E2: Colic Flashcards
What clinical sign will “give it away” that your patient has colic rather than being tied up or laminitic?
Incessantly moving/walking around
What non-GI disorders cause abdominal distress and can mimic or present as GI colics?
Liver disease
Renal disease
Spleen abscesses
Generalized peritonitis
Reproductive conditions/disorders
Neoplasia
What are the broad classifications for GI colic based on?
Process
Location
What does it indicate if a colic horse presents with multiple self-inflicted wounds and abrasions?
Severe pain (and probably severe colic, unelss the horse is a giant pussy Arabian)
Why may a horse with colic be on his back (in dorsal recumbency) in the stall? How do you help it up?
Stuck there after rolling around - “Cast” in stall
or
Gastric ulcers (Could also sit like a doggie; In adult horses usually indicates this, foals might just like doing that)
Never be on the limb side of the horse, reposition using mane and tail and a buddy
What causes pain in a horse with colic?
Excessive distension of the gut wall
Pulling on mesentary
Inflammation
Gas accumulates -> Pressure builds up ->Distension and activation of mechanoreceptors -> Pull on mesentary as gut moves -> Pain
Which of the following breeds are known for being stoic? Which are less pain tolerant?
a. Arabians
b. TBs
c. Belgians
d. Paints
e. Ponies
f. Percherons
e. Ponies
g. Percherons (and other Drafthorses)
Less tolerant: Arabians
What does an above normal body temperature indicate?
Infectious disease
Could also be due to hyperactivity/ intense exercise
What does/can elevated heart rate indicate?
Pain
Degree of cardiovascular compromise: Sequestration, shock, poor perfusion
Anxiety, stress
What does/can an elevated respiratory rate indicate?
Systemic metabolic status
A/B status
Pain
Anxiety
What may cause a horse to be depressed with a colic?
Shock and toxicity due to the inflammatory disease which caused the colic
If was previously over-active the think rupture
What is in the left dorsal (LD) quadrant? RD? LV? RV?
LD: Small intestine, Small Colon, spleen, +/- left kidney
In between if going to the right can feel aoerta and trace it to mesentary
RD: Cecum (2 diff types of bands (4 at the base, taper to 2 at the apex); can feel 1 of each type)
LV: Large colon (left dorsal colon= smooth, ventral= lognitudinal band), Pelvic flexure (can sometimes feel)
RV: Large colon
What is the term for normal intestinal sounds?
Borborygmi
What are the 2 types of motility in the GIT?
Segmental
Propulsive
Which of the following segments follows aborally from the right dorsal colon (RDC)?
a. Transverse colon
b. Pelvic flexure
c. Right dorsal colon
d. Diaphragatic flexure
e. Cecum
a. Transverse colon
(Joins the small colon and right doral colon-
LDC -> DF -> RDC-> TC-> small/descending colon)
How many bands are present on the ventral colon?
4
(4 on the floor)
What is between the left ventral and left dorsal colon?
Pelvic flexure
(LVC -> PF -> LDC)
What is between the right ventral and left ventral colon? What is between the left and right dorsal colons?
Sternal flexure
Diaphragmatic flexure
What does a cranial distension (under the ribs) indicate?
Distended small intestine
Cranial displacement of large colon
What could a tick-like distension throughout indicate (flanks pushed out)?
Large colon distension
Generalized peritonitis
Gas distension of entire abdomen (esp if dorsal)
GIT rupture
T/F: If the horse’s stomach distends it will not deform the contour of the abdomen.
True
What may a distension of the right flank indicate?
Gas in the cecum
Why must a NG tube be placed prior to surgery and not after induction/sedation?
Horse must be able to swallow to get it in place
Where is the lesion if you get a moderate volume of <7pH fluid? Small volume?
Moderate: Small intestines
Small: Gastric lesion, Severe large colon distension causing stomach outflow obstruction
What could a large volume of alkaline reflux indicate (lesion location)?
Small colon lesion
Small intestine lesion
Which of the following segments can be palpated normally?
a. Base of cecum
b. Inguinal rings
c. Bladder/repro
d. Pelvic flexure (+/-)
e. Spleen, nephrosplenic lig
f. Caudal 1/3 of L kidney
g. Small colon w/fecal balls
h. Small intestine
A-G
Cannot palpate small intestine unless abnormally distended
Where are the ‘pace-makers’ of the GIT? What segements does each control?
Cecum: ventral colon
Pelvic flexure: dorsal colon
Which of these is the correct order of the first (most oral) 3 segments of the LC after the cecum?
