22
Clinical evaluation of the foal
Evaluation of the foal with
colic
CS Cable
INTRODUCTION
" " """ ""
Colic in the foal is commonly encountered in equine
practice and has numerous etiologies. Evaluation of the
foal with colic is a diagnostic challenge since the rectal
examination - one of the primary tools used in the eval-
uation ofcolic in the adult horse - cannot be used in foals.
Furthermore, foals tend to be less tolerant of abdominal
pain than adults, making it difficult to distinguish
between conditions requiring medical or surgical
therapy. A significant number of foals with enteritis will
be initially examined for abdominal pain. Evaluation of
the foal with colic should include a thorough history, sig-
nalment, physical examination, clinicopathologic data,
and other diagnostic aids such as ultrasound examina-
tion of the abdomen and/or radiographic study of the
abdomen (with or without contrast medium). The infor-
mation obtained from these procedures can narrow the
list of differential diagnoses and help make the decision
as to whether medical or surgery therapy is warranted.
HISTORY
The historical events surrounding colic in the foal can
provide clues as to the true etiology of the colic episode.
Especially in the neonate, the peripartum events should
be discussed. Normal parameters for neonates are
gestational age - mean 341 days (range 315-365)
time to suckling reflex - normally suckles within 20
minutes
time to standing - mean 57 minutes (range 15-165)
time to nursing from mare - mean III minutes
(range 35-420).
In general, a foal that is not able to stand and nurse
by 2 hours of age should be considered potentially
abnormal.
Adequate intake and/or absorption of colostrum
should be evaluated by immunoglobulin (IgG) testing.
Inadequate immunoglobulin levels can result from
maternal disorders (premature lactation or agalactia),
or from illness in the foal. A foal with partial or com-
plete failure of passive transfer will be much more sus-
ceptible to infectious causes of colic (enteritis), than
the foal with adequate passive transfer.
Other information that should be obtained includes
age of the foal at the onset of colic
specific signs, e.g. bruxism, milk or food
regurgitation (reflux), nursing behavior, passage of
meconium and/or character of feces, straining to
urinate or defecate, rolling and/or lying on the
back
drugs administered and their effect
previous or current disease on the farm and its
treatment, e.g. diarrhea, respiratory infection (e.g.
Rhodococcus equi).
Furthermore, previous or concurrent disease in the
affected foal such as septicemia or musculoskeletal
disorders may predispose to gastrointestinal ileus,
ulceration, and/or peritonitis. Neonates undergoing
intensive care, especially those with premature body
449
22 GASTROINTESTINAL DISEASE IN THE FOAL
systems are predisposed to functional obstruction of
the gastrointestinal tract resulting from ileus. Older
foals with a history of diarrhea and/or chronic colic
and failure to thrive are more likely to have intermit-
tent or chronic ileocecal intussusception or gastric
ulceration.
SIGNALMENT
Age at the onset of signs of colic can help form the dif-
ferential diagnosis in a foal with colic, especially for the
neonate. For example, foals with atresia coli, lethal
white syndrome (ileocolonic aganglionosis), or meco-
nium impactions usually present within 12-36 hours of
birth with a distended abdomen and failure to pass
meconium. Neonates with uroperitoneum usually pre-
sent at 3 days of age with depression, distended
abdomen, and/or abnormalities with urination.
The breed of the horse can also help indicate disease
processes, for example, miniature horse foals are quite
predisposed to small colon impaction due to fecaliths.
EVALUATION AND PHYSICAL
EXAMINATION " ,q, , ' d " " d ' , '",'" ""
A complete physical examination is paramount in the
evaluation of the foal with colic, especially in the new-
born, as overlooking other congenital disorders not
associated with the cause of the abdominal pain can
lead to a disastrous end result, as well as needless waste
of money by the owners.
Observation from a distance
Examination of the foal should begin by observing the
foal in its environment without restraint. Valuable infor-
mation can be obtained by simply standing quietly at
the side of the stall. By observing the foal with the mare
in a stall or in a small paddock, the clinician can get a
better idea of the true severity of pain, as foals that are
being restrained often can not or will not display mild
to moderate signs of pain. The foal's nursing behavior
can also be observed, for example the foal that nurses
then detaches from the teat early and retreats to grind
its teeth and salivate, might indicate possible gastric
ulceration.
Foals should also be observed for abnormalities of
the musculoskeletal system such as lameness and angu-
lar or flexural deformities; these are problems that the
owner mayor may not be aware of. Lameness especially
warrants closer investigation as septic arthritis requires
immediate treatment and may decrease the prognosis
450
Figure 22.1 Foal with a ruptured bladder straining to
urinate frequently, the posture is characterized by spread
hind legs, a sunken back (concave shape), and elevated tail
significantly, the owner must be made aware of the
problem and appraised as to the potential for treatment
at this time or in the near future.
Foals that are straining can be observed in the
'" ,", ",>,,>,",' " " ,
stall, to ascertain if they are straining to defecate or
urinate. Foals that are straining to defecate arch their
backs (convex shape) and elevate their tails, while
foals straining to urinate will usually spread their legs,
sink their backs (concave shape) and elevate their
tails (Figure 22.1). This distinction is important and
can help guide further diagnostics. Methods to pre-
vent excessive straining should be used such as
epidural anesthesia or lidocaine enemas. At the
author's hospital foals have been seen to develop sec-
ondary uroperitoneum, because of excessive straining
to urinate or defecate.
Physical examination
After the distant examination is complete the foal
should be restrained for a thorough physical examina-
tion. During the physical examination it is again very
important to evaluate all body systems, not just the
gastrointestinal system. The age of the foal will dictate
normal parameters for the heart rate and respiratory
rate. A neonate will have an elevated heart rate and
respiratory rate compared to an older foal. Neonates
less than 1 week of age will have heart rates in the
range of 70-100 bpm and respiratory rates in the
range of 20-40 breaths per min, whereas older foals
will have heart rates in the range of 30-60 bpm and
respiratory rates in the range of 12-20 breaths per
min (Table 22.1).

