Elevated

31
Q

Abdominal Ultrasound - Q’s to ask

A

▪ Peritoneal fluid – increased volume?
▪ Small intestine – motility, distended?
▪ Stomach – full of fluid?
▪ Colon – distended, displaced?
▪ Intestinal wall thickness – increased?

32
Q

Blood analysis - PCV and TP

A
  • increased in dehydration/shock
33
Q

Blood analysis - WBC & differential

A
  • increased or decreased in infectious processes (depending on time frame)
34
Q

Blood analysis - SAA or Fibrinogen

A
  • increased if inflammatory/infectious process present
35
Q

Blood analysis - lactate

A
  • increase if compromised bowel present
36
Q

Blood analysis - electrolytes

A
  • electrolyte abnormalities
37
Q

Medical management (at home) for gaseous/spasmodic/idiopathic (mild) colic

A

▪ Analgesic – flunixin meglumine IV (Flunixin / Finadyne / Banamine)
▪ Spasmolytic – hyoscine butylbromide IV (Buscopan)
▪ No food but allow water
▪ Possibly oral fluids (isotonic electrolytes)
▪ Monitoring by owner
▪ Gradually return to normal diet the following day
▪Re-examination if doesn’t improve or colic recurs

38
Q

Medical management (at home) of pelvic flexure impaction

A

▪ Analgesic – flunixin meglumine IV (Flunixin / Finadyne / Banamine)
▪ Oral laxative fluids (MgSO4 / liquid paraffin)
→ may be repeated later in the day
▪ No food but allow water
▪ Monitoring by owner
▪ Definite re-examination 12-24hrs later
→ still showing mild colic signs
→ has only passed 1 small dropping
→ impaction still palpable on rectal exam

39
Q

Medical management (at clinic) of pelvic flexure impaction

A

▪ Analgesic – flunixin meglumine IV (Flunixin / Finadyne / Banamine)
▪ Oral laxative fluids (MgSO4 / liquid paraffin / water / isotonic electrolytes)
→ may be repeated up to 6 times during a day
▪ IV isotonic fluids (Hartman’s) at twice maintenance
▪ No food but allow water
▪ Monitoring by vets, nurses and students
▪ Regular re-examinations until:
→ large volume of faeces produced
→ colic signs resolve
→rectal exam confirm impaction has cleared
▪ Gradually return to normal feeding (and check the teeth)
– Soft food with short stem, e.g. grass or mashes if not grass season

40
Q

Pre-referral management of SI obstruction / incarceration / strangulation

A

▪ Analgesia – flunixin & opiate (butorphanol) IV
▪ Spasmolytic - hyoscine butylbromide IV
▪ Sedation – long acting a2 agonist (detomodine / romifidine) IV +/- IM ▪Decompress stomach – reflux and possibly leave tube in place
▪ IV fluid bolus isotonic (Hartmann’s) or hypertonic (7% NaCl)
– Hypertonic good for bringing circulating volume up quickly, needs to be followed with isotonic
▪ Contact referral centre – give details of presentation and management
▪ Assist owner to arrange immediate transport
▪ Try to keep owner calm

41
Q

Pre-surgical management of SI obstruction / incarceration / strangulation

A

▪ Broad spectrum antibiotic (usually penicillin & gentamicin)
– Gram positive and anaerobic cover with penicillin
– Gram negative cover with gentamicin
▪ Further anti-inflammatories?
▪ Tetanus prophylaxis?
▪ IV catheterisation
▪ IV fluid bolus isotonic (Hartmann’s) or hypertonic (7% NaCl)
▪ Correct acid-base and electrolyte abnormalities
▪ Naso-gastric intubation to empty stomach of reflux
– Keep it in for surgery so it can continue to drain
▪ Clip and scrub ventral abdomen
▪Don’t delay