- SF=sternal flexure, PF=pelvic flexure, DF= diaphragmatic flexure*
a. RDC, SF, DC
b. RDC, DF, RVC
c. LVC, SF, RVC
d. LVC, PF, LDC
e. RVC, SF, LVC
f. RVC, DF, LVC
e. RVC, SF, LVC
How many bands can you palpate at:
VC
PF
DC
SC
?
VC: 3
PF: 0
DC: 2
SC: 1
What occurs when there is nephrosplenic entrapment?
Left dorsal displacement of the large colon
Both the small colon and small intestine feel like loops of sausages, how do you differentiate them?
Small colon has 1 band
What may palpating a large balloon-like structure mean?
Distended cecum (will always be mostly on the right)
Distended large colon (can distend much larger and fill a lot of the abdomen)
Non-GIT: Urinary bladder, Gravid uterus
What is abdominocentesis used to assess?
Gut wall compromise
These are abdominocentesis samples. What types of fluid are a-c and what types of disease do they indicate? What would a yellow, viscous and opaque fluid indicate?
a. Transudate: Effusive abdominocentesis (clear, water-like fluid)
b. Modified transudate: Non-strangulating disease
c. Red-tinge, mild opacity: Strangulating disease= significant gut wall compromise (RBCs, some protein, some WBCs)
Yellow opaque: Purulent, primary peritonitits (expect high protein and high WBC count)
When an obstructive lesion occurs, what is the first change you expect in the abdonimal fluid? Second? Third?
What are the normal values for the above variables?
Typically by the time you perform an abdominocentesis on a horse with a strangulating injury, what will you expect in terms of the above variables?
1st Protein/TP (normal <2.5g/dl)
2nd RBCs (normal none)
3rd WBCs (normal <5000-10000 cells/microL)
Typically in a strangulating obstruction, by the time you see and perform abdominocentesis, there will be an increase in TP, RBC and WBC to the same degree at the same time
You have performed an abdominocentesis but because the sample resembles frank venous blood you think you may have tapped the spleen instead. How can you verify this? What can you do to avoid hitting the spleen?
Check PCV, if very high (70-80) probably spleen. Hemoperitoneum will most likely not be that high.
Avoid by always going to the RIGHT of midline for your tap.
T/F: If the abdominocentesis reveals bacreria and plant material the gut must have ruptured and the horse will probably have to be euthanized.
FALSE
Never base diagnosis on abdominocentesis alone, you might have hit the gut and accidentally performed an enterocentesis.
To confirm, either redo centesis of take horse to Sx and check.
Why would you run a CBC/fibrinogen on your patient? Why run a chem? Why run blood gas and on what sample?
CBC/FIB: To determine whether there is an infectious precess going on -qualify infectious process, degree of infection, duration
Chem: for surgical and complicated cases, to evaluate metabolic/systemic impact of the disease of the animal at the time
Blood gas: VENOUS sample (rarely have respiratory issues or compromise), assess metabolic impact
What is the purpose of evaluating lactates in a colic case?
Best for evaluating response to therapy - measure LAC upon admission and monitor changes as you treat (if decreasing rapidly = better prognosis)
In general, high lactate = poorer prognosis
May be measured in abdominocentesis to help determine whether strangulating or non-strangulating
Generally, what is the definition of a non-strangulating obstruction?
Obstruction without vascular (gut wall) compromise
What are the expected values for the factors below if you have a non-strangulating lesion:
Pain
CV compromise
HR
Distention
Reflux
Pain: Mild-moderate
CV: little to no compromise
HR: <70 bpm (can be 60-80; pain-sensititvity dependent)
Distension: none to minimal
Reflux: none to minimal
What are the expected values for the factors below if you have a strangulating lesion:
Pain
CV compromise
HR
Distention
Reflux
Pain: moderate to severe
CV: moderate to severe compromise
HR: >70-80 bpm
_Distention:_Typically present (rectal palp distension can be severe)
Reflux: Mild to severe depending on location
Generally, what is the definition of a strangulating lesion?
Interruption of intestinal arterial supply and/or venous drainage with accompanying obstruction of the intestinal lumen
What is the major factor responsible for the difference between strangulating and non-strangulating lesions?
Gut wall compromise
What colic classification does a reflux high in volume and pH indicate?
Strangulating small intestinal lesion
What are the 4 pathophysiologic categories for colic?
True obstructions (non-strang/simple or strangulating)
Thromboembolic (Verminous arteiritis- Large strongyls or cyathostomes/tapes (more common), purpura)
Ulcerations (NSAID tox, phenylbutaxone tox- Right doral colitis)
Inflammatory-Infectious (acute/subacute; more likely to colic)
Subcategory: Inflammatory- Infiltrative bowel disease (DO NOT PRESENT AT COLICS, rather weight-loss, PLE)
What (specifically) is the only factor which is ever used alone as a criteria for referral or surgery?
