University of Tennessee College of Veterinary Medicine

1
University of Tennessee College of Veterinary
Medicine
Department of Large Animal Clinical Sciences
2
Equine Special Topics

• Working Up A Colic CaseThe First Hour isThe
  Golden Hour
• Dr. Jose R. Castro
• November, 2003

3
The Gold of the Golden Hour

• Assess the case
• Decide between
• Medical treatment
• Surgical treatment
• Euthanasia
• Prognosis
• Start treating the patient!

4
Equine Emergencies
5
Equine Emergencies Laminitis
6
Equine Emergencies Laminitis
7
Equine Emergencies Lacerations/ Acute Lameness
8
Equine Emergencies Ophthalmology
9
Equine Emergencies Dystocia
10
Equine Emergencies C O L I C !!!
11
Equine Colic
12
Colic

• Colic is defined as the manifestation of
  visceral abdominal pain. It may be acute, chronic
  or recurrent
• Bradford Smith. Large Animal Internal Medicine,
  1996

13
Colic

• Colic is the number one killer of horses.
• A colic is not a disease it is merely a symptom
  of a disease.

14
Colic

• 10 of all colic cases are severe enough to
  require surgery or cause the death of a horse.
• The good news is that most cases of colic will
  resolve with simple medical treatment, and
  sometimes with no specific treatment.

15

• EVERY COLIC CASE SHOULD BE TAKEN SERIOUSLY!!!

16
Diseases That Cause Colic Signs
17
Diseases That Cause Colic Signs

• Acute gastric dilation
• Gastric impaction
• Gastric ulcers
• Duodenal or Gastric perforation
• Small intestinal intussusception
• Volvulus
• Internal hernia (epiploic foramen)
• External hernia ( inguinal, umbilical, ventral
  abdominal, diaphragmatic)

18
Diseases That Cause Colic Signs

• Pedunculated lipoma
• Ileal impaction
• Thromboembolic (verminous)
• Ascarid impaction
• Duodenitis/ Proximal jejunitis
• Nonstrangulation infarction
• Cecal impaction
• Cecal perforation

19
Diseases That Cause Colic Signs

• Large colon impaction
• Sand impaction
• Large colon displacements (R L)
• Large colon volvulus
• Ulcerative colitis
• Small colon impaction and foreign body
  obstruction
• Enterolithisis
• Meconium impaction

20
Diseases That Cause Colic Signs

• Rectal tears
• Uterine torsion
• Uterine rupture
• Hemoperitoneum (e.g., after castration)
• Cystitis or bladder calculi
• Peritonitis
• Diarrheas(Salmonellosis, Clostridium, E. coli,
  etc)
• Spasmodic colic (hypermotility)

21
Colic Signs
22
Depression
23
Pawing
24
Looking at Flanks
25
Rolling
26
Bruxism/ Ptyalism
27
Sweating
28
Flehmen Response
29
Sitting in a Dog- Like Position, or Lying on
its Back
30
Other Colic Signs

• Stretching out as if to urinate without doing so
• Repeatedly lying down and getting up or
  attempting to do so
• Lack of appetite (anorexia)
• Putting its head down to water without drinking

31
Other Colic Signs

• Rapid respiration and/ or flared nostrils
• Elevated pulse rate (gt 52 bpm)
• Cool extremities
• Absence of, or reduced digestive transit time

32
When Does A Colic Happen?
33
First Comes First

• A colic could happen
• Any day
• Any time
• Any where
• Any horse

34
But it Usually Happens

• On Friday, Saturday or Sunday
• After hours
• When you think the day is over
• When you are about to start eating!

35
So

• BE READY!!!

36
Why Does a Horse Colic?
37
Why Does a Horse Colic?

• We dont know
• Either becausethe sun goes up or the sungoes
  down

38
Why Does a Horse Colic?

• Lack of exercise

39
Why Does a Horse Colic?

• Lack of grazing time (confinement)

40
Factors Predisposing The Horse To Colic
41
Anatomical Factors Predisposing the Horse to Colic

• Inability of the horse to vomit
• Moveable position of the left colon.
• The long mesentery of the small intestine
• Upward movement of ingesta and narrowing of the
  lumen at the pelvic flexure.

42
Anatomical Factors Predisposing the Horse to
Colic

• The cecum is a blind sac
• Termination of the right dorsal colon into the
  much narrower transverse colon

43
Other Factors Predisposingthe Horse to Colic

• Parasites Tape worms
• Dental problems
• Diet
• Change in diet
• Type of diet Bermuda grass (Ileal impaction)
• Decrease water intake
• Bedding i.e. sand

44
The Phone Call
45
The Phone Call

• Hey Doc, my horse is sick.
• I think is colicking
• but I dont know what to think.
• It has been rolling,
• It has been pawing
• And doesnt want to eat.
• Whattya think Doc?