Age Heart rate (bpm)
newborn 40-80 (at birth)
130-150 (during attempts
to stand)
70-100 (first day)
7 days 70-100
3 months 30-60
Cardiovascularsystem
The cardiovascular system should be evaluated care-
fully. Mucous membranes should be moist and pink,
with a capillary refill time of 1-2 seconds. Tachycardia
can represent pain, hypovolemia, endotoxemia, and/or
septicemia. However, bradycardia may represent hypo-
glycemia which may warrant immediate treatment with
intravenous dextrose. Bradycardia can also be present
with severe hyperkalemia as can be seen with uroperi-
toneum. Murmurs are only common during the neo-
natal period, usually caused by the incomplete closing
of the ductus arteriosus. This often results in a loud,
grade I-IV systolic left-sided murmur at the third inter-
costal space.
Respiratory system
The respiratory system should also be evaluated care-
fully. Breath sounds are easily auscultated in the new-
born, unlike the adult. Foals should be evaluated as to
the pattern of breathing and for any lack of breath
sounds indicating severe respiratory disease, greatly
increasing complications while under anesthesia.
Neonates should also be evaluated for the possibility of
fractured ribs - displaced rib fractures can lead to
laceration of the lung tissue and pneumothorax.
Gastrointestinal system
The gastrointestinal system should, of course, be evalu-
ated carefully for evidence of the cause of colic.
Abdominal distension can be detected on visual exami-
nation. Abdominal distension can be caused by fluid
inside or outside the gastrointestinal tract as well as gas
distension of the small or large intestine (see
Differential diagnosis and evaluation of the foal with
abdominal distension). Unlike the adult, gas or fluid
distension of the small intestine can cause visible
CLINICAL EVALUATION OF THE FOAL 22
Capillary
Respiratory rate Temperature refill time
(breaths per min) (OC) (sec)
60-80 (first hour) 37.2-38.9 <2
20-40 (first day)
20-40 38.0-39.0 <2
12-20 37.5-38.5 <2
abdominal distension in the foal, whereas colonic
distension is more likely to cause visible abdominal
distension in the adult horse (see Chapter 17).
Excessive fluid within the abdomen can be caused by
ascites
peritonitis
uroperitoneum
hemoperitoneum.
Fluid and/or gas distension of the intestinal tract can be
caused by either enteritis or bowel obstruction (stran-
gulating or non-strangulating) and can not be defini-
tively diagnosed without radiographs or an ultrasound
examination of the abdomen. Abdominal distension can
be measured by shaving some hair on the dorsal aspect
of the foal's back as a marker and using white tape to
measure the circumference of the abdomen. This can be
effective at sequential examinations to determine if the
foal's abdomen is increasing or decreasing in size.
Rectal examination
A digital rectal examination can be performed, espe-
cially in the neonate to check for the presence of
retained meconium. The meconium is hard and
pelleted and usually felt at the brim of the pelvis. A
digital rectal examination should also be performed in
neonates without a history of meconium passage to
check for any fecal straining. The lack of fecal straining
and only the presence of mucus are indicative of a con-
genital disorder such as atresia coli or ileocolonic agan-
glionosis. If a digital examination is to be performed
the rectal temperature should be taken first. If the foal
is febrile and' colicky', enteritis should be suspected.
Auscultation and palpation
Auscultation of the abdomen can be performed to
determine if there is gastrointestinal motility.
451
22 GASTROINTESTINAL DISEASE IN THE FOAL
Simultaneous percussion and auscultation and a char-
acteristic 'ping' can determine the presence of a gas-
distended viscus. Abdominal ballottement can be used
to detect fluid present within the abdominal cavity.
Abdominal palpation can be rewarding in some foals,
however it is not useful if the abdomen is tense or in
older foals. Palpation of the external umbilicus should
be performed in all young foals to evaluate for
drainage, heat, or enlargement. Umbilical hernias
should also be evaluated and determined if reducible.
Non-reducible hernias usually indicate entrapped
bowel. A transabdominal ultrasound examination is
needed to fully evaluate the umbilical remnants. Intact
male foals should also be palpated externally in the
scrotal area to determine if an inguinal (scrotal) hernia
is present. If present, it must be determined if the her-
nia is reducible. Congenital inguinal hernias can be
manually reduced multiple times a day and after a few
weeks the vaginal ring will often decrease in size with
resolution of the hernia.
Examination of the eyes
An examination of the anterior chamber of the eye
should also be part of the physical examination of a
neonate. Uveitis characterized by fibrin within the ante-
rior chamber may indicate sepsis or blunt trauma to the
eye. The yellow fibrin in the anterior chamber may
make the normally brown iris appear green.
OTHER DIAGNOSTIC PROCEDURES
Nasogastric intubation
Another diagnostic procedure that can be performed
on foals of all ages is the passage of a nasogastric tube.
Obtaining gastric reflux in the neonate can be difficult,
even with a distended stomach. However, if gastric
reflux is obtained the presence of a functional or
mechanical obstruction of the stomach or small intes-
tine is indicated. For neonates, a stallion catheter can
often be used to check for reflux, in older foals a small
sized nasogastric tube can be used. Older foals may
need to be sedated to prevent injury to the foal, han-
dlers, or veterinarian.
Sedation during examination
Foals that are in severe pain can be hard to restrain, and
are dangerous and difficult to examine. Sedation of
these foals is warranted to prevent injury to handlers,
technicians, clients, and veterinarians. During the
examination, small doses of xylazine (0.5 mg/kg i.v.)
can be administered to allow both the physical
452
examination to proceed and the placement of ajugular
catheter to administer further medications and intra-
venous fluids. Xylazine, an alpha agonist, is a good
choice for short-acting sedation, also providing analge-
sia. The effects of xylazine usually last from 10-20 min-
utes with an intravenous dosage. This drug dosage can
also be administered with butorphanol, a mixed opioid
agonist/antagonist, to provide additional analgesia and
prolong the sedative effects. Other alpha agonists such
as detomidine, are not used in the author's hospital for
sedation of foals because of the profound sedation they
impart, as well as the duration of action which may
delay the decision for surgery. An overdose of the alpha
agonists can be reversed with yohimbine.
Radiography (see section on Diagnostic imaging)
Although, because of their size, a rectal examination
can not be performed in foals, abdominal radiographs
can be taken easily. Lateral views are the standard views
taken, with the foal standing or in lateral recumbency
after sedation. Dorsoventral views are usually not neces-
sary, and can be quite stressful for a foal with moderate
to severe abdominal distension. From these radi-
ographs the nature of the distension - small versus large
intestine - can be determined. Large loops of distended
small intestine with hairpin turns, for instance, repre-
sent an obstruction of the small intestine. Fluid outside
the gastrointestinal tract can also be identified.
Contrast radiography can be used to identify
obstruction of the gastrointestinal tract and/or disrup-
tion of the urinary tract. Barium can be used to identify
obstruction of the distal or proximal gastrointestinal
tract. Barium can be administered through a nasogas-
tric tube at 5 ml/kg (30% w/v) to identify delayed gas-
tric emptying and/or duodenal stricture. It has also
been reported that barium administered via a Foley
catheter as an enema at a dosage of 20 ml/kg has been
used to identify obstructions of the small and large
colon. According to one report, meconium impactions
and atresia coli have been identified using this
technique.
Ultrasonography (see section on Diagnostic imaging)
Ultrasonography has also been used to identify lesions
of the gastrointestinal tract in foals and adults, and can
provide valuable information for the foal with colic
and/or distended abdomen. A 5-MHz probe can be
used to evaluate the abdomen and determine the
quantity and character of peritoneal fluid.
Abdominocentesis can be performed after fluid is iden-
tified to decrease the risk of enterocentesis.
Ultrasonography can also be used to identify abscesses
or enlarged lymph nodes within the gastrointestinal
 CLINICAL EVALUATION OF THE FOAL 22
tract and abnormalities or abscesses of the umbilical for best viewing. The mucosal surface of the duodenum
remnants. Both small and large intestine can be imaged should be evaluated for erosions, ulceration, or stric-
to determine wall thickness and motility. The small tures.
intestine can be imaged also to determine lumenal size
(diameter). In a recent report, adult horses with acute Abdominocentesis
abdominal pain were evaluated via transabdominal
Abdominocentesis, a mainstay for evaluation of colic in
ultrasound prior to abdominal surgery. Horses within
the adult, is often not performed in the foal due to fears
this study with abnormal small intestine and lack of
of puncture or laceration of the bowel wall (see Chapter
motility detected on ultrasound prior to surgery, were
2). Abdominocentesis however, can yield significant
found to have 100 per cent sensitivity, specificity, and
information in determining the cause of the acute
positive and negative predictive values for having a
abdomen or to determine surgical versus medical
strangulating small intestinal lesion at surgery.
therapy. At the author's hospital abdominocentesis in
Although a similar study needs to be performed in foals,
the foal is not performed before a complete transab-
from this study, it is highly predictive that foals with
dominal ultrasound examination of the foal has been
abdominal pain and similar ultrasonographic findings
made. This examination can determine the quantity
(dilated, non-motile small bowel) would likely require
and location of peritoneal fluid in the abdomen. Foals
surgery.
with excessive abdominal fluid are good candidates for
abdominocentesis as they can be heavily sedated,
Endoscopy placed in lateral recumbency, and restrained well for
the procedure. To prevent inadvertent laceration of the
Endoscopy is used in foals with abdominal pain to assess
bowel in a foal, a teat cannula is used rather than hypo-
the esophagus, stomach, and proximal duodenum (see
dermic needles. A disadvantage of using a teat cannula
Chapters 2 and 23). It can also be used to assess the rec-
for abdominocentesis is that an omental hernia may
tum and small colon if other procedures fail to provide
subsequently occur in a small percentage of foals.
a diagnosis. Most commonly endoscopy is used to assess
Although this is a rather benign complication it can be
the stomach for gastric ulceration. The stomach is often
alarming to the owner. A small local block can be per-
assessed to confirm a diagnosis of gastric ulceration and
formed with 2% mepivacaine on the ventral abdomen
to monitor response to treatment. Foals should be
to the right of midline, or where fluid is located,
sedated or even anesthetized if necessary, to facilitate a
although avoiding the spleen and the umbilical rem-
complete endoscopic examination. To assess the
nants. A small stab incision is made with a no. 15 blade
stomach, foals will often need to be withheld from food
to penetrate skin and the abdominal musculature. The
and water and/or milk for 2-6 hours (depending on
sterile teat cannula is then gently introduced into the
age and amount of intake) before the examination to
abdomen and fluid is collected for evaluation.
allow the stomach to empty.
Furthermore, from this position foals with uroperi-
Gastroscopy in foals under 1 month of age can be
toneum can have a drain placed to help evacuate the
performed using a scope that is 1 meter in length and
excessive fluid. In older foals abdominocentesis can be
10 mm or smaller in diameter. Older foals (4-6 months
performed from a standing position with an 18-gauge
of age) will require an endoscope 2 meters in length to
needle or teat cannula. Abdominocentesis can be per-
evaluate the stomach and duodenum. The endoscope
formed safely in these foals if the foal is adequately
should be passed through the nostril and then into the
sedated and restrained.
esophagus. Passage is continued until the stomach is
entered. At this time, the stomach should be distended
with air to facilitate a complete examination. If the
stomach contains fluid and/or feed material, it may be CLINICOPATHOLOGIC DATA
possible to suction off the fluid, alternatively the proce-
dure can be postponed for several hours. Retention of Information obtained from clinicopathologic tests can
fluid or feed material within the stomach may indicate shed valuable information about the condition and
pyloric or duodenal stricture. The surfaces of the prognosis of the foal. In all foals presented for evalua-
stomach should be evaluated for areas of ulceration or tion of colic, a complete blood count, chemistry panel,
erosions. After complete evaluation of the stomach and venous blood gas analysis should be performed. An
(squamous portion, glandular portion, and margo abdominocentesis should be performed when applica-
plicatus and pyloric antrum) then the scope can be ble. Immunoglobulin levels should also be evaluated in
advanced through the pylorus into the duodenum. neonates.
Again, the duodenum will need to be distended with air The complete blood count can detect and/or