Uncontrollable pain that is unresponsive to appropriate therapy
How do you refer a colic case?
NG tube ALWAYS
Analgesia
Records (drugs, treatments, findings)- best to get in contact w/vet personally
What type of fluids could you give a horse that you are referring?
2L of hypertonic saline in 10 min
(= 20 L of crystalloids)
This may or may not be helpful
80% of colics will be simple obstructions. What are come examples of such colics?
Most common: Spasmodic colic (usually involving large intestines)
Impactions
Mild ileus
Mild tympany
What does mucus on the surface of feces indicate?
Slow transit through GIT (hypomotility)
What are the 3 mainstays of treating simple colics?
No feed until passes substantial amounts of manure
Walking to promote motility
Pain management
What are your options to manage pain in a simple colic?
Fluxin meglumine + Xylazine +/- Butorphanol
If spasmodic: Buscopan +/- Fluxin meglumine
How does Buscopan work? How long does it typically take to kick in? What are the side effects?
Antispasmodic, anticholinergic
Take 5-10 min (may take up to 30min)
SE’s: Hypomotility (for at least 30min), mydriasis, tachycardia (for 5-15min)
What are concerns with using Fluxin meglumine for colics? What are the benefits?
Can mask the severity of the colic (concern when not sure if moderate or moderate severe)
Can cause ulcers
(+): Anti-inflammatory, anti-endotoxic
What is the best class of drug for controlling pain in horses with colic? What are some examples and thier characterists?
A2 agonists
Xylazine: first choice, short-acting, good for evaluating response to therapy (if it lasts a long time, Sx may not be necessary)
Detomidine: if need longer pain control, long duration of action
Romifidine: causes less ataxia
Why is the use of opiates (e.g. butorphanol) not ideal for controlling pain in horses? When might it be useful?
Causes excitation
Useful as adjunct to xylazine for increased pain control, or for horses that are overly depressed
What are spasmodic colics often associated with? What does this mean you should include in treatment?
Tapeworms
Dewormer
What is the best prognostic indicator for colic?
Heart rate
(indicates pain and CV compromise)
What is the definition of ileus?
Impairment of normal propulsive bowel motility
What are the causes of ileus?
Pain: from gut (distension, peritonitis) or not (MSQ)
Decreased GIT perfusion
E-lyte abnormalities
Endotoxemia
Drugs - ATROPINE
What characterizes a late state post-op ileus? What can be given to prevent this?
Adynamic ileus due to inflammatory changes in circular or longitudinal muscle layers
Leukocyte infiltration into wall of intestinal tract
Prevent with lidocaine (start intra-op, continue as CRI for 24-36hrs)
What motility enhancers are used for the proxmal GIT? Large intestines? What are general motility enhancers?
Proximal: Metaclopramide (coordinates gastric to proximal SI motility), Lidocaine
LI: Neostigmine (problem: obtunds SI motility!!), Cisapride
General: Erythromycin (not used as often in horses), Lidocaine
Note: Lidocaine is the only primary therapy, others are secondary
What are the 3 most significant risk factors for colic?
Having had a previous colic
Change in diet
Change in exercise
(Also, apparently, “the moon”)
A 9 year old Hanoverian Gelding, Franz, was found at the 6am feeding rolling, getting up and down, incessantly walking around, and pawing. Visible multiple facial abrasions. He has never had a previous episode of colic.
NG intubation produced 18 L of malordorous pH 7.6 fluid.
Abdominal auscultation revealed a silent abdomen.
HR: 106bpm, thoracic auscultation WNL
RR: 48 B/m
T=99.2F
MM congested, CRT 3.5sec
Transrectal palpation: Multiple loops of tightly distended ‘sausages’/tubular structures without bands.
Evalutate this case- degree, classification, DDx
(What does the reflux tell you? What does the rectal tell you?)
- Hanoverian: German Warmblood*
- Note: You should know that after getting vitals and refluxing the horse, you need a rectal to evaluate what’s going on.*
Severity: Severe (multiple facial abrasions)
Reflux: Large V + Alkaline= Small intestine
Rectal: Multiple sausages, no band, tightly distended = Small intestine
Classification: Strangulating small intestine colic
DDx: Complete strangulating obstruction (Tx=Sx), Thromboembolic disease (Tx=Sx), Inflammatory (Tx=Rx; however would have expected MODERATE not severe distention)
If a complete obstruction occurs acutely, what do you expect in term of gut motility? What will it eventually progress to?
