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GI2 > Equine 3 - colic > Flashcards

Equine 3 - colic Flashcards

1
Q

what are the clinical signs of colic?

A
  • flank watching (early sign)
  • rolling
  • kicking abdomen
  • hunched posture
  • pawing
  • recumbent
  • sweating
  • increased resp rate
  • restlessness
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2
Q

what extra-abdominal conditions can manifest in a similar way to colic

A
  • fractured leg
  • sweet itch
  • pyelonephritis
  • urinary tract disease
  • choleliths
  • laminitis
  • pneumonia
  • any pleural pain
  • cardiac dysrhythmias
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3
Q

what diseases can lead to visceral and parietal pain

A
  • strangulating lesions
  • distension of regions of GIT (food, gas, impaction)
  • traction on the mesentery
  • intestinal ischaemia
  • abnormal intestinal motility (grass sickness)
  • mucosal inflammation particularly serosa
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4
Q

list the types of colic in descending order of prevalence

A
  • spasmodic/undiagnosed
  • surgical
  • Flatulent
  • pelvic flexure impactions
  • other impaction
  • colitis (uncommon)
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5
Q

what percentage of colic cases can be managed medically in the field

A

80-85%

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6
Q

what percentage of colic cases require surgery

A

7-8%

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7
Q

what are the causes of medical colic

A
  • EGS
  • spasmodic/flatulent
  • colitis
  • parasitic (cyathostomes)
  • large colon and ileal impactions
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8
Q

what causes of colic may be managed medically or surgically

A

left and right colonic displacements

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9
Q

what causes of colic must be managed surgically

A 
large colonic volvulus 
SI strangulation (many subgroups)
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10
Q

what does a major body system assessment involve in a colic case

A
  • GIT - bororygmi listened for in four quadrants

- CVS - hypovolaemia and dehydration

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11
Q

what may very loud or the absence of borborygnmi indicate

A

loud: spasmodic/flatulent colic or diarrhoea, unlikely to be surgical
absence: poorer prognosis.

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12
Q

what parameters are used for assessing hypovolaemia

A 
HR - increased 
CRT - prolonged 
mm colour - pale 
pulse quality - weak 
lactate - high 
USG - high 
(+RR and temp)
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13
Q

what parameters are useful for assessing dehydration

A

mm - tacky
eyes - sunken
skin - tents

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14
Q

what are the relevant questions when taking a colic history

A
  • age
  • duraton of colic (when last seen normal)
  • recent management changes
  • worming
  • previous colic history
  • stereotypies
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15
Q

What restraint may be used for rectal palpation

A
  • stocks (often unavailable)
  • sedation with A2A
  • nose/neck/ear twitch
  • position against wall
  • lift front leg
  • around stable door
  • IV buscopan or diluted lidocaine per rectum to reduce risk of tearing
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16
Q

describe safe entry for rectal palpation

A
  • gloves
  • lubricant
  • fingers in cone shape
  • stay ventral when entering rectum
  • extend arm (short sleeves)
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17
Q

what are the normal findings in rectal palpation

A

Aorta dorsal midline
caecum on the right
left kidney and caudal edge of the spleen on the left with nephrosplenic ligament
pelvic flexture runs left to right at the pelvic inlet ventrally
small colon in faecal balls present
bladder - may be large if colicing and don’t want to urinate
repro tract in mares
should not feel the SI

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18
Q

what may a strangulating SI lesion feel like on palpation

A

Distended SI 4-6cm diameter often RHS but may be anywhere

if gas distended the taenial bands will roll over. can follow its course.

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19
Q

what does a LI displacement feel like on palpation

A

tight taenial bands
pelvic flexure in wrong position
left dorsal displacement - piece of large colon through nephrosplenic ligament dorsal to ventral
right dorsal displacement - right bands and no pelvic flexure

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20
Q

what does a pelvic flexure impaction feel like on palaption

A

primary - doughy, smooth surface, large

secondary - firm balls of ingesta

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21
Q

where is the most common site for rectal tears due to palpation

A

near the pelvic inlet involving the peritoneal rectum. dorsal and longitudinal.

