Clinical Case Challenge – Mild Intermittent Colic
A 13-year-old Friesian gelding presented with a history of mild intermittent colic (abdominal pain) for the previous three days. The owner noted that he had been slowly losing weight over the past several months, despite attempts to increase his feed intake. A colic examination by his veterinarian did not reveal the cause of the abdominal pain or the weight loss.
Upon presentation at the Hospital for Large Animals, the gelding was bright and alert and was not exhibiting overt signs of colic. His heart rate was elevated at 48 beats per minute (normal 28-40) and his respiratory rate was increased at 40 (normal 8-12). His temperature was within normal limits. The remainder of his physical examination was within normal limits. On initial bloodwork, packed cell volume (PCV), total protein, and lactate were all within normal limits (PCV 34%, TP 7.2g/dL, lactate 0.9mmol/L). However, the fibrinogen was mildly elevated at 500mg/dL (normal <400mg/dL), suggesting a mild inflammatory process.
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Nasogastric intubation was performed, which yielded a small amount of food material but no net reflux. The nasogastric tube was left in place, and his stomach lavaged every four hours. As only small amounts of food material were obtained, the nasogastric tube was removed.
Abdominal ultrasonography was then performed where the stomach was observed extending from the 9-17th intercostal space, and had mild to moderate wall thickening. Twenty-four hours after admission (with fasting since admission and decreased feed intake prior to that), we then visualized the inside of the stomach by passing an endoscope (camera) through the nose down into the lumen (inside) of the stomach. We saw what is depicted in the image below.
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Diagnosis and Treatment:
Based on the enlarged stomach size on ultrasound (the stomach normally does not extend beyond five intercostal spaces) and the presence of the dense feed material on gastroscopic imaging, the gelding was diagnosed with a stomach impaction.
He was treated with gastric lavage via nasogastric tube over the course of the next four days. A repeat gastroscopy was performed daily during this time and impaction steadily decreased in size. Once the impaction was resolved severe gastric ulceration could be visualized in the non-glandular (squamous) mucosa (see image 2).
A repeat ultrasound of the stomach at that time showed a reduction in the overall size of the stomach, although it had not returned to normal. It was also noted that the stomach wall was thickened in several locations.
Treatment for the gastric ulcerations was initiated with omeprazole (Gastrogard) at 4mg/kg by mouth once daily for 28 days. The gelding was slowly refed using a pelleted feed in small meals every two hours. The amount was increased until his resting energy requirement was met through feeding of a mixture of complete pelleted feed, hay pellets and oil. A pelleted, low-bulk diet was maintained because of continued thickening and slight enlargement of the stomach on recheck ultrasound.
The gelding was rechecked following the course of omeprazole. He had returned to normal body condition and was reportedly continuing to do well on the pellet based diet. Ultrasound of the stomach was now within normal limits both in-term of size and wall thickness. On recheck gastroscopy the stomach still contained a moderate amount of feed material (even after a 20-hour fast). The stomach was again lavaged overnight and re-scoped the following afternoon. The feed material had cleared at that time and the gastric mucosa could be visualized. The ulcerations of the gastric mucosa were healed, except for the largest ulceration which had dramatically improved. Another 28-day course of omeprazole was initiated to aid in the remaining healing of the deep ulceration and we recommended that he remain on the low-bulk pelleted diet to help prevent a repeat gastric impaction.
There is evidence that Friesians and potentially some draft horse breeds are at an increased risk of gastric impactions. This, compared with the stoic nature of these breeds, may place them at an increased risk for gastric rupture. Whenever a Friesian or draft breed horse presents with even mild colic signs it is critical that a nasogastric tube be placed and a subsequent gastroscopy performed if there is suspicion of a gastric impaction. While confirmed delays of gastric emptying or motility disorders are difficult to prove, if there is concern for repeat gastric impactions then a low-bulk diet can be considered to aid in the emptying of stomach contents. The pelleted feed should be hay-based in order to decrease the chance of inciting gastric ulcerations that can be seen with a high grain diet. Grazing can also be encouraged and a means to provide easily digestible feed stuffs. [/accordion_panel] [/accordion]
About the Internal Medicine Service
Dr. Daniela Bedenice, Dr. Melissa Mazan, Dr. Nick Frank, and Dr. Alisha M Gruntman lead the Internal Medicine Service, a division of the Hospital for Large Animals at Cummings Veterinary Medical Center, and are all board certified by the American College of Veterinary Internal Medicine. In addition, Dr. Bedenice is the only board-certified specialist in Large Animal Emergency and Critical Care in New England. Supporting the faculty clinicians are trained technicians, interns, residents, students and staff within a state-of-the-art facility for providing diagnosis and advanced patient care.