Browsing tag: Horse abdominal pain

Part 3: Surgical Colic

As we saw in the previous part of this series, Medical colics are those which can be managed medically, usually on the yard. However, about 1 in 10 cases of colic require emergency referral to an equine hospital for surgery.

This is what most horse owners are terrified of. The general indicators that a horse has a surgical colic are:

1) Heart rate over 60 that isn’t relieved by injectable painkillers.
2) Dilated loops of small intestine on rectal exam.
3) Positive stomach reflux from the stomach tube.
4) A definite rectal diagnosis of a surgical problem.
5) “Toxic rings” – dark red or purple gums, that indicate that the horse is going into toxic shock.

Of course, it varies between horses, and the vet has to make a judgment call based on all the evidence available.

We also have to talk to the (by now usually frantic) owners about costs. Colic surgery usually costs between £4000 and £5000, but can easily be a lot more. Even if the horse is insured, it is important to check how much the insurance company will cover – there are a couple of companies out there who will only cover part of the costs of emergency surgery. If in doubt, always call your insurer’s helpline.

However, colic surgery is one of the most genuine emergency operations there is – and it can be truly life-saving.

So, what causes a surgical colic? Probably the most common are:

1) Twisted bowel. If a length of bowel twists around itself, it can cut off the circulation. At this point, the gut begins to die, and unless it can be removed by surgery, and quickly, the horse will go into toxic shock and die. This commonly happens in the small intestine or occasionally the colon, but there’s also a condition where the caecum gets turned partially inside out (an intussusception).

2) Small intestinal blockages. Horses rarely eat things that get stuck in the small intestine (although it can happen). More commonly, a really heavy worm burden can simply block up the bowel; with the bowel overfull, the blood supply starts to fail, and the gut, again, can die. I once had a patient who was a little foal with a severe colic; we removed two gallons of worms from her small intestine!

3) Strangulating Lipomas. These are really common in older horses and ponies. A small, benign, fatty tumour forms somewhere in the abdomen, causing no harm at all. However, it grows on a stalk, and eventually, the stalk gets wrapped around a length of gut, cutting off the blood supply… This results in the bowel dying, as if it had twisted. Fortunately, these are usually really simple surgical procedures; unfortunately, older horses and ponies are less likely to be insured for surgery.

There are also a number of medical conditions that can mimic those requiring surgery – particularly peritonitis and anterior (or proximal) enteritis. Horses with these conditions are often referred for possible surgery because it’s very hard for the vet in the field or on the yard to be 100% certain they’re not surgical. I think that most of us would say it makes a lot more sense to have the horse at the hospital, with a surgeon on call, to make the definitive diagnosis, rather than waste time in the stable, and risk having to then decide it needs surgery when it’s still an hour or more away in travelling time from the hospital!

So, what happens when the vet decides that a colic case isn’t suitable for medical management?

Firstly, they’ll talk to you about the options. If a horse isn’t insured, or there’s no money for treatment, it is a perfectly respectable and responsible decision to decide, sadly, to put the horse to sleep rather than prolong its suffering.

Hopefully, of course, that won’t be the case. Once you and the vet have decided that referral is the way forward, your vet will get in contact with a referral hospital. If you’re very lucky, it will be one run by your vet’s practice, but in most cases, it will be a specialist referral hospital. I must say here that not every centre with surgical facilities is able to cope with emergency colic surgery – they need not only to have the facilities (knock-down box, operating theatre, recovery box etc), but also the staff (not only a surgeon, but also enough vets and nurses to take care of your horse in the vital recovery period). Your vet will have a list of suitable referral hospitals – generally, its best to send the horse to the closest one with the shortest transport time, but your vet will be able to advise you.

