Examination of the GI Tract & Decision Making

Question 1

T/F: the decision to take a patient to surgery or not can be made within the first 10-30 minutes of evaluation

Answer 1

true
the plan can change with subsequent monitoring and evals
but a definitive diagnosis is not always required to make a decision

Question 2

What all is a part of the required “minimum database” for every horse GI case?

Answer 2

1. history
2. physical exam
3. rectal exam
4. nasogastric intubation
5. response to therapy (ie did banamine control the pain)

Question 3

How is signalment helpful to determine a rule out list for a suspect GI case?

Answer 3

stallion – testicular torsion or inguinal hernia more likely

mare – uterine rupture or torsion more likely

older horses – strangulating lipoma, epiploic foramen entrapment, etc.

neonate – meconium impaction

young – FB, ascarids, intussusception

Question 4

What 3 things can you evaluate on your physical exam that can assess perfusion?

Answer 4

MM (moisture, refill, color)
extremity temperature
pulse quality

Question 5

CRT is an indicator of …

Answer 5

perfusion

Question 6

What does ‘OPQRST’ stand for?

Answer 6

O- onset
P- palliation / provocation
Q- quality
R - region/radiation
S- symptoms/severity
T- timing

Question 7

What can you infer from a CRT > 2-3 seconds?

Answer 7

poor perfusion from either decreased cardiac output and/or hypovolemia

Question 8

What 3 things are you assessing during a rectal exam?

Answer 8

1. distention
2. displacement
3. abnormal structures

Question 9

In what scenario/instance would you want to immediately do a nasogastric intubation FIRST?

Answer 9

if the heart rate is >60.
You do this to check for /relieve gastric distention and to measure the volume of reflux (>4L abnormal)

Question 10

what is the purpose of using Butylscopolamine (Buscopan) prior to rectal examination?

Answer 10

• anticholinergic
• parasympatholytic
• antispasmodic

Question 11

What is “FLASH”?

Answer 11

fast localized abdominal sonography of horses

looks at 7 areas of the horse and can assess the presence of free fluid, small intestine appearance, contents in the large intestine, spleen, and left kidney.

Question 12

normal pcv in horses?

Answer 12

32-45%

abnormalities can be from dehydration, splenic contraction, or SIRS; anything >60 = poor prognosis

Question 13

normal TP in horses?

Answer 13

4.6-6.9
abnormalities can be from SIRS or altered mucosal function

Question 14

normal lactate in horses?

Answer 14

<2

higher indicated anaerobic metabolism or reduced hepatic clearance
>6.5 = poor prognosis

Question 15

what does decreased WBC count indicate?

Answer 15

endotoxemia – leukocyte margination

Question 16

fibrinogen > ____ indicates inflammation

Answer 16

400

Question 17

describe how to perform an abdominocentesis

Answer 17

sterile prep
insert teat cannula or needle just to right of midline (ultrasound guided)

Question 18

What are NORMAL abdominal fluid characteristics?

Answer 18

color - clear/yellow
protein <2
WBC < 5000
RBC rare

Question 19

what are the risks of abdominocentesis?

Answer 19

• enterocentesis
• bowel laceration
• hemoabdomen
• omental herniation

Question 20

Peritoneal fluid lactate > 4 at admission and increasing over time indicates what type of disease?

Answer 20

strangulating lesion

Question 21

Ponies are at DECREASED odds of ____________

Answer 21

colon displacements

Question 22

Ponies are at INCREASED odds for _____________

Answer 22

strangulation of small intestine

Question 23

miniature horses are at DECREASED odds for _______________

Answer 23

strangulating small intestinal lesions

Question 24

Draft breeds are at INCREASED odds of ________

Answer 24

cecal conditions

Question 25

Why is it the case that a horse with signs of colic for longer duration may be associated with having better outcomes?

Answer 25

perhaps the lesion is less severe

Question 26

T/F: some severe strangulation cases may present with minimal signs of pain

Answer 26

true – can be severely obtunded/decompensated which is blurring overt signs of pain.

typically, the worse the lesion, the worse the signs, but this is an exception.

Question 27

T/F: an increased level of pain is associated with increased need for surgery

Answer 27

true (severe pain has an OR of 57)

Question 28

T/F: tachycardia, abnormal mucous membrane color, and abnormal CRT have only a FAIR correlation with the severity of signs and indication for surgery

Answer 28

true – this is because they can be really ill horses, but NOT have surgical lesions. the abnormalities in these specific parameters can be from non-surgical things.

Question 29

T/F: increasing heart rate is associated with decrease survival

Answer 29

true – poor prognosis is >80

Question 30

T/F: if abdominal distention is present, it is significant and indicates a higher likelihood for surgery; however if it is not present, it does not rule out something significant or the need for surgery.

Answer 30

true
poor sensitivity

Question 31

T/F: abnormal borborygmi is clinically signfiicant

Answer 31

true – OR of ~12 for surgery

Question 32

what rectal exam finding is MOST significant and the best predictor for needing surgery?

Answer 32

distended small intestine
(OR of ~31)

Question 33

T/F: the presence of nasogastric reflux is non-specific for surgery indication. However, it is important for diagnosis and is also therapeutic.

Answer 33

true

if you get reflux and they are STILL painful after removing the fluid, then this indicates a strangulating lesion is likely.

Question 34

what is the most important/useful “additional diagnostic”?

Answer 34

abdominocentesis
abnormal findings are significant!
but it does have a poor sensitivity and specificity.

Question 35

what causes turbid peritoneal fluid?

Answer 35

the presence of cells, protein, GI contents, and/or fat.

Question 36

T/F: abnormally colored peritoneal fluid indicates the need for surgery

Answer 36

true -
sensitivity = 92%
specificity = 74%

much lower for normal color because a horse can have a mild/mod GI lesion and still have NORMAL peritoneal fluid.

Question 37

T/F: elevated total protein or NCC in the peritoneal fluid is not a useful indicator for surgery

Answer 37

true
they only indicate inflammation

Question 38

T/F: elevated peritoneal fluid lactate is correlated with need for surgical intervention

Answer 38

true (OR 15.5)
predicts intestinal ischemia better than plasma lactate.
if the lactate increases over time, this is an even higher OR for surgery (OR 62)

Question 39

What is Hct useful for – diagnosis, surgical indication, or prognosis?

Answer 39

prognosis
>60 = grave prognosis

not useful for decisions regarding surgery.

Question 40

T/f: hyperglycemia is associated with non-survival

Answer 40

true (>195)

Question 41

T/F: aozetemia and hypoproteinemia are non-specific in regards to surgical decision making

Answer 41

true

Question 42

What can we use serum lactate for?

Answer 42

as a marker for severity of disease
elevations are due to decreased tissue perfusion
so we can use it for prognosis.

Question 43

what are the 3 most important parameters for estimating prognosis?

Answer 43

1. heart rate
2. PCV
3. abnormal mucous membranes

Question 44

T/F: serosanguinous peritoneal fluid indicates that the patient is a surgical candidate

Answer 44

true