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22
Q

how are rectal tears detected

A

always check glove for blood

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23
Q

what is the immediate treatment for any rectal tear

A 
A2A sedation 
butylcsopolamine 
lidocaine per rectum 
epidural anaesthesia 
\+/- ketamine
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24
Q

how is rectal tear severity assessed

A

bare-armed rectal
palpate circumferentially from anus cranially
remove faeces
determine size, grade, position
discuss with owner - don’t accept liability
ask senior vet for help

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25
Q

describe a grade 1 rectal tear

A

Mucosa +/- submucosa involvement. heals without treatment. can give antibiotics, faecal softeners and diet modification for 5-7 days

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26
Q

describe a grade 2 rectal tear

A

Muscle layer involvement, mucosa and submucosa intact. very unusual, rarely causes a problem

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27
Q

describe a grade 3 rectal tear

A

Two types
a. only the serosal layer remains intact
b. only the fat filled mesorectum or the retroperitoneal tissues remain intact
bacteria leak through causing peritonitis relatively quickly.

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28
Q

describe a grade 4 rectal tear

A

disrupts all layers of the rectal wall. may be grade 4 from the outset or progress from grade 3. gross faecal contamination of the peritoneal cavity and rapid overwhelming SIRS and septic shock.

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29
Q

what are the first aid measures for grade 3 or 4 rectal tears

A

pack rectum with cotton wool retained in a stockinet bandage from anus to cranial to the tear or use gamgee
suture anus closed (purse-string) to retain packing
broad spectrum bactericidal antibiotic e.g. gentamycin.
NSAIDs
refer to surgical facility
PTS if cannot refer (speak to boss beforehand)

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30
Q

describe the method of NG intubation

A

tube into ventral meatus
flex horse’s neck
tube into oesophagus - check by watching left side of neck, negative pressure if suck on tube, horse swallows with passing, release of gas once in cardia

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31
Q

what is the normal volume of fluid recovered from NG intubation

A

1-2L. normal volume of stomach is 6-8L so some leeway e.g. if just had a large drink

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32
Q

what is the cut-off volume of fluid recovered for the lesion to be considered surgery

A

> 5L

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33
Q

what is the normal colour and total solids of fluid from a peritoneal tap

A

straw coloured

TS <20g/l

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34
Q

why might there be red cells in peritoneal fluid

A

iatrogenic - starts straw coloured then turns red

serosanguinous fluid due to red cell diapedesis usually secondary to ischaemic bowel. expect a lot of fluid

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35
Q

what causes increased cellularity of peritoneal fluid

A

septic peritonitis

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36
Q

what causes peritoneal fluid to be green/brown coloured?

A

GI rupture

check in case of incorrect needle placement (into the intestine)

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37
Q

what may be seen on peritoneal cytology

A

neutrophils - inflammation
ruptured viscous - inflammatory cells with intracellular bacteria (45-60mins after rupture). ingeseta present but this will not differentiate from GIT tap.

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38
Q

what lab parameters can be used to assess hydration

A

PCV
TP
Lactate
blood gas

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39
Q

how is lactate interpreted

A

produced in cells due to anaerobic respiration therefore sensitive marker of hypovolaemia. normal <2

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40
Q

how may PCV and TP change

A

hypovolaemia - increase (haemoconcentration)
haemorrhage/bleed/PLE - decrease
stress/exercise - increase due to splenic contraction
shire - 25% normal
TB - 40-45% normal
if disease causes reduction then animals becomes hypovolaemic then may look normal. check lactate.

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41
Q

What are possible tests used in a colic investigation

A
  1. palpation per rectum
  2. NG intubation
  3. peritoneal tap
  4. basic bloodwork. often send some if referring a horse so ready to run once there
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42
Q

what factors are used to assess clinical state/degree of pain

A

degree of tachycardia (higher = more hypovolaemic)
any faeces passed (none/mucoid = reduced transit)
mentation (obtunded = reduced blood to the brain)
pain - difficult to assess
response to analgesia

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43
Q

what parameters are used to assess CVS status

A

HR (28-44)
pulse quality
CRT
mm colour
- red = congestion. hyperdynamic phase of hypovolaemic shock)
- white = decompensated hypovolaemic shock. deaeth inevitable

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44
Q

how is borborygmi graded

A

0 - no sound. strangulation or torsion
1 - reduced. requires knowledge of animal
2 - normal. depends on diet. louder on grass than hay
3 - hear without stethoscope. spasmodic colic or diarrhoea
grade each quadrant

