Professional Documents
Culture Documents
19
Satellite Article
Small colon obstructions in the mature horse
J. SCHUMACHER
AND
T. S. MAIR*
Department of Large Animal Surgery and Medicine, College of Veterinary Medicine, Auburn University, Alabama
36849-5522, USA and *Bell Equine Veterinary Clinic, Mereworth, Maidstone, Kent ME18 5GS, UK.
Keywords: horse; small colon; obstruction; impaction; colic; enterolith; faecalith
Introduction
In this issue, Mair (2002) describes an unusual case of
small colon impaction associated with a granulosa cell
tumour in a pony mare. Small colon obstructions are
encountered quite commonly in practice and in this article
we describe the anatomy of the colon, together with the
clinical signs, diagnosis and causes and risk factors of such
conditions. We then consider the clinical implications
under the various categories of cause and pathogenesis.
Anatomy
The small (descending) colon originates at the aboral end of
the transverse colon, lies to the left of the root of the
mesentery and terminates at the pelvic inlet where it joins the
rectum. It is relatively long (2.5 to 4 m) and mobile within the
abdominal cavity, usually occupying the upper left quadrant,
together with the jejunum. The mesocolon of the proximal
portion of the small colon is short, but its length increases
caudally to 8090 cm, which allows it to move freely within
the abdomen (Getty 1975). Two wide muscular bands form
the characteristic sacculations of the small colon, in which
faeces accumulate in the form of faecal balls. One band is
concealed in the mesocolon and the other is situated along
the antimesenteric border. Blood is supplied to the small
colon via the left colic artery and cranial rectal artery.
Diagnosis
Small colon obstruction can sometimes be diagnosed by
palpation of the abdomen per rectum but, in other cases,
may be confirmed only by exploratory celiotomy (laparotomy).
Ultrasonography of the abdomen can also be useful for
diagnosis (Freeman et al. 2001). The classical finding during
palpation per rectum indicative of small colon obstruction and
impaction is the identification of a solid sausage-like tube
of ingesta within a section of intestine that has a palpable
antimesenteric band. The normal sacculations of the small
colon are lost as it distends with faeces. The smaller diameter
of the small colon usually distinguishes impaction of this organ
from the more common impaction of the large colon, but the
diameter of the distended small colon can be as much as
10 cm (Freeman et al. 2001).
Identifying the antimesenteric band can be difficult,
especially when the small colon is maximally distended. Gas
distension of the large colon and caecum may also
sometimes be identified during palpation per rectum of
horses with impaction of the small colon. Palpation of an
obstructing enterolith may be possible in some cases.
However, in many cases, enteroliths are located in the
proximal small colon and the stone and associated
gaseous distension are out of reach of the examiner.
The absence of positive rectal findings, therefore, does not
20
Vascular lesions
Intramural haematoma
Mesocolic rupture
Nonstrangulating infarction
Strangulating obstructions
Volvulus
Hernias
Intussusceptions
Pedunculated lipomas
Arabians, ponies and American miniature horses
appear to be predisposed to diseases of the small colon
compared with other breeds (Dart et al. 1992). Female
horses and horses greater than age 5 years are also more
likely to be affected.
Diffuse faecal impaction of the small colon occurs
most commonly in ponies and miniature horses and more
commonly in females (Dart et al. 1992). Old horses are more
susceptible to disease of the small colon caused by
strangulating lipomas, foaling injuries and intramural
Simple obstructions
Diffuse faecal impaction
Focal simple obstructions
- Enteroliths
- Foreign bodies
- Faecaliths
- Phytoconglobates
- Bezoars
Obstruction by an ovarian pedicle
Pedunculated lipomas
Neoplasia
21
Clinical signs
Horses initially exhibit mild signs of colic. Deterioration in
physical condition progresses slowly and results from
distension of viscera with gas and fluid proximal to the
obstruction. Deterioration progresses slowly because the
22
Diagnosis
Diagnosis on the basis of clinical signs and clinicopathological
data is often difficult. Consistently observed clinical features of
affected horses are reduced production or absence of
faeces, and absent or reduced borborygmi. Abdominal
distension is often present, and nasogastric reflux can be
obtained occasionally. Although the heart rate is usually
high, clinicopathological data (i.e. packed cell volume,
electrolytes, total plasma protein) are usually normal.
Examination per rectum is often helpful. One or more
loops of tubular, firm, digesta-filled intestine can be identified
during examination per rectum, and the single, free taenial
band can often be identified on the colon, confirming
the segment of intestine involved. Submucosal oedema of
the rectum and small colon, cranial to the pelvic inlet, can
sometimes be palpated (Edwards 1992). We have often
observed that, after palpation per rectum of horses with faecal
impaction of the small colon, the palpation sleeve is
covered with flecks of blood.
