Zita Makra SZIU FVS Large Animal Clinic … 2. Clinical observation and signs of pain 3. Physical...

1

Colic diagnostics

Zita MakraSZIU FVS Large Animal Clinic

makra.zita@aotk.szie.hu

2

ColicColic = = abdominalabdominal painpainIleusIleus: : intestinalintestinal obstructionobstruction andand temporarytemporaryfailurefailure ofof peristalsisperistalsisPreventsPrevents aboralaboral movementsmovements →→stasisstasis++distentiondistentiontotaltotal//partialpartialRapid Rapid andand accurateaccurate diagnosisdiagnosisBroadlyBroadly classifiedclassified: : physicalphysical oror functionalfunctionalobstructionobstruction

3

Classification of ileus (Gerber and Huskamp)

I. Mechanical disorders1. Inside the lumen

-impaction-obturation-stenosis-occlusion-invagination

∗small intestine∗ileum into caecum∗caecum into caecum∗caecum into large colon

4

Classification according to Gerberand Huskamp

•• 2. 2. DisordersDisorders outsideoutside thethe lumenlumen2.1 2.1 incarcerationincarceration

2.1.12.1.1. . epiploicepiploic foramenforamen herniationherniation2.1.2. 2.1.2. inguinalinguinal herniahernia2.1.32.1.3. . herniahernia ofof diaphragmdiaphragm2.1.4. 2.1.4. nephrosplenicnephrosplenic entrapemententrapement2.1.5. 2.1.5. mesentericmesenteric teartear

5

Classification according to Gerberand Huskamp

• II. Dynamic disorders1.Paralytic ileus:

1.1. primaer: grass sickness1.2. secunder: postoperative,

peritonitis, mechanical ileus

2.(Spasmodic colic): 2.1. After exercise or excitement2.2. Enteritis, parasitism, moldy feed

6

PhysicalPhysical obstructionobstruction

-- nonstrangulatingnonstrangulating –– mesentericmesenteric bloodbloodsupplysupply intactintact butbut bowelbowel lumen lumen occludedoccluded

-- intraluminalintraluminal reductionreduction / / massmass-- intramuralintramural thickeningthickening oror extramuralextramural

compressioncompression-- strangulatingstrangulating –– luminalluminal occlusionocclusion andand

reductionreduction ofof mesenterialmesenterial bloodblood supplysupply ––((incarcerationincarceration, , intussusceptionintussusception, , torsiontorsion>>180180--degree)degree)

7

FunctionalFunctional obstructionobstruction

DynamicDynamic, , paralyticparalytic ileusileus-- proximalproximal enteritisenteritis, , colitiscolitis-- plantplant poisoningpoisoning ((atropineatropine), ), postoppostop. .

paralyticparalytic ileusileus

8

MechanismMechanism

ObstructionObstruction →→ preventsprevents aboralaboralmovementsmovements, , distentiondistention, , venousvenousdrainagedrainage↓↓, , congestedcongested-- edematicedematic mucosamucosa,,>24 >24 hourshours: : irreversibleirreversible mucosalmucosal ischemiaischemia

9

InIn strangulatingstrangulating obstructionobstruction: : rapid rapid tissuetissue hypoxemiahypoxemia (4(4--6h)6h),,ischemiaischemia, , necrosisnecrosis ((rupturerupture)), , transmuraltransmural leakageleakage,,endotoxemiaendotoxemia, , hypovolemiahypovolemia

10

How to get rapid and accurate diagnosis?

1. History2. Clinical observation and signs of pain3. Physical examination4. Nasogastric intubation5. Rectal examination6. Abdominocentesis7. Ultrasonography

The order can be changed if inicated.

11

Diagnosis1. History

– Management- changes of diet- consumption of water- excercise level- stabling changes- dentistry- pregnancy- etc

12

HistoryPresumptive diagnosis• Young racehorse orthopedic inj – impaction• Sex: stallion – inguinal hernia

mare – disease of the genital tract• Age: foal – meconium, NMS, inherited

problemsOlder, obese horse – lipomaold – tooth problem

• Breed: shetland pony: small colon obstructionthoroughbred and standardbred: inguinal

hernia

13

HistoryPresumptive diagnosis• Geographic incidence of colics

appears uniform, but e.g. in Germany ilealimpaction more often than in other parts ofthe world

• Recently foaled mare – large colon volvulus• Adult horse recurrent colic passing mineral oil

– enterolith (arabian, QH)• Cribbers – epiploic foramen entrapement• Dewormed foals – ascaris impaction

14

1. History

• Medical- any links to this episode of colic(deworming)- repetitive colic: previous abdom. surg.?