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45
Q

what additional procedures may be used in a colic investigation

A 
abdominal ultrasonography 
- rectal - little use 
- transabdominal useful for LDD and EFE (other SI lesions). generally in clinic. 
radiography - sand impaction in foals 
endoscopy
46
Q

what parameters may indicate that a case of colic can be managed medically

A 
mild pain responsive to analgesia 
HR < 60
CRT <3
mm normal colour 
borborygmi present 
normal peritoneal fluid 
lactate <2
PCV/TP normal for breed 
<3-5L recovered from NG intubation 
mildly abnormal rectal findings dependent on disease
47
Q

what parameters may indicate that a colic case needs surgical management

A 
severe pain, less likely to respond to analgesia (breed dependent) 
HR >60
CRT 3-4s 
mm dark red, congested 
absent borborygmi 
peritoneal fluid serosanguious with protein >30g/l
lactate >2 
PCV/TP outside reference range 
>5L recovered from NG intubation 
rectal findings obviously abnormal
48
Q

which conditions managed medically don’t fit the normal presentatio n

A 
grass sickness - HR>60
anterior enteritis - severely hypovolaemic and large volume of NG reflux (common outside UK)
colitis - severely hypovolaemic 
peritonitis - high HR, hypovolaemic 
spasmodic colics - can be very painful
49
Q

when may a surgical condition not present in the expected way?

A

epifloic foramen entrapment - SI trapped cranially on RHS (normal rectal findings)
ponies and donkeys - very stoic, may not show pain

50
Q

what are the indications for referral of a colic case?

A
  • surgery needed
  • medical case not manageable in field (IVFT, intensive care)
  • chronic EGS
  • any client that requests it
51
Q

what makes up the initial medical management of colic

A 
analgesia 
- NSAIDs
- opioids 
- ketamine 
anti-spasmodics 
A2As (fast action IV, longer IM, unlicensed for colic) 
fluid therapy 
exercise
52
Q

which NSAIDs may be used in colic

A

any

  • phenylbutazone
  • flunixin meglumine - some concern about masking surgical cases. lower dose, won’t mask hypovolaemia
  • carprofen/meloxicam
53
Q

which opioids are indicated in colic

A

buprenorphine - licensed
methadone - SA licence. bolus or infusion
morphine - may use over morphine as better PK/PD for CRIs
NOT butorphanol - poor analgesia

54
Q

for which colic types are anti-spasmodics particularly useful

A

spasmodic colic

pelvic flexure impaction - relax colon to help ingesta pass

55
Q

list some anti-spasmodics

A

butylscopolamine and metamizole - short acting ~20mins
pethidine - licensed for spasmodic colic but currently unavailable. lasts ~1hr
buprenorphine
(methadone)

56
Q

what effects with A2As have

A
  • analgesia
  • reduced HR unless hypovolaemic
  • increased urination
  • sedation
  • reduced gut motility - may help spasmodic colic
  • warn owner regarding cardiovascular collapse due to vasodilation (very rare)
57
Q

what are the indications for fluid therapy

A

hypovolaemia - IVFT

pelvic flexure impaction - PO

58
Q

what are the contraindications for oral fluids

A

obstruction - torsion, strangulation, ileal impaction

hypovolaemia (won’t be absorbed)

59
Q

what are the maintenance fluid requirements in adults and foals

A

adults - 2ml/kg/hr

foals - 5ml/kg/hr

60
Q

when is exercise indicated in colic

A

minimal pain e.g. mild, large colonic tympany palpable on rectal
spasmodic colic - if mild pain
LDD and RDD if not too painful/taenial bands not too tight
note: don’t exercise/walk before assessment

61
Q

what may cause ileus

A 
hypovolaemia 
lack of feeding 
excessive handling of gut/trauma during surgery (damage to nerves) 
long surgery time  
stress/pain 
(hypothermia in small animals)
62
Q

how is ileus diagnosed

A

no faecal output
absent borborygmi/present with no forward movement
ultrasound
lots of NG reflux

63
Q

how is ileus managed

A

generally in clinic rather than field
secondary to peritonitis - reduce inflammation (no pro-motility agent will be of use until neutrophils and toxins reduced)
post op ileus - analgesia, anti-inflammatories, promotility agents

