Acute Abdomen

Louise L. Southwood, BVSc, PhD, Dipl ACVS, Dipl ACVECC

Colic is the most common problem necessitating emergency care of horses. Obtaining a
thorough history and performing a meticulous physical examination is critical when exam-
ining a horse with colic. Ancillary tests, such as hematology and serum biochemistry,
peritoneal fluid analysis, ultrasonography, and radiography, can be used to obtain a more
specific diagnosis, determine the need for exploratory celiotomy, and estimate prognosis.
While the causes of colic are numerous and in some cases life-threatening, the majority of
horses showing signs of colic respond to basic medical management. The prognosis for
horses with more serious causes of colic has improved dramatically over the past 10 years,
predominantly because of early referral and surgical intervention. Future epidemiological
studies investigating the causes of colic and novel treatment methods for horses with
strangulating lesions are necessary for continued improvement in survival rates of the colic
patient.
Clin Tech Equine Pract 5:112-126 © 2006 Elsevier Inc. All rights reserved.

KEYWORDS equine, colic, gastrointestinal disease, impaction, large colon displacement,

nephrosplenic entrapment, large colon volvulus, colitis, epiploic foramen entrapment,
strangulating lipoma

C olic is the most common reason for equine emergency

treatment. The cause can vary from mild gas or spas-
modic colic to life-threatening large colon (LC) strangulation.
Obtaining a detailed history and performing a meticulous
physical examination is the cornerstone for an accurate as-
sessment of a horse with colic. Basic treatment consists of
analgesia, as well as oral, and occasionally intravenous (IV),
fluid therapy. More recently, with the introduction of Busco-
pan (N-butyl-scopolammonium bromide; Boehringer In-
gelheim, St Joseph, MO) to the United States, spasmolytics
are used as part of the initial management of horses with
colic. In severe cases, management of shock is necessary and
involves IV fluid therapy with crystalloids and colloids, elec-
trolyte correction, and antiendotoxin treatment. The use of
inotropes and pressors, such as dopamine, dobutamine, epi-
nephrine, and vasopressin, has not gained widespread use in
horses with colic because of the possible adverse effect of
these drugs on gastrointestinal tract (GI) perfusion1; these
drugs may become an important part of future treatment
regimens to manage critically ill horses with GI disease.
Colic is an important cause of morbidity and mortality in
the equine population. The annual national incidence of colic
in the U.S. horse population was estimated to be 4.2 colic
events/100 horses per year at an estimated annual cost of
Department of Clinical Studies, New Bolton Center, University of Pennsyl-
vania, Kennett Square, PA.
Address reprint requests to: Louise L. Southwood, BVSc, PhD, DACVS,
DACVECC, University of Pennsylvania, Department of Clinical Studies,
New Bolton Center, 382 W. Street Rd, Kennett Square, PA 19348. E-
mail: southwoo@vet.upenn.edu
$115.3 million to the equine industry.2 The fatality rate was
11%, and 1.4% of colic events resulted in surgery.2 Risk
factors for colic identified in epidemiological studies are out-
lined in Table 1.3-6 Recognition of and management changes
to avoid these predisposing factors is important for prevent-
ing colic.
Early referral and surgical intervention is the key to a suc-
cessful outcome with an improved prognosis during the past
10 years attributed to early, appropriate treatment and the
evolution of the specialty of equine emergency and critical
care. The Glass Horse (www.3dglasshorse.com; Figs. 1 to 3)
and the American College of Veterinary Surgeon’s (ACVS)
Web site (www.acvs.org) are new resources available to cli-
ents and veterinarians to enhance the understanding of GI
disease.
Signalment and History
The signalment (age, breed, and gender) is important in
forming a differential diagnosis. For example, geriatric horses
(⬎16 years old) commonly suffer from strangulation of the
small intestine (SI) by a pedunculated lipoma.7 The mean age
of horses with a strangulating lipoma (19.2 years) was signif-
icantly higher than that of horses with entrapment of the SI in
the epiploic foramen (EFE, 9.6 years) and other SI lesions
(7.7 years), and the proportion of horses with a strangulating
lipoma increased with increasing age.7 Geriatric horses also
appear to be predisposed to impaction, possibly as a result of
poor dentition and altered intestinal motility. Right dorsal
displacement of the LC (RDD) was more likely to occur in

