Medical Colic 1

Question 1

Types of medical colic.

Answer 1

Spasmodic, undiagnosed, gas, impaction.

Question 2

P’s of colic to decide if patient needs an emergency surgery.

Answer 2

Pain.
Passage of time.
Pulse.
Pass a tube.
Palpate per rectum.
Peritoneal fluid.
PCV.
Pyrexia.
Per abdominal ultrasonography.

Question 3

Conditions for giving flunixin in colic cases.

Answer 3

Done a thorough investigation.
You follow up the progress of your case, interpreting info in the light that you have given flunixin.
You move to surgery if pain persists even after the full dose of flunixin has been given.

Question 4

Analgesia for medical colic cases?

Answer 4

Ambulatory practice, start with IV phenylbutazone for mild-moderate pain.
Often give hyoscine (buscopan) to aid rectal palpation.
Ideally sedate with xylazine (short-acting better if CV compromised) for own safety for rectal.
- can relieve pain as spasmolytic but last 20-30 mins.
If no access to bute, consider half dose flunixin.
If not signed out of food chain, meloxicam.

Question 5

1. Spasmodic colic.
2. Proposed risk factors causing spasmodic colic.

Answer 5

1. Spasm of muscle layers in SI.
   - causes pain.
2. Excitement.
   Physical exertion.
   Fatigue.
   Parasite migration.
   Mouldy feed.
   Change of diet.
   Excess grain, low fibre.
   Weather changes.
   Tapeworm infestation - risk increases proportionally to burden.

Question 6

Spasmodic colic diagnosis.

Answer 6

Fairly recent onset.
Mild-moderate signs of pain.
Can be intermittent.
Passes all the P’s.
Pulse <60.
Might hear/feel/see hypermotile intestine on auscultation / rectal / ultrasound.
Should respond to treatment - always reassess.

Question 7

Spasmodic colic treatment.

Answer 7

IV.
Spasmolytic agents.
- Hyoscine/butylscolpolamine.
— buscopan.
- butylscolpolamide + dipyrone (weak NSAID).
— buscopan compositum.
If mild colic, can just give either alone.
If doesn’t respond, reassess, but don’t usually need to panic.
Analgesia:
- NSAID.
- can give alone or with hyoscine (but probably already gave that for a rectal).
Judge for individual case (may not matter that much).
Phenylbutazone OR half dose flunixin OR (Carprofen/ketofen/meloxicam).
Starve while treating and shortly after:
- about 8 hours.
Then treat as normal.

Question 8

Spasmodic colic recovery.

Answer 8

Usually rapid.
Occasionally horse may re-present after several hours.
- need to work-up from beginning again.
Alarm bells ring a little if present twice but can be ok, ring a lot of present a third time.

Question 9

Spasmodic colic - what next?

Answer 9

Try to identify any risk factors and minimise future risk.
Review routine care - parasites and teeth.
Worming history, FEC, tapeworm ELISA, check teeth.

Question 10

1. Gas colic.
2. Proposed risk factors causing gas colic.

Answer 10

1. Excess production of gas in all or part of large intestine.
   Pain from stretching intestinal wall.
2. Diet change.
   Rich grass.
   Rich haylage.
   >2kg concentrate on any one meal.
   If repeated, consider IBD.
   Parasites.
   Poor dentition.

Question 11

Gas colic diagnosis.

Answer 11

May be unable to differentiate from spasmodic or undiagnosed.
Similar presentation but…
- can be a bit more painful.
- may be a bit bloated.
Passes the P’s, but…
- rectal — gas distended but still squishy viscera.
— BUT, get this with LI displacement or LI torsion.
—> gas colic often a precursor to developing these.
—> displacements may need surgery.
—> torsions need surgery NOW!
So, I’d think has colic but fails ANY of the other P’s, doesn’t respond to treatment, or viscous taught with bands and/or large abdominal distension = REFER!

Question 12

Gas colic treatment.

Answer 12

As for spasmodic.
PLUS
Stomach tube with water (~1L/100kg) may help as activates gastro-colic reflex (ALWAYS check for reflux first).
Gentle trot lunging may help.
Refer more quickly if does not resolve.

Question 13

Has colic - what next?

Answer 13

Check teeth, parasites.
Check diet.
If recurrent:
- change to wet hay.
- add Yeasacc / another hind gut supplement to feed?
- further investigation (for IBD or other causes).

