Difference between revisions of "Gastric Dilation and Rupture - Horse"

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Also known as: '''''Gastric Rupture
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| Also known as:
 
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|'''Gastric Rupture'''
 
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==Introduction==
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| See also:
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Gastric dilation in the horse may be primary, secondary or idiopathic.<ref name="Sanchez">Sanchez, L.C (2010) ''Other Disorders of the Stomach'' in Reed, S.M, Bayly, W.M. and Sellon, D.C (2010) '''Equine Internal Medicine''' (Third Edition), ''Saunders'', Chapter 15.</ref>
−
|'''[[Colic, Gastric Causes]]'''
 
−
|}
 
  
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==Description==
+
See also: '''[[Colic, Gastric Causes|Gastric causes of colic]]'''
−
Gastric dilation in the horse may be primary, secondary or idiopathic.<ref name="Sanchez">Sanchez, L.C (2010) ''Other Disorders of the Stomach'' in Reed, S.M, Bayly, W.M. and Sellon, D.C (2010) '''Equine Internal Medicine''' (Third Edition), ''Saunders'', Chapter 15.</ref>
 
  
 
==Aetiology==
 
==Aetiology==
  
−
*'''Primary causes:''' [[Gastric Impaction - Horse|gastric impaction]], food engorgement, excessive water intake after exercise, aerophagia, ''Gasterophilus'' infestation and habrenomiasis.<ref name="Camp">Campbell-Thompson, M.L, Merritt, A.M (1999) Alimentary system: diseases of the stomach.  In Colahan, P.T, Mayhew, I.G, Merritt, A.M, Moore, J.N ''Equine medicine and surgery'', St Louis, Mosby, pp 699-715.  In: Sanchez, L.C (2010) ''Other Disorders of the Stomach'' in Reed, S.M, Bayly, W.M. and Sellon, D.C (2010) '''Equine Internal Medicine''' (Third Edition), ''Saunders'', Chapter 15.</ref><ref name="Todhunter">Todhunter, R.J, Erb, H.N, Roth, L (1986) Gastric rupture in horses: a review of 54 cases. ''Equine Vet J'', 30:344-348.</ref>  Excessive consumption of fermentable feeds (grains, lush grass, and beet pulp) causes a large increase in the production of volatile fatty acids which is thought to delay gastric emptying.<ref name="Merck">Merck & Co (2008) '''The Merck Veterinary Manual (Eighth Edition)''', ''Merial''.</ref>
+
<u>'''Primary causes:'''</u>
−
*'''Secondary causes:''' primary intestinal ileus or small or large intestinal obstruction. Dilation resulting from small intestinal obstruction is the most common cause.  Fluid from the obstructed small intestine accumulates in the stomach, causing [[Colic Diagnosis - Naso-gastric Intubation|naso-gastric reflux]]. Gastric dilation may also occur with certain colonic displacements, especially '''right dorsal displacement of the colon''' around the caecum. It is hypothesised that the displaced colon obstructs duodenal outflow. Gastric fluid accumulation is also characteristic of '''proximal enteritis-jejunitis'''.<ref name="Merck">Merck & Co (2008) '''The Merck Veterinary Manual (Eighth Edition)''', ''Merial''.</ref>
+
 
 +
[[Gastric Impaction - Horse|Gastric impaction]], food engorgement, excessive water intake after exercise, aerophagia, ''[[Gasterophilus spp.|Gasterophilus]]'' infestation and [[Habronema and Draschia spp.|habrenomiasis]].<ref name="Camp">Campbell-Thompson, M.L, Merritt, A.M (1999) Alimentary system: diseases of the stomach.  In Colahan, P.T, Mayhew, I.G, Merritt, A.M, Moore, J.N ''Equine medicine and surgery'', St Louis, Mosby, pp 699-715.  In: Sanchez, L.C (2010) ''Other Disorders of the Stomach'' in Reed, S.M, Bayly, W.M. and Sellon, D.C (2010) '''Equine Internal Medicine''' (Third Edition), ''Saunders'', Chapter 15.</ref><ref name="Todhunter">Todhunter, R.J, Erb, H.N, Roth, L (1986) Gastric rupture in horses: a review of 54 cases. ''Equine Vet J'', 30:344-348.</ref>  Excessive consumption of fermentable feeds (grains, lush grass, and beet pulp) causes a large increase in the production of volatile fatty acids which is thought to delay gastric emptying.<ref name="Merck">Merck & Co (2008) '''The Merck Veterinary Manual (Eighth Edition)''', ''Merial''.</ref>
 +
 
 +
<u>'''Secondary causes:'''</u>
 +
 
 +
Primary intestinal ileus or small or large intestinal obstruction. Dilation resulting from small intestinal obstruction is the most common cause.  Fluid from the obstructed small intestine accumulates in the stomach, causing nasogastric reflux. Gastric dilation may also occur with certain colonic displacements, especially [[Large Colon, Right Dorsal Displacement - Horse|right dorsal displacement of the colon]] around the caecum. It is hypothesised that the displaced colon obstructs duodenal outflow. Gastric fluid accumulation is also characteristic of '''proximal enteritis-jejunitis'''.<ref name="Merck">Merck & Co (2008) '''The Merck Veterinary Manual (Eighth Edition)''', ''Merial''.</ref>
  