112 1534-7516/06/$-see front matter © 2006 Elsevier Inc. All rights reserved.
doi:10.1053/j.ctep.2006.03.005
Acute abdomen
Table 1 Risk Factors for Colic3–5 and Colonic Obstruction and
Distention6 That Were Identified in Epidemiological Studies
in Texas and the United Kingdom
Location Risk Factor
Texas 3–5 Change in diet, type or batch of hay,
type of grain or concentrate fed
Less exposure to pasture
Feeding >2.7 kg of oats per day,
hay from round bales, Coastal
Bermuda grass hay
Change in housing or weather
Thoroughbred and Arabian breeds
Aged >8 or 10 years
Having had a previous episode of
colic or having undergone an
exploratory celiotomy for colic
Recent (<7 days previously)
administration of an anthelmintic
[note: Regular anthelmintic
administration reduces the risk of
colic.]
United Kingdom6 Hours spent in a stable
Residing at the present stable for
<6 months
Change in exercise regimen
Travel within the preceding 24 hours
Having had a previous episode of
colic
Absence of administration of an
ivermectin or moxidectin
anthelmintic within the previous
12 months
Infrequent teeth checks
Aerophagia (crib-biting,
wind-sucking)
horses 4 to 10 years of age compared with a hospital- and
colic-control population.8 The most common causes of colic
in neonates were uroperitoneum, meconium impaction, in-
tussusception, and enterocolitis in older foals.9
Horses of different breeds and gender are predisposed to
different causes of colic. For example, RDD was more com-
mon in wide-body horses, such as Quarter Horses, compared
with the hospital- and colic-control population.8 Miniature
breeds are predisposed to small colon (SC) obstruction with
a fecalith.10 Broodmares are commonly affected by LC volvu-
lus (LCV)11 1 to 3 months postfoaling; however, an LCV can
also occur peripartum. In a retrospective study of horses with
LCV referred to Colorado State University (CSU), 22.6% (74
of 327) of all horses and 40.9% (74 of 181) of female horses
were reported to be either pregnant or had recently foaled
with a the median duration of time postpartum of 37 days.12
A complete history should be obtained for all horses with
colic (Fig. 4). Pertinent historical findings include geographic
region in which the horse lives or has lived and exposure to
predisposing factors3-6 (Table 1). The geographical region the
horse has lived in is important; for example, horses from
California are predisposed to enterolithiasis13; horses from
sandy regions, such as California, Arizona, Colorado, Mich-
igan, Florida, and New Jersey, often have colic as a result of
sand accumulation or impaction14,15; and ileal impactions
occur in horses in the south eastern United States where
113
Coastal Bermuda grass hay is fed.16 The owner or caretaker
should be asked about the duration, character, consistency,
and severity of clinical signs. The recent history of defecation
(amount and consistency), appetite, water consumption, and
urination should be obtained. Aerophagia (“cribbing” or
“wind-sucking”) has been identified as a risk factor for colic6
and more recently with entrapment of the ileum and/or jeju-
num in the epiploic foramen.17 When horses with strangu-
lating SI lesions were evaluated retrospectively, horses with a
history of aerophagia were 34.7 times (University of Illinois)
and 8.2 times (University of London) at increased risk of
having an EFE than horses with no history of aerophagia.17
Physical Examination
Physical examination begins with observing the horse for signs
of pain, abdominal distention, sweating, and any injuries that
occurred when the horse was painful. Heart rate, respiratory
rate, rectal temperature, oral mucous membrane color and
moistness, capillary refill time, and auscultation of borborygmi
are part of the initial examination. Changes in physical exami-
nation findings over a period of time are often more useful than
physical examination findings at a particular moment in time.
Heart rate is important to assess pain and the cardiovascular
status of the horse, and is a useful prognostic indicator for sev-
eral causes of colic (see below). A nasogastric tube is passed
immediately in any horse showing signs of colic and tachycardia
(heart rate ⬎60 beats/min) to prevent gastric rupture. Respira-
tory rate varies, and observing nostril flare and depth of respira-
tion can be a useful indicator of the degree of pain (Fig. 5). Rectal
temperature can be useful for differentiating horses with an in-
flammatory or infectious condition (enteritis or colitis) from a
horse with a surgical colic; however, horses with surgical lesions
may have a fever associated with the systemic inflammatory
response syndrome (SIRS; Table 2) or an unrelated disease (for
example, respiratory tract infection). Signs of endotoxemia,
SIRS, or hyperdynamic shock include hyperemic (injected,
bright pink) oral mucous membranes as a result of peripheral
vasodilation (Fig. 6a), and signs of hypodynamic or terminal
shock include dark or cyanotic membranes as a result of poor
peripheral perfusion. Dry oral mucous membranes (and pro-
longed skin tent) is a sign of dehydration, which is a loss of total
body water, particularly from the subcutaneous tissue. Clinical
signs of dehydration can be detected when fluid loss is 5% of the
body weight (ie, 22.5 L in a 450-kg horse) and the horse will be
moribund when the fluid loss is 12% of the body weight (ie, 54
L in a 450-kg horse). A prolonged capillary refill time (and slow
jugular refill time) is a sign of hypovolemia or loss of water from
the intravascular space (Fig. 6b). Perfusion can also be assessed
by palpating the skin temperature of the extremities; cool ex-
tremities are associated with poor peripheral perfusion. Auscul-
tation of borborygmi is best classified as present or absent and
increasing or decreasing compared with that observed on pre-
vious auscultation.
Palpation per rectum requires adequate restraint (halter
and lead rope, nose twitch, stocks, sedation), copious lubri-
cation with or without lidocaine, and a gentle technique to
prevent a rectal tear and injury to the examining veterinarian.
If gas distention is present, the anatomical location of the gas
distention (SI, LC, cecum, SC) is determined based on the
size, structural features, and location of the distended vis-
114
cus.22 If an intra-abdominal mass is palpated, the consistency
(ie, fecal material consistent with an impaction versus an
abscess or tumor) should be assessed. If a firm fecal impac-
tion is palpable, its anatomical location (pelvic flexure/ven-
tral colon, cecum, SC) should be evaluated based on the size,
structural features, and the location of the impacted viscus.22
Ancillary Tests
Laboratory Data
Hematocrit, total protein, as well as total leukocyte and dif-
ferential count can be used to further assess the systemic
L.L. Southwood
Figure 1 Right dorsal displacement of
the large colon. (A) Left lateral and (B)
right caudolateral views. The large co-
lon is displaced between the cecum
and the right body wall. Image pro-
vided courtesy of The Glass Horse
(www.3dglasshorse.com) and the
University of Georgia. (Color version
of figure is available online.)
condition of the horse as well as the severity and type of
disease. Hematocrit can be used to evaluate the degree of
hemoconcentration/hypovolemia; however, is not the most
reliable measurement because other factors, such as splenic
contraction and blood loss, can contribute to the final hemat-
ocrit. The hematocrit may be severely increased compared
with normal (⬎55%) in horses with SIRS because of the
alteration in vascular endothelial function and subsequent
water leakage from the intravascular space. Large volumes of
fluid can also be lost from the intravascular space into the GI
lumen and/or wall. Hypoproteinemia is common in horses
with SIRS as a result of a loss of albumin from the intravas-
Acute abdomen 115

