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How I Treat Enteritis/Colitis. Can it be Performed Successfully in the Field and What is the Prognosis?
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The initial issue of treatment of either enteritis, colitis, or enterocolitis involves obtaining an accurate diagnosis and differentiation from other possible causes of colic. Adult equine patients with profuse watery diarrhea imply the obvious presence of colon dysfunction, whereas, a patient with depression, inappetence, variable-to-no abdominal pain, fever, leukopenia, and occasionally hypoproteinemia – all clinical signs associated with enteritis – may not be as immediately obvious as having a diagnosis of enteritis. Especially in those cases where the initial clinical signs are so vague, the use of the ultrasound examination of the abdomen must be used to confirm the presence of enteritis and can help guide the treatment process.
With enteritis, the abdominal ultrasound exam may reveal multiple segments of fluid-filled, small intestine with variable motility, and occasionally gastric fluid distension secondary to small intestinal dysfunction. With impending enterocolitis or typhlocolitis, there may be variable fluid distension of the cecum or large colon – prior to the appearance of diarrhea.
Diagnostic procedures to identify an etiologic agent should be considered, including bacterial culture of gastric reflux or feces or diarrhea fluid. Additional diagnostics might include serology for Potomac Fever or other etiologic agents. The importance of early diagnostics might be useful in guiding medical therapy over time.
If the animal is painful, this is often due to secondary gastric distension, so immediate gastric decompression by passage of a nasogastric tube should be performed first. Following this, several observations can trigger multiple treatment steps.
The points to be considered in treatment of enteritis or colitis include:
- analgesics
- the need for intravenous fluid replacement
- anti-inflammatory medication
- anti-endotoxin medication
- enterally administered medications in attempts to adsorb luminal toxins or to impair bacterial adhesion to the enterocytes
- possibly antimicrobial administration
- management of gastric reflux due to poor intestinal motility associated with enteritis may also be required
- prevention of secondary laminitis should be considered
Perhaps the one limiting factor when deciding where to manage the adult equine patient with enteritis is the consideration for parenteral fluid therapy and possibly the need for frequent gastric decompression. Those patients demonstrating dehydration or even hypovolemia are likely going to require some period of intravenous fluid support. If this can be performed – at least on an intermittent basis – then it is possible to manage the patient on the farm. Frequent observation and evaluation, including hematology, clinical chemistry, and serial abdominal ultrasound is indicated in monitoring the clinical response and progression of enteritis. The type of parenteral fluid used can vary, but most commonly involves balanced electrolyte-containing crystalloids (Plasmalye®, Normosol®). Monitoring plasma electrolyte concentrations is useful, and occasionally supplementation with additional calcium or potassium may be helpful. The author likes to use colloid-containing fluid (hetastarch and occasionally plasma) when treating enteritis in an effort to decrease potential worsening of edema in the intestinal wall. Hetastarch is a colloid with a high molecular weight (450,000 dalton average) that can be used in the field setting as a bolus infusion of 10 ml/kg, perhaps repeated in 48 hours.
With profound colitis, continual administration of large volumes of crystalloid fluids may be required to replace the continual large volume of fluid lost via diarrhea. In addition, serial monitoring is required to evaluate whether protein loss is also an issue – requiring significant colloid replacement therapy. Animals in this severe condition require close monitoring by skilled nursing staff for intravenous catheter maintenance, early detection of complications such as venous thrombosis (secondary to loss of plasma proteins including antithrombin III), or early signs of laminitis. If the animal is initially maintained on the farm, frequent serial monitoring in the initial phases of treatment should be performed to determine if the condition is responding adequate for the current amount of care or if referral is needed. At least initially, daily collection of blood samples should be performed for evaluation of the hemogram, total protein, electrolytes, and creatinine concentration. These could be considered a minimum database to determine if the current therapy is sufficient at replacing lost fluids, maintaining serum electrolyte concentrations, maintaining sufficient renal blood flow to avoid or minimize azotemia, and to determine whether there is significant loss of plasma proteins from the inflamed intestine. Hand-held portable lactate analyzers can be used in the field to assess lactate levels as a marker of severity and to assess the response to initial therapy, and in some situations to help determine the need for referral when more aggressive fluid resuscitation is required to correct perfusion deficits.
Analgesia may be required initially when managing enteritis and colitis. Variable signs of colic are often present in the early stages of enteritis and colitis. Some colitis patients may become profoundly painful, either from severe intestinal distension with fluid or from intestinal ischemia associated with mucosal thrombosis and hypoperfusion. In some patients, N-butylscopolammonium bromide (Buscopan→, 0.3 mg/kg slowly IV) may be useful in relieving intestinal cramping. Non-steroidal anti-inflammatory medications such as flunixin meglumine are commonly used for control of inflammation and colic. Initially, a full dose may be given (1.1 mg/kg, IV, q 8-12 hours) followed by a lower dose (0.25 mg/kg, IV, q 6-8 hours) for its anti endotoxic effects. Other medications thought to suppress inflammatory mediators associated with endotoxin include pentoxifylline (8.5 mg/kg, PO, q 8-12 hours). In some patients with evidence of severe endotoxemia, polymixin B (2,000-6,000 IU/kg, q 8-12 hours IV) may be useful in binding the lipid A portion of endotoxin and minimizing its effects of the cardiovascular system. In animals with gastric reflux, some compounded formulations of pentoxifylline may be available for parenteral administration. Patients with more profound signs of pain may require advanced analgesia with medications such as butorphanol (0.01 – 0.04 mg/kg, IV, PRN). Continuous rate infusion (CRI) of lidocaine (0.05 mg/kg/minute after a loading dose of 1.3 mg/kg, IV) may also be useful in reducing pain, inflammation, and possibly ileus associated with enteritis. This certainly requires continuous monitoring and may not be feasible outside of a hospital facility. It should be noted that other physical causes of abdominal pain such as intestinal displacement, large or small colon impaction, or intestinal vascular compromise must be ruled-out before aggressive analgesic therapy is initiated and continued. [...]
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