 
Untreated, gastric dilation can rapidly lead to '''gastric rupture''' whereby the stomach usually tears along its greater curvature.  It has been proposed that the '''seromuscularis''' weakens and tears before the gastric mucosa.<ref name="Todhunter">Todhunter, R.J, Erb, H.N, Roth, L (1986) Gastric rupture in horses: a review of 54 cases. ''Equine Vet J'', 30:344-348.</ref><ref name="Kiper">Kiper, M.L, Traub-Dargatz, J, Curtis, C.R (1990) Gastric rupture in horses: 50 cases (1979-1987), ''J Am Vet Med Assoc'', 196:333-336.  In: Sanchez, L.C (2010) ''Other Disorders of the Stomach'' in Reed, S.M, Bayly, W.M. and Sellon, D.C (2010) '''Equine Internal Medicine''' (Third Edition), ''Saunders'', Chapter 15.</ref>  Most cases of rupture occur secondary to mechanical obstruction, ileus, and trauma.  The rest are due to overload or idiopathic causes.<ref name="Merck">Merck & Co (2008) '''The Merck Veterinary Manual (Eighth Edition)''', ''Merial''.</ref>  Rupture can occur secondary to [[Gastric Ulceration - Horse|gastric ulceration]], in which case full-thickness tearing usually occurs in all layers of the gastric wall.<ref name="Sanchez">Sanchez, L.C (2010) ''Other Disorders of the Stomach'' in Reed, S.M, Bayly, W.M. and Sellon, D.C (2010) '''Equine Internal Medicine''' (Third Edition), ''Saunders'', Chapter 15.</ref>  Certain '''risk factors''' have been identified for gastric rupture<ref name="Todhunter">Todhunter, R.J, Erb, H.N, Roth, L (1986) Gastric rupture in horses: a review of 54 cases. ''Equine Vet J'', 30:344-348.</ref><ref name="Kiper">Kiper, M.L, Traub-Dargatz, J, Curtis, C.R (1990) Gastric rupture in horses: 50 cases (1979-1987), ''J Am Vet Med Assoc'', 196:333-336.  In: Sanchez, L.C (2010) ''Other Disorders of the Stomach'' in Reed, S.M, Bayly, W.M. and Sellon, D.C (2010) '''Equine Internal Medicine''' (Third Edition), ''Saunders'', Chapter 15.</ref> including:
 
Untreated, gastric dilation can rapidly lead to '''gastric rupture''' whereby the stomach usually tears along its greater curvature.  It has been proposed that the '''seromuscularis''' weakens and tears before the gastric mucosa.<ref name="Todhunter">Todhunter, R.J, Erb, H.N, Roth, L (1986) Gastric rupture in horses: a review of 54 cases. ''Equine Vet J'', 30:344-348.</ref><ref name="Kiper">Kiper, M.L, Traub-Dargatz, J, Curtis, C.R (1990) Gastric rupture in horses: 50 cases (1979-1987), ''J Am Vet Med Assoc'', 196:333-336.  In: Sanchez, L.C (2010) ''Other Disorders of the Stomach'' in Reed, S.M, Bayly, W.M. and Sellon, D.C (2010) '''Equine Internal Medicine''' (Third Edition), ''Saunders'', Chapter 15.</ref>  Most cases of rupture occur secondary to mechanical obstruction, ileus, and trauma.  The rest are due to overload or idiopathic causes.<ref name="Merck">Merck & Co (2008) '''The Merck Veterinary Manual (Eighth Edition)''', ''Merial''.</ref>  Rupture can occur secondary to [[Gastric Ulceration - Horse|gastric ulceration]], in which case full-thickness tearing usually occurs in all layers of the gastric wall.<ref name="Sanchez">Sanchez, L.C (2010) ''Other Disorders of the Stomach'' in Reed, S.M, Bayly, W.M. and Sellon, D.C (2010) '''Equine Internal Medicine''' (Third Edition), ''Saunders'', Chapter 15.</ref>  Certain '''risk factors''' have been identified for gastric rupture<ref name="Todhunter">Todhunter, R.J, Erb, H.N, Roth, L (1986) Gastric rupture in horses: a review of 54 cases. ''Equine Vet J'', 30:344-348.</ref><ref name="Kiper">Kiper, M.L, Traub-Dargatz, J, Curtis, C.R (1990) Gastric rupture in horses: 50 cases (1979-1987), ''J Am Vet Med Assoc'', 196:333-336.  In: Sanchez, L.C (2010) ''Other Disorders of the Stomach'' in Reed, S.M, Bayly, W.M. and Sellon, D.C (2010) '''Equine Internal Medicine''' (Third Edition), ''Saunders'', Chapter 15.</ref> including:
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*Pale mucous membranes
 
