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 Featured Case of the Month: Matthew HISTORY AND PRESENTATION: Matthew presented to SWEMSC for evaluation of his poor appetite and reduced manure production. He had been increasingly uninterested in food for three days prior to his arrival here. He had been treated in the field 2 days prior by the referring veterinarian for suspected gastric ulcers or mild colic, but there was no improvement in his appetite despite Banamine, nasogastric intubation with mineral oil and water, and anti-ulcer medication. Additionally, he had not passed manure for 24 hours. He had never acted overtly colicky or uncomfortable. Matthew had no history of exposure to toxic plants or substances, and was up-to-date on vaccinations. He had no history of any illness. PHYSICAL EXAM:
Bloodwork: Complete blood count (CBC): Within normal limits, neutrophil count was in the low-normal range. No evidence of anemia or infection. Chemistry Panel: Within normal limits except for a mildly elevated total bilirubin - most likely associated with anorexia (not eating). Sedation: Administered 100mg xylazine and 3mg butorphanol to allow for a thorough oral examination and other necessary diagnostics. Oral Examination: A speculum was used to perform a thorough oral exam. No foreign bodies, ulcerations, abscesses, or masses were seen in the oral cavity. There were no dental abnormalities noted that may be causing his inappetence. Rectal Examination: A small amount of pasty, mineral oil covered feces was present in the rectum. The GI tract was empty on palpation, and no other abnormalities were palpable. Abdominal Ultrasound: There was small intestine visible in the inguinal region that was contracting normally and the stomach was moderately full of ingesta. No masses or internal abscesses were seen. The diaphragm was intact (no evidence of a hernia). No abnormalities were present in the liver, spleen or kidneys. Gastric Endoscopy: The upper airway was evaluated and found to be within normal limits (no swelling or inflammation in the throat). The upper esophagus was normal; however there was feed material in the lower esophagus obscuring the entrance into the stomach, so the stomach could not be evaluated. Nasogastric Intubation: A tube was passed into the lower esophagus and stomach. A large amount of non-rancid, thick feed material was lavaged out with 100L (25gal) of water in small volume increments (4-6L at a time). Repeat Gastric Endoscopy: Matthew was placed in a stall with a muzzle for 3 hours, and repeat endoscopy performed. Feed material was still lodged at the distal esophagus. Gastric lavage was attempted again, and more thick feed material that was rancid-smelling was removed from the stomach until the water ran clear (an additional 80 L lavage). Gastric impaction was suspected due to the continued presence of feed in the stomach despite lavage, and the stale, rancid smell. Water and antacid were left in the stomach after the lavage to help loosen feed material in the stomach. TREATMENT: Coca-Cola, Lavage, and Scope! Water and antacid were left in the stomach overnight to attempt to soften any feed in the stomach. Endoscopy was repeated the next morning, but the camera still could not be passed into the stomach. Therefore, gastric lavages were repeated to remove any loose feed material, and water and 3 cans of Coco-cola were left in the stomach to break up the impaction. Lavages continued every 3 hours that day and overnight, although they were minimally productive. The next evening, the scope could be passed into the stomach revealing a large ball of hardened feed material (called a phytobezoar).  The ball was directly infused through the scope with water, coke, and Dioctyl Sodium Succinate, although it was too firm to be completely penetrated. Lavages and water/coke/antacid infusions continued for 2 more days until repeat endoscopy revealed resolution of the impaction. At that time, the stomach lining could be visualized, revealing moderate (grade 2) gastric ulceration at the margo plicatus and lesser curvature of the stomach. It is unknown whether these ulcers contributed to causing the impaction, or if they occurred as a result of the impaction.  Matthew was started on the anti-ulcer medications Sucralfate and Ranitidine. He was started back on feed, eating only well-soaked pellet mashes. At the time of discharge, the mashes were clearing his stomach, he had a great appetite, and he was passing manure normally. He was fed soaked pellet mashes for 4 weeks after hospitalization, and gradually transitioned back to hay with no recurrence of the impaction. EDUCATION: Gastric impactions (impactions of the stomach) are a relatively uncommon cause of inappetence in horses (we typically see 4-6 gastric impactions per year at Southwest Equine). Most impactions in horses occur in the colon or small intestine and cause colic signs; however, it is important to be aware that gastric impactions do occur and cause horses to feel chronically "full" and disinterested in feed. Although gastric impactions are uncommon compared to a large colon impactions, they can be severe and life threatening if left untreated. Although a cause is not always determined, horses can be predisposed to developing an impaction. Anything that delays gastric emptying, including ulceration or inflammation of the pylorus (the area where the stomach empties into the small intestine), foreign bodies, masses obstructing the area, or other motility disorders can cause feed to accumulate in the stomach. Additionally, dehydration, feed that expands on ingestion, or dental issues causing the fiber size to be too large can cause impaction. Affected horses most commonly present with reduced or no appetite or interest in feed. They can also present with chronic, recurrent mild colic, or acute and painful colic depending on the degree of impaction and the primary cause. Left untreated, the stomach may spontaneously rupture. In the past, most gastric impactions were diagnosed at the time of surgery, but with more endoscopy and ultrasound being performed, we can now often diagnose this issue before it becomes too severe or before surgery is performed unnecessarily. Caught early, these can be successfully treated medically with frequent (every 3hr), aggressive (70-100L) gastric lavages. The acidity and carbonation in coca-cola has been shown to help break up these hard balls of feed, therefore coke, water, and surfactant is left in the stomach in between lavages to soften the ball. Once the impaction has been eliminated, it is important to fully evaluate the stomach for any underlying issues affecting motility (masses, strictures, ulcers). Horses with gastric impactions should be fed frequent small meals of soaked, small fiber size pellets for 4-6 weeks (until the stomach has time to heal and regain normal motility). Encouraging excellent hydration and treating any known underlying causes are important in preventing recurrence. | |
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