Treatment
Affected horses may be treated medically or surgically, but
horses treated medically may have a higher long-term survival
rate (Ruggles and Ross 1991). Horses with mild impactions are
generally responsive to simple treatments, including the
administration of mineral oil or solutions of saline or
magnesium sulphate via nasogastric tube, but more severely
affected horses require more intensive therapy.
Medical treatment
Objectives of medical treatment of horses with faecal
impaction of the small colon are to maintain hydration,
stimulate gastrointestinal motility, soften the impaction by
the administration of osmotic laxatives or lubricants and
control pain (Ruggles and Ross 1991). Intravenous
administration of a balanced electrolyte solution can be used
to overhydrate the horse, which causes secretion of fluid into
the intestine to hydrate and soften the mass of ingesta
directly. Intestinal motility is stimulated by replacement of
fluids and potassium and calcium. The frequency of urination
can be used to assess clinically the success of administration
of fluids in causing overhydration.
Treatment of horses with faecal impaction of the small
colon by administration of an enema has been advocated
as a method of achieving hydration inexpensively and for
softening the impaction. Because of the risk of perforating the
small colon during administration of an enema, care should
be taken when administering an enema to a standing
horse (Edwards 1992). Enemas should not be administered
under pressure. An enema bell (Fig 1) can be used, which is
Surgical treatment
The horse should be treated surgically when: 1) medical
management fails to resolve the impaction; 2) the abdomen
distends; 3) cardiovascular deterioration is detected; 4) the
nucleated cell count and concentration of total protein in the
peritoneal fluid increase, indicating early loss of intestinal
viability or 5) the horse remains painful even after
administration of analgesic drugs.
During celiotomy, the small colon is found to be packed
uniformly with ingesta, creating a tubular structure that has
none of the usual sacculations (Fig 3). Often the impaction
terminates at the pelvic inlet. The obstruction is cleared by
lavage introduced through a tube inserted through the anus
into the small colon. Insertion of the tube is aided by
transmural manipulation by the surgeon. Intraluminal lavage
with warm water and extraluminal massage by the surgeon
are used to relieve the obstruction (Meagher 1974).
Extreme care should be taken during manipulation of
the small colon to avoid intestinal rupture. Excessive trauma
to the intestinal wall may result in oedema which may predispose
to a recurrence of impaction (Edwards 1992). An alternative
technique to lavage via the anus is to perform lavage via an
enterotomy incision in the upacked segment of small colon; this
allows the impaction to be cleared with less trauma to the bowel
wall. To minimise early postoperative recurrence of small colon
impaction, the large colon should be evacuated through an
enterotomy at the pelvic flexure, if it is filled with ingesta.
Broad-spectrum antimicrobial agents should be
administered perioperatively. Metronidazole is effective
against anaerobic bacteria, which are in high concentration in
the small colon, and the authors have found this drug to be
useful in the postoperative period. Anorexia is an uncommon
adverse effect of metronidazole treatment (Sweeney et al.
1991). Fever, diarrhoea and laminitis are common
complications after surgery of the small colon and may
be related to increased absorption of toxins through the
inflamed intestinal wall. Horses undergoing surgery for
disorders of the small colon may be at high risk of developing
salmonellosis (Moore 1990; Edwards 1992), and antimicrobial
therapy may increase this risk by altering gastrointestinal flora.
The cause of the high incidence of salmonellosis in
horses treated surgically for impaction of the small colon is not
known. Feeding a complete pelleted diet for several weeks
after resolution of impaction may help to prevent re-impaction
by reducing colonic filling by increasing the concentration of
faecal water and by reducing resistance to flow through the
gastrointestinal tract.
Enteroliths
Enteroliths, or intestinal calculi, are mineralised concretions
(Fig 4) that develop in the large colon by concentric deposition
of salts around a central nucleus, usually a small silicon stone
or metal object (Ferraro et al. 1973; Blue 1979; Evans et al.
1981; Lloyd et al. 1987; Murray et al. 1992; Hassel et al.
1999). An enterolith can remain within the large intestine for
long periods without causing clinical signs of disease, and only
when it obstructs the lumen of the large/transverse or small
colon does the horse shows signs of abdominal pain.
Currently, enterolithiasis appears to be rare in the UK and
Germany but, in the 1800s, there were many reports of the
condition in England, especially in millers horses (Page 1856).