*Pale mucous membranes
 
*Retching<ref name="Merck">Merck & Co (2008) '''The Merck Veterinary Manual (Eighth Edition)''', ''Merial''.</ref>
 
*Retching<ref name="Merck">Merck & Co (2008) '''The Merck Veterinary Manual (Eighth Edition)''', ''Merial''.</ref>
−
*Ingesta appears at the nares in severe cases (rare)
+
*Ingesta at the nares in severe cases (rare)
 
*Gastric reflux  
 
*Gastric reflux  
−
NB: the time to development of reflux is proportional to the distance to the intestinal segment involved, (e.g. 4 hours with duodenal obstruction<ref>Puotunen-Reinert, A, Huskamp, B (1986) Experimental duodenal obstruction in the horse.  ''Vet Surg'', 15:420-428.  In: Sanchez, L.C (2010) ''Other Disorders of the Stomach'' in Reed, S.M, Bayly, W.M. and Sellon, D.C (2010) '''Equine Internal Medicine''' (Third Edition), ''Saunders'', Chapter 15.</ref>).  Furthermore, '''''nasogastric intubation does not preclude the possibility of gastric rupture.<ref name="Todhunter">Todhunter, R.J, Erb, H.N, Roth, L (1986) Gastric rupture in horses: a review of 54 cases. ''Equine Vet J'', 30:344-348.</ref>'''''
+
''NB: the time to development of reflux is proportional to the distance to the intestinal segment involved, (e.g. 4 hours with duodenal obstruction<ref>Puotunen-Reinert, A, Huskamp, B (1986) Experimental duodenal obstruction in the horse.  ''Vet Surg'', 15:420-428.  In: Sanchez, L.C (2010) ''Other Disorders of the Stomach'' in Reed, S.M, Bayly, W.M. and Sellon, D.C (2010) '''Equine Internal Medicine''' (Third Edition), ''Saunders'', Chapter 15.</ref>).  Furthermore, '''nasogastric intubation does not preclude the possibility of gastric rupture.<ref name="Todhunter">Todhunter, R.J, Erb, H.N, Roth, L (1986) Gastric rupture in horses: a review of 54 cases. ''Equine Vet J'', 30:344-348.</ref>'''''
  
 
'''Gastric rupture''' typically results in:
 
'''Gastric rupture''' typically results in:
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*Depression
 
*Depression
 
The inevitable '''peritonitis''' and '''endotoxic shock''' will lead to:
 
The inevitable '''peritonitis''' and '''endotoxic shock''' will lead to:
−
*Reluctance to move(Proudman)
+
*Reluctance to move<ref name="Proudman">Proudman, C.J, Baker, S.J (1994) Satellite Article: Gastric disease in the adult horse: a clinical perspective.  ''Equine Vet Educ'', 6(4):178-184.</ref>
 
*Tachypnoea
 
*Tachypnoea
 
*Tachycardia
 
*Tachycardia
 
*Sweating
 
*Sweating
 
*Muscle fasciculations
 
*Muscle fasciculations
−
*Blue or purple mucous membranes (Proudman)
+
*Blue or purple mucous membranes<ref name="Proudman">Proudman, C.J, Baker, S.J (1994) Satellite Article: Gastric disease in the adult horse: a clinical perspective.  ''Equine Vet Educ'', 6(4):178-184.</ref>
−
NB: rupture of a stomach containing dry, fibrous material may produce a more insidious onset of clinical signs of peritonitis than rupture of a fluid distended viscus. This probably relates to the speed at which gastric contents are able to disperse around the peritoneum.(Proudman)
+
''NB: rupture of a stomach containing dry, fibrous material may produce a more insidious onset of clinical signs of peritonitis than rupture of a fluid distended viscus. This is probably because it takes longer for the dry gastric contents to disperse around the peritoneum.''<ref name="Proudman">Proudman, C.J, Baker, S.J (1994) Satellite Article: Gastric disease in the adult horse: a clinical perspective.  ''Equine Vet Educ'', 6(4):178-184.</ref>
  
 
==Diagnosis==
 
==Diagnosis==
 +
'''Primary gastric dilation''' should be suspected if there are copious amounts of [[Colic Diagnosis - Naso-gastric Intubation|gastric reflux]] in the absence of small intestinal distension on [[Colic Diagnosis - Rectal Examination|rectal examination]] and the absence of endotoxaemia.<ref name="Proudman">Proudman, C.J, Baker, S.J (1994) Satellite Article: Gastric disease in the adult horse: a clinical perspective.  ''Equine Vet Educ'', 6(4):178-184.</ref>  A retrospective diagnosis of '''primary gastric dilation''' can be made if colic signs cease following decompression, and other clinical parameters return to normal.  Primary gastric dilation does not cause any significant change in peritoneal fluid parameters until rupture occurs.<ref name="Proudman">Proudman, C.J, Baker, S.J (1994) Satellite Article: Gastric disease in the adult horse: a clinical perspective.  ''Equine Vet Educ'', 6(4):178-184.</ref>
  