Figure 2 Left dorsal displacement of

the large colon or entrapment of the
colon over the nephrosplenic liga-
ment. (A) Left lateral and (B) caudal
views. Image provided courtesy of
The Glass Horse (www.3dglasshorse.
com) and the University of Georgia.
(Color version of figure is available
online.)

cular space because of altered endothelial function. Protein
can also be lost into the damaged GI lumen. A high hemato-
crit and low total protein has been associated with a less
favorable prognosis for horses with many causes of colic (see
following discussion). Fibrinogen can be used to assess the
inflammatory response and as an early indicator of a coagu-
lopathy. Hyperfibrinogenemia (⬎400 g/dL) is uncommon in
horses with colic and should alert the clinician to the pres-
ence of an underlying or unrelated inflammatory process.
Hypofibrinogenemia is also uncommon and is most likely to
be observed in horses with severe systemic disease and early
signs of disseminated intravascular coagulopathy (DIC) and
multiple organ dysfunction syndrome (MODS; Table 2). If
hypofibrinogenemia is observed, a coagulation profile should
be performed. Leukocyte count can be used to help differen-
tiate an inflammatory disease (enteritis or colitis) from a non-
inflammatory disease. While leukopenia, neutropenia, and a
high number of immature (band) neutrophils are often asso-
ciated with enteritis or colitis, it is imperative to remember
that horses with severe compromise to GI integrity or with
SIRS can become leukopenic as a result of leukocyte margin-
ation associated with leukocyte and endothelial cell activa-
tion.
Azotemia (high serum creatinine concentration, ⬎2 mg/
116
dL), hyperlactatemia (⬎2 mmol/L), and low venous oxygen
tension (PvO2 ⬍45 mm Hg) or saturation (SvO2 ⬍65%) are
indications of poor tissue perfusion in horses with colic.23
However, serum creatinine can also be high in horses with
renal failure and hyperlactatemia can occur as a result of
other factors, such as high epinephrine concentration and
poor hepatic clearance of lactate. Persistent azotemia follow-
ing fluid therapy warrants further assessment of renal func-
tion. Electrolytes should be measured and any abnormalities
corrected in horses with colic. Preoperative total and ionized
magnesium concentrations were low in 17% and 54% and
total and ionized calcium concentrations were low in 57%
and 86% of horses undergoing abdominal surgery, respec-
tively, and ionized calcium and magnesium concentrations
were lower in horses with strangulating compared with non-
strangulating lesions.24 Similarly, in a retrospective study of
horses with LCV, we found that 69% of horses were hypocal-
cemic (total calcium), 23% were hyponaturemic, 54% were
hypochloremic, and 3% were hypokalemic preoperatively.12
Liver enzymes are often high in horses with colic; however,
there has been no association with prognosis in horses with
primary GI disease.12,25
Abdominocentesis is generally not performed in cases
that are managed medically in the field but rather when
the horse has been referred for further assessment and
more intensive treatment. Abdominocentesis can be per-
formed by using a 1 ½-inch 20-gauge needle or a teat
cannula to the right of midline at the most dependent part
of the ventral abdomen.26 While peritoneal fluid analysis
can be useful, abdominocentesis carries with it the risk of
enterocentesis (which has a low rate of adverse sequelae)
and omental herniation in foals when a teat cannula is
used (which can be corrected by transecting the herniated
omentum and apposing the skin). The gross appearance of
the fluid (clear yellow [normal], opaque yellow [peritoni-
tis], serosanguinous [severely damaged intestine]) is im-
L.L. Southwood
Figure 3 A counterclockwise or ven-
tromedial-dorsolateral large colon
volvulus at the base of the large colon
as viewed from the right side of the
abdomen. Image provided courtesy of
The Glass Horse (www.3dglasshorse.
com) and the University of Georgia.
(Color version of figure is available
online.)
portant. The published normal value for peritoneal fluid
nucleated cell count is ⬍5000 to ⬍10,000 cells/␮L, and
for the total protein concentration ⬍2.5 g/dL.26 Peritoneal
fluid analysis can be used to assess intestinal viability
(gross appearance, total protein concentration) as well as
the presence of peritonitis or neoplasia (cytology). In
horses with strangulating lesions, total protein concentra-
tion and nucleated cell count will gradually increase com-
pared with normal. Horses with enteritis or colitis will
often have a high total protein concentration (⬎4 g/dL)
with a normal nucleated cell count. Horses with a stran-
gulating ischemic intestinal obstruction had a higher peri-
toneal lactate concentration (8.45 mmol/L) compared
with horses with a nonstrangulating obstruction (2.09
mmol/L).27 Because of an overall lack of specificity and
sensitivity of routine peritoneal fluid assessment for diag-
nosing strangulating intestinal lesions, the use of markers
for assessing intestinal viability has also been investigated.
For example, Nieto and coworkers28 reported that the
equine intestinal fatty acid binding protein concentration
in serum and peritoneal fluid was useful for predicting
survival and the need for abdominal surgery in horses with
colic.
Imaging Techniques
Radiology is not often used as a diagnostic modality for
adult horses with colic. However, radiography can be use-
ful for diagnosing the presence of enteroliths29 (Fig. 7) and
sand30 (Fig. 8) in adult horses. A barium contrast enema
and radiography can be used to determine the location of
an aboral obstruction in foals with colic. Ultrasonography
can be a useful ancillary test for assessing a horse with
colic.31,32 Ultrasonography is more sensitive than palpa-
