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Medical Management of the Colicky Foal
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Take Home Message
Following on the information presented in the initial evaluation and the ultrasound examination of the foal, we will create an outline approach to medical interventions for the colicky foal including: pain control, fluid therapy, intestinal motility management, and nutritional support.
Introduction
Perhaps the most important issue in approaching the foal with colic is to determine the specific cause and whether the problem is or has the potential to require surgical treatment for correction. Ultrasound imaging has changed the playing field in evaluation of abdominal pain in the foal over the past two decades. Today, we are able to accurately identify alterations in content and structure of abdominal organs of the foal rapidly and easily using ultrasound, and monitor the condition over time. Abdominal radiography is occasionally useful in evaluating the contents of the foal’s abdominal cavity. Endoscopy also has its place in the evaluation of abdominal pain in the foal – from gastroscopy in the patient suspected of having gastric ulcer disease to rectal endoscopy for assessment of suspect atresia coli. Between the physical examination and diagnostic imaging, a more specific cause of the colic signs in the foal can often be identified. As with evaluation of abdominal pain in a patient of any age, the clinician’s goal is to determine whether the condition is a surgical problem or could potentially become one. This may require serial evaluations over time. The classic example is the foal with enteritis that later develops a small intestinal intussusception requiring surgical correction. Continued monitoring of the patient thus becomes an important component of the medical management of the foal with abdominal pain.
Pain Control for the Colicky Foal
The initial medical management of the colicky foal is often providing pain control.
Analgesic medications are often used as a first line approach to control abdominal pain associated with colic. Flunixin meglumine (1.1 mg/kg, IV, not more often than once daily for neonates) is commonly used as a first line medication to control mild to moderate abdominal pain in a foal. More severe pain may require medications such as alpha-2 agonists (xylazine, 0.2 to 1 mg/kg IV) to control pain and prevent secondary injury to the foal. Opiate drugs such as butorphanol (0.05 mg/kg, IV) may be used alone or in combination with an alpha-2 agonist to provide additional analgesia.
Pain associated with colonic gas distension (tympany) of the neonate with a meconium impaction may respond to a prokinetic agent such as neostigmine (0.005-0.02 mg/kg SQ q 1 hr, usually up to 3 times). Similarly, a foal presenting with colonic fluid distension associated with the onset of rotavirus infection may respond either to neostigmine (for presumed colonic ileus) or to suppression of colon cramping with loperamide (0.1 – 0.2 mg/kg PO, q 6 hr).
Gastric distension from intestinal reflux associated with small intestinal obstruction (volvulus, duodenal stricture, intussusception) can be a cause of pain and passage of a nasogastric tube – before or after identification of the presence of a fluid-distended stomach on ultrasound – should be performed immediately in an attempt to provide pain relief for the affected foal.
Meconium Impaction
Meconium impaction represents a common and unique cause of colic for the neonatal foal. The clinical signs are commonly observed within the first 24 hours of age and are seen as repeated posturing to defect and protrusion of the anus. Diagnosis can be done with a digital rectal exam, but occasionally meconium impactions are more serious and may require abdominal ultrasound and/or abdominal radiography to determine the extent and severity of the impaction. Gross abdomimal distension in foals showing these signs is an indication for ultrasonography to rule out other causes such as uroperitoneum (whether primary or secondary to straining with the meconium impaction), or other intestinal lesions.
Often, simple meconium impactions can be resolved with commercially available phosphate enema preparations (Fleet enemas). More proximal impactions may require soapy (Ivory liquid soap) water enemas (300-500 ml) administered using an enema bucket and a Harris flush tube. The tube is advanced carefully up the rectum using abundant lubricant jelly. Repeated enemas can cause the rectal mucosa to become edematous and friable. Oral administration of milk of magnesia (30ml per 50 kg, PO, up to QID) can be useful in hydrating proximal meconium impactions. In some cases where the meconium is quite firm, an acetylcysteine retention enema can be helpful in loosening the mucus material within the meconium impaction. Materials for an acetylcysteine retention enema include 150 ml water, 6 grams acetylcysteine powder, 20 grams sodium bicarbonate power (baking soda), and a cuffed 14-24 French foley catheter. The foley catheter is placed into the rectum (up to 6 inches) using sterile lubricant and the cuff is inflated with saline. The solution is infused into the rectum with gravity flow or using a 60 ml catheter tip syringe. A clamp is placed on the catheter to allow retention of the solution in the rectum for approximately 20-30 minutes, after which time the clamp and catheter can be removed. This timeframe should allow the solution to diffuse up the rectal lumen to aid in dissolution of the mucus within the meconium and thus aid in its breakdown and passage.
In foals that are quite painful and not nursing sufficiently, parenteral fluids may be necessary to prevent or correct dehydration and to aid in hydrating the meconium mass.
Pain control for meconium impactions is as described above, and may require repeated dosing and close observation by skilled personnel. Those patients with severe, unrelenting pain and abdominal distension are best handled at a hospital facility. [...]
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