453
22 GASTROINTESTINAL DISEASE IN THE FOAL
confirm sepsis, hypoproteinemia, or anemia. The pres-
ence of band neutrophils (left shift) with or without
toxic changes on the hemogram can also help deter-
mine the severity of infection.
Electrolyte analysis is also very important not only in
the diagnosis of abdominal disorders in foals, but can
direct initial treatment as foals with colic can have sig-
nificant fluid loss or sequestration. Portable electrolyte
units such as the I-Stat, can make electrolyte and blood
gas analysis in the field feasible, quick, and very afford-
able, thus reducing the time between recognition of the
problem and its treatment. Electrolyte values for foals
can be different to those for adults, as foals often have
higher phosphorus and lower sodium values than
adults. Electrolyte values for certain diseases are very
characteristic, such as uroperitoneum and enteritis.
Foals with uroperitoneum usually have
hyponatremia
hypochloremia
azotemia
hyperkalemia.
Whereas foals with enteritis often have
hyponatremia
hypochloremia
acidemia.
Glucose should also be evaluated in neonates because
foals that are unable to nurse can develop profound
hypoglycemia. Glucose is usually part of a routine
chemistry panel but can also be evaluated with a gluco-
meter or reagent strip in the field for quick analysis.
Venous or arterial blood gas should be a routine part
of the complete clinicopathologic data set on a foal with
abdominal pain. Severe abdominal distention can
lead to respiratory compromise in the young foal.
Furthermore, if neonates are allowed to remain in lat-
eral or dorsal recumbency, they may also have difficulty
maintaining normal oxygenation.
Evaluation of the peritoneal fluid in foals includes
total protein, total nucleated cell count, red blood cell
count, and a cytologic examination. The normal range
of total protein in abdominal fluid is the same in foals
and adults, less than 2.5 g/dl. The total nucleated cell
count however, has been reported to be lower in foals
than adults and as such nucleated cell counts greater
than 1.5 x 109/1 1500 cells/ill) are considered abnor-
mal. Cytologic examination of the fluid is also impor-
tant in the foal, as in the adult, to screen for bacteria,
plant material, or degenerative changes in the cells.
Foals with suspected uroperitoneum should have a sam-
ple of abdominal fluid evaluated for creatinine levels.
This level should be compared to the creatinine level in
serum, and if the ratio of peritoneal creatinine to serum
454
creatinine is greater than or equal to 2:1, the diagnosis
of uroperitoneum can be confirmed.
Thorough evaluation of the foal with abdominal
pain including a complete physical examination, and
using additional modalities such as radiography, ultra-
sound, endoscopy, and clinicopathologic data, enables
the veterinarian to compile a list of differential diag-
noses, initiate treatment, and decide between medical
and surgical therapy in the foal. Although these cases
can be challenging, the outcome can be quite success-
ful.
Diagnostic imaging
procedures in the foal
JM Reimer
Ultrasonography of the gastrointestinal tract of the foal
is particularly rewarding because of the high incidence
of small intestinal disorders and the reduced digestive
development of the colon in the foal. In contrast to the
value of ultrasonography in identifying small intestinal
problems, the content of the colon often contains a
large amount of gaseous material which impedes ultra-
sonographic evaluation. Plain radiography may be use-
ful in the evaluation of disorders in the foal in which a
large amount of gas is present within the small intestine
or colon. Diaphragmatic hernias and pneumoperi-
toneum can also be diagnosed with radiography.
Contrast radiography is primarily useful in the diagno-
sis of meconium impactions, colonic atresia, and duo-
denal stricture in the foal.
ULTRASONOGRAPHY
The abdomen should be clipped as for exploratory
celiotomy. In lieu of clipping, liberal amounts of alco-
hol may be applied to the region to be examined in
some cases. If possible, the examination should be per-
formed with the foal in a standing position because
fluid-filled, edematous, or intussuscepted segments of
intestine, or any excessive peritoneal effusion, will tend
to gravitate to the dependent portion of the abdomen.
Such abnormalities may be difficult to visualize with the
foal in lateral recumbency. Otherwise an attempt
should be made to place the transducer as far beneath
the foal as possible, or to elevate the foal's abdomen in
order that the transducer may be positioned ventrally.
Ultrasonography performed with the foal in dorsal
recumbency will rarely be rewarding as gas-filled seg-
ments of intestine will often obscure visualization of
 CLINICAL EVALUATION OF THE FOAL 22
underlying structures. Transducer frequencies in the which there is gastric distension due to increase in gas-
range of 7.5-5.0 MHz are recommended for evaluation tric fluid content, the lumen of the stomach and the
of the gastrointestinal tract of the foal. Depth display borders of the stomach may be visible (Figure 22.4). A
depends in part on limitations of the transducer fre- gas-fluid interface may also be noted in some cases.
quency used; generally using a depth display of 10 em
initially, and altering it during the examination is Small intestine
appropriate. If there is a large amount of fluid ingesta
The small intestine normally has few contents within its
or peritoneal effusion present, then a greater depth dis-
lumen (Figure 22.5), and grossly visible motility may be
play will enable visualization of deeper structures and a
difficult to discern. In disease states, the small intestine
lower frequency transducer may be necessary. A shorter
can be evaluated for wall thickness, lumen content,
depth display and possibly a higher frequency trans-
degree of distension, and motility. Amotile loops of
ducer will provide optimal diagnostic images if detailed
intestine that appear taut are typical of complete
imaging of a structure adjacent to the body wall is
mechanical obstruction such as small intestinal volvulus
desired. The presence of gas at any depth obviates an
(Figure 22.6), while a less taut appearance may be seen
increase in depth display as the ultrasound beam will
with incomplete mechanical obstruction, or functional
not penetrate beyond that point.
ileus as seen in some cases of enteritis (Figure 22.7). In
Ultrasonography enables visualization of portions of
the stomach, duodenum, jejunum, and some segments
of the large intestine and small colon (if filled with fluid
contents or meconium).

The stomach
The stomach can be visualized from the left cranial
abdomen in the young foal. Occasionally the stomach
will be in contact with the ventral body wall, or at least
be visible immediately dorsal to the ventral aspect of the
liver when viewed from the ventral abdomen (Figure
22.2). Mild curds surrounded by anechoic fluid, uni-
form echogenic fluid, or gas-bubble-laden fluid is nor-
mally seen in suckling foals within the stomach lumen
(Figure 22.3). Otherwise only the stomach wall will be
seen as the high gas content of the ingesta will result in
a bright linear echo at the lumen, and the character of Figure 22.3 Normal stomach in a neonatal foal as viewed
the gastric contents will not be appreciable. In cases in from the left cranial abdomen. Notice the echogenic
material (presumed to be mild curds) surrounded by fluid

Figure 22.2 Normal stomach in a neonatal foal as viewed Figure 22.4 Markedly fluid-filled stomach in a neonatal
from the left cranioventral abdomen. Cranial is to the left. foal with anterior enteritis. Cranial is to the right. Notice
In this case the stomach is visible immediately dorsal to the the splenic vein (arrows) which can be used as a landmark
spleen

455
22 GASTROINTESTINAL DISEASE IN THE FOAL
Figure 22.5 Normal small intestine dorsal to the spleen, as
visualized from the ventral abdomen in a neonatal foal
Figure 22.7 Distended fluid-filled loop of small intestine
(amotile in real time) in a foal with ileus due to enteritis
Figure 22.9 Gas-bubble-laden fluid in the colon (long axis
view) of a young foal with colitis
456
Figure 22.6 Distended fluid-filled small intestine (short axis
view) with sedimentation of contents in one segment
(arrows) in a foal with complete mechanical obstruction
and ileus found to be due to small intestinal volvulus. It
should be noted that differentiation between mechanical
ileus and severe functional ileus may be difficult
Figure 22.8 Thickened or edematous small intestinal wall
(short axis view) with increased lumenal fluid content,
amotile in real time, in a neonatal foal with abdominal
pain and diarrhea. The foal died at 48 hours of age
because of clostridial enteritis
Figure 22.10 Small intestinal intussusception, short axisview
 CLINICAL EVALUATION OF THE FOAL 22
cases in which strangulation has resulted in devitaliza-
tion of the affected segment, differentiation of me chan-
ical ileus from enteritis with functional ileus may be
difficult. Devitalized segments of strangulated small
intestine may appear less taut because of loss of intesti-
nal tone, and thicker as edema of the wall develops.
Typically small intestine enteritis is manifest as hyper-
motile fluid-filled segments of small intestine with nor-
mal wall thickness. Infrequently, the wall may be
thickened or edematous (Figure 22.8). In cases of
necrotizing enteritis gas may be seen within the wall of
the intestine (it should be noted that gas may also be
seen within the wall of devitalized strangulated small
intestine) or the wall may appear very thin. Increased
fluid content in the large intestine (Figure 22.9) may be Figure 22.11 Meconium (arrows) in a foal with a
observed in some cases of enteritis, and its presence meconium impaction. Because meconium may be seen in
may be of help in the differentiation offunctional from the intestine normally, the diagnosis of meconium
impaction should not be based on the results of ultra-
mechanical small intestinal ileus. The diagnosis may be
sonographyalone
unclear in some instances and repeat ultrasound exam-
inations may be of benefit.
Small intestinal intussusceptions have a typical
'bull's eye' appearance when viewed in short axis
(Figure 22.10). Variable amounts of small intestinal dis-
tension proximal to the lesion may accompany intussus-
ception. It is particularly important to position the foal
standing if possible in order that the most dependent
portion of the abdomen can be examined with ultra-
sound. Affected loops of fluid-filled or edematous intes-
tine, or intussuscepted intestine; will tend to gravitate to
the most dependent area of the abdomen.