tion per rectum for identifying SI distention and can be
used to assess the degree of distention, wall thickness,
Acute abdomen
Figure 4 An example of a history sheet
for horses with abdominal pain used
at Colorado State University. A for-
matted history sheet facilitates obtain-
ing a thorough history and in part can
be completed by the client at the time
of admission. (A) Front page and (B)
back page.
luminal contents, and motility. Ultrasonographic identifi-
cation of distended, thickened, amotile SI was 100% sen-
sitive and 100% specific for the presence of a strangulating
lesion.33 Specific causes of colic where ultrasonography
has been used to help with obtaining a more definitive
diagnosis include nephrosplenic ligament entrapment
(NLE),34 RDD,35 LCV,36 intussusception,35 and peritoni-
tis.31
Gastrointestinal Lesions
Gas or Spasmodic Colic
Gas or spasmodic colic is probably the most common
cause of colic in horses.4 It is often a presumptive diagno-
sis based on spontaneous resolution of pain or resolution
of pain following administration of analgesia and oral flu-
ids. Horses generally show mild to moderate pain; how-
ever, occasionally horses can be severely painful and dis-
tended. Surgical intervention is rarely necessary. Typically
horses are treated with flunixin meglumine (1 mg/kg IV),
followed by xylazine (0.2 to 0.5 mg/kg IV) and butorpha-
117
nol (0.01 to 0.02 mg/kg IV) if the pain is persistent. It is
important to administer flunixin meglumine IV and not
intramuscularly, because intramuscular injection has been
associated with an often fatal Clostridium spp myositis.37
The amount of flunixin meglumine administered should
not exceed 1 mg/kg every 12 hours and the horse should
be well hydrated, because of complications such as renal
papillary necrosis and GI ulceration. Referral for further
assessment and treatment is indicated in any horse that is
persistently painful following treatment with a dose of
flunixin meglumine as well as a dose of the xylazine-bu-
torphanol combination. Since its introduction to the
United States Buscopan (Boehringer Ingelheim), a spas-
molytic drug, has been used by some practitioners for
managing horses with gas or spasmodic colic. While the
results of clinical studies from Europe showed favorable
results,38 there have been no prospective, randomized
controlled studies on the use of Buscopan for treatment of
gas or spasmodic colic. High doses of Buscopan caused
intestinal stasis and colic,39 and while the authors reported
that lower doses (100 mg every 2 hours [q2 hour]) were
118
Figure 4 (Continued)
safe, caution should be used when giving this type of drug
to horses with GI disease. It is important to note that the
product marketed as Buscopan in the United States does
not contain dipyrone.
Impactions
Impactions of the pelvic flexure (left ventral colon), right
dorsal colon, and SC occur commonly. Horses show signs of
mild to moderate colic and become progressively more dis-
tended if the impaction is not resolved. A pelvic flexure or SC
impaction can often be diagnosed by using palpation per
L.L. Southwood
rectum. Impactions can occur with ingesta or sand and the
LC or SC can become obstructed with concretion formation
around a foreign body or an enterolith. A RDD (Fig. 1) can
occur secondarily to a pelvic flexure impaction and this
should be considered in a horse with a pelvic flexure impac-
tion that does not respond to medical management, becomes
more painful and distended, or if the findings on palpation
per rectum change. While there are several oral water and
electrolyte solutions, laxatives, lubricants, and cathartics that
have been used, Lopes and coworkers40 recently demon-
strated that an oral balanced water and electrolyte solution
Acute abdomen
Figure 5 Nostril flare can be an impor-
tant sign indicating pain, particularly
in a stoic horse. (Color version of fig-
ure is available online.)
was efficacious for hydrating the right dorsal colon contents
and feces and was more efficacious than magnesium sulfate,
water, or IV polyionic isotonic fluids in normal fistulated
horses. The balanced electrolyte solution caused fewer sys-
temic electrolyte alterations particularly when compared
with oral water alone and sodium sulfate.40 The balanced
water and electrolyte solution was 5.27 g NaCl, 0.37 g KCl,
and 3.78 g NaHCO3 in 1 L of water administered orally at a
rate of 5 L per hour at a constant rate infusion.40 Surgery is
indicated for horses with a LC or SC impaction that do not
respond to medical treatment and are persistently or severely
painful, have moderate to severe or progressively increasing
abdominal distention, are not defecating, and have worsen-
ing tachycardia. Surgery involves a pelvic flexure enterotomy
for horses with a LC impaction and a high enema or SC
enterotomy for horses with an SC impaction. Heart rate, re-
spiratory rate, blood leukocyte count, blood lactate concen-
tration, and peritoneal fluid total protein concentration at
admission were significantly associated with outcome in
horses with an LC impaction.41 The survival for horses with
an LC or SC impaction is good41,42 (Table 3). Interestingly,
43% (16/24) of horses with an SC impaction that were man-
aged surgically had Salmonella spp. isolated from their feces42
and particular attention to biosecurity and isolation proce-
dures should be followed when managing horses with an SC
impaction.
Cecal impactions are a particularly serious form of large
intestinal obstruction. While some horses with a cecal impac-
tion may respond to medical management with IV fluids as
well as oral fluids and laxatives, the risk of, and fatality asso-
ciated with, cecal perforation leads to many clinicians being
reluctant to pursue medical therapy for longer than 12 to 24
hours unless there is major clinical improvement. Surgery is