−
'''Primary gastric dilation''' should be suspected if there are copious amounts of [[Colic Diagnosis - Naso-gastric Intubation|gastric reflux]] in the absence of small intestinal distension on [[Colic Diagnosis - Rectal Examination|rectal examination]] and the absence of endotoxaemia.  A retrospectvie diagnosis of '''primary gastric dilation''' can be made if colic signs cease following decompression, and other clinical parameters return to normal.  Primary gastric dilation does not cause any significant change in peritoneal fluid parameters until rupture occurs.(Proudman)
+
'''Secondary gastric dilation''' should be considered if there is persistent [[Colic Diagnosis - Clinical Signs|colic]], repeated retrieval of [[Colic Diagnosis - Naso-gastric Intubation|nasogastric reflux]], intestinal distension on [[Colic Diagnosis - Rectal Examination|rectal examination]] and clinical signs of endotoxaemia.<ref name="Proudman">Proudman, C.J, Baker, S.J (1994) Satellite Article: Gastric disease in the adult horse: a clinical perspective.  ''Equine Vet Educ'', 6(4):178-184.</ref>  These are all indications for '''exploratory laparotomy''' to look for an intestinal obstruction.   
  
−
'''Secondary gastric dilation''' should be considered if there is persistent [[Colic Diagnosis - Clinical Signs|colic]], repeated retrieval of [[Colic Diagnosis - Naso-gastric Intubation|nasogastric reflux]], intestinal distension on [[Colic Diagnosis - Rectal Examination|rectal examination]] and clinical signs of [[Colic Diagnosis - Clinical Signs|endotoxaemia]].  These are all indications for '''exploratory laparotomy''' to look for an intestinal obstruction.   
+
NB: ''excessive fluid within the stomach is not always detected by nasogastric intubation, despite repeated attempts with frequent repositioning of the tube. Furthermore, gastric impaction with solid food material may be too firm to be retrieved by this method.''<ref name="Proudman">Proudman, C.J, Baker, S.J (1994) Satellite Article: Gastric disease in the adult horse: a clinical perspective.  ''Equine Vet Educ'', 6(4):178-184.</ref>  
  
−
Failure to detect excessive gastric contents by stomach tube aspiration does not entirely preclude their presence. Repeated attempts at obtaining reflux with frequent repositioning of the stomach tube are necessary. For reasons unknown, there are occasions when even the most diligent attempts at gastric decompression are unsuccessful in spite of large volumes of fluid being present.  It should also be emphasised that gastric impaction with solid food material is probably too firm to be siphoned by stomach tube.  
+
'''Gastric rupture''' results in septic peritonitis which will be reflected in the [[Colic - Peritoneal Fluid Analysis|nature of fluid collected by abdominocentesis]]<ref name="Proudman">Proudman, C.J, Baker, S.J (1994) Satellite Article: Gastric disease in the adult horse: a clinical perspective.  ''Equine Vet Educ'', 6(4):178-184.</ref>:
−
 
+
*Foetid, turbid sample containing particulate matter
−
Septic peritonitis as a result of gastric rupture is reflected in a foetid, turbid peritoneal fluid sample containing particulate matter, a white cell count often in excess of 40 x 10% and a protein content of >30g/l.
+
*White cell count >40 x 10<sup>9</sup>/l
−
The diagnosis of gastric rupture may be supported by characteristic findings on rectal examination, namely: a gritty feeling on the serosal surfaces of intestine due to adherent food material, and the impression of 'space' in the abdomen due to gas in the peritoneal cavity.(Proudman)
+
*Protein content >30g/l.
−
 
+
Findings on [[Colic Diagnosis - Rectal Examination|rectal examination]] may include<ref name="Proudman">Proudman, C.J, Baker, S.J (1994) Satellite Article: Gastric disease in the adult horse: a clinical perspective.  ''Equine Vet Educ'', 6(4):178-184.</ref>:
−
'''[[Colic Diagnosis - Clinicopathologic Evaluation|Laboratory findings]]<ref name="Camp">Campbell-Thompson, M.L, Merritt, A.M (1999) Alimentary system: diseases of the stomach.  In Colahan, P.T, Mayhew, I.G, Merritt, A.M, Moore, J.N ''Equine medicine and surgery'', St Louis, Mosby, pp 699-715.  In: Sanchez, L.C (2010) ''Other Disorders of the Stomach'' in Reed, S.M, Bayly, W.M. and Sellon, D.C (2010) '''Equine Internal Medicine''' (Third Edition), ''Saunders'', Chapter 15.</ref>:'''
+
*A 'gritty feeling' on the serosal surfaces of intestine due to adherent food material
 +
*An impression of 'space' in the abdomen due to gas in the peritoneal cavity.
 +
[[Colic Diagnosis - Clinicopathologic Evaluation|Laboratory findings]]<ref name="Camp">Campbell-Thompson, M.L, Merritt, A.M (1999) Alimentary system: diseases of the stomach.  In Colahan, P.T, Mayhew, I.G, Merritt, A.M, Moore, J.N ''Equine medicine and surgery'', St Louis, Mosby, pp 699-715.  In: Sanchez, L.C (2010) ''Other Disorders of the Stomach'' in Reed, S.M, Bayly, W.M. and Sellon, D.C (2010) '''Equine Internal Medicine''' (Third Edition), ''Saunders'', Chapter 15.</ref> may include:
 