Making an emergency referral is simple – but only your vet can do it. A referral hospital will not accept referrals from the horse’s owner! Once you’ve made the decision to refer, your vet will call them and speak to the veterinary team on call, who will be available 24/7/365 (when I was part of one such team, we ALWAYS seemed to get our referrals at about 10pm!). They’ll let him or her know what they want done during transport – generally, they’ll describe what painkillers they want given, and what samples they want taken (don’t be surprised if your vet gives you a couple of blood tubes to take up and give to the referral team). In addition, they’ll sometimes ask the vet to put in a stomach tube and tie it in for the journey – this is to prevent the stomach from getting over-full and bursting if there’s an obstruction in the small intestine. Don’t forget your horse’s passport – legally, they do need it even when being rushed to emergency surgery.

Your vet will generally give you directions and a contact number for the hospital, and send you on your way. Remember, they can’t normally go with you, because your horse’s colic, while devastating, is probably only one of several cases they’ll have to deal with.

If there’s a problem (e.g. your horse getting distressed) in transit, call your vet or the referral number you were given – but if at all possible don’t stop unless they tell you to! Remember, you’re on your way to the best equipped help available.

On arrival at the hospital, you can expect to be met by the veterinary and nursing team. Your horse will be rushed to an assessment area, and you’ll probably be given a lot of scary-looking paperwork to sign. Generally, this comes into 2 parts – firstly, you’re signing to give consent for whatever they need to do (and remember, a lot of drugs aren’t technically licensed for use in horses, because the manufacturers haven’t paid for an official license for that drug in horses. It doesn’t mean a drug is dangerous or experimental, it’s probably used on a daily basis by the hospital. You’ll have to sign consent to use unlicensed medication – it’s absolutely routine, and nothing to worry about). Most hospitals will also ask to see your passport – if you haven’t got it, or it isn’t signed to mark the horse as “not intended for human consumption”, legally the hospital can refuse treatment (although they rarely do).

The second set of paperwork you’ll sign is a bit more pedestrian – you’ll be signing to say that you will pay for any treatment!

While you’re contemplating the paperwork, your horse will be undergoing another examination by the veterinary team. This is to establish what’s going on, and what’s changed since your vet examined him back on the yard. They may well repeat some tests – most colic conditions are dynamic (i.e. constantly changing), and sometimes the change is more useful in working out what’s going on than a one-off test. Other tests they may wheel out include ultrasound – the powerful ultrasound systems available in a hospital environment can give the vets a lot more information about what’s going on. The vets will then make a decision about what to do – don’t be disappointed or worried if they don’t rush immediately to surgery! They may decide to try a course of medical treatment first (remember, they don’t have to rush as much as your vet does – if your horse’s situation deteriorates, they can operate at a moment’s notice).

In many cases, however, they will decide to take the horse straight to theatre. If so, you normally won’t be able to follow, so I’m going to describe what happens once you’ve been gently steered in the direction of a waiting room.

To begin with, the horse will have an intravenous catheter fitted, to allow easy access for fluids and drugs. A horse with colic is systemically weakened, so will almost invariably be given intravenous fluids during surgery. He’ll then be given a premed – this is a sedative, designed to make induction into anaesthesia gentler. It will usually contain the drug acepromazine, because the use of this before surgery has been demonstrated to reduce the risks of anaesthetics.

He’ll then be led into a knock-down box: this is a special padded room, designed to make induction of anaesthesia safer. Then he’ll be anaesthetised with an injection containing (usually) a mixture of 2 anaesthetic agents, ketamine (no, it’s not a tranquilizer, it’s an anaesthetic) and diazepam or a similar drug. Shortly after the injection, he’ll go wobbly, and then quickly lie down.

Once he’s asleep, the team will swing into action: a tube will be passed down his throat to help him breathe and he’ll be moved into the operating theatre. While this was going on, the surgeon(s) will have been scrubbing up, ready to start.

Once he’s in theatre and safely ensconced on a well cushioned table (to prevent pressure sores etc), he’ll be put onto anaesthetic gas to keep him asleep.