»adhesionsenterolithsingestion of sandlinear foreign body

15

2. Clinical observation and signs of discomfort /acute abdominal pain in horses

Appreciate the level of discomfort:

restlessness, sweating, scratching, rolling, strange position, watching theflank region, kicking at their abdomen, (apathetic-indifferent)

Tachycardia, hypertension, dyspnoe, mydriasis, lack of appetite, musclefasciculation, shock (pain, hypovolaemia, endotoxaemia)

16

Clinical observation (attitude)

• Level of discomfort>severity, duration, response

• Mild / moderate / severe not response toanalgesic (>surg)

17

Grading system for colic

• 1. mild discomfort (gastric ulcer)• 2. getting up and down, looking at the

abdomen (obstipation)• 3. sweating, rolling (LDD)• 4. not controlable horse because of pain

(torsion of LC)• 5. apathy

– (foramen epiploicum hernia indolent phase)

18

3. Physical examination((ToTo knowknow normalnormal rangerange ofof clinicalclinical datadata!!)!!)

CheckCheck cardiovascularcardiovascular+GI +GI tracttract!!!!!!

-T: 37,5-38,5°C (↔,↑peritonitis, enteritis; ↓ severeshock)

--HR: 28HR: 28--42 /min, 42 /min, pulsepulse qualityquality--RR: 14RR: 14--18/min18/min--SkinSkin turgorturgor, , mucousmucous membranemembrane, CRT: 1, CRT: 1--2 sec2 sec

venuosvenuos refillrefill--AbdominalAbdominal shapeshape ((distensiondistension))--AbdominalAbdominal auscultationauscultation ++ percussionpercussion--CheckCheck scrotumscrotum inin stallionsstallions!!

19

20

PCV: 32PCV: 32--42 % (42 % (↑↑ splenicsplenic contractioncontraction, , dehydrationdehydration))

TPP: 6.0 TPP: 6.0 –– 7.5 g/dl (7.5 g/dl (↑↑ , , ↓↓ protprot. . lossloss intointo thethe lumen lumen ororperitonealperitoneal cavitycavity) )

BloodgasBloodgas analysisanalysis: : art.art.pH:pH: 7.35 7.35 -- 7.45 (7.45 (acidemiaacidemia))PaOPaO22 ((HgmmHgmm): 80 ): 80 -- 112112PaCOPaCO22 ((HgmmHgmm): 36 ): 36 –– 46 (46 (hypercapniahypercapnia))HCOHCO33 ((mEqmEq/l) : 22 /l) : 22 –– 29 (29 (basebase deficit) deficit) BaseBase excessexcess: : --1.7 1.7 -- +3.9+3.9

ElectroliteElectrolite determinationdetermination

21

Clinical pathology

• EMERGENCY – minimal clinical pathology data• PCV, TPP – hydration status↓TPP and ↑PCV – protein loss, dehyd, poorprognosis

• Electolyte levels, blood gas status – guide fluid replacement

• WBC ↓: colitis, visceral rupture• CK: renal disease, dehydr.• GGT: liver disease, colonic displacement

22

4. Nasogastric intubation

All horses!!

-gastric decompression↔primary/secondary distension- flushing of fluid – empty the stomach-if small-intestinal obstruction or enteritis is suspected(10-20 l reflux)- leave the tube in place to preventgastric rupture! (anesthesia!)

23

5. Rectal examination

General statementsAlways should be done (pony, foal US!)Before paracentesisMay be an indication for surgery

TechniqueSedatives+spasmolytic iv.Twitch, in stocks, be careful!LubricationMucosa: lesions, bloodAs deep as possible

24

5. Rectal examination

systematic examination!