*Haemoconcentration
 
*Haemoconcentration
 
*Hypokalaemia
 
*Hypokalaemia
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==Treatment==
 
==Treatment==
−
Prokinetic agents
+
'''[[Colic, Medical Treatment|Medical treatment]]:'''
−
Impaired gastric motility has been treated with several
 
−
drugs, especially in the context of treatment for postoperative
 
−
ileus. Metoclopramide (0.10-0.25 mg/kg bwt
 
−
3-4 times daily) has been used, but the frequent
 
−
occurrence of neurological side effects limits its utility.
 
−
Cisapride, a 5-HT4 agonist, has received some
 
−
attention. It has been given per 0s and i.v. but
 
−
commercially only an oral formulation is available. A
 
−
suggested dose is 0.1 mg/kg bwt q. 8 h (Gerring et a/.
 
−
1991). However, its therapeutic benefits have been found
 
−
to be equivocal.
 
−
Bethanecol. a muscarinic agonist, has also been used to
 
−
promote gastric emptying (0.00250.03 mg/kg bwt sub cut.
 
−
q. 4 h then 0.3-0.75 mg/kg bwt per 0s 3-4 times daily), but it
 
−
produces doserelated gastrointestinal side effects including
 
−
colic, diarrhoea and salivation (Murray 1990).
 
−
These prokinetic agents should be used only when
 
−
anatomical obstructions have been ruled out.
 
−
Nonsteroidal anti-inflammatory drugs appear to be
 
−
beneficial in equine post operative ileus, possiblyby inhibiting the release of prostaglandin synthesis
 
−
induced by endotoxin. Both flunixin meglumine and
 
−
phenylbutazone have been used and there is some
 
−
evidence to suggest that phenylbutazone may be more
 
−
efficacious (King and Gerring 1989).
 
−
Supportive therapy
 
−
Because of the uncertain benefits of drug treatment for
 
−
equine gastric diseases, considerable care must taken
 
−
with non-specific supportive measures. In particular,
 
−
in cases of delayed gastric emptying, gastric
 
−
decompression must be maintained either by an
 
−
indwelling nasogastric tube, with the attendant risks of
 
−
prolonged intubation, or by repeated intubation.
 
−
Hydration should be effectively maintained by parenteral
 
−
fluid therapy.(Proudman)
 
  
−
Surgical
+
If anatomical obstructions have been ruled out, '''prokinetic agents''' such as '''metoclopramide''' or '''bethanecol''' may prove useful to restore gastric motility, especially in the presence of post-operative ileus.  Unfortunately, metaclopramide causes neurological side effects and bethanecol produces dose-related gastrointestinal problems including colic, diarrhoea and salivation.<ref>Murray, M.J (1990) Gastric ulceration.  In: Smith, B.P, '''Large Animal Internal Medicine''', ''CV Mosby Publishing Company'', USA, pp 648-652. In: Proudman, C.J, Baker, S.J (1994) Satellite Article: Gastric disease in the adult horse: a clinical perspective. ''Equine Vet Educ'', 6(4):178-184.</ref>  '''Nonsteroidal anti-inflammatory drugs (NSAIDs)''' such as '''flunixin meglumine''' and '''phenylbutazone''' may also be beneficial in post operative ileus to help combat the effects of endotoxin. It is crucial that '''gastric decompression''' is maintained in cases of delayed gastric emptying.  This can be achieved with an indwelling nasogastric tube, (although prolonged intubation carries its own risk) or by repeated intubation.  '''IV fluid therapy''' should be given to ensure adequate hydration.<ref name="Proudman">Proudman, C.J, Baker, S.J (1994) Satellite Article: Gastric disease in the adult horse: a clinical perspective. ''Equine Vet Educ'', 6(4):178-184.</ref>
−
The stomach of the adult horse, by virtue of its anatomical
 
−
location in the cranial abdomen, partially enclosed by
 
−
C. J. Proudman and S. J. Baker 183
 
−
diaphragm and thoracic body wall, is difficult to access
 
−
surgically. Extension of a midline laparotomy incision
 
−
cranially improves access marginally but also increases
 
−
the probability of post operative wound problems. With
 
−
such difficult access and without the possibility of
 
−
mobilising the stomach to bring it closer to the incision
 
−
surgical options for treating gastric disease are very
 
−
limited. Gastrotomy and evacuation of impacted food
 
−
material has been reported (Clayton-Jones et a/. 1972)
 
