2 ileus, stasis, bloat or blockage how to tell them apart by The All Ears Podcast

Ileus, stasis, bloat or blockagehow to tell the apart?

Terminology • Gut stasis: ‘stasis’ is a term that many people use to describe any rabbit that isn’t eating • Ileus- is a term that vets often use. May be called ‘non-obstructive’ or ‘obstructive’ • Bloat- term that breeders use to describe a rabbit with a distended abdomen. Often attributed to clover or grass cuttings. Can be due to mucoid enteropathy • Blockage- intestinal obstruction. Usually small intestine There is overlap between conditions

Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

Gut motility • Gut motility is complex and important • Supplies the caecum with nutrients and fluid • Passage of food, especially large particles of indigestible fibre appear to have a direct effect on gut motility

Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

Fusus coli • Fusus coli is innervated and has a good blood supply • Influenced by metabolites (glucose etc), hormones and the autonomic nervous system • Rabbits seem more susceptible than other species to the effect of stress on gut motility Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

Regulation of gut motility • Intestinal tissue will contract on its own • Adrenaline will slow gut movement • In rabbits, hindgut motility is complex • Regulated by a specially adapted area of the colon- the fusus coli (another feature of lagomorphs)

Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

Causes of stress and slow gut motility • Pain • Illness So any clinical problem can slow gut motility Examples of other causes: • Loss of companion • Travelling

Surgery is painfuleffective analgesia is very important in rabbits (it is in all species)

Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

Gut stasis is not a diagnosis • There is always a cause of gut stasis • It doesn’t just happen • It is not a diagnosis • ? Influence of diet – not proven My opinion: • Gut stasis is as likely to occur in rabbits on a high fibre diet. • However, rabbits on a high fibre diet are healthier and less like to suffer from some of the underlying causes

Dental spur and tongue damage

Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

Abdominal catastrophes • Obstruction of gut e.g. by foreign body or tumour • Strangulation of gut – where part of gut is constricted e.g in a hernia or by a loop of intestine • Torsion or twisting of a section of gut or other abdominal organ such as uterus • Rupture of an abdominal organ e.g bladder, gut or uterus • Peritonitis- can be result of any of above or due to infection e.g surgery, appendicitis (humans) or enterotoxaemia Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

Absence of signs of abdominal catastrophe in rabbits • Don’t sweat • Can’t vomit • Normal heart rate is 150-300bpm i.e. to fast to count easily • Pulse is hard to find • Hide and sit quietly when they are in pain • Any signs of colic are subtle

Anorexia may be the only sign that is obvious to the owner

Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

Signs of pain and stress in rabbits • Immobile • Unresponsive • ? Increased heart rate • ? Increased respiration • Anorexia- most obvious to the owner

Is it trivial or life-threatening

Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

Signs of abdominal catastrophe in other species • Complaining (humans) • Whimpering • Depressed and unhappy • Colic • Sweating • Fast, weak pulse • Vomiting • Anorexia Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

Blood glucose measurement in rabbits • Glucose quickly rises in response to stress • Can get very high in very painful conditions • Can also be low if insufficient nutrients are absorbed from digestive tract NB: Diabetes is rare (and rabbit would be eating) Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

Blood glucose measurement Reference range: 4.2-8.2 mmol/l

<2mmol/l- significant e.g Insulinoma <2-4mmol/l- needs food (gut stasis) or terminal 4-8mmol- reassuringly normal 8-15mmol/l- probably due to stress > 15mmol/l – severe stress, look for diagnosis > 20mmol/l –severe stress and pain. Could need surgery > 25mmol/l- serious stress and pain-surgery is probably only hope This is only a guide: there are exceptions

Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

Blood glucose in early stages of gut stasis • Variable • May be marginally high because rabbit is stressed by condition causing gut stasis • May be marginally low because insufficient nutrients from GI tract • Unlikely to be greater than 15mmol/l

• Food doesn’t move through gut • Stagnates • Pockets of gas collect in gut because gas producing organisms are present • Faecal output ceases • Hard faeces may accumulate in colon Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

Demeanour of rabbit in early stages of gut stasis

May be bright and responsive at outset unless there is serious illness or pain

Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

Left untreated- GI tract empties • Small stomach • Empty caecum and colon • Reduced absorption of glucose from gut • Reduced absorption of nutrients to and from caecum

Gut stasis- Initial changes

Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

Demeanour of rabbit • Often sitting quietly at back of cage • Hunched posture • No interest in eating on its own • Will probably take syringe feed (why?)