46
The Phone Call

• Referring DVM Name and Phone Number (Cell phone
  Important)
• Client Name and phone number (Cell phone also.
  Very important)
• Patient signalment Name, age, breed, sex

47
The Phone Call

• CC Chief Complaint colicking, pawing, not
  eating, vomiting, etc.
• Distance between the horse and the facility.
• Is the horse insured?

48
Primary Action Plan
49
Primary Action Plan

• Keep the horse as calm as possible
• Move animal to a safe area where it is unlikely
  to be injured or cause injury to handlers
• Remove all food and water!

50
Primary Action Plan

• Walk the horse for periods no longer than 20
  min.
• Suggest DO NOT OVER ADMINISTER DRUGS, especially
  analgesics, tranquilizers or sedatives.

51
Step No. 1

• Decide where to work up the colic

52
Step No. 1Decide between

• See the patient on the field
• Bring the patient into the facility

53
How To Makethat Decision?

• Type and Severity of the case
• Time since the colic episode began
• Level of knowledge of the owner about horses and
  colic
• Distance between the patient and the facility

54
Step No.2

• Work - up

55
Step No.2Work Up

• Diagnosis
• - History
• - Physical Exam
• - Ancillary Tests
• Prognosis
• Initial Treatment

56
Diagnosis of a Colic

• 50 History
• 40 Physical Exam
• Mental Attitude (BAR,QAR)
• Parameters T,P,R, etc
• Rectal Normal vs. Abnormal
• Nasogastric intubation reflux vs. no reflux
• Self Inflicted trauma
• 10 Ancillary Tests
• Blood work
• Abdominocentesis
• Images Endoscopy, Radiology, U/S

57
Diagnosis of a Colic

• History
• Physical Exam
• Ancillary Test

58
History Insurance

• Is your horse insured? Yes _ No_
• If Yes
• Ask the owner to contact them ASAP !!!
• What kind of insurance? Major _ Minor_
• Value of the horse
• Company
• Agent
• Phone Numbers

59
History Vaccinations
60
History General Care

• EIA
• Last Coggins Test?
• Pos___Neg___ Date__/__/__
• Parasite Control
• Last time de-wormed __/__/__
• What was used?
• Fecal test ever performed? Yes__No___

61
History General Care

• Does your horse have any possible access to feed
  or storage bins? Yes_ No__ What kind of
  feed?
• Has your horse been drinking water as usual?
• When was the last time your horse had a dental
  exam or its teeth floated?

62
History Diet

• What does the horse normally eat?
• Pasture___ Hay___ Grain ___
• Type and amount of each
• Recent change in hay type?
• Recent change in feed?
• Supplements
• Type and amount of each

63
History Activity

• What kind of work does your horse normally do?
• Has there been any change in activity level?

64
History Activity

• How do you plan to use your horse in the future?
• Is your horse mainly in the stall or in the
  pasture
• How much turn out does your horse receive in a
  day?

65
History Breeding

• STALLIONS
• When was the last time your horse was used for
  breeding? __/__/__
• Has this horses sire or any siblings had
  problems with scrotal hernias or any other
  congenital defects? Yes___ No___

66
History Breeding

• MARES
• Last breeding date __/__/__
• Pregnant? Yes___ No___ How long? __________
• Recently foaled?
• Yes___ No___
• Difficult birth? Yes___ No___
• Explain

67
HistoryPrevious Medical Problems
68
Previous Medical Problems

• What medical problems has your horse had in the
  past?
• Does your horse have any current medical
  conditions and if so, what are they (laminitis,
  COPD, HYPP, etc.)?

69
Previous Medical Problems

• Is your horse currently on any medications?
• Yes___ No___
• Type and dose

70
Previous Medical Problems

• Any known allergies to medications?
• Any surgeries in the past? Yes___ No___When and
  what kind?

71
History Infectious Diseases
72
Infectious Diseases

• Has your horse recently been moved or had
  exposure to new horses? Yes___ No___
• When?_______________
• Has your horse recently been to a show or other
  event? Yes___ No___

73
Infectious Diseases

• Has your horse been expose or had any diarrhea or
  respiratory signs (coughing, ocular or nasal
  discharge, sneezing, wheezing, or difficulty
  breathing) within the last two weeks?
• Yes___ No___
• Which signs?___________________

74
Present Condition
75
Present Condition

• Has the horse ever had any previous colic
  problems? Yes___ No___If so, how were they
  resolved?
• How long has this colic been going on?
• Describe the signs exactly that you have seen?
• How long did it take to get here?