−
but is extremely difficult to achieve without causing gross
 
−
peritoneal contamination. Softening of gastric impactions
 
−
can be successfully achieved during surgery by instillation
 
−
of fluid into the stomach by stomach tube, or by
 
−
transmural injection from the peritoneal side; and by
 
−
manual mixing of the fluid and impacted food material
 
−
by the surgeon massaging the stomach wall. The latter
 
−
technique is often used because of the difficulty of
 
−
passing a nasogastric tube in the anaesthetised horse in
 
−
dorsal recumbency.(Proudman)
 
  
 +
'''Surgical treatment''':
  
−
Surgical repair has been reported for partial thickness tears<ref>Steenhaut, M, Vlaminck, K, Gasthuys, F (1986) Surgical repair of a partial gastric rupture in a horse.  ''Equine Vet J'', 18:331-332.  In: Sanchez, L.C (2010) ''Other Disorders of the Stomach'' in Reed, S.M, Bayly, W.M. and Sellon, D.C (2010) '''Equine Internal Medicine''' (Third Edition), ''Saunders'', Chapter 15.</ref> and one case of a full thickness repair<ref>Hogan, P.M, Bramlage, L.R, Pierce, S.W (1995) Repair of a full-thickness gastric rupture in a horse.  ''J Am Vet Med Assoc'', 207:338-340.  In: Sanchez, L.C (2010) ''Other Disorders of the Stomach'' in Reed, S.M, Bayly, W.M. and Sellon, D.C (2010) '''Equine Internal Medicine''' (Third Edition), ''Saunders'', Chapter 15.</ref>
+
The surgical options for managing gastric disease are limited since the equine stomach is difficult to access surgically.  Extending the midline laparotomy incision cranially may improve access slightly but also increases the risk of post operative wound problems.<ref name="Proudman">Proudman, C.J, Baker, S.J (1994) Satellite Article: Gastric disease in the adult horse: a clinical perspective.  ''Equine Vet Educ'', 6(4):178-184.</ref>  Gastrotomy and removal of impacted food material has been reported<ref>Clayton-Jones, D.G, Greatorex, J.C, Stockman, M.J.R, Harris, C.P.J (1972) Gastric impaction in a pony: Relief via laparotomy.  ''Equine Vet J'', 4:98-99.  In: Proudman, C.J, Baker, S.J (1994) ''Satellite Article'': Gastric disease in the adult horse: a clinical perspective.  ''Equine Vet Educ'', 6(4):178-184.</ref> but carries a high risk of gross peritoneal contamination. For gastric rupture, surgical success has been reported for repairing partial thickness tears<ref>Steenhaut, M, Vlaminck, K, Gasthuys, F (1986) Surgical repair of a partial gastric rupture in a horse.  ''Equine Vet J'', 18:331-332.  In: Sanchez, L.C (2010) ''Other Disorders of the Stomach'' in Reed, S.M, Bayly, W.M. and Sellon, D.C (2010) '''Equine Internal Medicine''' (Third Edition), ''Saunders'', Chapter 15.</ref> and also in one case of a full thickness rupture.<ref>Hogan, P.M, Bramlage, L.R, Pierce, S.W (1995) Repair of a full-thickness gastric rupture in a horse.  ''J Am Vet Med Assoc'', 207:338-340.  In: Sanchez, L.C (2010) ''Other Disorders of the Stomach'' in Reed, S.M, Bayly, W.M. and Sellon, D.C (2010) '''Equine Internal Medicine''' (Third Edition), ''Saunders'', Chapter 15.</ref>
  
 
==Prognosis==
 
==Prognosis==
−
The prognosis for survival may be excellent in most cases of gastric dilation<ref name="Merck">Merck & Co (2008) '''The Merck Veterinary Manual (Eighth Edition)''', ''Merial''.</ref> but gastric rupture is usually '''fatal''' because of widespread contamination of the peritoneal cavity, septic peritonitis, and septic shock. '''Food engorgement''' also carries the risk of secondary [[laminitis]].
+
The prognosis for survival may be excellent in most cases of gastric dilation<ref name="Merck">Merck & Co (2008) '''The Merck Veterinary Manual (Eighth Edition)''', ''Merial''.</ref> but gastric rupture is usually '''fatal''' because of widespread contamination of the peritoneal cavity, septic peritonitis, and septic shock. '''Food engorgement''' also carries the risk of secondary laminitis.
 +
 
 +
{{Learning
 +
|flashcards = [[Equine Internal Medicine Q&A 01]]
 +
|literature search = [http://www.cabdirect.org/search.html?q=title:(gastric)+AND+(title:(dilat*)+OR+title:(ruptur*))+AND+od:(horses) Gastric Dilatation or Rupture in horses publications]
 +
}}
  