also indicated for any horse suspected of having a cecal im-
paction that is persistently painful and nonresponsive to an-
algesic drugs. Cecal impaction can usually be diagnosed
119
based on palpation per rectum. Many of these horses do not
show obvious signs of colic, and inappetence, lack of fecal
production, and mild intermittent pain may be the only clin-
ical findings. It is especially important to monitor horses
following unrelated surgery, such as orthopedic procedures,
for these signs. Complete cecal bypass (jejuno- or ileocolos-
tomy) and/or typhlotomy are the two most common surgical
procedures performed to treat horses with a cecal impaction.
In the past, surgeons have recommended performing a com-
plete cecal bypass if the cecum appeared to have a functional
problem at surgery (ie, the cecum was large, fluid-filled, in-
flamed). More recently, however, success with performing a
typhlotomy only for surgical treatment of horses with a cecal
impaction has been reported anecdotally and also pub-
lished.43 Nine of 10 horses undergoing typhlotomy-only for a
cecal impaction thought to be associated with a dysfunctional
cecum survived an average of 43 months.43 Anthelmintic
treatment (pyrantel pamoate) was recommended as Anoplo-
cephala perfoliata was recovered in several cases.43 Slow rein-
troduction of good quality, low-residue feed is critical to
prevent reimpaction in the early postoperative period.
Large Colon Displacements
Displacements of the LC include RDD and left dorsal dis-
placement (LDD) or NLE. Other displacements, such as pel-
vic flexure retroflexion, can also occur and are likely a form of
the more commonly reported displacements. Horses gener-
ally present with signs of mild to moderate colic and abdom-
inal distention. Horses may be mild to moderately dehy-
drated and hemoconcentrated. An LC displacement can be
diagnosed based on palpation per rectum.
RDD involves the LC becoming displaced between the
cecum and the right body wall. The pelvic flexure can move
in a counterclockwise (most common) or clockwise (less
common) direction around the cecum as viewed from the
120
Table 2 Nomenclature for Systemic Conditions Affecting Horses With Colic Based on Information From Human and Veterinary
Critical Care18 –21
Nomenclature (Acronym)
Endotoxemia
Systemic inflammatory response syndrome (SIRS)
Multiple organ dysfunction syndrome (MODS)
Sepsis
Severe sepsis
Septic shock
Hyperdynamic shock
Hypodynamic shock
Disseminated intravascular coagulopathy (DIC)
ventral abdomen (Fig. 1). In a study of 168 horses with RDD
diagnosed at surgery or necropsy, 71 (43%) were Quarter
Horses, the median age was 9 years (range 6 months to 21
years), 82 (49%) were female, 71 (43%) were castrated
males, and 14 (8%) were intact males.12 Most of the cases
occurred in the summer (June to August, 39% [63 of 160]),
followed by the fall, and then spring.12 Forty-three percent
(55 of 128) of the horses were reported to have had at least
one previous episode of colic.12 Tachycardia (heart rate ⬎48
beats/min) was reported in approximately half the horses.12
Reflux following passage of a nasogastric tube was obtained
in 17% (13 of 78) of horses.12 Hematology was unremarkable
in most (⬎70%) horses. The most notable abnormalities on
serum biochemistry are shown in Fig. 9. Recently, Gardner
and coworkers25 have also reported high serum gamma glu-
tamyl transferase (GGT; 49% [18 of 37] of horses) and bili-
rubin (33% [8 of 24] of horses) in horses with RDD, but not
in horses with LDD or NLE, and proposed that this was
caused by transient extrahepatic bile duct obstruction sec-
ondary to the RDD. Most important, high liver enzymes were
not associated with a poor prognosis or with persistent signs
of liver disease in horses with RDD in either study.12,25 While
some horses with RDD may respond to medical management
L.L. Southwood
Clinical Signs
Endotoxin (lipopolysaccharide from Gram-negative bacteria cell
wall) circulating in the blood; endotoxin can stimulate a
systemic inflammatory response (SIRS)
Systemic inflammatory response to severe clinical disease with
2 or more of the following: (1) fever or hypothermia, (2)
tachycardia, (3) tachypnea or hypocapnia, and (4)
leukopenia, leukocytosis, or a high number of circulating
immature (band) neutrophils
Functional abnormality of more than 1 vital organ system
including lungs, kidneys, cardiovascular, central and
peripheral nervous systems, coagulation, gastrointestinal
tract, liver, adrenal glands, and skeletal muscle
SIRS plus infection
Sepsis plus MODS, hypoperfusion, or hypotension
Sepsis-induced hypotension despite adequate fluid
resuscitation plus perfusion abnormalities (lactic acidosis,
oliguria, altered mentation)
Tachycardia, tachypnea, hyperemic mucous membranes, rapid
capillary refill time, decreased borborygmi compared to
normal, muscle fasciculations, and dullness; hyperdynamic
shock is characterized by a high cardiac output and low
peripheral vascular resistance
Tachycardia, tachypnea (rapid, shallow respiration), prolonged
capillary and jugular refill times, dry and purple to pale
mucous membranes, weak peripheral pulses, cool
extremities, and hypothermia; hypodynamic shock is
characterized by low cardiac output, high peripheral vascular
resistance, and systemic hypotension; MODS often follows
signs of hypodynamic shock
Abnormality in 3 of 5 of the following categories:
thrombocytopenia, hypofibrinogenemia, prolonged clotting
time tests (prothrombin time [PT], partial thromboplastin time
[PTT], activated clotting time [ACT]), decreased antithrombin
III (ATIII) activity compared to normal, high fibrin (fibrinogen)
degradation products (FDP)
(withholding feed, IV polyionic isotonic fluids), surgery is
indicated in most cases. Surgical correction involves colonic