64
Q

list some pro-motility agents

A

analgesia (lack of pain promotes motlity even if drug inherently reduces it e.g. opioids)
lidocaine IV - anti-ileus, analgesic and anti-SIRS
metaclopramide IV
erythromycin IM

65
Q

list some risk factors for colic

A 
change in diet 
change in housing e.g. box rest 
poor condition of teeth 
anti-parasiticides/high worm burden 
seasonality 
stable vices/stereotypies 
previous colic/colic surgery 
stress 
age
66
Q

what is the likelihood of survival from colic

A

SI strangulating leisons (surgery) - 60-80%
large intestinal displacements - 70-85% (overall), 90% (surgical)
LI torsions - 25-50%. varied due to timing of how soon lesion is corrected. lots of ischaemic bowel –> SIRS

67
Q

what are the most important predictors of prognosis following colic surgery

A

SIRS markers

  • ischaemic bowel
  • serosanguinous fluid
68
Q

What does palpable small intestine distension indicate the need for

A

colic surgery

69
Q

list the three broad categories that SI obstructions can be classed as

A
  1. physical - most common
  2. neurological e.g. EGS
  3. vascular e.g. infarction due to cyathostome larvae
70
Q

what is a simple obstruction

A

partial or complete but no interference of blood supply

71
Q

what is a strangulating obstruction

A

obstruction of blood supply to the intestine from the outset

72
Q

what may cause a simple SI obstruction

A

adhesions
neoplasia
abscesses

73
Q

what is the consequence of complete obstruction of the SI in terms of fluid

A

sequestration of fluid oral to the obstruction in the intestine and eventually the stomach. leads to a reduced circulating volume, increased HR and PCV, end result is hypovolaemic shock

74
Q

what volume of secretions pass through the SI per day and where is most absorbed?

A

> 100L, absorbed mostly in the Large intestine

75
Q

what are the consequences of progressive intraluminal pressure in the SI

A

hydrostatic pressure in the vasculature leads to loss of protein through the gut wall into the abdomen
impaired blood supply leading to ischaemia

76
Q

what are the clinical signs of a strangulating SI obstruction

A
  • severe pain
  • progressive increase in HR
  • progressive deterioration in pulse quality
  • congested mm
  • increased CRT
  • progressive increase in PCV and total protein through haemoconcentration with subsequent hypoproteinaemia
  • increased RR
  • marked changes in peritoneal fluid
77
Q

whether a strangulating lesion is venous or arterial depends on what?

A

degree of compression of the blood supply

78
Q

describe the pathology that occurs with venous strangulating obstruction

A
  • arterial supply unaffected initial so blood still enters
  • blood cannot flow out
  • rapid mural congestion
  • intestine becomes dark red and oedematous
  • red blood cells present in all layers diapedese into peritoneal cavity causing serosanguinous peritoneal fluid
  • increased mural thickness and luminal distension increases pressure against constricting structure
  • pressure eventually exceeds arterial pressure
  • no further blood enters the strangulated segment
  • mucosa starts to become necrotic within 1 hour (apices of villi initially then crypts by 4 hours)
79
Q

what proportion of blood supply does the mucosa receive

A

80%

80
Q

describe the pathology of arterial strangulating lesion

A
  • pressure on intestinal vessels obstructs veins and arteries from the outset
  • cell dead occurs rapidly
  • ischaemic changes result in the wall becoming paper thin and easily ruptured
  • rapid onset of clinical signs
  • shock develops due to necrosis
81
Q

what aids bacterial multiplication in SI strangulating lesions

A

mucosal damage –> bleeding into the lumen

82
Q

what does endotoxins breaching damaged mucosa lead to

A

SIRS

83
Q

what does the severity of shock in strangulating SI lesions depend on

A
  • length and diameter of intestine involved (larger area = more endotoxins)
  • degree of vascular occlusion
  • length of time the obstruction has been in existence
84
Q

what are the clinical findings in SI obstructions

A 
hypovolaemia and endotoxaemia 
- tachycardia 
- congested mm 
- delayed CRT
- increased PCV (>45%) and TP 
distended loops of SI on rectal and US exam 
NG reflux (depending on level of obstruction) 
serosanguinous peritoneal tap
85
Q