Enteroliths are most commonly seen in horses age 510 years
(Dart et al. 1992). The Arabian seems to be the breed most
commonly affected, and females of all breeds are more likely
than males to develop enteroliths (Lloyd et al. 1987; Dart et al.
1992; Edwards 1997).
Diagnosis
Diagnosis of obstructing enterolithiasis is based on clinical
signs and physical examination. An obstructing enterolith
blocks the passage of faeces but may allow the passage of gas
and intestinal lubricants, such as mineral oil. When mineral oil,
but not faeces, is passed, enterolithiasis should be suspected.
However, this sign is not diagnostic of enterolithiasis, since
other intestinal obstructions may also allow mineral oil to pass
to the rectum. An enterolith within the small colon typically
causes complete obstruction, and affected horses tend to
show signs of more severe abdominal pain than do horses
with partial or intermittent obstruction of the transverse or
right dorsal colon. Palpation of an enterolith in the small colon
is usually possible only when it is lodged in the rectum or distal
portion of the small colon. An enterolith in the proximal
aspect of the small colon is usually beyond the reach of
the examiner, and small colon distal to the enterolith is
usually flaccid and difficult to identify. If the enterolith has
lodged in the middle or distal portion of the small colon, loops
of gas-filled small colon may be recognised.
Diagnosis of enterolithiasis in horses showing clinical signs
of the disease can sometimes be confirmed by radiography
(Rose et al. 1980; Yarbrough et al. 1994). The large size of the
mature horse precludes obtaining radiographs that show
abdominal detail (Fischer 1997). Rare earth screens, highspeed film and an 8:1 focused grid should be used. Units with
an output of 600 mA may be required. The radiographic
technique with most conventional radiography units for an
average-sized horse requires an exposure time of up to 2 s.
Fischer (1997) reported the average exposure for the
mid-abdomen in his clinic to be 450 mA and 110 kVp.
Radiography is less helpful in the diagnosis of enterolithiasis of
the small colon than of the large colon (i.e. transverse colon),
and the absence of radiographic findings does not preclude
the presence of an enterolith. The incidence of failure of
radiographic examination to identify the presence of
23
Treatment
Treatment of horses suffering from obstruction of the small
colon by an enterolith is to remove the enterolith through a
celiotomy. Before removing an enterolith it should be
moved a few centimetres distally or proximally, if possible, so
that the enterotomy can be made in a more viable portion of
intestine. Studies show that longitudinal enterotomies
made through the antimesenteric taenia of the small
colon are superior to those made adjacent to the taenia in
maintaining the diameter of the lumen, in ease of closure,
and in minimising interruption of the blood supply (Archer et
al. 1988; Beard et al. 1989). Enterotomy performed through
the antimesenteric taenia results in less haemorrhage and
less inflammation, and sutured incisions through the taenia
are stronger at 96 h than sutured incisions adjacent to the
taenia. Closure of the mucosa as a separate layer offers no
advantage or disadvantage to healing in normal horses
(Beard et al. 1989).
Complications associated with enterotomies of the small
colon include leakage, visceral adhesions and stricture
formation. Factors that may adversely affect the outcome of
surgery of the small colon in the horse include the small
colons relatively poor blood supply, its high concentration
of collagenase, its high intraluminal concentration of
bacteria (including large concentrations of anaerobic
organisms), its muscular activity and the presence of firm
faeces (Stashak 1982; Keller and Horney 1985). The
mesocolon of the small colon is relatively short, making
exteriorisation of the proximal and distal ends of the small
colon difficult or impossible. The risk of peritoneal
contamination is high if enterotomy or resection and
anastomosis are necessary for those parts of the small colon
that are difficult to exteriorise.
An enterolith in the proximal end of the small
colon must often be repelled into the right dorsal colon and
then into the left dorsal colon for removal through an
enterotomy. An enterolith can be most easily and safely
dislodged and repelled proximally by retrograde infusion of
water into the small colon. To repel an enterolith proximally,
a stomach tube is inserted into the rectum and passed into
the small colon. The tube is guided to the obstruction by the
surgeon and, while the small colon is occluded by holding it
tightly to the tube, water is infused into the intestine until
the lumen expands to a size large enough to allow the
enterolith to be dislodged proximally (Taylor et al. 1979).
The enterolith is then repelled into the left dorsal colon
where it can be removed safely via enterotomy remote from
the abdominal cavity.