42
Q

Surgical management of SI obstruction / incarceration / strangulation

A

▪ Immediate ventral midline exploratory laparotomy under G.A
▪ Incision normally starts at the umbilicus and moves forward
– Incision length depends on what the suspected problem is
▪ Systematic examination of abdomen
→ for small intestine start at caecum, work through proximally through ileum, jejunum & duodenum
– Body of duodenum lies agains the ventral body wall
▪ Identify and correct lesion
▪ Viable bowel is left in situ
▪ Necrotic bowel is removed by resection & anastomosis
→ jejuno-jejunal or jejuno-ileal - end to end
→ jejuno-caecal – side to side
▪ Abdominal lavage
▪ 3 layer closure – linear alba, sub-cutis, skin

43
Q

Post-surgical management of SI obstruction / incarceration / strangulation

A

▪ 5-7 days broad spectrum antibiotics – usually penicillin & gentimicin
▪ 5-7 days analgesia / anti-inflammatories as required – usually flunixin
▪ Regular clinical examination and adjustment of management
▪ Regular naso-gastric intubation to decompress stomach
→ post operative ileus is common following S.I. surgery
▪ IV fluids to correct dehydration, acid base imbalance and electrolyte deficits
▪ Gradual re-introduction of food and water after a few days
▪ Sometimes repeat laparotomy required
▪ Stable rest for approx. 8 weeks, then gradual turn out and return to exercise ▪ Lots of other things as well – every case is different
▪ Often put hay or feed outside the stable so they can smell it
– Hoping to induce gut motility
– Don’t know if this actually works

44
Q

Clinical assessment of bowel viability - viable vs necrotic bowel

A

Viable bowel:
- Pink / red colour
- Colour improves as time passes
- Mild oedema
- Strong pulse in mesenteric arteries
- Serosa is shiny
- Motile

Necrotic bowel:
- Purple / green colour
- Colour does not improve
- Severe oedema
- Weak / absent pulse in mesenteric arteries
- Serosa is dull
- Non-motile

45
Q

Surgical management of colon displacement/torsion

A

▪ Immediate ventral midline exploratory laparotomy under G.A
▪ Systematic examination of abdomen
→ for large intestine exteriorise caecum and entire colon (will require long incision)
▪ Identify and correct lesion, replace colon into correct location
→ gas removed with suction
→ ingesta may be emptied through pelvic flexure enterotomy
▪ Abdominal lavage
▪ 3 layer closure – linear alba, sub-cutis, skin
▪ Post surgical care similar to small intestinal disease, but ileus much less likely

46
Q

Post surgical outcome

A
  • ~70% go home from hospital
  • ~50% long term survival
47
Q

Pre-surgical factors predicting / affecting post surgical outcome

A
  • Duration of signs prior to surgery
  • Level of dehydration (TP & PCV)
  • Level of endotoxaemia (MM colour, HR)
  • SAA
  • Lactate (circulating v peritoneal)
48
Q

Intra-operative / post-surgical factors predicting / affecting post surgical outcome

A
  • Specific lesion
  • Length of bowel involved
  • If resection & anastomosis required
  • Expertise of veterinary staff
  • Owner financial position
49
Q

Post surgical complications (in increasing likelihood)

A
  • laminitis
  • repeat colic surgery
  • d+
  • reflux
  • ileus
  • incisional hernia
  • jugular vein thrombosis
  • wound infection
  • colic
50
Q

Enteritis vs colitis vs gastritis

A

enteritis = inflammation of the SI

colitis = inflammation of the LI

gastritis = inflammation of the stomach

51
Q

Which horses/ponies are most likely to get strangulating lipomas?

A
  • older horses
  • fat ponies
52
Q

What type/cause of colic can stallions get (that mares/geldings can’t)?

A
  • scrotal hernias -> entrapment of the intestines
53
Q

Why is recent foaling relevant to colic?

A
  • recently foaled mares had a big gravid uterus that has now shrunken down -> lots of room that wasn’t there previously -> colon twist potentially could happen
54
Q

Why can recent worming cause colic?

A
  • if they had a high burden it can cause abdominal pain for a few days after worming
55
Q

Why can horses lie down or on their back with colic?

A
  • if reduces the weight/pull of the intestines on the mesentery
56
Q

Are oral or IV fluids better for impaction?

A
  • oral

Y4 Equine - GI (25 decks)

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