Colon
The colon often contains gaseous ingesta and its lumen
is generally not easily evaluated in the equine. In foals
with colitis, the contents of the colon may appear as
bubble-laden fluid (Figure 22.9). Meconium appears as
hypoechoic structures within the large and/or small
colon (Figure 22.11). Because meconium can be visual-
ized in the normal equine neonate a diagnosis of meco-
nium impaction by ultrasound alone can be erroneous.
Peritoneum
Peritoneal effusions can be identified in foals with peri-
tonitis, uroperitoneum, hemoperitoneum, and transu-
dates. Effusions due to accumulation of transudate may
be identified in foals with mechanical gastrointestinal
obstructions. The fluid may appear anechoic in cases of
uroperitoneum, transudative effusions, and ruptured
viscus. In cases of ruptured viscus, the effusion may
range in appearance from anechoic to echogenic, and
mayor may not contain a large amount of gas bubbles
or other echoes within the fluid (Figure 22.12). Gas
echoes within the fluid are not always identified in cases
Figure 22.12 Marked peritoneal effusion with particulate
matter in a foal with a ruptured viscus. The spleen is
indicated by arrows
of ruptured viscus, however a gas-fluid or gas-spleen
interface may be seen from the left paralumbar fossa
(with the foal in a standing position) in cases with
significant pneumoperitoneum. Abdominocentesis
should be performed to confirm the type of fluid
present as the ultrasound appearance of effusions is not
specific. Visual inspection of the fluid, as well as exami-
nation of the fluid microscopically (particularly if the
cell count is normal) is very important to rule out a rup-
tured viscus.
RADIOGRAPHY
Ultrasonography has obviated radiography for most
gastrointestinal disorders in the foal because of the

457
22 GASTROINTESTINAL DISEASE IN THE FOAL

Figure 22.13 Distended barium-filled stomach, 3D minutes

after administration of barium sulfate via nasogastric
tube, in an unthrifty weanling foal with bruxism,
inappetance, and gastric reflux. Notice the absence of
barium in the small intestine. Duodenal stricture was
confirmed at surgery
Figure 22.14 Lateral radiographic view following a barium
sulfate enema of a 3D-hour-old foal with colic due to
meconium impaction. Notice the silhouetting of
meconium balls in the rectum and terminal small colon,
and the marked gas distension of the colon

portability of the ultrasound units and because of its

ability to both visualize intestinal motility in real time
and detect peritoneal effusions. It is often not possible
to distinguish mechanical from functional obstructions
with radiography, and ultrasonography may provide
more diagnostic information in such cases.
Diaphragmatic hernias may be identified radiographi-
cally, as with ultrasonography. Radiography, in combi-
nation with contrast studies, is most useful for the
diagnosis of atresia coli, meconium impactions, and
evaluation of gastrointestinal transit time. Standing
lateral radiographs are exposed at 10-15 rnA and
80-120 kVp, with an 8:1 grid, film focal distance of
1 meter, and rare earth film screen combination. Gas
Figure 22.15 Lateral radiographic view of the abdomen
caps are normally seen over the stomach, small intes-
following a barium sulfate enema of an 8-hour-old foal
tine, cecum, and colon. For contrast studies, barium sul- with abdominal distension and colic. Notice the barium
fate is administered at 5-10 ml/kg as a 30 per cent w/v through the small colon, it has entered the large colon and
solution by nasogastric tube. The stomach should begin ended in a blind pouch. Exploratory celiotomy revealed a
to empty by 15 to 30 minutes and be nearly empty by 2 wall or diaphragm closure between the left and right ven-
hours, at which time contrast material may be seen in tral colons at the level of the sternal flexure, with intact
the cecum and colon. Duodenal stricture will result in mesentery. An anastomosis was performed and the foal
gastric distension and retention of barium (Figure recovered uneventfully. In the vast majority of cases of
22.13). Retrograde contrast radiography is highly sensi- atresia coli, a large segment of the large, transverse, or small
tive and specific for evaluating obstructions of the small colon is absent, and surgical correction is rarely feasible
colon or transverse colon, such as those due to meco-
nium impaction. Approximately 500-1000 ml of barium immediately. Meconium impaction will appear as filling
sulfate solution (30% w/v) for a 50 kg foal is adminis- defects within the small colon or rectum, with silhouet-
tered via enema into the rectum by gravity flow using a ting of the fecal balls by the barium (Figure 22.14). If
soft flexible catheter. The author has found that a Foley the obstruction is just proximal to the pelvic inlet, a
catheter has been unnecessary for such studies. widening of the small colon at this location because of
Sedation of the foal may be required in some cases. meconium may be observed. Atresia coli may also be
Administration of barium should be discontinued when diagnosed by retrograde contrast radiography in most
the barium flows back around the catheter or the cases. The contrast material will stop abruptly in a blind
foal becomes uncomfortable. Radiographs are taken pouch (Figure 22.15). Tapering of the contrast material

458

Figure 22.16 Lateral radiographic view following barium
enema of the terminal small colon and rectum of a 1-day-
old foal with abdominal pain and distension. An inadequate
amount of barium sulfate has been administered to reach
the small colon, however notice the empty corrugated
appearance of the small colon. Because of intractable
abdominal pain, the foal was taken to surgery rather than
continue with the diagnostic procedure. Atresia coli was dis-
covered at exploratory surgery and the foal was euthanized
within the small colon indicates that an inadequate
amount of contrast material has been administered to
reach the transverse colon (Figure 22.16) and more
barium may be required. In general, standing radi-
ographic views have been sufficient in the author's
experience, however ventrodorsal views may be neces-
sary in some cases. Occasionally the atretic segment is
too proximal to be diagnosed with a retrograde contrast
study. Incidentally, a collapsed corrugated appearance
to the small colon has been observed by the author in
some cases of atresia coli (Figure 22.16).
Differential diagnosis and
evaluation of the foal with
abdominal distention
CS Cable
INTRODUCTION
Abdominal distension can occur in foals of any age and
is most often accompanied by signs of abdominal pain.
Abdominal distension can occur in the foal however,
without signs of colic. Abdominal distention occurs
most commonly in adult horses with large colon disten-
sion (see Chapter 17). However, in foals, small and
CLINICAL EVALUATION OF THE FOAL 22
large intestinal distention, as well as excessive abdomi-
nal fluid accumulation, will lead to abdominal disten-
tion. Abdominal distention in the foal is most
commonly caused by gastrointestinal disorders, usually
some type of intestinal obstruction (functional or
mechanical, congenital or acquired). However, other
disorders such as rupture or leakage of the urinary tract
can lead to uroperitoneum and subsequent abdominal
distention. This section considers the differential diag-
nosis of abdominal distention in the foal and the evalu-
ation of foals with this condition.
History
Evaluation of the foal with abdominal distention begins
with a thorough history, including peripartum events.
Neonates should be evaluated as to their immunoglob-
ulin status and treated if partial or complete failure of
passive transfer is suspected.
PHYSICAL EXAMINATION
An initial step in the physical examination is to take
the rectal temperature as a fever may indicate infectious
causes of the distention. Foals with abdominal
distension often have elevated heart rates. When large
quantities of peritoneal effusion are present, the foal
often develops hypovolemic shock. When gram-nega-
tive bacterial infection is the culprit, endotoxemia may
also be a potential source of the tachycardia. Therefore,
thorough evaluation is necessary to treat the foal appro-
priately. Foals with abdominal distention may also have
elevated respiratory rates as excessive fluid can press
upon the diaphragm causing difficulty in breathing,
especially when the foal is recumbent. Furthermore,
the chest should be auscultated carefully to determine
if pleural fluid is present (possibly extending from the
abdomen), also leading to difficulty in breathing.
Examination of the distended abdomen should include
external palpation, radiography, and/or an ultrasound
examination to determine the cause of the distention.
RADIOGRAPHY AND
ULTRASONOGRAPHY
To determine the exact location of the gastrointestinal
obstruction or site of urine leakage, contrast studies will
need to be performed. For the location of gastrointesti-
nal obstructions in the rectum and small colon, barium
enemas can be performed. The authors prefer to infuse
barium through a Foley catheter via gravity flow. The
Foley catheter after it is inflated, keeps the barium
459
22 GASTROINTESTINAL DISEASE IN THE FOAL
within the rectum and small colon. For identifying the
site of leakage in cases of uroperitoneum, contrast cys-
tography or excretory cystography can be performed.
Retrograde injection of dye into the bladder followed
by simple abdominocentesis will allow the clinician to
determine whether or not uroperitoneum is present,
but the site of leakage will remain unknown. Further-
more, collection of abdominal fluid for cytology, creati-
nine measurement and culture and sensitivity should be
performed prior to retrograde injection of dye.
ABDOMINOCENTESIS
Abdominocentesis is best performed in cases of abdom-
inal distension after radiographs and/or ultrasound
examination has been performed. The risk of bowel
perforation is low if there is a large amount of peri-
toneal fluid within the abdomen. However, iflarge gas
distended or fluid distended loops of bowel are present
on radiography or ultrasound examination, then
abdominocentesis is often not performed to avoid the
risk of laceration of the bowel wall. To decrease the
risk of inadvertent bowel wall perforation when
abdominocentesis is performed, the foal should be well
restrained with adequate levels of sedation and sub-
cutaneous local anesthetic infiltration. Furthermore,
abdominocentesis with the use of a teat cannula is often
preferred over an I8-gauge needle to prevent bowel
laceration.
Cytologic evaluation of the abdominal fluid will help
narrow the list of differential diagnoses for foals with
abdominal distension. High nucleated cell counts with
bacteria present can represent bacterial peritonitis due
to sepsis, ruptured abscess, or ruptured viscera. As
mentioned in Evaluation of the foal with colic,
Clinicopathologic data the normal nucleated cell count
of abdominal fluid in foals is lower than that in adults.
NASOGASTRIC INTUBATION
Because small intestinal distension can lead to abdomi-
nal distension in the foal, then all foals that present with
abdominal distension should be evaluated for gastric
reflux, via a small bore nasogastric tube or stallion
catheter. Lack of reflux does not mean there is no accu-
mulation of fluid within the stomach, however obtain-
ing reflux indicates some form of bowel obstruction
(functional or mechanical). Evaluation of the pH of the
sample can help determine if the reflux is from the
stomach or the small intestine. Intestinal fluid from the
small intestine will have a higher pH (6-8) than that
refluxed from the stomach which is more acidic.
460
EXPLORATORY SURGERY
There are many differential diagnoses for foals with
abdominal distension, and often the exact reason can-
not be elucidated until an exploratory celiotomy is per-
formed. However, careful and thorough diagnostics can
help guide the veterinarian toward the true nature of
the problem and help decide what treatment is
warranted. The following sections describe differential
diagnosis for foals with abdominal distension.
NEONATES
Neonatal foals are those within the first 2 weeks of age.
In these foals congenital as well as acquired disorders of
the gastrointestinal and urinary tract must be consid-
ered as differential diagnoses for foals with abdominal
distension, these include
meconium retention
intestinal atresia - atresia coli, atresia recti, atresia
ani
ileocolonic aganglionosis
uroperitoneum
fecaliths
peritonitis
enteritis/colitis.
Meconium retention (see Chapter 25)
Meconium retention is one of the most common causes
of abdominal pain and abdominal distension in the
neonatal foal. Meconium is comprised of swallowed
amniotic fluid and intestinal secretions that accumulate
within the gastrointestinal tract in foals during gesta-
tion. Meconium is usually a dark color and pelleted in
shape. These meconium pellets can be quite firm and
dry and often lead to difficulty in passage through the
newborn foal's narrow pelvis and rectum. Colts are
thought to be more commonly affected than fillies,
because of their relatively smaller pelvic size. Meconium
may be retained within the rectum, small colon, and even
within the large colon. Foals should begin to pass their
meconium within a few hours of birth. Foals may pass
small amounts of meconium then begin to show signs of
discomfort. Typical signs of meconium retention include
straining to defecate, colic, and gradual abdominal
distension as fluid and ingesta accumulate within the
gastrointestinal tract proximal to the obstruction.
Evaluation of these foals includes a thorough physi-
cal examination including evaluating the character of
straining if present. Foals that are straining to defecate
will have their backs arched with their tails in the air.
Digital palpation of their rectum will often reveal