Colic3 - SurgeryThe surgery involves a long incision down the midline of the belly. The surgeons can then have a good look through all the intestines, to find the problem. This is the exciting, sexy bit, but it’s actually pretty simple in principle: “if in doubt, cut it out”. In other words, removing devitalized (dead) bowel, emptying out anything in the bowel that shouldn’t be there (e.g. a caecal impaction), replacing anything that’s got stuck in the wrong place (e.g. an entrapment) and untwisting anything that’s tied up. There are usually at least 2 surgeons, because one person is needed to hold loops of intestines (and they don’t stay still – sometimes they wriggle around in your arms)! Meanwhile, the anaesthetist will be carefully monitoring all sorts of parameters (heart rate, blood pressure, ECG, reflexes, breathing and blood gasses can all be monitored at many hospitals) and adjusting the anaesthetic and any other drugs to give the safest and most effective anaesthetic.

Once whatever the problem was has been found and (hopefully) sorted out, your horse will be returned to the recovery room. In many ways, this is the most dangerous part of the procedure. Horses are very prone to breaking things when they wake up, so everything is done to keep it as calm and quiet as possible. Sometimes, the veterinary team will help the horse to rise, using hoists and lifts; other times, it works out better to let him get up in his own time. In either case, he will be moved into a padded room, and left in dim light, as quietly as possible, so he wakes up slowly.

Once awake, and steady on his feet, he’ll be moved to an intensive care box; he’ll almost certainly be on a drip to keep him hydrated. At regular intervals through the next 24 hours (or longer) he’ll be checked by vets and nurses. In some cases, the guts don’t start working properly on their own, and medication may be needed to encourage motility (e.g. a lidocaine drip). Although everyone gets excited about the surgery, it is this recovery period that is in many ways the most important in getting a good long-term prognosis.

As time goes on, the vets and nurses will try and tempt the horse to eat – normally, we’ll try and get him eating fresh grass as soon as possible. As soon as he is stable enough and eating on his own, he’ll be sent home – most horses do better in their own home environment, so as soon as they no longer require advanced medical intervention, they can go home. Once home, it’s important that the discharge instructions from the hospital are followed – it can be tempting to try and speed things up, but don’t rush it! Major abdominal surgery takes time to recover from.

Colic is a worrying condition to have to deal with as an owner, especially as it often seems to come out of the blue. However, if you ever have to go through it, I hope that having read these blogs, you’ll have some idea of what’s being done, and why. Remember, our aim as vets is to help your horse and, if at all possible, send him home to you fit and well.

If you are worried your horse or pony may be suffering from colic, talk to your vet, or check the symptoms using our Interactive Equine Symptom Guide to help assess how urgent the problem may be.

Colic: Part 1: Diagnosis and Workup

Horse colic examination and anatomy
When talking about colic, it’s important to have some idea of what the various parts of the equine gut are… So, here we go:
Stomach – quite small, and hidden away deep up in the ribcage.
Small intestine - this is very long, but quite narrow (perhaps 1 or 2 inches across). It is all coiled up throughout the abdomen.
Large intestine – this is divided into three parts:
The Caecum is a large sac perhaps four or five feet long, pointing forward, and can be heard on the right flank. Generally, it makes a loud gurgling noise every 20 to 30 seconds in a normal, healthy horse.
The Large Colon makes up a double U shape, lying on the bottom of the abdomen. It can be up to a foot across, but at each end is a sharp 180-degree bend; the bend near the pelvis (the pelvic flexure) is especially narrow.
The Small Colon runs from the large colon down to the rectum, along the top of the abdominal space.

It’s something all horse owners dread – colic. However, colic is a symptom, not a disease in its own right, and has a wide range of different causes. This is the first in a three-part series where I’ll be looking at colic in horses – its diagnosis and treatment, and what happens if your horse has to be referred for surgery.

Put simply, all colic is, is abdominal pain. However, before you’re tempted to dismiss it as a stomach ache, it’s worth remembering that the horse’s intestines are as complicated as a major chemical factory! Anything that causes disruption to their function is potentially life-threatening.