Question 14

1. Where can impactions occur in the horse?
2. The pathophysiology of impactions.

Answer 14

1. 40% at the pelvic flexure.
   Stomach.
   Ileum.
   Caecum.
   Large colon.
   Small colon.
2. Tend to occur just oral to sites of:
   - intestinal narrowing
   And/or
   - active pacemakers.
   E.g. pelvic flexure, ileocaecal junction.
   Impaction causes back up of ingesta.
   This stretches mucosal wall, stimulating mural stretch receptors, causing pains
   If severe/prolonged, potential vascular compromise (pressure on blood vessel).

Question 15

Proposed risk factors of LI impaction.

Answer 15

Reduced water intake.
Physical exertion (sweating).
Reduction in exercise.
Parasite migration.
Dental disease (don’t chew long fibre).
Others.

Question 16

LI impactions in donkeys.

Answer 16

Associated with dental diastema.
50% survival rate.
Study bias towards geriatric population.
Often picked up very late.
- show pain differently.

Question 17

Diagnosis of LI impactions.

Answer 17

May have been exposed to 1 or more possible risk factors.
Mild-moderate signs of pain.
Pass the P’s (do not perform a peritoneal tap - risk puncturing intestine if impaction is large).
- abnormal rectal.
— most LI impactions at the pelvic flexure.
MIGHT perform a peritoneal tap if gives info on whether there is gut damage - have you time to try medical management, or does it need surgery?
Risk-benefit analysis on individual case (CV parameters, duration, response to treatment).

Question 18

LI impaction treatment.

Answer 18

Aim is to (over) hydrate ingesta so that gut peristalsis can clear the impaction.
Pro-motility drugs contraindicated as may result in intestinal rupture.
Main-stay is oral fluids:
- most effective, cheaper, lower risk.
- just tap water.
- can add Lectade (or similar) to make fluid isotonic rather than hypotonic.
- can add a cathartic — magnesium sulphate (evidence more effective than water alone) —> once per 24hrs (add ~1g/kg).
— Dioctyl Sodium Sulphate (DSS).
—> better than water alone, not as good as MgSO4.
—> once per 24hrs (10-20mg/kg).
(Can supplement with IV to aid over hydration).
Liquid paraffin:
- may have place as emollient.
- doesn’t help break up the impacted material.
- reasonable expensive.
- kills if you mis-place the tube into the lungs.
Give treatments via stomach tube.
ALWAYS check for reflux.
Give water (or water plus whatever you’ve added to it).
About 1L/100kg.
Give by gravity, stop and think again if resistance.
Analgesia is as for spasmodic.
Follow up with at least a phone call after a few hours, probably a visit.
Often need repeated tubing.
Can take days but if not an easy fix, hospitalise.
Can tube more frequently or place indwelling tube to continuously deliver fluid from drip bags.
Can give IV as well (but not instead).
If don’t respond i.e. don’t pass faeces / remain painful or CV deterioration, reassess, may need peritoneal fluid sample.
- might not be just an impaction.
- some need surgery.
— poorer Px.

Question 19

LI impactions - what next?

Answer 19

Try to identify any risk factors and minimise future risk.
Review routine care - parasites and teeth.
FEC, tapeworm ELISA, check teeth.

Question 20

Ileal impactions.

Answer 20

Usually at ileocaecal junction of SI.
- impacted with ingesta.
— usually due to hypertrophy of wall at ileocaecal junction secondary to tapeworm (Anoplocaephala).
- or impacted with Parascaris.
— often within 24hrs of deworming ‘too effectively’ when have a high burden.
Is surgical problem.

Question 21

Ileal impaction - anoplocephala.

Answer 21

Often <4 years old.
Should deworm with praziquantel or double dose Pyrantel in the last 6 months.

Question 22

Ileal impaction - Parascaris.

Answer 22

Often <2 years old.
Should have had fenbendazole at 2-3 months, 6 months ivermectin/moxidectin/Pyrantel, 9 months moxidectin and praziquantel, 12 months Pyrantel.

Question 23

Diagnosis of ileal impactions.

Answer 23

Simple small intestinal obstruction.
Takes much longer for compromise to blood supply of gut wall than a strangulation.
Present as for small intestinal strangulation.
- distended SI on rectal, scan.
- raised pulse, PCV up.
- slow to reflux.
- peritoneal tap slow to change.
Needs to go to surgery!

Question 24

Treatment of ileal impactions.

Answer 24

Whether sure of Dx or not, presenting signs indicate surgery required.
Clear impaction.
May have to perform ileocaecal bypass if junction very thickened.

Question 25

Ileal impactions - what next?