 
==References==
 
==References==
 
<references/>
 
<references/>
  
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[[Category:To_Do_-_Nina]]
+
 
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{{review}}
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==Webinars==
 +
<rss max="10" highlight="none">https://www.thewebinarvet.com/gastroenterology-and-nutrition/webinars/feed</rss>
 +
 
 +
[[Category:Expert_Review - Horse]]
 
[[Category:Surgical_Colic_in_the_Horse]]
 
[[Category:Surgical_Colic_in_the_Horse]]
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[[Category:Colic - Gastric Causes]]
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[[Category:Medical Colic in the Horse]]
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[[Category:Stomach Diseases - Horse]]

Latest revision as of 17:35, 6 January 2023

Also known as: Gastric Rupture

Introduction

Gastric dilation in the horse may be primary, secondary or idiopathic.[1]

See also: Gastric causes of colic

Aetiology

Primary causes:

Gastric impaction, food engorgement, excessive water intake after exercise, aerophagia, Gasterophilus infestation and habrenomiasis.[2][3] Excessive consumption of fermentable feeds (grains, lush grass, and beet pulp) causes a large increase in the production of volatile fatty acids which is thought to delay gastric emptying.[4]

Secondary causes:

Primary intestinal ileus or small or large intestinal obstruction. Dilation resulting from small intestinal obstruction is the most common cause. Fluid from the obstructed small intestine accumulates in the stomach, causing nasogastric reflux. Gastric dilation may also occur with certain colonic displacements, especially right dorsal displacement of the colon around the caecum. It is hypothesised that the displaced colon obstructs duodenal outflow. Gastric fluid accumulation is also characteristic of proximal enteritis-jejunitis.[4]

Untreated, gastric dilation can rapidly lead to gastric rupture whereby the stomach usually tears along its greater curvature. It has been proposed that the seromuscularis weakens and tears before the gastric mucosa.[3][5] Most cases of rupture occur secondary to mechanical obstruction, ileus, and trauma. The rest are due to overload or idiopathic causes.[4] Rupture can occur secondary to gastric ulceration, in which case full-thickness tearing usually occurs in all layers of the gastric wall.[1] Certain risk factors have been identified for gastric rupture[3][5] including:

  • Feeding grass hay
  • Not feeding grain
  • Gelding
  • Non-automatic water sources

Clinical signs

Gastric dilation usually produces:

  • Acute, severe colic
  • Tachycardia
  • Pale mucous membranes
  • Retching[4]
  • Ingesta at the nares in severe cases (rare)
  • Gastric reflux

NB: the time to development of reflux is proportional to the distance to the intestinal segment involved, (e.g. 4 hours with duodenal obstruction[6]). Furthermore, nasogastric intubation does not preclude the possibility of gastric rupture.[3]

Gastric rupture typically results in:

  • Relief
  • Depression

The inevitable peritonitis and endotoxic shock will lead to:

  • Reluctance to move[7]
  • Tachypnoea
  • Tachycardia
  • Sweating
  • Muscle fasciculations
  • Blue or purple mucous membranes[7]

NB: rupture of a stomach containing dry, fibrous material may produce a more insidious onset of clinical signs of peritonitis than rupture of a fluid distended viscus. This is probably because it takes longer for the dry gastric contents to disperse around the peritoneum.[7]

Diagnosis

Primary gastric dilation should be suspected if there are copious amounts of gastric reflux in the absence of small intestinal distension on rectal examination and the absence of endotoxaemia.[7] A retrospective diagnosis of primary gastric dilation can be made if colic signs cease following decompression, and other clinical parameters return to normal. Primary gastric dilation does not cause any significant change in peritoneal fluid parameters until rupture occurs.[7]

Secondary gastric dilation should be considered if there is persistent colic, repeated retrieval of nasogastric reflux, intestinal distension on rectal examination and clinical signs of endotoxaemia.[7] These are all indications for exploratory laparotomy to look for an intestinal obstruction.

NB: excessive fluid within the stomach is not always detected by nasogastric intubation, despite repeated attempts with frequent repositioning of the tube. Furthermore, gastric impaction with solid food material may be too firm to be retrieved by this method.[7]

Gastric rupture results in septic peritonitis which will be reflected in the nature of fluid collected by abdominocentesis[7]:

  • Foetid, turbid sample containing particulate matter
  • White cell count >40 x 109/l
  • Protein content >30g/l.

Findings on rectal examination may include[7]:

  • A 'gritty feeling' on the serosal surfaces of intestine due to adherent food material
  • An impression of 'space' in the abdomen due to gas in the peritoneal cavity.

