An Unusual Case of Colic

Names have been changed to observe patient and client privacy.


Juniper

Juniper, an 8-year-old quarter horse mare, was presented to the emergency services at the equine hospital around 11 PM on a Saturday night. Her owners were distraught yet composed, both standing quietly while we unloaded Juniper. Juniper was steaming when we moved her into the examination room. Muscle fasciculations were constant and she was sticky and wet with sweat. The severity of her pain was evident on her face. Ears pinned back, tightening around the orbit, crevice around her bottom lip, eyelids half closed in a painful meditation. She was conscious, but paid us little attention as we ran through the initial examination and diagnostic gamut.

The couple had two toddlers in hand, and they tried to distribute their attention appropriately. Between the toddlers’ random tantrums, we collected a brief history that led to an increasingly poor prognosis for Juniper. Since we had arrived at the hospital only minutes before Juniper, we still had to gather up the rest of the standard “colic gear.”

[briefly] the initial colic case prep

The typical exam tools (stethoscope, thermometer, gloves) are used for overall examination, and depending on the heart rate and likelihood of gastric distension, we then address gastric reflux. A nasogastric tube is passed through the nostril and proceeds down the esophagus when timed correctly with the horse swallowing. In the stomach, suction is created by mouth or using a dosing syringe. This is effectively siphoning out the stomach contents. Often times warm water is then flushed into the stomach and drawn out along with the reflux (if present). Gastric reflux is most often due to fluid’s inability to proceed through the small intestine. The stomach can become so distended that there can be rupture with ensuing fatality. A high heart rate (60-80 bpm) has been correlated with excessive gastric distension, and if this heart rate is present early on a tube is often times the immediate treatment performed.

Since a PCV, TP and lactate are frequently run in the first 10 minutes of arrival to assess critical status and help with a preliminary prognosis, the usual blood collection items are included. An EDTA (purple top) and red top blood collection tube, 20 and 18 gauge needles, and a 6 ml syringe are usually adequate. If the decision is made to catheterize, usually for fluid administration or part of pre-surgical prep, then a rectangular path is clipped above either the left or right jugular. Asceptic preparations are done before setting a 14 or 16 gauge catheter with suture stabilization and elasticon. Often times before the catheter is placed, fluid from the abdomen is collected for gross evaluation. For an abdominocentesis we frequently grab a teat canula, small EDTA tube, scrub prep, gloves and sometimes a scalpel blade. The ultrasound is the last item we bring over.

a poor prognosis and

a difficult decision

Juniper had a heart rate of 80 and a nasogastric tube was passed immediately with little net gastric reflux. An abdominal ultrasound did not show evidence of abnormalities and the abdominocentesis revealed slightly pink fluid. However, Juniper became increasingly uncomfortable and she was burning through any analgesics and sedatives we gave. Rectal palpation done by Dr. Cheer revealed a firm, large mass in the right caudal abdomen. He was suspicious of a lipoma considering the severe pain, presenting signs, history and overall frequency at which lipoma occur. Even though she was only 8, and lipomas usually occur in older horses, it still remained at the top of our list. Because of Juniper uncontrollable pain, medical management was not an option and if it was a lipoma, her condition would continue to decline.

Financial constraints, the overall prognosis and Juniper’s excruciating state of pain led the owners to decide to euthanize Juniper. They took turns petting her and whispering to her before they collected their two sons and went to their car. Being present for the euthanasia process is always a choice of owners and is not an indicator of the level of love and commitment they have. It’s a personal choice. They waited in the truck, hooked up to their empty trailer. We let them know that Juniper was gone and that everything had been peaceful. They both left in tears, and we took Juniper to our holding cooler where she would be picked up by the removal truck tomorrow morning.

Before the truck arrived in the morning, Juniper’s owners called with questions about unanswered questions. The tentative diagnosis had been toward a strangulating lesion, but no definitive diagnosis had been made. This is not unusual considering that most people do not have their horses necropsied to find the cause. From a veterinary medicine stand point and learning mind-set, I feel a lack of closure when the definitive diagnosis is absent. Dr. Cheer felt the same way about this case, something unsettled him. He had grown unaccustomed to not having the definitive answer, even if it left questions lingering in his mind.

post mortem findings

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Post mortem findings

At all of my preceptors, externs, shadowing and so forth experiences, I have never once had an owner ask or show interest in having a necropsy done. Perhaps it’s because the findings don’t bring their beloved horse back, and perhaps the answer would be worse than never knowing. Juniper’s owners wanted more answers and they consented to letting us perform a necropsy. Since there was limited time in the schedule, we conducted an abbreviated one that involved exploring the abdomen. Incising across the abdomen and up the paralumbar fossa, we shoved the mass of small intestines, cecum and other vastly normal tissue. Amidst a section of discolored bowel, we identified an abnormal structure held taunt in the abdomen by a ligamentous band. I identified it as the suspensory ligament, and subsequent abnormally large, firm ovary.

An enlarged ovary with some involvement of the small intestines was the only abnormalities we ended up finding. Sufficient to cause the signs of colic we saw, and tissue strangulation not unlike a lipoma would cause. I’ve been meaning to research this more, as I’ve never heard of a strangulating enlarged ovary but the pendulous nature of this 8 pound structure made it a sensible conclusion. Off the top of my head I think of causes of enlarged ovaries as hematomas, tumors, cystic. The most common ovarian tumor in the horse is the granulosa cell tumor. The thickness of the tissue, and size distribution made it appear less like a hematoma.

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Ovarian tumors in the mare

Although we were unable to send it in for histopathology, we had accomplished what Juniper’s family had wanted…more answers and probably the affirmation that they had done the right thing. Sometimes I feel we are helpless as practitioners, especially when there is no magic bullet or effective treatment. This was a reminder that sometimes the end is inevitable and the best thing we can do is help with the emotional aftermath of losing a beloved animal.