retained meconium. Plain radiographs can reveal the
retained meconium within the rectum and/or small
colon with gas/fluid-distended colon proximal to the
obstruction. Contrast radiography with barium enemas
(administered through a Foley catheter) can also be
performed to help determine the location and nature
of the obstruction.
Intestinal atresia (see Chapter 16)
Intestinal atresia in the horse is a rare occurrence. It has
been reported to occur in the colon (atresia coli), and
in the rectum or anus (atresia recti or ani) of the horse.
Atresia coli is approximately twice as common as other
types of atresia in the horse.
The most popular theory regarding the pathogene-
sis of intestinal atresia is that of a vascular accident. The
vascular accident is theorized to arrest growth and
result in atrophy of a bowel segment which becomes the
atretic segment. Louw's theory has been tested and
shown that every type of atresia can be duplicated by
selective ligation of mesenteric vessels.
Foals with intestinal atresia are born 'normal'.
However, they usually present within the first 24-48
hours of life for signs of colic, failure to pass their
meconium, and abdominal distension. Administration
of an enema will only produce clear water and mucous
- no fecal coloration. Foals with abdominal distension
and/or colic with no history of meconium passage
should be strongly suspected of intestinal atresia.
Evaluation of these foals should include a thorough
history, physical examination, and immunoglobulin
testing. Results of a complete blood count and chem-
istry panel are non-specific for this condition. Plain
radiographs of the abdomen and contrast studies may
help determine the site of obstruction.
Ileocolonic aganglionosis (lethal white
syndrome) (see Chapter 25)
This gastrointestinal disorder has been reported to
occur in white foals out of Overo-Overo Paint crosses.
Both male and female foals can be affected. Recently it
was reported that a recessive gene is responsible for this
disease. The affected foals suffer from a lack of myen-
teric ganglia within the ileum, cecum, and/or the
entire large colon. The lack of myenteric ganglia results
in lack of propulsive motility within the gastrointestinal
tract.
These foals, although normal at birth, will begin to
show signs of colic within 12-24 hours of birth, they will
not pass any meconium, and digital palpation or admin-
istration of enemas will not produce any fecal material.
There is no treatment for these foals at the time of writ-
ing and euthanasia is recommended. However, horses
CLINICAL EVALUATION OF THE FOAL 22
can now be tested prior to breeding to determine if they
carry the gene responsible for the disease, using a DNA
test on the animal's blood or hair. The veterinary genet-
ics laboratory at the University of California, Davis can
perform the test.
Uroperitoneum
Uroperitoneum is a common cause of abdominal dis-
tension in foals and is the result of urine leaking from
the urinary tract into the abdomen. Possible sites of
urine leakage include the urachus, ureter, urethra, or
most commonly, the bladder. Colts and fillies can be
affected, however colts are more commonly affected.
The pathogenesis ofuroperitoneum includes increased
abdominal pressure during delivery, external trauma,
infection within the urachus, or necrotic cystitis. Tears
or defects within the bladder occur most commonly on
the dorsal aspect of the bladder.
Foals that develop uroperitoneum may not show
clinical signs for 2-3 days following the formation of the
defect within the urinary tract. Clinical signs include
progressive abdominal distension, tachycardia, tachyp-
nea, depression, and decreased interest in nursing.
Although many foals will have stranguria or oliguria,
foals with defects within the urinary tract have been
known to urinate normally.
The evaluation of foals with suspected uroperi-
toneum involves a thorough physical examination. The
external umbilicus, prepuce, and vulva of foals should
be examined closely. Urine leakage into the subcuta-
neous tissues or retroperitoneally from tears of the ura-
chus, ureters, or urethras can lead to subcutaneous
swelling and edema. Complete blood counts may only
reveal hypovolemia, unless concurrent sepsis or infec-
tion is present. Electrolyte abnormalities resulting from
uroperitoneum classically include hyponatremia,
hypochloremia, hyperkalemia, and azotemia. An ultra-
sound examination of the abdomen should reveal
excessive amounts of peritoneal fluid (Figure 22.17).
Imaging a fluid-distended bladder should not lead to
discounting uroperitoneum as the diagnosis, as the
urine accumulation can, of course, originate from a dif-
ferent site. The diagnosis can be confirmed through the
collection of abdominal fluid. Abdominocentesis
should yield voluminous clear, pale yellow fluid. The
fluid should be evaluated via cytology and comparison
of the creatinine values from serum versus abdominal
fluid. The diagnosis can be confirmed when the creati-
nine concentration of the abdominal fluid is twice that
of the serum concentration.
Treatment of foals with uroperitoneum almost
always requires surgical repair of the defect. How-
ever, stabilization of the electrolyte and acid-base
461
22 GASTROINTESTINAL DISEASE IN THE FOAL
Figure 22.17 Abdominal ultrasonogram of a foal with a rup-
tured bladder. There is a large excess of anechoic peritoneal
fluid in which the collapsed bladder is seen 'floating'
abnormalities must be performed prior to surgery to
prevent anesthetic complications or even death.
Medical stabilization should include drainage of the
excessive abdominal fluid, either through a teat can-
nula or small chest trocar (for more continuous
drainage over several hours). Removal of the urine will
not only reduce pressure on the diaphragm allowing
the foal to breathe more easily, but will decrease both
serum creatinine and more importantly potassium con-
centrations.
Intravenous fluids should be administered to correct
hypovolemia and electrolyte abnormalities. Normal
saline can be administered intravenously along with
dextrose to combat hypoglycemia and promote move-
ment of potassium intracellularly. Severe or non-
responsive hyperkalemia can also be treated with
intravenous calcium (4 mg/kg slowly LV. over 10 min-
utes) or subcutaneous insulin (0.1 IV/kg) regular
insulin LV. Furthermore, for foals with severe or non-
responsive hyperkalemia, attempts at complete
drainage of abdominal fluid should be made along with
catheterization of the bladder to prevent further accu-
mulation of urine within the abdomen. At the author's
hospital, foals with uroperitoneum are not anesthetized
until the serum potassium is below 5.5 mEq/dl. We
believe that at this level, the risk of cardiac arrhythmias
is much less under general anesthesia.
Fecaliths (see Chapter 16)
Fecaliths occur more commonly in pony or miniature
horse foals than in the larger breeds. These concretions
of fecal material and other ingested material (such as
shavings) can occur in neonates, but also cause obstruc-
462
tions in older foals. Fecaliths cause abdominal disten-
sion and mild to moderate colic, similar to that seen
with meconium impactions, as gas and ingesta accumu-
late proximal to the obstruction. The obstruction is
commonly within the small colon. Although the
obstruction is usually quite distal within the intestinal
tract, enemas are usually not effective and surgical
removal of the object is often necessary.
Peritonitis
Peritonitis can occur in any age foal and often results in
abdominal distension and low-grade colic with profound
depression. Peritonitis in foals can have many different
etiologies, including bacterial, chemical, or traumatic.
Neonates can develop bacterial peritonitis from
systemic bacterial infection (sepsis)
severe bacterial enteritis
leakage of bacteria from a gastroduodenal ulcer
that has perforated
leakage of bacteria from an umbilical remnant
abscess
a mesenteric abscess
damage of the gastrointestinal tract from parasite
migration.
Chemical peritonitis can occur from uroperitoneum or
hemoperitoneum. Trauma to the abdomen of foals can
result in hemoperitoneum from several different sources,
including the spleen, liver, or umbilical remnants.
OLDER FOALS
The more common causes of abdominal distention in
older foals are
small intestinal obstructions - intussusceptions,
volvulus
fecaliths
peritonitis
enteritis/colitis.
Small intestinal obstructions such as intussusception
can lead to abdominal distention; these typically occur
in foals that are 3-5 weeks of age, however, older foals
and horses can be affected as well. Intussusceptions can
occur in two forms, acute and subacute. The acute form
is indicated by a sudden onset of severe unrelenting
pain. The subacute form includes chronic colic,
anorexia, and an unthrifty appearance.
Small intestinal volvulus can also result in abdominal
distension, but again the acute nature of the pain often
precedes the development of distention. Small intesti-
nal volvulus commonly occurs in foals that are 2-4
months of age.