Answer 25

Check parasite management for that horse and its cohort.
Check parasite management for that horse and it’s cohort.
Tapeworm ELISA, FEC.
Deworm for tapeworm with concurrent corticosteroid?

Question 26

Caecal impactions.

Answer 26

Primary.
Secondary - usually unrelated surgical process that result in pain (usually ortho).

Question 27

Diagnosis of caecal impactions.

Answer 27

Mild colic, or no colic.
May just be dull.
Reduced faecal output but still some.
Can be very hard to detect.
Tend to blame depression and reduced faecal output on original surgical procedure.
But can then rupture (fatal) without warning!
Monitor horses very closely post-op.
Diagnose by rectal (impaction over the RHS).

Question 28

Treatment of caecal impaction.

Answer 28

Treat as for LI impaction.
Monitor peritoneal fluid for signs of caecal wall compromise.
May need surgical intervention +/- bypass.

Question 29

Sand impaction.

Answer 29

From ingestion of sand:
- grazing on sandy soil.
- turnout in a sand paddock or arena.
Common in some areas, rare in others.
Irritates LI wall.
- can cause recurrent colic.
- hypertrophy, poor motility secondary to inflammation can lead to impaction.
Present as recurrent colic or similar to LI impaction.

Question 30

Dx of sand impaction.

Answer 30

Hx.
Sedimentation test increases suspicion.
Lateral abdominal radiograph (hospital setting).

Question 31

1. Sand impaction treatment.
2. Sand impaction prevention.

Answer 31

1. As for LI impaction.
   Feed psyllium.
   May need surgery (same decision making process).
2. No sand paddock turnout.
   If sandy soil, keep good grass cover.
   Feed psyllium.

Question 32

Small colon impaction.

Answer 32

Can be hard to diagnose.
Association with salmonella?
Often need surgery.
Common cause of death in developing world due to ingestion of plastic bags.

Question 33

Gastric impactions.

Answer 33

Aetiology not fully understood.
- motility disorder?
Often chronic, stomach can be huge.
May rupture.
Chronic, recurrent or acute colic.

Question 34

1. Diagnosing gastric impactions.
2. Treatment of gastric impactions.
3. Prognosis of gastric impactions.

Answer 34

1. Difficult to pass stomach tube.
   Spleen pushed caudally on rectal.
   Large stomach on U/S.
   Gastroscopy.
2. Try to lavage via stomach tube.
   Coke (scary).
   Difficult surgery.
3. Px generally poor.

Question 35

1. Oesophageal obstruction (choke) presentation if acute.

Answer 35

Brown, frothy material from the nose.
Gagging.
Coughing.
Distress.

Question 36

1. Primary cause of choke.
2. Predisposition to choke.
3. More rare causes?

Answer 36

1. Impactions of food.
2. Eating too quickly, having dental abnormalities.
3. Oesophageal trauma, diverticulum, intra/extra mural masses, eating things they shouldn’t e.g. dry sugar beet, suede.

Question 37

Presentation if chronic?

Answer 37

Dehydration.
Electrolyte imbalance.
Acid-base imbalances.
Aspiration pneumonia.
Oesophageal rupture: crepitus, cellulitis, systemic inflammation.

Question 38

Tx of choke?

Answer 38

If mild, often resolve whilst on way to yard.
Need to sedate as want horse’s head down to try to reduce aspiration risk.
If a recent choke that didn’t clear while on way, sedate and then wait.
- get more invasive if that doesn’t work.
If horse has secondary effects of choke, likely need referral.
If have gastroscope, pass to see obstruction (wouldn’t work in field).
Aim is to lavage obstruction back out of the oesophagus.
- not to force it through into stomach.
- take care not to rupture oesophagus.
- take care to reduce risk of aspiration pneumonia.
Pass NG tube:
- gently to obstruction then pull back a little.
Pour 1L water in, then tube down to floor to empty back out.
Water coming out will be food contaminated.
Repeat, sometimes for ages.
- if for too long, refer!
- sedation and IV fluids.
If not straightforward, gastroscope oesophagus to look for any damage (if so, risk structure/diverticulum).
Consider NSAIDs and starve for a few hours, then slow re-introduction to feeding with short fibre food (longer if damage).

Question 39

Choke - additional things to monitor and check for.

Answer 39

Aspiration pneumonia (auscultation, temp.)
Owner to monitor horse and temp for a few days.
Check teeth / other reasons why might have choked.
NB choke can be very minor, or very major with serious follow-on problems.