76
Present Condition

• Has your horse been seen by a veterinarian for
  this colic?
• Did the doctor pass an NG tube?
• Any reflux from the tube?Yes___ No___How much?

77
Present Condition

• Did the doctor do a rectal exam?
• What did the veterinarian find/ say?

78
Present Condition

• Since you first noticed the colic, has your
  horse gotten
• Worse ?
• Better ?
• Stayed about the same ?

79
Present Condition

• Has your horse passed feces since it began to
  colic?
• What did the feces look like?
• How long ago was the last bowel movement?

80
Diagnosis of a Colic

• History
• B. Physical Exam
• Ancillary Test

81
Physical Exam

• More mistakes are made because of the things you
  do not see, than because of thethings you do
  not know.

82
Physical Exam

• PART 1
• Mental Attitude (BAR,QAR)
• Parameters
• - T, P, R, MM, GS, DP, BG, BP
• Evaluation of self inflicted trauma
• PART 2
• Nasogastric intubation reflux vs. no reflux
• Rectal Normal vs. Abnormal

83
Perform Physical ExamPart 1BEFORESedation
84
Vital ParametersWhat is Normal?

• Temperature 99.5 to 101.5
• Heart Rate 28 52 bpm
• Respiratory Rate 12 20 bpm
• MM Pink
• CRT 2 sec

85
Vital ParametersWhat is Normal?

• Gut Sounds
• Digital Pulses

LU Left upper RU Right Upper LL Left
Lower RL Right Lower
LF Left Front RF Right Front LR Left
Rear RR Right Rear
86
Physical ExamWeight
87
Physical ExamTemperature
Normal 99.5 100.5F
88
Fever

• In the absence of extreme muscle exertion,
  suspect inflammatory disease enteritis, colitis,
  peritonitis, as the cause of abdominal pain

89
Physical ExamHeart Rate
Normal 28 52 BPM
90
Physical ExamRespiratory Rate
Normal 12 20 BPM
91
Tachycardia Tachypnea

• Indicators of
• Abdominal pain
• Cardiovascular shock
• Endotoxemia

92
Physical Exam Mucous Membranes
Dark red
Normal Pale/Pink
93
Physical ExamCRT
(Normal 2 - 3 seconds)
94
MM/ CRT

• Normal
• Moist, pale/ pink
• 2 sec
• Decrease in circulation
• dry dark pink/ red
• 2-3 sec
• Shock, endotoxemia
• Dry, reddish blue to purple (cyanosis)

95
Physical ExamPulse
Normal Strong
96
Physical ExamGut Sounds
97
Auscultation

• Repeat auscultation is vital when monitoring
  horses with acute abdominal pain.
• Although auscultation alone will not be
  diagnostic, a progressive decline in the
  frequency or intensity of intestinal sounds may
  be associated with an unfavorable prognosis.

98
Fluid and Bubbling

• Impending colitis/ enteritis
• US distended small intestine with increase
  motility

99
Physical ExamDigital Pulses
100
Perform Physical ExamPart 2UNDERSedation/A
nalgesia
101
Analgesics Relative Efficacy for Control of
Acute Abdominal Pain
102
Sedatives

• Use Xylazine!
• Break the sedation!!!

103
Nasogastric intubation
104
Nasogastric Intubation

• Restrain the patient
• Sedate the patient
• Oil the N.G Tube

105
Nasogastric Intubation

• Perform nasogastric intubation IMMEDIATELY in
  individuals with abdominal pain.
• NG Reflux may be secondary to small intestinal
  obstruction or secondary to ileus from the
  large/small intestine.

106
Nasogastric Intubation

• If small intestinal obstruction or enteritis is
  suspected, it is essential to leave the tube in
  place to prevent spontaneous gastric rupture and
  subsequent death!

Leave the tube in place!!!
107
RectalExamination
108
Rectal Exam

• Sedate patient
• Lubrication
• Empty the rectum

109
Physical Exam Rectal
110
Rectal Exam

• Systematic approach
• Diagnosis of the problem
• Determine normal or abnormal

111
Rectal Examination

• Position
• Size
• Mobility
• Thickness
• Evidence of edema
• Tight mesenteric bands
• Distention of mesenteric bands
• Presence of fluid or ingesta

112
Rectal Exam

• Caudal abdominal wall
• Inguinal rings
• U.Bladder

• Lower left
• Small colon
• Large colon

• Upper left
• Spleen
• Nephrosplenic ligament
• Kidney

• Midline
• Mesenteric Stalk
• Aorta
• Duodenum?