Medical therapy in the foal
with abdominal pain
G Perkins
INTRODUCTION
This section provides a general guide to the medical
management of a foal with colic. The goals of medical
therapy are to
correct the primary cause of colic
correct electrolyte and metabolic imbalances
provide pain relief
provide continued nutritional support
provide decompression of the bowel
provide intestinal rest if distension persists.
Treatment for gastric ulceration is covered elsewhere
(see Chapter 23).
Foals are more likely to show signs of colic with
enteritis than adults, therefore 'colicky' foals are often
treated medically. If aggressive medical management
does not relieve the pain or distension, or if ancillary
tests such as ultrasound and radiography suggest
obstruction, surgical exploration should be considered
(see Evaluation of the foal with colic).
FLUID THERAPY
Supportive care of the equine neonate begins with fluid
therapy to restore and maintain fluid homeostasis. The
total body water of a foal accounts for 70-75% of its
body weight. Gastrointestinal disease can result in
severe fluid shifts because of loss of sodium, protein,
and fluid into the gastrointestinal lumen or peri-
toneum. Endotoxemia and the resultant activation of
the inflammatory cascade results in pooling within the
gastrointestinal capillary beds and increased permeabil-
ity to macromolecules, exacerbating the fluid shifts.
The resultant hypovolemia, if progressive, can lead to
decreased perfusion of the tissues, anaerobic metabo-
lism, and metabolic acidosis.
Indicators of dehydration that can be used to calcu-
late the percentage dehydration include
decreased skin turgor
dry mucous membranes
decreased urinary output
sunken eyes
muscle weakness.
CLINICAL EVALUATION OF THE FOAL 22
Hypovolemic shock is suspected when the following are
observed
decreased distensibility of the jugular vein
prolonged capillary refill time
cold extremities
increased heart rate
decreased pulse pressure
decreased skin turgor.
Increases in the packed cell volume and total protein
are indicators of dehydration but are not specific.
Azotemia, elevated blood urea nitrogen and creatinine,
can occur secondarily to dehydration but renal failure
should be ruled out by urinalysis and response to fluid
therapy. Interestingly, even without clinically detectable
dehydration, fluid therapy can be very beneficial in the
management of colic in foals and adult horses.
Calculations for fluid volume are
volume deficit = (% dehydration) x (body weight (kg))
maintenance fluids = (60 - 120 ml x
(body weight (kg)) per day plus
ongoing losses = (estimated volume) =
(liters) to be given over I day
The electrolyte abnormalities most commonly
encountered with gastrointestinal disease in the foal
include
hyponatremia
hypochloremia
hypokalemia
hypoglycemia
metabolic acidosis.
Mild colic with a hypermotile intestine and no obstruc-
tion can occasionally be managed with small amounts of
fluid given via a nasogastric tube. The total volume to
be placed directly into the stomach should be small
(8-12 ml/kg). In most instances intravenous adminis-
tration of a balanced polyionic electrolyte solution such
as plasmalyte or lactated Ringer's solution is preferred.
Bicarbonate is required for the treatment of severe
metabolic acidosis (HC0 3 < 16 mEq/dl) with a normal
anion gap. The following calculation should be used to
determine the bicarbonate deficit
(base deficit) x (0.4) x (body weight (kg)) = HC0 3
deficit (mEq)
or
(normal HC0 3 - measured HC0 3 ) x (0.4) x
(body weight (kg)) = HC0 3 deficit (mEq)
One half of the deficit should be replaced over
1-4 hours and the remainder over the following
463
22 GASTROINTESTINAL DISEASE IN THE FOAL
12-24 hours. Isotonic bicarbonate is nearly 1.25% and
intravenous bicarbonate solution comes commercially
prepared as 8.4% (l mEq/ml) and 5% (0.6 mEq/ml)
solutions. Successful management of metabolic acidosis
in the foal with diarrhea can sometimes be achieved by
administering oral bicarbonate. This should be
attempted only when the foal is well hydrated and the
anion gap is normal. The base deficit can be calculated
by converting 1 gram bicarbonate into 12 mEq and dos-
ing orally.
Hypokalemia occurs as a result of decreased intake
and loss through the gastrointestinal tract and urine.
Potassium may be added to the intravenous fluids at
approximately 20-40 mEq/liter. The potassium supple-
mentation should not exceed 3-5 mEq kg/d and 0.5 mEq
kg/h. Hyperkalemia in the foal with gastrointestinal dis-
ease is usually secondary to metabolic acidosis and
translocation of the potassium to the extracellular space.
In a rare case it may be a result of acute renal failure.
Treating the metabolic acidosis with bicarbonate-rich
fluids generally corrects the hyperkalemia. Dextrose
solutions (2.5-5.0%) promote the movement of potas-
sium back into the cells. Insulin (0.1 IV/kg regular
insulin i.v.) can also be used but is generally not recom-
mended. If severe cardiac arrhythmias or atrial standstill
are detected, calcium gluconate can be administered at
4 mg/kg i.v. slowly over 10 minutes to protect the heart.
NUTRITION
Enteral nutrition in foals with abdominal distension
and colic can be contraindicated. A muzzle can be
placed on a foal that is reasonably bright and active to
prevent nursing until the colic subsides. Foals with colic
that are being fed with a nasogastric tube should be fed
only very small amounts of milk. If the foal tolerates the
small quantities, the amount can be increased slowly
over a few days to maintenance levels of 15-20% body
weight per day. Parenteral nutrition should be consid-
ered in foals that may be unable to receive enteral nutri-
tion for more than 24-36 hours. Since neonates have
minimal reserves of glycogen and fat, food deprivation
for 1 day may have profound effects. Parenteral nutri-
tion is also indicated in prematurity, septicemia, and
diarrhea where the gastrointestinal tract is unable to
transport and digest milk. The decision to do partial or
total parenteral nutrition is based on the gastrointesti-
nal tract function. It is important to continue stimulat-
ing the enterocytes by feeding small amounts of milk
(50 ml q. 1-2 hr) if possible. Any electrolyte abnormali-
ties should be corrected with fluids prior to initiating
TPN. A foal should receive approximately 100-150 kcal
kg- I day:'. Parenteral nutrition derives its energy from
464
Foal's weight (50 kg)
Level of nutritional support 100 kcallkg/d
Total daily calories 100 kcal x 50 kg
.. 5000 kcal
Non-nitrogen <;jlloriedistributioo
40% dextrose = 2000kcal dextrose
60% lipid .. 3000 kcal lipid
etm.ln
A. Ratio of 300 non-nitrogen ,a/lg of nitrogen
5000 total dally kcal I 300 (ratio): 16.5 9
nitrpgen
=
B. 16.59 nitrogenl16% nitrogen in protein 100 9
protein
C. Example to determine volume of an amino 8.4%
add solution:
100g nitrogenl0.084 amino add solution:
1176.5ml
three sources; amino acid solutions, dextrose, and
lipids. The non-protein nitrogen sources; dextrose and
lipids should be distributed at 40% and 60%, respec-
tively. The ratio of non-nitrogen calories to grams of
nitrogen has been extrapolated from humans to be
approximately 15D-300. Protein contains 16% nitrogen,
therefore an amino acid solution can be approximated
by dividing the protein by 6.25. The kcal derived from
protein is 4 kcal/g, glucose is approximately 4 kcal/g,
and fat is 9 kcal/g. This value should lie within the ratio
of non-nitrogen calories to grams of nitrogen.
Strict attention to aseptic techniques should be paid
when managing the TPN solutions since they can sup-
port the growth of bacteria and fungi, The amino acids
should be mixed with the dextrose before adding the
lipids. A freshly made bag can be kept refrigerated for
24 hours prior to use. The solution should be delivered
through a TPN dedicated intravenous line and very
careful handling of the catheter ports and intravenous
lines should be undertaken with daily replacement of
the lines. When beginning the TPN, start at approxi-
mately one-third of the desired rate. Monitor the blood
frequently for lipemia, and the urine and blood for
hyperglycemia (blood glucose> 180 mg/dl). Increase
the flow rate slowly if normoglycemia is maintained.
ANALGESICS
Controlling pain in a colicky foal that is rolling is
important in reducing self inflicted trauma, as well as