decompression and repositioning of the colon. The prognosis
following surgical correction of RDD is excellent12 (Table 4).
Duration of colic, heart rate, and peritoneal fluid total protein
concentration were associated with short-term survival12 (Fig.
10). Long-term follow-up results are shown in Table 4.12 While
the actual recurrence rate of RDD was not obtained, horses that
had experienced an episode of colic before the episode necessi-
tating surgery were significantly more likely to show signs of
colic after surgery compared with horses that had not experi-
enced a previous episode of colic (P ⬍ 0.01).12
LDD or NLE occurs when the LC becomes displaced
between the spleen and the left body wall or entrapped
over the nephrosplenic ligament (Fig. 2). In a recent ret-
rospective study of 161 horses diagnosed with 174 epi-
sodes of NLE, the median age of horses was 5 years (9
months to 24 years). Interestingly, nasogastric reflux (ⱖ2
L) was obtained in 28% (32 of 113) of horses.44 Treatment
options for horses with NLE include IV phenylephrine
combined with light exercise, rolling under general anes-
thesia, and surgery. Phenylephrine is an alpha-adrenergic
receptor agonist that can be administered at a dose rate of
Acute abdomen
Figure 6 (A) Hyperemic (injected, bright pink) oral mu-
cous membranes. (B) Prolonged capillary refill time.
Courtesy of Dr. Josie Traub-Dargatz, Colorado State
University.
3 ␮g/kg/min for 15 minutes. At this dose the splenic area
reduces to 28% of baseline measurements.45 Phenyleph-
rine causes vasoconstriction and a reflex bradycardia and
horses should be monitored closely during phenylephrine
administration. The horse can be exercised (walking and
light trotting) for a very short time (5 to 10 minutes)
immediately following phenylephrine administration. Ex-
cessive or prolonged exercise may result in colonic rup-
ture. While the success of treating horses with NLE with
phenylephrine is reported to be high (5 of 5),44 obtaining
a definitive diagnosis of NLE is difficult and it is possible
that some horses that “respond” to treatment with phen-
Table 3 Prognosis for Survival for Horses With an Impaction of the Large or Small Colon
Impaction Site Duration of Follow-Up (Treatment)
Large colon 41 Short-term (overall)
Long-term (medical)
Long-term (surgical)
Small colon42 Short-term (medical)
Short-term (surgical)
Long-term (medical)
Long-term (surgical)
121
ylephrine may not have had an NLE. If the horse does not
respond to treatment with phenylephrine, rolling under
general anesthesia and/or surgery is necessary to correct
the NLE. Recently, we have reported the successful man-
agement of a horse with NLE using laparoscopy.46 The
horse of this report had minimal signs of colic or colonic
distention and had been treated several times with phen-
ylephrine. Laparoscopy was useful for confirming the di-
agnosis of NLE and repositioning the colon. The recur-
rence rate of NLE was reported to be 8% (13 of 161).44
Laparoscopic ablation of the nephrosplenic space by using
a suturing technique has been reported to successfully
Survival, % (Surviving Horses/Total Horses)
94.6% (139/147)
95.1% (78/82)
57.8% (11/19)
87.0% (41/47)
86.0% (32/37)
72.7% (24/33)
75.0% (21/28)
122
prevent the recurrence of NLE.47 Laparoscopic ablation of
the nephrosplenic space by using a mesh that is tacked to
the kidney and spleen may be a technically simpler lapa-
roscopic alternative to the previously reported suturing
technique (K. Epstein and E.J. Parente, unpublished data).
Large Colon Volvulus
LCV is a rapidly life-threatening lesion and requires the most
immediate attention for a favorable outcome. The LC is usu-
ally rotated in a counterclockwise (ventromedial-dorsolat-
eral) direction at the base of the colon or adjacent to the
cecocolic ligament (Fig. 3). Immediate surgical intervention
is necessary and involves colonic decompression and derota-
tion. In some cases, a pelvic flexure enterotomy to empty the
contents of the LC and administer intraluminal treatment,
such as di-tri-octahedral smectite (Biosponge; Platinum Per-
formance, Buellton, CA) and psyllium, or an LC resection is
performed. There has been recent anecdotal evidence that an
extensive LC resection can lower the morbidity and mortality
Figure 8 Abdominal radiograph showing the presence of
sand in the large colon. Courtesy of Dr. Josie Traub-Dar-
gatz, Colorado State University. (Color version of figure is
available online.)
L.L. Southwood
Figure 7 Abdominal radiograph that
was used to diagnose enterolithiasis
(arrow). Courtesy of Dr. Josie Traub-
Dargatz, Colorado State University.
(Color version of figure is available
online.)
for horses with an LCV by reducing the absorption of inflam-
matory mediators and toxins and creating a smaller surface
area over which the mucosa needs to regenerate.48 Horses
with an LCV often require intensive postoperative monitor-
ing and treatment.49 The prognosis for horses with an LCV
remains fair12 (Table 4). The overall short-term survival rate
for horses with an LCV was higher in 1999 (68%) compared
with 1987 to 1989 (25%).12 Recently, Embertson and co-
workers11 reported a survival rate of 83% (169 of 204) for
horses with an LCV. The high success rate in this study em-
phasizes the importance of early surgical intervention for
attaining a successful outcome. Duration of colic, heart rate,
hematocrit, blood glucose concentration, serum creatinine
concentration, serum chloride concentration, anion gap,
peritoneal fluid total protein, and mean arterial pressure un-
der general anesthesia were associated with short-term out-
come.12,49 Interestingly, liver enzymes were high in 60% to
80% of horses; however, there was no association between
high liver enzyme concentration and a poor outcome.49
Acute abdomen 123

