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Detection of signs of post-operative ileus in horses after colic surgery with the help of abdominal ultrasound

A. Klohnen Chino Valley Equine Hospital, 2945 English Place, Chino Hills, CA 91709 USA; e-mail: topgun96@att.net.

Background Post-operative ileus is an important cause of morbidity and mortality in the postsurgical period for horses with colic. The diagnosis has classically been made on the basis of post-operative reflux obtained through nasogastric intubation and possible post-operative signs of abdominal pain in conjunction with reflux. According to the veterinary literature, post-operative ileus has mainly been defined by the volume of reflux that is recovered from a horse during a 24-hour period. This is neither a definitive nor accurate method of diagnosing post-operative ileus. Abdominal ultrasonography is a proven diagnostic modality in the pre-operative diagnosis of small intestinal lesions, and is potentially a useful diagnostic imaging technique to assess distention, contractility, wall edema and motility of small intestine post-operatively. Objective It was our hypothesis that routine ultrasonographic examination of the post surgical abdomen will allow for a more definitive and accurate detection of decreased small intestinal motility indicating a diagnosis of post-operative ileus. Methods Medical records from March 2007 to December 2008 were reviewed and 340 horses had undergone an exploratory celiotomy. Horses were included in the study if lidocaine was used for treatment of post-operative ileus. The medical records were evaluated to determine on which post-operative day the small intestinal ileus was ultrasonographically detected. The medical records were also evaluated in regards to the surgical diagnosis, the total duration of lidocaine treatment, how many horses had naso-gastric reflux and if a horse required a second surgery during the initial hospitalization. Three-hundred and forty horses that underwent an exploratory celiotomy were assessed using ultrasonography every 24 hours after surgery until there was no further evidence of small intestinal distention. The right and left paralumbar fossa and ventral abdomen were evaluated for signs of post-operative ileus. Post-operative intestinal ileus was defined by the presence of multiple (n>3) distended loops of small intestine with decreased intestinal contractility and motility. After the diagnosis of ileus was established, horses were treated with a slow IV lidocaine bolus (1.3mg/kg over 15 minutes) followed by an infusion of 0.05mg/kg/min of 152

lidocaine in saline until ultrasonographic findings demonstrated complete resolution of all postoperative signs of intestinal ileus. Once a horse was diagnosed with post-operative ileus, a nasogastric tube was placed in order to check for reflux. Results Seventy-three horses showed ultrasonographic signs of post-operative intestinal ileus (distended loops of small intestine with decreased motility and intraluminal contractility) and were treated with lidocaine. Forty-three out of 73 horses (59%) with signs of post operative ileus had a small intestinal lesion diagnosed as the cause of colic. Thirty-eight out of 43 horses (88%) had a strangulation obstruction of the small intestine as a primary diagnosis. Five out of 43 horses (12%) had a non strangulating small intestinal lesion as the primary diagnosis. Thirty out of 73 horses (41%) had large intestinal lesions as the primary cause of colic. The average time to diagnosis the post-operative signs of intestinal ileus were 2 days, with ultrasonographic signs being evident for 2.5 and 19 days with an average duration of treatment or 4-5 days. Twentyeight out of 73 horses (38%) did not have any evidence of post-operative reflux, although the small intestine appeared to be distended with decreased motility. Twenty-one out of 28 horses (75%) that did not have any post-operative reflux but had ultrasonographic evidence of postoperative ileus had a small intestinal lesion as a primary diagnosis. Seven out of 28 horses (25%) had a large intestinal problem as the primary intra-operative diagnosis. Ten out of 73 horses (13.7%) with post-operative ileus required a repeat surgery, whereas only 1 out of 269 horses (o.4%) without post-operative ileus required a repeat celiotomy. Discussion The results of this study demonstrate that abdominal ultrasound is a reliable method for the diagnosis and monitoring of post-operative signs of intestinal ileus and is potentially a more useful technique than the current analysis of gastric reflux volume. In addition, this study has demonstrated that both small intestinal and large intestinal lesions can contribute to postoperative ileus of the small intestine. Interestingly, 88% of the small intestinal ileus cases were associated with a strangulating obstruction, supporting the view that ischaemia and intestinal stress at surgery may contribute to intestinal ileus. However, it is also interesting to note that 41% of ileus cases were diagnosed as having a primary large intestinal lesion. Abdominal ultrasonography appeared to be more accurate in the detection and diagnosis of post-operative intestinal ileus compared to reflux obtained via a naso-gastric tube.

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