decreasing inflammation that is causing ileus. Non-
steroidal anti-inflammatory drugs (NSAIDs) can be of
benefit but should be used judiciously because of the
ulcerogenic effects on the glandular portion of the
stomach and renal papillary necrosis. Drugs with a low
cyclooxygenase-l:cyclooxygenase-2 ratio are thought to
be safest. Unfortunately, pharmacokinetics and toxicity
trials of NSAIDs in the foal are not well documented.
Flunixin meglumine (0.5-1.0 mg/kg i.v.) has been
reported to be the most effective drug for gastrointesti-
nal pain. Ketoprofen has been documented as the least
ulcerogenic NSAID compared with phenylbutazone
and flunixin meglumine in the horse, but anecdotal
reports indicate that its pain relief in colic is not as pro-
nounced as flunixin meglumine. Butorphanol, an opi-
oid analgesic, (0.01-0.04 mg/kg i.m. or i.v.) can be used
in addition to, or to limit the amount of, NSAIDs given
when gastroduodenal ulceration is a concern. Xylazine
(0.1-0.5 mg/kg i.v.) provides sedation and analgesia,
but can cause profound decreases in gastrointestinal
motility. If repeated doses of analgesics are required
surgical exploration should be considered.
DECOMPRESSION
A nasogastric tube can be passed to relieve gastric dis-
tension. Unfortunately, the diameter of a foal's nasal
passages limits the size of the nasogastric tube to either
a stallion catheter or a 1 em diameter nasogastric tube.
A stylet can be used for ease of swallowing and passage
of the tube from the nasopharynx into the esophagus.
The stomach can be lavaged gently with small amounts
of water (60 ml at a time). Frequently, even if reflux is
present in the stomach, it is difficult to manually extract
the fluid. The tube should be left in place and capped
to prevent air aspiration.
Percutaneous bowel trocarization is indicated if
severe abdominal distension coupled with respiratory
compromise persists. The owner should be warned of
the inherent risks of peritonitis and that the foal may
require surgical exploration if the condition persists.
The foal should be sedated and/or placed in lateral
recumbency. The abdomen should be percussed for a
prominent gas ping. The area where the ping is heard
best should be clipped and prepared aseptically. A small
lidocaine bleb should be infused at the puncture site. A
16-18-gauge 1.5-inch needle or 3.5-inch catheter over
stylet can be advanced through the skin and body wall
into the distended viscus and air should be drained. A
small volume of antibiotic (i.e. amikacin or gentamicin)
should be infused as the needle/catheter is withdrawn.
The foal should be maintained on systemic antibiotic
therapy for 3-5 days following trocarization.
CLINICAL EVALUATION OF THE FOAL 22
PROKINETICS
Motility enhancing drugs are considered controversial
in the foal with colic. Surgical and/or obstructive dis-
eases should be ruled out before administering proki-
netic agents. The most common indication for
prokinetic agents in a foal is ileus secondary to sep-
ticemia, enteritis or neonatal maladjustment. The
dosages and side effects have been extrapolated for the
most part from human and small animal studies, and
little data exists in the literature on foals. Cisapride
(0.2-0.4 mg/kg p.o. q. 4-8 h) is a third generation ben-
zamide that acts as a serotonin agonist within the myen-
teric plexus. Cisapride has effects on the colon,
esophagus, stomach, and small intestine and, therefore,
can impact the entire gastrointestinal tract. Cisapride
has been well tolerated in adult horses. Metoclo-
pramide (0.25-0.50 mg/kg i.v, as a l-h infusion q. 4-8 h
or 0.6 mg/kg p.o. or per rectum q. 4-6 h), a dopamine
antagonist, has been well documented to increase gas-
tric emptying with coordinated increase in tone of the
lower esophageal sphincter and contraction of the
stomach. Caution and constant monitoring for neuro-
logic signs should be used when giving this medication
because of the permeability of the blood-brain barrier
and extra-pyramidal signs. Erythromycin, (1.0-2.0 mg/
kg i.v, administered as a I-h infusion q. 6 h or p.o. q.
6 h) at sub-antibiotic levels stimulates motilin receptors.
Ranitidine (1-2 mg/kg p.o. or i.m, q. 8-12 h), an H 2-
blocker, has also been shown to have effects on gas-
trointestinal motility and positive effects on gastric
emptying disorders. Ranitidine would be a wise choice
since it is also useful in treating gastric ulceration. An
acetylcholine esterase inhibitor, neostigmine (0.02 mg/
kg s.c.), is a potent prokinetic agent and can sometimes
cause severe cramping and colic in the horse. It has
been used successfully along with sedation in foals with
non-obstructing large colon gas distension.
Surgical decision for the foal
with colic
CS Cable
INTRODUCTION
Foals with colic are challenging cases to manage.
Often the most difficult aspect of their management is
determining when and if the foal requires surgery.
Delaying surgery may unnecessarily compromise the
foal's physical condition and increase the risks of
465
22 GASTROINTESTINAL DISEASE IN THE FOAL
general anesthesia. Furthermore, delaying surgery
when devitalized bowel is involved can change a
closed bowel operation into a resection and anastomo-
sis, thereby greatly reducing the overall prognosis. On
the other hand, placing a neonatal foal under general
anesthesia to perform an exploratory celiotomy can
greatly increase the risk of pneumonia and/or peri-
tonitis. Furthermore, there is still a great deal of con-
troversy regarding the risk of foals developing
postoperative intra-abdominal adhesions, despite
recent publications suggesting that foals are not at
greater risk than adult horses of these complications.
These conflicting factors make the surgical decision
for abdominal surgery in foals difficult.
The decision to perform surgery in a foal should be
made only after a complete and thorough physical
examination has been performed with careful atten-
tion being paid to the historical events preceding the
colic. In addition, laboratory values (along with radio-
graphs, ultrasound, and possibly an endoscopic exami-
nation) can be very helpful in making the surgical
decision.
HISTORY AND PHYSICAL
EXAMINATION
As mentioned in previous chapters, a complete history
can be very beneficial in providing clues to the origin of
the colic episode. The following can provide valuable
information
peripartum events
age of the foal at the onset of clinical signs
farm history of disease
previous illness or surgery
feeding program
anthelmintic history
For example, a poor-doing weanling with a history of
chronic intermittent colic is highly suggestive of a
chronic ileocecal intussusception.
The physical examination should be performed
keeping in mind the differences in the normal values of
heart rate and respiratory rate between neonates and
older foals (see Evaluation of the foal with colic). Those
foals with an elevated temperature should be closely
evaluated for sepsis and/or enteritis as the cause of
colic. Enteritis in foals can be especially difficult to dis-
tinguish from surgical lesions, as the foal often becomes
quite painful from intestinal distension before diarrhea
is present. In the author's experience, Clostridial
enteritis in particular causes moderate to severe pain in
the foal requiring frequent analgesia.
Foals with colic often have distended abdomens.
466
The severity of distension can be monitored by repeat-
edly measuring around the foal's abdomen at specific
points with a tape to detect changes. Foals with severe
abdominal distension can have great difficulty breath-
ing properly. These foals will require decompression
(percutaneous or surgical) of the gas-distended bowel
even if the lesion is usually amenable to medical ther-
apy. Percutaneous methods of bowel decompression
carry risks in the neonatal foal, mostly from peritonitis
after the bowel puncture because of the thinness of the
intestinal wall.
Palpation of the foal externally can aid in identifying
large obstructions within the abdomen, but is often
impossible on a larger foal or one in severe pain. The
foal with colic should always be evaluated for hernias
(umbilical or inguinal/scrotal) and other congenital
defects. Reducible hernias are not a surgical emer-
gency, but entrapped (non-reducible) hernias require
immediate surgery. Ruptured indirect inguinal hernias,
(inguinal hernias that have broken through the vaginal
tunic), although not strangulating in nature, often
require immediate surgery as they can dissect through
the subcutaneous tissues becoming very large and much
more difficult to manage.
A nasogastric tube (small size) should also be passed
in foals with colic, however, the presence of reflux does
not always indicate a mechanical obstruction.
Furthermore the lack of reflux does not rule out a small
intestinal surgical lesion. The presence of reflux alone
therefore is not conclusive for a surgical lesion. The pH
of the reflux can help identify its source - acidic reflux
originating in the stomach and basic reflux usually orig-
inating in the small intestine. Furthermore, a gram
stain of a reflux sample may help identify bacterial
enteritis, especially if an overwhelming population of
one type of bacteria is found.
Foals tend to be more sensitive to gastrointestinal
pain than adults, and this makes it difficult to decide to
perform surgery on a foal, on the basis of signs of pain.
However, the foal displaying persistent, severe pain that
is not responsive to analgesia is a candidate for an
exploratory celiotomy. Even if ileus alone is the culprit,
decompression of the bowel can relieve the pain and
speed recovery.
LABORATORY EXAMINATION
As in the adult, a foal should be evaluated using a com-
plete blood count, chemistry panel, and abdominocen-
tesis if possible. The presence of leukopenia, left shift,
or evidence of toxic neutrophils suggests sepsis; infec-
tious causes of colic, such as enteritis, should then be
considered. Neonatal foals should be evaluated further