100 that toxigenic strains of Clostridium difficile were cultured

90 from 100% (5 of 5) of horses with DPJ and from none of the
80 horses with other causes of nasogastric reflux (0 of 6). Early
70 disease recognition and appropriate treatment is critical for a
% of horses

60 favorable outcome. Horses may show signs of severe colic

50
40
30
20
10
0
GLY AZO CA SDH GGT BILI AST CK
Serum biochemistry measurement
Figure 9 Serum biochemistry abnormalities in horses with a right
dorsal displacement of the large colon. The percentage of horses
with an abnormal value is shown on the y axis and the serum
biochemistry measurement is shown on the x axis. GLY, hypergly-
cemia (serum glucose ⬎110 g/dL, 89 of 129 horses); AZO, azotemia
(serum creatinine concentration ⬎2.1 g/dL, 16 of 145 horses), CA,
hypocalcemia (total calcium concentration ⬍11 g/dL, 80 of 142
horses); SDH, high serum sorbitol dehydrogenase (⬎12 g/dL, 53 of
95 horses); GGT, high serum gamma glutamyl transferase (⬎22
g/dL, 29 of 103 horses); BILI, high serum bilirubin concentration
(⬎2.1 g/dL, 78 of 125 horses); AST, high serum aspartate transam-
inase (⬎375 g/dL, 77 of 117 horses); CK, high serum creatinine
kinase (⬎470 g/dL, 49 of 125 horses). (Color version of figure is
available online.)
Long-term follow-up results on horses discharged following
surgical treatment of an LCV are shown in Table 4.12 Horses
that had experienced an episode of colic before the episode
necessitating surgery were significantly more likely to have
an episode of colic after surgery compared with horses that
had not experienced a previous colic episode (P ⫽ 0.03).12
Enteritis and Colitis
Enteritis (duodenitis-proximal jejunitis, DPJ) and colitis refer
to inflammation of the SI and LC, respectively.50 While in
many cases the cause is unknown, infection with Clostridium
spp and Salmonella spp has been reported in cases of both
DPJ and colitis.50 Recently, Arroyo and coworkers51 reported
initially, but then become dull. Horses with DPJ are often
tachycardic, have distended SI on palpation per rectum and
ultrasound examination, and large volumes of reflux follow-
ing passage of a nasogastric tube. Horses with colitis are also
tachycardic, may have abdominal distention, hypermotile to
amotile borborygmi, and on palpation per rectum or abdom-
inal ultrasound examination may have a fluid-filled LC. The
challenge is differentiating a horse with DPJ or colitis from a
horse with a surgical lesion. While there is no definitive di-
agnostic test to differentiate between these types of lesions;
anecdotally, dullness, fever, leukopenia, and yellow-to-or-
ange peritoneal fluid with a very a high total protein concen-
tration (⬎4 g/dL) and a normal nucleated cell count are more
likely associated with DPJ or colitis than with a surgical le-
sion. Recently, it was reported that horses with DPJ were
more likely to have hepatic injury, indicated by a high GGT,
serum aspartate transaminase (AST), and alkaline phospha-
tase (ALP), than horses with a strangulating lesion and that
the mechanism of hepatic injury in horses with DJP was
possibly ascending infection from the common bile duct,
absorption of endotoxin or inflammatory mediators from the
portal circulation, or hepatic hypoxia associated with SIRS
and shock.52 Treatment for horses with DPJ or colitis involves
aggressive fluid and electrolyte therapy with crystalloids and
colloids, analgesia, anti-inflammatory drugs, antiendotoxin
therapy, and laminitis prevention.50 Motility stimulation may
also be useful for horses with DPJ. While an exploratory
celiotomy is expensive and associated with infrequent but
inherent complications with general anesthesia and surgery,
it is useful for obtaining a definitive diagnosis. Decompress-
ing the SI in cases of DPJ may be beneficial and an enterotomy
may be useful for emptying the contents of the LC in cases of
colitis. Seahorn and coworkers53 reported an overall survival
of horses with DPJ of 66% (50 of 75), with 88% (66 of 75) of
the horses in the study being managed medically, and 12% (9
of 75) of the horses undergoing surgery. Anion gap, abdom-

Table 4 Survival Rate for Horses With a Right Dorsal Displacement of the Large Colon (RDD) or a Large Colon Volvulus (LCV)*
Lesion Duration of Follow-Up (Classification) Survival, % (Surviving Horses/Total Horses)
RDD Short-term (overall) 80% (134/168)
Short-term (operated) 86% (133/155)
Short-term (recovered from general anesthesia) 93% (133/143)
Long-term (alive & no subsequent colic episodes) 52% (14/27)
Long-term (alive & >1 subsequent colic episodes) 48% (13/27)
Long-term (died from colic) 15% (4/27)
LCV Short-term (overall) 35% (144/327)
Short-term (operated) 51% (105/206)
Short-term (recovered from general anesthesia) 78% (105/135)
Long-term (alive & no subsequent colic episodes) 63% (29/46)
Long-term (alive & >1 subsequent colic episodes) 22% (10/46)
Long-term (died from colic) 13% (6/46)
Short-term, discharged from the hospital; long-term, longer than 6 months after surgery and the survival rate reported is for horses that were
discharged from the hospital for which follow-up was available; overall, survival rate for all horses that were admitted with a definitive
diagnosis of RDD or LCV; recovered from general anesthesia, survival rate for the horses that were recovered from general anesthesia.
*The results are from horses admitted to Colorado State University between 1987 and 1999.12
124 L.L. Southwood

A100 Table
B100 Table
90 90
Postop Postop
80 80 Discharge
Discharge
70 70

% of horses
% of horses

60 60
50 50
40 40
30 30
20 20
10 10
0 0
<1 2 to 3 3 to 4 >4 <50 50 to 70 70 to 90 90 to 100 >100
Duration of colic (days) Heart rate (beats per minute)

C100 Table
90
Postop
80 Discharge
Figure 10 The association between short-term survival of horses
70 with a right dorsal displacement and the duration of colic (A),
% of horses

60 heart rate (B), and peritoneal fluid total protein (C). The percent-
50 age of horses is shown on the y axis and the category for duration
of colic (days), heart rate (beats per minute), and peritoneal fluid
40
total protein (g/dL) is shown on the x axis. Table, euthanized or
30 died on the surgical table under general anesthesia; Postop, eu-
20 thanized or died following recovery from general anesthesia be-
fore discharge from the hospital; Discharge, discharged from the
10
hospital (short-term survival). (Color version of figure is avail-
0 able online.)
<2.5 2.5 to 3 3 to 4 >4
Peritoneal fluid total protein (g/dL)