Palpable intraabdominal structures:

-caudal border of the spleen-nephrosplenic ligament-caudal pole of the left kidney-mesenteric root-ventral cecal band-cecal base (head)-small colon containing discinct fecal balls-pelvic flexure-examine: internal inguinal rings, bladder, reproductive tract

25

Abnormal rectal findings:-distended small intestine, cecum, large/small colon

-marked intramural/mesenteric edema

-bowel malposition, displacement

-herniation

-impaction

-intussusception

-intraabdominal space-occupying mass(abscess/hematoma/tumor)

-enterolithiasis

-volvulus of the mesenteric root, urogenital abnormality

-free abdominal gas/ingesta (visc. rupture)

26

6. AbdominocentesisMost dependent part18G, 7,5 cm, Collect into serum tube – TP

EDTA – cytology, cell countRISK: bowel laceration, enterocentesis,amniocentesis – US helps, kick

27

6. Abdominocentesis

• Clear-transparent, pale yellow• Normal: WBC < 3000-5000/µl

TP< 2,5 g/dl• Presence of bacteria!• Exploratory celiotomy, castration, laparoscopy: ↑ TP, WBC

28

6. Abdominocentesis

Strangulating ileusReduced iv. volume:- ↓perif. perfusion, HR↑, PCV↑,

mucous membranesShock: inadequate tissue oxygenationPoor periferal tissue perfusion+anaerob metabolism⇒Lactate↑Lactate indicates endotoxic mitochondrial hypoxiaHorses are suseptible for endotoxins (have a lot ofreceptors on WBC)Preop. Lactate measurement!:

- how suseptible for endotoxins- how hypoxic=assessment of perfusion

Blood lactate<2mmol/lPeritoneal lactate > 5-6 mmol/l⇒strang. Ileus (LC volvulus)Peritoneal>blood lactate⇒strang. Ileus, prognosis

29

6. Abdominocentesis

Blood-tinged fluid⇒intestinal necrosis=99% surgeryHb↑- Strangulating ileus

Hypocalcemia in the bloodCa2+↓ in colic casesEndotoxemia⇒PTH release in serum⇒ Ca2+↓Intracellular Ca overload⇒inflammatory enzymes

activatedHypocalcemia: severity of disease (cellular injury!),prognosisHR- phrenic n. transmission-diaphragm-abd. wall tremor

30

7. Ultrasonography

• Becoming routine part• Sprayed with alcohol• From the line of diaphragmatic reflection down to

the ventral midline• 2-3,5 MHz• Gastric distention (fluid, carcinoma), 8-15 ICS• SI: movements, thickness <3mm,(>5mm-incarc)

dilatation >5cm• Intussusceptions, inguinal hernia• Lesions involving the caecum• LC: <5mm (>9mm–torsion)

31

7. Ultrasonography

• Intraabdominal fluid, masses• Foal: instead of rectal exam• By rectal tears• Postop: to control peristaltic• Thickness of intestinal wall (hypertrophy-

oedem)• Intestinal content (gas, fluid, sand etc.)• Incarceration (oedem+fluid in the lumen)• Invagination (snail-like pattern)

32

7. Radiography

• Enteroliths (Us) • sand accumulation – ventral abdomen, low

power• Diaphragmatic hernias• FOAL, small horses: conventional/contrast

(30% BaSO4 orally or rectally)- meconium, segmental atresia

33

What to do?

Pain reliefStabilization of cardivascular + metabolic statusMinimizing the deleterious effects of endotoxemiaEstablishing a patent and fuctional intestine:

analgesic th.fluid therapy+cardiovascular supportdecompression of stomach, cecum, large colonlaxativesantiendotoxin th.th. for ischemia-reperfusion injuryantimicrobial th.nutritional supportsurgical intervention

34

Diagnosis:

Immediate surgical management or euthanasia

Medical management with further monitoring andpossible surgery

Medical management

Decision can be based on the available information

35

Indications for exploratory celiotomy in horses:

-persistent or recurrent, unrelating abdominal pain-refractory to analgesics-increased HR-progressive abdominal distention-abscence of borborygmi-large quantities of gastric reflux-abnormal rectal examination-serosanguineous abdominal fluid with ↑TP and

nucleated cell count

Early surgical intervention, even if it unnecessary is lessdangerous to the horse with colic than delayed surgicalintervention that results in visceral rupture!