by gamma globulin levels (IgG) to assess passive transfer
of immunoglobulins and the likelihood of sepsis. Foals
that have less than 800 mg/dl (80 g/I) of IgG are
treated for failure of passive transfer in the author's
hospital.
Chemistry panels are performed to evaluate the
foal's electrolyte status. Marked hyponatremia and
hypochloremia suggest enteritis. Hyperkalemia with
hyponatremia and hypochloremia suggests uroperi-
toneum.
Abdominocentesis can be very helpful in identifying
surgical lesions in foals. Care must be taken to avoid
inadvertent bowel puncture when acquiring the sam-
ple, so in the author's hospital an ultrasound examina-
tion of the abdomen is performed to locate the area
where fluid is most likely to be obtained. Foals with
moderate to marked abdominal distension from bowel
distension are usually not evaluated via abdominocen-
tesis because of the higher risk of bowel perforation.
The fluid is analyzed for white blood cell count, total
protein, and cytology. White blood cell counts greater
than 1500-3000/1l1 (1.5-3.0 x 109 / 1) are considered
abnormal in foals. If uroperitoneum is suspected, the
fluid should be evaluated for creatinine concentration
and its level compared with serum creatinine concen-
trations. If the ratio is greater than 2: 1 urinary tract
rupture/perforation is likely.
ADDITIONAL DIAGNOSTIC
PROCEDURES
The use of radiographs and/or ultrasound has greatly
enhanced the veterinarian's ability to determine the
location of the gastrointestinal obstruction in the foal
and decide if surgery is necessary. Although plain radi-
ography can help determine the nature of the foal's
abdominal distension if present (i.e. small versus large
bowel distension), contrast radiography is often much
more specific in giving the location of the lesion.
Contrast radiographs taken after barium has been
administered can enhance the view of the gastroin-
testinal tract and locate specific sites of obstructions.
Barium can be administered to the foal through a
nasogastric tube, dose syringe, or through a Foley
catheter (barium enema). Barium administered
through a dose syringe can help identify problems
with the oral cavity, soft palate, esophagus, or cardia.
Barium administered through a nasogastric tube
should be made into a solution (30% w/v) and dosed
at 5 ml/kg. This can help identify lesions of the car-
dia, stomach (e.g. gastric ulcers), or duodenal stric-
tures. Barium administered via an enema can help
identify lesions of the rectum, small colon, and even
CLINICAL EVALUATION OF THE FOAL 22
the distal large colon at a dose of 18-20 ml/kg. Foals
are best sedated for this procedure
Evaluation of the foal's abdomen via ultrasound can
also greatly help in the decision for medical versus sur-
gical treatment. Although a rectal examination (a stan-
dard and often vital part of the examination of an adult
horse with colic) cannot be used in the foal, an ultra-
sound examination can help provide the information
needed to make the decision for surgery. Identification
of thickened and non-motile small intestine is highly
suggestive of a strangulating small intestinal lesion.
Other lesions that can be identified include intussus-
ceptions which appear as a 'bull's-eye ' lesion (rings with
a circular echogenic core), and copious amounts of
abdominal fluid suggesting either uroperitoneum or
peritonitis if the fluid is echogenic.
CONCLUSION
Differentiating surgical versus medical therapy in a foal
with colic can be a formidable task. Severe pain often
dictates our decision, but this degree of pain can some-
times be caused by relatively minor obstructions.
Initially medical therapy is often chosen for the less
obvious surgical patients. However, progressive abdom-
inal distension, persistent pain, and/or changing
abdominocentesis values all warrant an exploratory
celiotomy. Improved surgical techniques and medica-
tion used to minimize adhesion formation (see
Chapters 10 and 11) appear to have kept the rate of
adhesion formation following exploratory celiotomy
low. In this author's opinion, it is better to perform a
careful, early exploratory celiotomy on a relatively sta-
ble foal than frantic, desperate surgery on a dying one.
BIBLIOGRAPHY
Evaluation of the foal with colic
Chaffin M K, Cohen N D (1995) Assessing the history,
signalment, and examination findings in foals with colic.
Vet. Med. 8:765-9.
Chaffin M K, Cohen N D (1995) Diagnostic tests and
procedures in foals with colic. Vet. Med. 8:770-6.
Cohen N D, Chaffin M K (1995) Assessment and initial
management of colic in foals. Compo Cont. Educ. Pract. Vet.
17(1):93-102.
Cudd T A (1990) Evaluation of acute abdominal pain. In
Equine Clinical Neonatology, A M Koterba, W H Drummond,
PC Kosch (eds.). Lea and Febiger, Philadelphia, pp.
367-78.
Cudd T A, Wilson] H (1990) Diagnostic techniques for
abdominal problems. In A M Koterba, W H Drummond,
PC Kosch (eds.) Equine Clinical Neonatology, Lea and
Febiger, Philadelphia, pp 379-412.
467
22 GASTROINTESTINAL DISEASE IN THE FOAL
Klohnen A, Vachon A M, Fisher A T (1996) Use of diagnostic
ultrasonography in horses with signs of acute abdominal
pain.] Am. Vet. Med. Assoc. 209(9): 1597-1601.
Koterba AM (1990) Physical examination. In A M Koterba,
W H Drummond, P C Kosch (eds.) Equine Clinical
Neonatology, Lea and Febiger, Philadelphia, pp 71-83.
Murray M] (1997) Foal stomach and duodenum. In Equine
Endoscopy] L Traub-Dargatz, C M Brown (eds.) 2nd edn.
Mosby, Baltimore, pp 159-71.
Orsini,] A (1997) Abdominal surgery in foals. Vet. Clin. North
Am. Equine Pract. 13(2) :393-413.
Diagnostic imaging procedures in the foal
Fisher A T, Yarbrough TY (1995) Retrograde contrast
radiography of the distal portions of the intestinal tract in
foals.] Am. Vet. Med. Assoc., 207:734-7.
Reef V B (1992) Pediatric abdominal ultrasonography. In
EquineDiagnostic Ultrasound, WB Saunders, Philadelphia,
pp. 364-403.
Reimer] M and Bernard W V (1998) Abdominal sonography
of the foal. In EquineDiagnostic Ultrasonography, N W
Rantanen and AO McKinnon (eds): Williams and Wilkins,
Baltimore, 627-36.
Reimer] M (1998) The Gastrointestinal Tract: The Foal. Atlas 0/
EquineUltrasonography. Mosby, St Louis, pp. 200-11.
Differential diagnosis and evaluation of the
foal with abdominal distension
Benamou A E, Blikslager A T, Sellon D C (1995) Intestinal
atresia in foals. Compo Cont. Educ. Pract. Vet.
17(12):1510-16.
Chaffin M K, Cohen N D (1995) Assessing the history,
signalment and examination findings in foals with colic.
Vet. Med. 8:765-776.
Cohen N D, Chaffin M K (1994) Intestinal obstruction and
other causes of abdominal pain in foals. Compo Cont. Educ.
Pract. Vet. 16(6):780-90.
Cohen N D, Chaffin M K (1995) Assessment and initial
management of colic in foals. Compo Cont. Educ. Pract. Vet.
17(1) :93-9.
468
Fisher A T ]r, Yarbrough T B (1995) Retrograde contrast
radiography of the distal portions of the intestinal tract in
foals.] Am. Vet. Med. Assoc. 207:734.
Medical therapy in the foal with abdominal
pain
Cohen N D, Chaffin M K (1995) Assessment and initial
management of colic in foals. Compo Cont. Educ. Pract. Vet.
17(1):93-103.
MacAllister C G, Morgan S], Borne AT, Pollet RA (1993)
Comparison of adverse effects of phenylbutazone, flunixin
meglumine and ketoprofen in horses.] Am. Vet. Med.
Assoc. 202(1):71-7.
Spurlock S L, Ward M V (1991) Parenteral nutrition in
equine patients: principles and theory. Compo Cont. Educ.
Pract. Vet., 13(3):461-8.
Vaala W E (1998) Neonatology. In Manual ofEquine
Emergencies: Treatment and Procedures,] A Orsini, T] Divers
(eds). W B Saunders, Philadelphia, pp. 473-503.
Surgical decision for the foal with colic
Bernard WV (1992) Differentiating enteritis and conditions
that require surgery in foals. Compo Cont. Educ. Pract. Vet.
14: 535-7.
Cable C S, Fubini S L, Erb H N et al: (1996) Abdominal
surgery in foals: a review of 119 cases (1977-1994). Equine
Vet.] 29(4):257-61.
Klohnen A, Vachon A M, Fisher A T (1996) Use of diagnostic
ultrasonography in horses with signs of acute abdominal
pain.] Am. Vet. Med. Assoc. 209(9):1597-601.
Orsini,] A (1997) Abdominal surgery in foals. Vet. Clin. N.
Am. EquinePract. 13(2):393-413.
Ragle C A (1999) The acute abdomen: diagnosis,
preoperative management and surgical approaches. In
Equine Surgery,] A Auer. and] A Stick (eds): 2nd edn WB
Saunders, Philadelphia, p 224-32.
Vatistas N], Snyder] R, Wilson W D (1996) Surgical
treatment for colic in the foal (67 cases): 1980-1992.
Equine Vet.] 28(2):139-45.