Hypermotility
Silent abdomen
With variation in motility in between
A horse presents with a mild episode of colic. The temperature and heart rate are normal and there are no signs indicating shock.
There is no reflux when you place a NG tube.
The transrectal palpation revealed a very firm, slightly indentable, structure in the left ventral quadrant coming across the pelvic inlet.
- Classify this colic.
- What structure(s) did you palpate?
- Non-strangulating large intestine colic
- Pelvic flexure filled with ingesta (large colon)
This is probably a pelvic flexure/ascending colon impaction.
A horse is reevaluated for colic 24hours post-op large colon displacement. You suspect a mesenteric rent was created while running the small intestines which has strangulated the small intestines. What do you expect the NG reflux to be? What do you expect to feel on the rectal?
High volume, low pH
Multiple bandless sausages in the caudal abdomen
What is usually the source point when a small intestine impaction occurs? Why is it often (usually) impossible to palpate this if the impaction did not occur recently?
Ileocecal junction
The jejunum proximal to the impaction distends with gas and fluid
T/F: If a cecal impaction has occured, you should be able to palpate the distended cecum in it’s normal postition in the abdomen. You will also be able to indent the cecum with finger pressure.
True
Which cecal band is usually easily palpated during rectal examination when the cecum is full, distended or impacted?
Ventral
What type of colitis associated with the administration of NSAIDs, is characterised by ulceration of the mucosa, inflammation and edema in the wall of the colon?
Right dorsal colitis
There are 2 scenarios for how sand impactions occur. In one, the sand accumulates in right dorsal colon and eventually obstructs the junction of the right dorsal and the ___________. The other scenario is that sand accumulates in the dependent portions of the colon, which are the ___________ and ___________. The causes the _______ to flatten and the mucosa to thicken.
Transverse colon
Left and Right Ventral colon
Haustra (sacculations)
Left dorsal displacement of the ascending colon occurs when the colon becomes trapped in the space bounded by the ___________, ___________, and ___________. Eventually the dorsal colon becomes ventral.
Spleen
Left kidney
Nephrosplenic ligament
What is the most oral part of the small intestine? Which side of the abdomen does it lie on? What comes after this? What is the terminal portion of the small intestines called?
Duodenum
Right
Jejunum
Ileum
Anatomy of the Ascending Colon:
The ascending colon originates on the _____ side of the abdomen at the junction with the _____. It extends toward the sternum, and at the level of the __________ it bends sharply as the _____ flexure to the left side. Near the enterance to the pelvic inlet, it bends sharply _____, which is knows as the _____ flexure, and the diameter decreases from about 20cm to 8cm. It then reverses direction as the _____ dorsal colon and extends orally. The part where it turns aborally to become the _____ dorsal colon is known as the _____ flexure.
The ascending colon then terminates in the short _____ colon which is attached to the _____ body wall near the _____ _____artery.
The ascending colon originates on the RIGHT side of the abdomen at the junction with the CECUM. It extends toward the sternum, and at the level of the XYPHOID CARTILAGE/ PROCESS it bends sharply as the STERNAL flexure to the left side. Near the enterance to the pelvic inlet, it bends sharply DORSALLY, which is knows as the PELVIC flexure, and the diameter decreases from about 20cm to 8cm. It then reverses direction as the LEFT dorsal colon and extends orally. The part where it turns aborally to become theRIGHT dorsal colon is known as the DIAPHRAGMATIC flexure.
The ascending colon then terminates in the short TRANSVERSE colon which is attached to the DORSAL body wall near the CRANIAL MESENTERIC artery.
What characterizes the ventral colon?
Haustra
The ______ or descending colon begins at the end of the ______ colon and continues from there to the _______. Upon rectal palpation, one may be able to feel the characteristic ______ ______ which are formed here, within the _________.
The SMALL or descending colon begins at the end of the TRANSVERSE colon and continues from there to the RECTUM. Upon rectal palpation, one may be able to feel the characteristic FECAL BALLS which are formed here, within the SACCULATIONS.
The stomach of a horse is relatively small with a capacity of approximately _____L. It is situated dorsocranially on the _____ side of the abdomen within the confines of the _____ _____. Because of its shape, the junction between esophagus and stomach, known as the _____, is near the _____, which connects the stomach to the small intestines.
The stomach of a horse is relatively small with a capacity of approximately 10-15 L. It is situated dorsocranially on the LEFT side of the abdomen within the confines of the RIB CAGE. Because of its shape, the junction between esophagus and stomach, known as the CARDIA, is near the PYLORUS, which connects the stomach to the small intestines.