Laboratory findings[2] may include:

  • Haemoconcentration
  • Hypokalaemia
  • Hypochloraemia

Treatment

Medical treatment:

If anatomical obstructions have been ruled out, prokinetic agents such as metoclopramide or bethanecol may prove useful to restore gastric motility, especially in the presence of post-operative ileus. Unfortunately, metaclopramide causes neurological side effects and bethanecol produces dose-related gastrointestinal problems including colic, diarrhoea and salivation.[8] Nonsteroidal anti-inflammatory drugs (NSAIDs) such as flunixin meglumine and phenylbutazone may also be beneficial in post operative ileus to help combat the effects of endotoxin. It is crucial that gastric decompression is maintained in cases of delayed gastric emptying. This can be achieved with an indwelling nasogastric tube, (although prolonged intubation carries its own risk) or by repeated intubation. IV fluid therapy should be given to ensure adequate hydration.[7]

Surgical treatment:

The surgical options for managing gastric disease are limited since the equine stomach is difficult to access surgically. Extending the midline laparotomy incision cranially may improve access slightly but also increases the risk of post operative wound problems.[7] Gastrotomy and removal of impacted food material has been reported[9] but carries a high risk of gross peritoneal contamination. For gastric rupture, surgical success has been reported for repairing partial thickness tears[10] and also in one case of a full thickness rupture.[11]

Prognosis

The prognosis for survival may be excellent in most cases of gastric dilation[4] but gastric rupture is usually fatal because of widespread contamination of the peritoneal cavity, septic peritonitis, and septic shock. Food engorgement also carries the risk of secondary laminitis.


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References

  1. ↑ 1.0 1.1 Sanchez, L.C (2010) Other Disorders of the Stomach in Reed, S.M, Bayly, W.M. and Sellon, D.C (2010) Equine Internal Medicine (Third Edition), Saunders, Chapter 15.
  2. ↑ 2.0 2.1 Campbell-Thompson, M.L, Merritt, A.M (1999) Alimentary system: diseases of the stomach. In Colahan, P.T, Mayhew, I.G, Merritt, A.M, Moore, J.N Equine medicine and surgery, St Louis, Mosby, pp 699-715. In: Sanchez, L.C (2010) Other Disorders of the Stomach in Reed, S.M, Bayly, W.M. and Sellon, D.C (2010) Equine Internal Medicine (Third Edition), Saunders, Chapter 15.
  3. ↑ 3.0 3.1 3.2 3.3 Todhunter, R.J, Erb, H.N, Roth, L (1986) Gastric rupture in horses: a review of 54 cases. Equine Vet J, 30:344-348.
  4. ↑ 4.0 4.1 4.2 4.3 4.4 Merck & Co (2008) The Merck Veterinary Manual (Eighth Edition), Merial.
  5. ↑ 5.0 5.1 Kiper, M.L, Traub-Dargatz, J, Curtis, C.R (1990) Gastric rupture in horses: 50 cases (1979-1987), J Am Vet Med Assoc, 196:333-336. In: Sanchez, L.C (2010) Other Disorders of the Stomach in Reed, S.M, Bayly, W.M. and Sellon, D.C (2010) Equine Internal Medicine (Third Edition), Saunders, Chapter 15.
  6. ↑ Puotunen-Reinert, A, Huskamp, B (1986) Experimental duodenal obstruction in the horse. Vet Surg, 15:420-428. In: Sanchez, L.C (2010) Other Disorders of the Stomach in Reed, S.M, Bayly, W.M. and Sellon, D.C (2010) Equine Internal Medicine (Third Edition), Saunders, Chapter 15.
  7. ↑ 7.00 7.01 7.02 7.03 7.04 7.05 7.06 7.07 7.08 7.09 7.10 Proudman, C.J, Baker, S.J (1994) Satellite Article: Gastric disease in the adult horse: a clinical perspective. Equine Vet Educ, 6(4):178-184.
  8. ↑ Murray, M.J (1990) Gastric ulceration. In: Smith, B.P, Large Animal Internal Medicine, CV Mosby Publishing Company, USA, pp 648-652. In: Proudman, C.J, Baker, S.J (1994) Satellite Article: Gastric disease in the adult horse: a clinical perspective. Equine Vet Educ, 6(4):178-184.
  9. ↑ Clayton-Jones, D.G, Greatorex, J.C, Stockman, M.J.R, Harris, C.P.J (1972) Gastric impaction in a pony: Relief via laparotomy. Equine Vet J, 4:98-99. In: Proudman, C.J, Baker, S.J (1994) Satellite Article: Gastric disease in the adult horse: a clinical perspective. Equine Vet Educ, 6(4):178-184.
  10. ↑ Steenhaut, M, Vlaminck, K, Gasthuys, F (1986) Surgical repair of a partial gastric rupture in a horse. Equine Vet J, 18:331-332. In: Sanchez, L.C (2010) Other Disorders of the Stomach in Reed, S.M, Bayly, W.M. and Sellon, D.C (2010) Equine Internal Medicine (Third Edition), Saunders, Chapter 15.
  11. ↑ Hogan, P.M, Bramlage, L.R, Pierce, S.W (1995) Repair of a full-thickness gastric rupture in a horse. J Am Vet Med Assoc, 207:338-340. In: Sanchez, L.C (2010) Other Disorders of the Stomach in Reed, S.M, Bayly, W.M. and Sellon, D.C (2010) Equine Internal Medicine (Third Edition), Saunders, Chapter 15.


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