• Lower right
• Body of cecum
• Small intestine?

• Upper right
• Base of cecum

• Peritoneal surface?
• Excess fluid
• Fibrin

113
Pelvic Flexure

• Always attempt to locate and examine the pelvic
  flexure because it is a frequent site of
  impaction.
• This structure is mobile and may reside in a
  number of positions but is not necessarily
  displaced.

114
Blood Collection
115
Physical ExamBlood Sample
116
Blood Collection

• Take your blood sample before IV Fluid Therapy
• Get 1 purple top tube
• CBC, Fibrinogen
• Get 1 green top tube
• Chem and Lytes
• Get 2 red top tubes
• Serology

117
Working Up The Case In The Field
118
Working Up The Case In The FieldOptions

• Conservative Medical Treatment
• Refer the case to a Hospital Facility
• Euthanasia

119
Conservative Medical Treatment

• Continue with the primary action plan
• Analgesics
• Oral Fluids
• Mineral Oil
• NPO !!!

120
Reasons To Refer

• Uncontrollable pain (unresponsive to pain meds)
• Surgery
• Hospitalization
• Fluid Therapy
• Further work up

121
Reasons To Refer

• Unresolved colic over several hours or days
• Impending or possible diarrhea
• Owner insistence and/ or anxiety
• Second opinion

122
Diagnosis of a Colic

• History
• Physical Exam
• C. Ancillary Test

123
Ancillary Test

• Blood work
• Basic PCV, TS
• Complete
• Hematology- CBC
• Chemistry- Chem
• Electrolyte Panel- Lytes
• Fibrinogen

124
Ancillary Test

• Blood Pressure
• Abdominocentesis
• Endoscopy
• Radiology
• Ultrasonography

125
Blood Work
126
PCV/TS

• Hypovolemia secondary to intestinal dysfunction
  results is dehydration

127
Hematology

• Hemoconcentration is common in association with
  abdominal diseases including obstruction,
  peritonitis, diarrhea and endotoxic shock

128
Serum Biochemistry

• In addition to losses of electrolytes, a common
  change is acidosis due to intestinal bicarbonate
  loss in association with severe enteritis and
  diarrhea.
• Liver
• Kidney
• G.I
• Etc

129
Fibrinogen

• The third major fraction of total plasma protein
  measured reflects the severity and duration of an
  inflammatory disease.
• Normal 200-400 mg/ dl

130
Blood Pressure

• Assess using a blood pressure cuff and Doppler
  applied to the coccygeal artery.
• Normal systolic blood pressure (100-125 mm hg)
• Poor prognosis if lt 80 mm hg

131
Abdominocentesis
132
Abdominocentesis
133
Peritoneal Tap
Copied with out permission from Orsini and Divers
Manual of Equine Emergencies
134
Peritoneal Tap
Copied with out permission from Orsini and Divers
Manual of Equine Emergencies
135
Peritoneal Fluid
136
Endoscopy
137
Endoscopy

• Gastroscopy
• Colonoscopy
• Other

138
Endoscopic Evaluation Adults
Murray (personal communication), 1999. Photos
courtesy of MJ Murray to Dr. Frank Andrews
139
Endoscopic Evaluation Foals
Murray (personal communication), 1999. Photos
courtesy of MJ Murray to Dr. Frank Andrews
140
Radiology
141
Radiology

• Enteroliths
• Retro pharyngeal abscess

142
Enteroliths
Single Enteroliths
Multiple Enteroliths
143
Enteroliths
144
Ultrasonography
145
Ultrasound Examination

• Provides evidence of increased fluid
  accumulation within the abdominal cavity,
  fibrinous accumulations on the peritoneal wall,
  and, at times, the presence of masses in the
  liver, spleen or kidneys.

146
Fluid Filled Cecum
147
Distended SI
Normal SI
NORMAL SI
DISTENDED SI
148
Normal Duodenum
149
Ultrasound - SI
Thickening
Distension
150
Ultrasound - SI
Scrotal hernia
Intussusception
151
Ultrasound - Nephrosplenic
152
Colon Ultrasound
Normal
Halstra
Colon Wall Edema
Abnormal
153
Peritonitis
154
Working Up The Case In The Hospital
155
Working Up The Case In The Hospital Options

• Medical Treatment
• Surgical Treatment
• Surgical Medical Treatment
• Euthanasia

156
Medical Treatment
157
Medical Treatment

• Fluid Therapy
• Colloids
• Crystalloids
• Antibiotics
• Analgesics
• Anti ulcers
• Continuous reflux
• TPN/PPN
• Etc

