Written by a CuraCore Veterinary Medical Acupuncture course graduate. Signed release obtained from client/author. 4L2018052
Abstract:
– Post-operative ileus with primary gastritis in a 9 year old Quarter Horse Mare that underwent exploratory celiotomy after a colic episode that did not respond to medical management.
– Patient was able to return to a normal diet and manure production following intermittent periods of reflux that was treated with electroacupuncture.
History and Presentation:
– Ruby presented for colic on 10/27/18. Upon presentation, Ruby was quiet, alert and responsive. Physical exam parameters were within normal limits with decreased borborygmi in all four quadrants.
– She is used as a cutting horse and maintained in a stall on coastal hay during the night and access to a large turnout during the day. She has no history of previous colic episodes.
Physical Examination and Clinical Assessments:
– Lactate: 0.6, PCV: 38% TP: 5.4. Rectal palpation was within normal limits. No net reflux was obtained via nasogastric intubation and Ruby was administered 5L of water and electrolytes. At this point, Ruby became uncomfortable in the stocks and was moved to a stall where she continued to be uncomfortable. She was sedated with 150mg xylazine and 5mg butorphanol IV and administered a 5L fluid bolus IV. Due to the continued pain despite analgesics, colic surgery was elected. In surgery, moderate to severe gas distention was found in the large colon and cecum. A large colon displacement was appreciated with retroversion of the pelvic flexure. This was resolved surgically. The small intestine showed no abnormalities and normal motility. Ruby recovered uneventfully from anesthesia and was maintained on IV fluids, antibiotics, Banamine and Ulcergard.
– Ruby remained bright the first 24 hours following surgery. She was gradually reintroduced feed. The evening of 10/29 she became uncomfortable and began refluxing. IV fluid therapy was initiated. A total of 22L of reflux was obtained over the next 24 hour that gradually decreased in frequency and amount.
– Ruby again remained comfortable for an additional 24 hours but starting reflux again on the evening of 11/2. Our differential diagnoses include primary clostridial gastritis, enteritis and/or ileus. The treatment with IV fluid therapy, lidocaine, electroacupuncture, and Banamine was continued through the weekend. Ruby responded well to aggressive treatment. Abdominal ultrasound was used to monitor the motility of the small intestine as well as the distension of her stomach. She was refed slowly this time (as the intestinal motility continued to improve and the stomach remained an appropriate size) and was only allowed to graze for the first 48 hours. She has since continued to pass normal manure and has maintained an appropriate appetite.
Differential Diagnoses: for colic
– Vascular: Infarction (mesenteric)
– Infectious: Clostridial enteritis
– Neoplastic: Strangulating lipoma
– Degenerative: Gastric/Duodenal Ulceration
– Iatrogenic: Post-surgical Dysbiosis
– Congenital: Meconium Impaction
– Autoimmune: Inflammatory Bowel Disease
– Traumatic: Gastric/Enteric Rupture
– Endocrine: Pars Pituitary Intermediary Dysfunction
– Myofascial: Secondary back pain due to abdominal discomfort and surgery
Definitive Diagnosis:
– Primary Gastritis (with grade II-III squamous ulcers) and Proximal Enteritis
– A gastroscopic exam was performed on the morning of 11/1 and revealed a large area of grade II-III squamous ulcers orad to the Margo plicatus. The Margo plicatus itself showed no ulcerations. She was maintained on 1 tube of Ulcergard and started on Sucralfate.
Medical Decision Making:
– Our primary goal was to get Ruby comfortable by returning the small intestine to normal motility, prevent her from refluxing and heal the areas of gastric ulcerations. With the resolutions of these symptoms, we hoped to gradually re-introduce feed to return her to a normal diet with a great appetite and normal manure production.
– Musculoskeletal palpation revealed mild-moderate epaxial muscle sensitivity in the caudal lumbar and lumbosacral junction. The acupuncture points and electroacupuncture points were chosen based on this sensitivity as well as the need to promote motility and decrease inflammation within the stomach and small intestine.
Medical Acupuncture and Related Techniques:
Treatments were performed twice daily (every 12 hours) for 4 days for 15 minute sessions. These were performed using Seirin J-Type Acupuncture needles (length: 30mm, diameter 0.20mm)
Dry-Needle technique for the first treatment (to see how well Ruby would tolerate the needles):
LI 18, BL 28, BL 29, BL 30, BL 21 (gastric ulcers), BL 23, BL 24, BL 25, Bai Hui
Autonomic Stimulation: ST 36, BL 34
Electroacupuncture (Ito Unit with two leads, at low frequencies at settings 1 and 2 followed by settings 2 and 3) for the second – seventh treatments:
Leads were alternating (red and black) at BL 21 and BL 23
Dry needles were placed at the same points listed above.
Outcomes, Discussions, References:
– Ruby improved via medical management (IV fluids with electrolytes and lidocaine, Banamine, Ulcergard and Sucralfate and acupuncture). Dry needle techniques coupled with electroacupuncture was used to help promote small intestinal motility and decrease musculoskeletal pain post-operatively.
– Ruby was able to remain comfortable in hospital and stop refluxing. She maintained a great appetite, normal manure production and was dismissed into the care of her owners.
– The plan is for Ruby to return home for the remainder of her recovery. She is to be treated for ulcers for one month. A recheck gastroscopy will be performed prior to discontinuing ulcer treatment. She is to have stall rest an additional 6 weeks. After which, she may have a stall with a small run for 2 weeks. On December 28th she may resume normal turnout and light riding with a gradual increase in work over 2 months. The staples were removed prior to discharge.