how is the cause of an SI obstruction discovered

A

laparotomy

86
Q

what is the average cost of colic surgery

A

£5000

87
Q

what are the steps involved in stabilising a patient for colic surgery

A
  • NG decompression
  • IV fluids
  • NSAIDs
  • antibiotics
88
Q

what surgical technique is used for colic

A

exploratory midline laparotomy

  • correct strangulation
  • ingesta removed/milked into caecum
  • evaluate intestinal viability
  • anastomosis of healthy sections
89
Q

how much of a horse’s SI can be removed before nutrient absorption is compromised

A

50% (~9m in typical horse)

90
Q

describe the post-op care after colic surgery

A
  • maintain hydration status
  • gradual re-introduction of water and food
  • 5 days NSAIDs and antibiotics
  • monitor for complications
  • off work for minimum 3-4 months
91
Q

list some complications following colic surgery

A 
colic recurrence 
wound suppuration 
jugular thrombosis 
ileus 
incisional hernia formation 
re-laparotomy 
diarrhoea 
laminitis 
salmonellosis
92
Q

what is the main cause of colic recurrence following surgery

A

adhesion formation. most cases within 1 year of surgery

93
Q

what are the signs and treatment of wound infections after surgery

A

massive oedema
breakdown of skin margins (linea alba usually holds)
clean regularly, remove crusts and skin sutures
usually resolves in 7-10 days

94
Q

what are the risk factors for an incisional hernia post-op

A 
wound suppuration post-op 
higher HR (more severe SIRS) at admission
95
Q

how are incisional hernias managed

A

small - conservative

large - mesh repair

96
Q

how is jugular thrombosis managed

A

remove catheter
hot pack
+/- DMSO

97
Q

what are the risk factors for jugular thrombosis

A

sicker horse

  • PCV on admission
  • heart rate >60
98
Q

what is the prevalence, average time to onset and prognosis of post-op ileus

A

10%
24 hours post-op
50% with post-op reflux survive

99
Q

what are the risk factors of post-op ileus

A

PCV

pedunculated lipoma strangulation

100
Q

what are the common causes of a re-laparotomy

A

epiploic foramen entrapment

post-op ileus (unless straightforward)

101
Q

what is the best way to prevent complications

A

early referral before SIRS causes deranged cardiovascular parameters

102
Q

what are the most common indications for SI colic surgery

A 
ileal impaction 
idiopathic focal eosinophilic enteritis 
epiploic foramen entrapment 
pedunculated lipoma 
(grass sickness - exploration)
103
Q

what may cause an ileal impaction

A
  • physical obstruction of ingesta (milk through to caecum)

- anoplocephala burden

104
Q

what are the signs of idiopathic focal eosinophilic enteritis

A 
very elevated PCV
severe pain 
reflux 
difficult to distinguish from SI strangulation 
- huge numbers of eosinophils
105
Q

how is idiopathic focal eosinophilic enteritis treated during surgery

A

milk ingesta through to caecum

administer steroids

106
Q

what makes up the epiploic foramen

A

caudate lobe of liver
hepatic portal vein
gastropancreatic fold
epiploic = greater omentum

107
Q

how does epiploic foramen entrapment occur

A

small portion of SI may fit through a gap, peristaltic movement draws more in, SI becomes compromised, distended and pressure increases

108
Q

what are the risk factors for epiploic foramen entrapment

A

taller horses - not seen in miniatures/donkeys

crib-biting/windsucking

109
Q

what is a pedunculated lipoma

A

benign fatty lump which occurs in the mesenteric window. gravity draws the lump out on a stalk. eventually becomes heavy enough to wrap around the SI and strangulate it

110
Q

in which horses are pedunculated lipomas most common

A

geldings > mares

ponies > horses

111
Q

what lesions can cause strangulation

A 
pedunculated lipoma 
hernia (internal or external) 
intussusception 
volvulus 
merckel's diverticulum (rare)
112
Q

why may grass sickness cases be taken to surgery

A
  • chronic forms often present clinical signs similar to strangulated SI
  • no obstruction at surgery then take a biopsy and euthanase horse
  • not a surgical disease in itself

GI2 (27 decks)

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