158
Fluid Therapy
159
Medical Treatment

• Crystalloids
• Hypertonic saline
• 4-8 ml/ kg ( 2 liters/ horse )
• Short term solution to hypovolemia
• Positive ionotropic effects
• Must follow with isotonic fluids
• Quickly equilibrates with interstitial tissue
• Can cause intracellular dehydration

160
Medical Treatment

• Crystalloids
• Isotonic Fluid
• 1 ml//Hr
• Add electrolytes
• Add others i.e. DMSO

161
Medical Treatment

• Colloids
• Hetastarch/ Plasma
• 10-20 ml/ kg/ hr
• Expensive
• Remains in the vasculature
• Anti-inflammatory effects as well as osmotic
• Combination of both may be helpful
  
  

162
Surgical Treatment
163
Parameters Indicating Need for Surgery

• Abnormal rectal finding
• Continuous, intermittent / uncontrollable pain
• Increase heart rate and week pulses
• Decreased/ absent abdominal sounds
• Self inflicted trauma
• No specific diagnosis is determined

164
Factors Indicating a Poorer Prognosis Pre-op

• HR gt 100
• PCV gt 50
• TS gt 9
• Small Intestine vs Large Intestine
• Strangulating vs. Nonstrangulating
• Current problems (kidney, dehydration)
• Shocky, weak pulses

165
Factors Indicating a Poorer Prognosis
Intra-operative

• of affected bowel (gt 30 feet chronic sick)
• Discoloration of the bowel (Black means dead)
• Bowel wall thickness(Compromise of the mucosa)
• Doesnt bleed on cut section
• Poor motility

166
Owners ConcernsAbout Surgery

• Cost
• Return to function
• Level of comfort after surgery / Complications

167
Cost

• A client will say
• Do what ever you have to do!!!
• Money is not an issue

168
Well

• Money is always an issue!!!
• Some owners, even with a poor prognosis, will ask
  you to perform an exploratory celiotomy.

169
Complication of a Colic Surgery
170
Complication of a Colic Surgery

• Endotoxemia
• DIC
• Ischemia/ Reperfusion
• Incisional infection

• Ileus
• Adhesions
• Diarrhea
• Laminitis
• Reoccurrence

171
Small Intestine Strangulation
172
Small Intestine Distension
173
Grey Area

• Medical
• vs.
• Surgical

174
Anterior Enteritis or Surgical Lesion
175
Large Colon DisplacementsSurgical vs. Medical
Management
176
Euthanasia
177
Euthanasia

• Few things in life are as difficult to accept as
  death
• Euthanasia is performed to avoid and terminate
  incurable or excessive suffering

178
AAEP Euthanasia Guidelines

• Is the condition chronic or incurable
• Does the immediate condition suggest a hopeless
  prognosis for life
• Is the horse a hazard to himself or his handlers
• Will the horse require continuous medication for
  the relief of pain for the remainder of its life

179
Prevention of Colic
180
Prevention of Colic

• Exercise
• Turn Out
• Efficient parasite control
• Diet
• Dental Float
• Bedding

181
Summary
182
Remember

• 1 killer in horses, thus every case should be
  taken seriously
• Phone Call
• Insurance

183
Remember

• Options for workup in the field or in the
  hospital
• Options for treatment medical, surgical,
  euthanasia
• Take parameters before sedation
• Take blood samples before fluids

184
Remember

• Perform nasogastric intubation IMMEDIATELY in
  individuals with abdominal pain.
• If reflux is present, leave the tube in place

185
Remember

• Sedation Xylazine 0.25 1.1 mg/Kg/IV or IM
• Analgesia Banamine 0.2-1.1 mg/Kg/IV or IM
• Act promptly

186
But The Most Important

• Ready!!!

187
Sources

• Orsini Divers Manual of Equine Emergencies
  Treatment and Procedures Saunders
• Rose Hodgson Manual of Equine Practice.
  2nd.Edition Saunders 2000
• UTCVM Class notes 2001-2003
• www.3Dglasshorse.com

188
Acknowledgments

• Nicholas Frank, DVM, PhD, ACVIM UTCVM
• Frank Andrews, DVM, Ms, ACVIM - UTCVM
• Paul Plummer, DVM Medical Resident - UTCVM
• Ben Buchanan, DVM Medical Resident - UTCVM

189
Acknowledgments

• Lindsay German, LVT UTCVM
• Phil Snow, Medical Photographer UTCVM
• Teresa Jennings, Instructional Resources/ Graphic
  Illustration - UTCVM