Blood glucose falls

Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

Glucose may be low, normal or slightly raised

Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

Formation of a hairball or ‘Trichobezoar’

After 2-3 days

• Gas continues to accumulate in stomach and caecum • Dehydration • Stomach contents become impacted Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

Demeanour of rabbit • Often sitting quietly at back of cage • Hunched posture • No interest in food • May frantically chew paper or hay • ? Response to abdominal pain • Rabbit has not eaten or passed faeces for 35 days.

Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

Next stage: Hepatic lipidosis • After 4-7 days of untreated gut stasis • Fat is mobilised and transported to liver as an energy source • Metabolic bottle neck occurs • Fat destroys liver cells • Rabbit dies from liver failure

Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

Clinical features of hepatic lipidosis • Rabbits are cold and wobbly • Unresponsive • Pale mucous membranes • Won’t take syringe feed- dribbles out of mouth • Terminal

• Impacted fur and food forms in ball in the stomach • ‘Hairball’ or ‘trichobezoar’ • Used to be thought to be cause of anorexia • Now it is known to be an effect

Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

Gastric ulceration

1.5mg/kg meloxicam

Stage when some owners first notice a problem

Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

• Can occur in rabbits with gut stasis • Only diagnosed during post-mortem examination or laparotomy • Role of NSAIDs (painkillers) is uncertain Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

Meloxicam • Trend to use high doses (0.61.5mg/kg) • Based on a study of a small number of healthy (not ill) rabbits • Showed that meloxicam is metabolised rapidly and rabbits are tolerant of high dose My opinion • Lower doses (0.15mg/kg twice daily) are effective and safer • Is the option to use higher doses if needed Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

Pineapple juice • Traditional remedy for gut stasis • Reputed to dissolve hair (doesn’t) • Does provide oral fluid • Also source of absorbable sugars and electrolytes

Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

Provide tempting foods

Prevention and treatment of gut stasis • Vitally important in rabbit medicine and surgery • Recognise any rabbit that is not eating and defaecating • Identify and treat the underlying condition • Provide effective analgesia • Prevent negative energy balance by ensuring rabbit has food going through gut • Stimulate gut motility • Reduce stress • MAKE A DIAGNOSIS (not always possible) Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

Syringe feeding • Provides fluid and electrolytes • Provides calories to prevent negative energy balance • Provides fibre to nourish caecal microflora • Safe and easy

Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

Medical treatment • Analgesia • Antiulcer medication • Drugs to stimulate gut motility -cisapride -metoclopramide -domperidone -zantac (ranitidine) also anti-ulcer

Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

Intestinal obstruction and bloat

Gastric dilation (bloat) • Common emergency • Sudden complete anorexia • Palpably enlarged stomach • NOT just gut stasis • NOT dietary • Is usually due to physical obstruction in intestine

Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

Recap:

Gas and fluid in stomach

Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

What happens if intestine is obstructed

• Stomach is very distensible • Strong cardiac sphincterone way valve • Saliva is continuously produced and swallowed • Stomach contents contains caecotrophs If exit to stomach is with gas producing blocked, there is nowhere bacteria for gas to escape

• •

• • •

No exit for food Rapid fermentation of stomach contents and gas production Fluid continues to be swallowed and secreted No exit for gas and fluid Stomach becomes distended 4 hours later

Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

Causes of intestinal obstruction: 1. Pellets of impacted hair

Gastric dilation • Stomach is distended beyond normal limits • Palpable behind ribs on left • Rabbit is unwell • Intestine fills with gas proximal to site of obstruction

Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

• Most common cause of obstruction • Only found during surgery or post-mortem examination • Can pass through GI tract so no definitive diagnosis made • Debate about origin

Blood glucose rises- >15mmol/l

Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

Theories about origin of pellets • ? Pieces of trichobezoars that have formed in stomach • ? Mats of hair that have been ingested during grooming • Hard faecal pellets containing impacted hair

Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

What happens if rabbit swallows a hard faecal pellet of compressed hair • If it is small, the pellet will pass straight through • If it is medium sized it can pass though but may obstruct intermittently • If it is large, it will obstruct the small intestine completely Pain may influence process by slowing gut motility Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

When pellet moves through ileocolic valve… • All the gas and fluid that has built up in stomach and small intestine is released into hindgut • Pellet passes through colon and out through anus

Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

‘Hairy poos’ • Large amounts of hair is ingested during grooming • Compressed during passage through colon • Passed out as pellets of compresses hair • Some rabbits eat hard faecal pellets as well as caecotrophs Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

Moving pellets • Pellets can move along and periodically obstruct gut • Pain probably slows motility and passage through gut • Analgesia might will help • Prokinetics might help

Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

What happens when obstruction goes through? Either: 1. Pain resolves and rabbit feels better. Improvement in demeanour and return of appetite - may be interpreted as successful response to treatment 2. Or rabbit has been ill so long that shock, secondary paralytic ileus, acute renal failure and/or electrolyte imbalances kill it

Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

Case report: 3yo MN Angora- Sunday afternoon

After 15 minutes 15 minutes later

Sudden onset anorexia, palpable stomach, glucose 19.6 mmol/l

Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

After 30 minutes

Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

After 2 hours

Rabbit started to eat- could be interpreted as successful response to treatment. Analgesia probably helped Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

What if the obstruction does not pass through to hind gut?

Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

Rupture of stomach or intestine • Rabbit will definitely die • Intestinal obstruction is a common cause of sudden death in pet rabbits

Blood glucose goes dramatically high

Shock, dehydration and electrolyte imbalances Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

Other causes of intestinal obstruction

Intestinal tumours

• Strangulations • Spherical hard objects- locust beans, sweetcorn kernels • ? Carpet fibre • ? Other ingested foreign bodies

• Common neoplasms of rabbits • Often aggressive • Usually inoperable • May be minimal signs (reduced appetite, weight loss) until obstruction occurs

Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

Options for rabbit with gastric dilation 1. Euthanasia 2. Surgery 3. Treat in same way as gut stasis with fluids, analgesia and motility stimulants Each case is different • Cost may be an issue • Confidence with anaesthesia and surgery may be an issue

Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

My options

Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

Case example: My rabbit Joe • 5.30 pm Friday 29th March 2015 • Moulting • Suddenly unwell • Had eaten well a few hours previously • Sitting in a corner • Unresponsive • Palpably enlarged stomach behind ribs on left Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

Further investigations

• Meloxicam and other painkillers • Motility stimulants • Massaging stomach • Infacol • Making him run around • Pineapple juice • Further investigations Not JoeIllustrative example of gastric dilation Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

• 6.15pm by time we arrived at practice • Not our night on duty • Friday evening • Gave analgesic • Took radiograph • Confirmed gastric dilation

Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

Options

Blood glucose measurement

• Meloxicam • Other painkillers • Motility stimulants • Fluid therapy • Surgery • Further investigations It was Friday evening

Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

Decision making

Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

Surgery

Surgery is expensive Friday night and inconvenient Probably a pellet of impacted hair causing the obstruction There is a chance that foreign body could move through on its own BUT • Delaying surgery increase the risks as the rabbit becomes more unwell • Rabbit is in pain with distended stomach • Surgery will resolve situation • Prevents the rabbit dying with a ruptured stomach or intestine And it is my rabbit…. • • • •

Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

Milking obstruction along

Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

Pushing pellet into hindgut

Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

?Right decision to operate Concerns: • Was surgery really necessary? • Have I made him worse? BUT • No longer obstructed • Was able to remove some of stomach contents and relieve pressure under GA

Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

They are not all so lucky

Outcome • Intravenous fluids disconnected after surgery • Needed syringe feeding for 36 hours • ‘Aggressive’ motility therapy • Meloxicam (0.15mg/kg 0.1mls/kg) twice daily • Antibiotics

Monday- less than 72 hours after surgery

Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

The end

• Having an obstruction seems to be just bad luck • Many get better without surgerymotility stimulants, analgesia etc. etc. • Others die • Makes treatment difficult Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery

Frances Harcourt‐Brown BVSc FRCVS, RCVS Recognised Specialist in Rabbit Medicine and Surgery