Occasionally, colic pain comes from a non-intestinal source, e.g. Liver disease (think ragwort poisoning, or liver fluke), or a kidney issue. In mares, it can also be caused by certain disorders of the reproductive tract. However, the vast majority are due to disease, damage or malfunction of the intestines.

If you call your vet and tell them that your horse has colic, they’ll treat it as an emergency, because it can be. They’ll generally take a bit of history from you, a quick description of what the horse is doing at the moment, and then they’ll head out to examine the horse. Most vets will also give instructions for what to do while you’re waiting; it’s important to do what they say, not what someone else on the yard suggests. This is because they may have an idea what sort of colic your horse has, and will try to tailor their instructions to the specific case. For example, some forms of colic respond well to being trotted around on the lunge; however, that can worsen other types.

When they arrive, the vet will want to establish three things:
Firstly, does the horse actually have colic? I’ve been called out to “colic” cases that proved to be laminitis; to a mare foaling down; once even to a tired (but perfectly healthy) horse sleeping in his stable!
Secondly, assuming it is a colic, is it a Medical or a Surgical Colic? (I’ll talk more about this distinction in a minute).
Third and finally, can they make a specific diagnosis of what kind of colic it is?

Every vet will have their own routine, but my workup goes something like this:

What’s the horse’s behaviour like? Is he alert, or dull and unresponsive? Is he thrashing about, or just looking at his flanks occasionally? Generally, a quieter horse is likely to have a milder colic, unless he or she is so toxic that they are depressed or spaced out. One exception is that some spasmodic colics are incredibly painful – however, the pain usually comes in waves.

Are there any droppings in the stable? Hard, dry lumps of faeces is suggestive of an impaction, or blockage; while very runny faeces or diarrhoea may suggest colic secondary to an infection, e.g. Salmonella.

Then I’ll start my examination:

Mucous membranes (gums are usually most accessible and reliable) – what colour are they, what is the refill time, are they tacky?
The normal colour is described as being “salmon pink”, and if you press with a finger for a moment, the colour should fade to white, then return within 2 seconds. They should also be nice and moist to the touch. If they are red, or purple, or the colour doesn’t fade, it is highly suggestive of toxic shock (like septicaemia). This is a marker of a really, really severe injury to the gut wall, that’s allowing bacterial toxins to enter the circulation. If the refill time is greater than 2 seconds, or the membranes are tacky or dry, it suggests dehydration and/or shock.

Heart rate - how fast, is the rhythm good? As a (very rough and ready!) general rule, a heart rate under 60 beats per minute implies a Medical colic, while over 80 suggests a Surgical case. If there’s an abnormality in the rhythm, it can mean heart disease as well, or severe toxic shock.

Gut sounds - what do the guts sound like in all 4 quadrants?
This is where you’ll see your vet putting a stethoscope to the horse’s flanks, listening to the guts. The normal, healthy gut makes a wide range of bubbling, gurgling noises (the sort that anywhere else you would associate with really cheap plumbing!). The bottom left is the left Large Colon, bottom right is the right Large Colon and perhaps some Caecum, the top right is the base of the Caecum, and the top left is mainly small intestine. This is one of the most useful tests we can do – reduced sounds mean the guts are “slowing down” – this can mean an impaction or blockage, but it can also mean a serious disease e.g. a twisted gut. Increased sounds is generally a good sign, as it usually means a Spasmodic colic.

Finally, I’d want to take the temperature (a horse with a fever is likely to have another disease, e.g. Salmonella, that is the underlying cause of the colic), and then, if at all possible, do a rectal exam. People get very excited about this, and it’s one of the standard jokes about vets, but I’d like to go on record and say that I doubt anyone actually enjoys rectalling a horse! Apart from anything else, it’s dangerous to the vet, and uncomfortable to the horse… However, it can provide more information than almost any other test. What we’re feeling for is anything unusual: is the large colon a normal size and texture? How about the Caecum? Can you feel the small intestine? Usually, the small intestine is almost impossible to feel – it just slithers out of the way. If, however, you can feel thick, swollen loops of intestines (they feel a bit like black pudding, or really thick, soft sausages, if you’re interested!), it is an indication of a complete blockage in the small intestine, which needs emergency colic surgery. On the other hand, if you feel a doughy, squishy mass in the colon, that means the horse has an impaction.