If the enterolith cannot be repelled into the left
dorsal colon, a taeniotomy technique can be employed,
whereby the seromuscular layer of the antimesenteric taenia is
incised to increase the luminal diameter of the small colon
adjacent to the obstruction. Using this technique, a
24
Prognosis
25
Clinical signs
Treatment
The obstruction must be removed before the small colon
surrounding it becomes necrotic. At surgery, the obstruction
should be manipulated a few centimetres distal or proximal to
the site of obstruction so that the enterotomy can be made in
normal intestine. If the involved segment cannot be
exteriorised, however, the obstruction should be repelled
proximally by retrograde infusion of water into the small colon
and removed through an enterotomy at the pelvic flexure of
the ascending colon (Taylor et al. 1979).
Fig 14: Strangulated small colon caused by a pedunculated
lipoma (courtesy of David Moll).
26
Pedunculated lipomas
Pedunculated lipomas usually cause strangulating obstructions
(see below) but, occasionally, the small colon may become
entwined around the pedicle, forming a half-hitch (Edwards
1992). This results in obstruction of the lumen but with only
minimal interference to venous drainage. If the obstruction
occurs towards the distal end of the small colon, a distinct
constriction in the small colon may be palpated per rectum.
Neoplasia
Neoplasia affecting the small colon is rare. Both lymphoma
(King 1993) and leiomyoma (Haven et al. 1991; Mair et al.
1992) (Fig 11) have been reported to occur at this site.
Mesocolic rupture
Mesocolic rupture and subsequent segmental ischaemic
necrosis of the small colon occur as a complication of
foaling. The condition is the result of direct trauma caused by
the foal as it positions itself for delivery. During late pregnancy,
the fetus is positioned ventrally but, during the first stage of
labour, the foal rotates into a dorsal position for delivery using
vigorous reflex movements of its neck and forelimbs. During
these movements, the small colon of the mare may become
trapped between uterus and dorsal portion of the body wall,
causing the mesocolon to tense and tear (Livsey and Keller
1986; Dart et al. 1991a).
Mesocolic rupture can also result from type IV rectal
prolapse, a condition sometimes associated with parturition.
The vascular arcade of the mesocolon may stretch and tear
when more than 30 cm of the rectum and small colon
prolapse through the anus (Fig 12).
Regardless of the cause of mesocolic rupture, infarction
results, causing functional obstruction and progressive signs of
colic. Segmental ischaemic necrosis of the small colon caused
by disruption of the mesocolonic vasculature should be
considered when examining a postparturient mare that shows
signs of abdominal pain. A consistent finding in affected
horses is failure of the horse to pass faeces.
Treatment involves resection of the infarcted colon. Access
to the viable portion of the small colon may be impossible,
however, especially if mesocolic rupture has occurred
secondary to rectal prolapse. In these cases, a colostomy or
rectocolostomy can be performed (Edwards 1997).
References
Archer, R.M., Parsons, J.C. and Lindsay, W.A. (1988) A comparison of
enterotomies through the antimesenteric band and the sacculation
of the small (descending) colon of ponies. Equine vet. J. 20, 406-413.
Beard, W.L., Robertson, J.T. and Getzy, D.M. (1989) Enterotomy
technique in the descending colon of the horse. Effect of location
and suture pattern. Vet. Surg. 18, 135-140.
Blue, M.G. (1979) Enteroliths in horses - a retrospective study of 30
cases. Equine vet. J. 11, 76-84.
Boles, C.L. and Kohn, C.W. (1977) Fibrous foreign body impaction
27
28
management of small colon impaction in horses: 28 cases (19841989). J. Am. vet. med. Ass. 199, 1762-1766.
Moore, J.N. (1990) Diseases of the small colon and rectum. In: The
Equine Acute Abdomen, Ed: N.A. White, Lea and Febiger,
Philadelphia. pp 392-402.
Spiers, V.C., van Veerendaal, J.C., Christie, B.A., Lavelle, R.B. and Gay,
C.C. (1981) Obstruction of the small colon by intramural
haematoma in three horses. Aust. vet. J. 57, 88-90.
Rose, J.A., Rose, E.M. and Sande, R.D. (1980) Radiography in the
diagnosis of equine enterolithiasis. Proc. Am. Ass. equine Practnrs.
26, 211-219.
Ross, M.W., Stephens, P.R. and Reimer, J.M. (1988) Small colon
intussusception in a brood mare. J. Am. vet. med. Ass. 192, 372374.
Yarbrough, T.B., Langer, D.L., Snyder, J.R., Gardner, I.A. and O'Brien,
T.R. (1994) Abdominal radiography for diagnosis of enterolithiasis
in horses: 141 cases (1990-1992). J. Am. vet. med. Ass. 205,
592-595.