36

Indication of surgery

- distended edematous SI without motility by Us- presence of enterolith on X-ray- physiologic deterioration despite medical

therapy, IV fluids and supportivetreatment=failure of conservative treatent

37

Ancillary diagnostic aids

• Endoscopy (eosophagus, stomach, duodenum, rectum distal small colon) (3m)

• Laparoscopy: acute and chronic- trauma after foaling, abdominal cavity trauma,

splenic disease, adhesions, large colon displacements, visceral rupture, abdominalneoplasia

38

Status presens• Circulation: conservative / surgical

• Pulse <80/min <100/min• Mucosa pink – red livid - cyanotic• Body surface OK cold• PCV - TPP < 50 ; 6-7.5 g/dl >50 ; >7.5g/dl

• Alimentary tract• Palpation abdomen not tight +; ++; +++• Peristaltic OK, hyperactive -• Rectal exam. Normal pathological

finding• Nasogastric tube no reflux reflux• Abdominocentesis clear, transp., turbid, reddish• Ultrasonographic examination

• Pain, faces, sweating

39

Nonintestinal colic disorders

• Cardiovascular (a. iliaca thrombus, pericarditis)

• airways (pleuritis, pleuropneumonie)• abdominal cavity (tumor, abscess,

peritonitis, haematome)• liver (cholelithiasis, cholangiohepatitis)• spleen (abscess, splenomegalie)• urogenital tract (nephrolits, pyelonephritis,

cystitis, ruptured bladder)

40

Basic equipment for colicexamination in the praxis• stetoscope• twitch• Nasogastric tube• Rectal gloves, gel• PCV centrifuge, refractometer• Caecum trocar, instruments for surg.

Preparation, iv. catether• Drugs

41

Transabdominal caecum punctionaseptic surg. preparation, ab,trocar with mandrine

Large colon transrectal decompression

42

Pain control

• Disguises colic!• Flunixine-meglumine (0,5-1 mg/kg) –

endotoxemia! (mask signs!)• Xylazine (0,2-0,5 mg/kg) potent analgesic,

short duration• Butorphanol tartrate (0,01-0,02 mg/kg IV)• Detomidine: longer acting

43

Treatment•• 1. 1. AnalgeticsAnalgetics::

-- decompressiondecompression -- nasogastricnasogastric tubetube, , -- caecumcaecum headhead/LC /LC trocarisationtrocarisation

-- DetomidineDetomidine, , XylazineXylazine-- ButorphanolButorphanol (0,1mg/kg)(0,1mg/kg)-- NovaminoNovamino –– SulfonSulfon: : VetalginVetalgin, , NovalginNovalgin-- MetamizolMetamizol--NaNa: : BuscopanBuscopan, , ChosalganChosalgan-- FlunixinFlunixin megluminmeglumin: : FinadyneFinadyne

44

Treatment•• 2. 2. SedativeSedative:: XylazinXylazin, , DetomidinDetomidin reduce propulsive

motility in caecum and LC, promote transit of ingesta injejunum

•• 3. Fluid 3. Fluid theraphytheraphy::-- ReduceReduce hypovolhypovol::KristalloidKristalloid: 20: 20--40 ml / kg / h ~1040 ml / kg / h ~10--20 l/h20 l/h

hypertonichypertonic salinesaline 4ml/kg=2 l4ml/kg=2 lKolloid: Kolloid: FrozenFrozen plasmaplasma, HAES 10ml/kg, , HAES 10ml/kg, DextranDextran infinf..

•• 4. 4. AntiendotoxinesAntiendotoxines::FrozenFrozen plazma, plazma, flunixinflunixin, OTC, , OTC, doxycyclindoxycyclin,,activatedactivated charcoalcharcoal, paraffin , paraffin oiloil

•• 5. 5. LaxativesLaxativesparaffin, paraffin, linseedlinseed

45

Treatment•• 6. 6. TheraphyTheraphy forfor ischemiaischemia--reperfusionreperfusion injuryinjury

absorption of endotoxin across ischaemic-injuredmucosa, flunixin retards mucosal repair, syst. lidocainhas anti-inflammatory effects, improve mucosal recovery

•• 7. 7. CholinergicCholinergic stimulatesstimulates::-- cisapridecisapride ((PropulsidePropulside) 0,1mg/kg ) 0,1mg/kg -- smallsmall andand largelarge

colon colon propulsivepropulsive effecteffect-- metoclopramidemetoclopramide ((CerucalCerucal))-- pilocarpinpilocarpin hydrochloridhydrochlorid--atropineatropine poisoningpoisoning

•• 8. 8. AnticholineseteraseAnticholineseterase::-- NeostigmineNeostigmine: : stimulatesstimulates largelarge colon, colon, butbut increaseincreasesmallsmall intestinalintestinal secretionsecretion ((KonstigminKonstigmin))

•• 9. 9. ColicColic surgerysurgery

46

Referencees

• Auer & Stick: Equine Surgery 3rd edition• Orsini and Drivers: Manual of equine

emergencyes• www.glasshorse.com

47

Thank You for Your attention!