Sometimes, if there is doubt about whether food is passing from the stomach or not, the vet will pass a stomach tube and see how full the stomach is. This looks really easy in theory – you pass a tube up the horse’s nose, he swallows it, and then you syphon out the stomach. If you get lots, it’s too full, if not, it’s fine. However, not all horses are quite so easy! Some horses are really difficult to get to swallow the tube, and it can take several attempts to make sure it’s not in the windpipe (which would be a disaster). Also, the equine stomach is, as one equine surgeon I know once put it, “a fantastic organ – it can be completely dilated (full), and you’ll get nothing out of it until you move the tube half an inch, then it all comes spurting out”. However, if there’s any doubt, it can be a great tool to ensure that there isn’t a rapidly life- threatening blockage; it can also be emergency first aid to prevent the horse’s stomach rupturing in a severe surgical colic.

The vet will also sometimes take blood samples – we tend to hold onto these in case they’re needed, but the main things we’re looking for are:
1) Evidence of dehydration – the blood tests will allow us to quantify the degree of dehydration, making it easier to plan a course of treatment.
2) Evidence of infection – if the white cell count is significantly abnormal, it suggests there may be something else causing the colic that we might need to look into.
3) Liver and kidney function – sometimes liver or kidney disease can present as colic
4) MOST IMPORTANTLY – Fibrinogen levels. Fibrinogen is a substance that can be used to assess inflammation and tissue damage – a high Fib level in a colic case is very suggestive that the gut integrity is damaged, and that surgical intervention may be needed.

There’s one other sample that can be very useful, especially as a “rule out” test if the clinical findings are contradictory or unclear. This is a peritoneal tap. This test carries some risk, but sometimes it’s the best way to find out what’s going on inside the abdomen. The belly of the horse is clipped, and prepared so make it as sterile as possible – we don’t want to risk introducing infection. The area is numbed with local anaesthetic, and then either a small incision is made with a scalpel and a blunt cannula inserted or (more usually) a small sterile needle is VERY CAREFULY inserted through the abdominal wall. The fluid that comes out is collected in a sterile sample pot for examination. The risk, of course, is that damage is done to the intestines; however, we’re very careful to avoid them as far as possible, and instead to collect the fluid that surrounds the intestines, the peritoneal fluid. In the lab, the numbers of cells can be counted to assess if there’s infection in the belly (peritonitis); however, in the field we can tell three things:
1) The tap fluid is clear (you can read text through it) yellowish – this suggests that the abdomen is basically OK, and means that in the absence of any other findings, the case can be managed medically.
2) The tap is cloudy, reddish or umber in colour - this means severe damage to the gut walls and/or peritonitis (infection in the abdominal cavity). This horse needs urgent referral for investigation at a hospital.
3) The tap contains gut contents (green or brown, lumpy) – sadly, this means that the intestines have ruptured; the horse is highly unlikely to survive. Alternatively, this may mean that the needle has gone into a part of the intestines, so if I get this, I’ll usually repeat the tap a few inches away, to make sure. If the needle has damaged the intestine, it’s not a disaster, but it is something to be avoided if possible.

So, using all the information from our history and workup, the vet has to decide if the colic is Medical or Surgical.

The terms are more or less self-explanatory: a medical colic can be managed with drugs, while a surgical colic needs emergency surgery.

As a rule of thumb, 9/10 colics are medical, and can almost always be managed on the yard. In my next blog, I’ll be looking at these Medical colics, their causes and treatment.

If you are worried your horse or pony may be suffering from colic, talk to your vet, or check the symptoms using our Interactive Equine Symptom Guide to help assess how urgent the problem may be.

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