inal fluid total protein concentration, and volume of reflux
obtained when a nasogastric tube was passed during the first
24 hours were associated with short-term survival out-
come.53 The prognosis for horses with colitis (acute diarrhea)
to survive short-term was 74.6% (91 of 122) and a history of
antimicrobial treatment for an unrelated disease, azotemia
(serum creatinine concentration ⬎2.0 g/dL), hemoconcen-
tration (hematocrit ⬎45%), tachycardia (heart rate ⬎60
beats/min), and low serum total protein concentration were
associated with a failure to survive.54
Strangulating Small Intestinal Lesions
There are several causes of SI strangulation. Strangulating
lipoma and EFE are two of the most common causes. Early
referral and surgical intervention are essential for a favor-
able outcome. Surgical treatment involves transection of
the mesenteric pedicle associated with the lipoma and
removal of the jejunum or ileum from the epiploic fora-
men in cases of strangulating lipoma and EFE, respec-
tively. Visual assessment of intestinal viability is per-
formed and the decision made with regard to the necessity
for a resection and anastomosis. Nonviable intestine is
resected and a jejunojejunostomy or jejunocecostomy is
completed. In many cases where surgical intervention oc-
curs early, resection and anastomosis is not necessary. In a
recent retrospective study, it was reported that all horses
with a strangulating lipoma not requiring a resection and
anastomosis survived more than 1 year.55 Postoperative
ileus and adhesion formation are the most challenging
complications following SI surgery in horses, and while
there are many motility modifying drugs and published
adhesion prevention strategies, early surgical intervention
and meticulous surgical technique are critical for prevent-
ing these postoperative complications. The 2-week and
1-year survival rates for horses with a strangulating lipoma
that required a jejunojejunostomy were 84% (27 of 32)
and 69% (22 of 32), respectively, and for horses requiring
a jejunocecostomy 68% (19 of 28) and 43% (12 of 28),
respectively.55 Undergoing surgery before 1992, heart rate
⬎80 beats/min, abnormal peritoneal fluid color, pale oral
mucous membranes, the necessity for an intestinal resec-
tion, and an inability to maintain a mean arterial blood
pressure of 100 mm Hg or higher under general anesthesia
was associated with a poor survival rate.55 A less favorable
prognosis for horses with EFE compared with horses with
other causes of SI strangulation has been reported.56 Free-
man and Schaeffer57 recently reported a survival rate of
95% (20 of 21) for horses with EFE that underwent sur-
gical correction (⫾ resection and anastomosis) and recov-
ered from general anesthesia,57 which was significantly
higher than the prognosis for horses with a strangulating
lipoma (84%, 32 of 38) and miscellaneous causes of SI
strangulation (91%, 49 of 54).56 The authors57 concluded
that prompt diagnosis of EFE is essential for a favorable
outcome, and that improved jejunocecostomy and viabil-
ity assessment (to avoid intestinal resection) techniques
Acute abdomen
are important for improving the survival rate of horses
with EFE.
Decision Making
for Referral and
Surgical Intervention
The decision of when to refer a horse to a secondary or
tertiary surgical facility and when surgical intervention is
necessary can be challenging. The inherent complication rate
associated with equine general anesthesia and surgery has
decreased to being low to negligible at most hospitals with
experienced surgeons and anesthesiologists. However, the
expense associated with abdominal surgery is the major
drawback to surgical intervention in a case in which it may
not be necessary.
Early referral to a surgical facility is recommended for a
horse with colic that is severely painful or that has been
treated with flunixin meglumine as well as xylazine and bu-
torphanol and remains painful. In addition to persistent or
severe pain, abdominal distention, tachycardia (heart rate
⬎60 beats/min), absence of borborygmi, nasogastric reflux,
or abnormal findings on palpation per rectum are indications
for referral. The owner should be informed of the dire con-
sequences of delayed referral and provided with an estimate
of the cost, prognosis, and expectations regarding further
evaluation and treatment at the referral hospital.
It is important to remember that abdominal exploration is
diagnostic and therapeutic. Surgery is indicated in any horse
with severe or persistent colic. The decision for surgery can
be challenging in horses showing very mild signs of pain that
are responsive to analgesia. In addition to pain, worsening
tachycardia and abdominal distention, abnormal findings on
palpation per rectum, absence of borborygmi or fecal pro-
duction, and abnormal peritoneal fluid are indications for
abdominal surgery. In a recent survey of veterinarians,58 the
findings on initial examination of a horse with colic that were
associated with the need for surgery were moderate, severe,
or persistent pain, return of pain after treatment, repeated
pain treatments, and decreased or absent borborygmi. Ab-
normal findings on palpation per rectum on the initial exam-
ination were not associated with the need for surgery,58 em-
phasizing the importance of repeat patient evaluation and
assessing the change in physical examination findings over
time.
Prognosis and Future Directions
While the short-term survival has improved for horses un-
dergoing surgical treatment, there are still concerns among
owners regarding the long-term prognosis for survival and
athletic activity. Horses that had undergone operation for
colic in France between 1999 and 2000 were followed long-
term.59 Two-thirds of the horses were reported to have re-
sumed activity identical to that before surgery; 26% had
short-term complications (ie, most commonly wound infec-
tion, hernia, and edema) and half of the horses had at least
one additional episode of colic.59 Horses with SI lesions took
longer to recover and had fewer postoperative complications
compared with horses with LC problems. Similarly, Santschi
125
and coworkers60 reported that young Thoroughbreds were
significantly less likely to race (63%) following a celiotomy
compared with unaffected siblings (82%); age at the time of
surgery was associated with the ability to race.60 Affected
foals that were able to race won as much money, raced as
often, with as many starts as their siblings.60 The authors
concluded that while colic surgery may have a negative im-
pact on future racing, the majority of foals discharged from
the hospital were able to perform athletically as adults.60
Future research directed toward improving the long-term
prognosis and usefulness of horses with colic is necessary.
Epidemiological studies are needed to improve our under-
standing of the causes of GI disturbances, particularly recur-
rent colic, to lower the incidence of colic in horses. Intense
laboratory and clinical research is ongoing with the goal of
improving our understanding of intestinal healing, patho-
physiology of SIRS and shock in horses, and to study novel
treatments to improve the prognosis for horses with strangu-
lating intestinal lesions and horses undergoing major abdom-
inal surgery.
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