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Abdominal Ultrasonography in the Equine Patient with Acute Signs of Colic

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Abdominal Ultrasonography in the Equine Patient with Acute Signs of Colic IN-DEPTH: ULTRASOUND OF THE THORAX AND ABDOMEN Abdominal Ultrasonography in the Equine Patient With Acute Signs of Colic Andreas Klohnen, DVM, Diplomate ACVS Author’s address: Chino Valley Equine Hospital, 2945 English Place, Chino Hills, CA 91709; e-mail: [email protected]. © 2012 AAEP. 1. Introduction of a horse with signs of abdominal pain, the baseline Abdominal pain in horses is one of the most common pain level should be considered. An abdominal ul- presenting clinical signs and a major cause of mor- trasound examination should not be performed if a tality in horses. Rapid and effective evaluation of horse has fractious behavior or is showing signs of horses with signs of colic is necessary for prompt uncontrollable abdominal pain despite sedation. surgical intervention, thereby allowing for more suc- The abdominal wall is saturated with isopropyl cessful outcomes. However, determining the ac- alcohol using a spray bottle to dampen the hair and tual cause of colic in horses is a diagnostic challenge, create adequate contact with the transducer to and the decision for selecting abdominal surgery in achieve adequate image quality. Ultrasonographic horses with colic is not always straightforward. coupling gel can then be applied liberally to the Analgesic administration or stoic horses may delay ultrasound transducer to further enhance the image necessary abdominal surgery, resulting in a de- quality. A 3.5-MHz convex linear transducer with creased prognosis for survival. a maximal depth range of at least 25 cm is used for The decision between medical management and sur- ultrasonographic examination of the equine abdo- gical intervention is largely made on the basis of phys- men. To evaluate the deeper areas of the equine ical examination, abdominocentesis, abdominal abdomen, the focal zones should be positioned in the palpation per rectum and, most importantly, persis- far field to enhance visualization of deeper struc- tent signs of abdominal pain despite medical treat- tures. In most ambulatory settings, a practitioner ment. More recently, abdominal radiography and may not have a 3.5-MHz probe available. A 5-MHZ abdominal ultrasonography have become more useful linear rectal probe may be used instead but will give in evaluating horses with abdominal pain. Several the examiner a much smaller ultrasonographic win- recent studies have shown that abdominal ultrasonog- dow of the abdomen. The 5-MHz probe does not raphy in the colic patient can be a very useful diagnos- provide the same level of penetration as a 3.5-MHz tic tool. convex linear transducer, but it is adequate to eval- uate portions of the equine adult abdomen for signs Technique of abdominal pain. Abdominal ultrasonography is a very safe and non- A systematic approach to each ultrasound exami- invasive diagnostic test. After initial examination nation in a horse for signs of colic is recommended. NOTES AAEP PROCEEDINGS ր Vol. 58 ր 2012 11 Orig. Op. OPERATOR: Session PROOF: PE’s: AA’s: 4/Color Figure(s) ARTNO: 1st disk, 2nd beb spencers 8 F1-3,5-10,12 3407 IN-DEPTH: ULTRASOUND OF THE THORAX AND ABDOMEN C O L O R Fig. 1. Large colon wall. The abdomen is divided into three regions (right paralumbar fossa [PLF] region, ventral region/ingui- nal region, and left paralumbar fossa). Each region can be further subdivided into right PLF 1, 2, and 3; ventral (V) 1, 2, and 3; and left PLF 1, 2, and 3. The examination should start in the right paralumbar fossa and continue to the ventral/inguinal region and then the left paralumbar fossa region after the horse is C turned around or the machine moved to the other side O of the horse. The right and left intercostal regions L should also be evaluated for possible intestinal abnor- O malities. The margins of these regions are meant to R serve as a guideline for a systemic ultrasound exami- nation. In most equine cases with colic, an individual Fig. 2. A, Distended loop of small intestine. B, Several distended region does not correspond with a specific diagnosis for loops of small intestines. the signs of colic. Abdominal Ultrasound of the Normal Horse the width of the measuring cursors (Ͻ3mm). Itis In clinically normal horses without signs of abdom- very rare to visualize distended loops of small intes- inal pain, the large intestine can be distinguished tine in a clinically normal horse. from the small intestine by size and appearance. The nephro-splenic space is imaged in the left PLF The large colon can be visualized in all three regions 1 region, where the left kidney and caudal edge of and appears as a bright hyperechoic line correlating the spleen are consistently identified (Fig. 3). The F3 with the ventral colon sacculations or the wall of the stomach wall should be visualized in the left inter- F1 dorsal colon (Fig. 1). Because of the size of the costal spaces, but the stomach should not be dis- large colon and the presence of gas and feed within tended with fluid. the colon, the deep border is often not visualized and Examination of the right PLF 1 region and the the colon cannot be imaged as a complete loop. rightmost caudal intercostal areas should demon- In a normal horse, individual layers of the colon are strate the right kidney and the duodenum. In a not typically visible. clinically normal horse, there should not be any Transverse sections of the small intestine are im- significant distention or increased wall thickness in aged as complete loops, and usually more than 1 loop the duodenum. F2 can be viewed (Fig. 2, A and B). In a normal horse, In a clinically normal horse, the ventral region the small intestine can be imaged as circular densi- (V1, just caudal to the sternum) may demonstrate ties that show continuous movement. The small the presence of abdominal fluid. intestine is often visible along the ventral axial sur- face of the spleen from the left side and in the Abdominal Ultrasound of the Horse With Signs of inguinal regions. Small intestine wall thickness in Abdominal Pain clinically normal horses is difficult to measure when Abdominal ultrasound in the horse with signs of scanning at maximal depth because it is less than abdominal pain has been most helpful for the detec- 12 2012 ր Vol. 58 ր AAEP PROCEEDINGS Orig. Op. OPERATOR: Session PROOF: PE’s: AA’s: 4/Color Figure(s) ARTNO: 1st disk, 2nd beb spencers 7 F1-3,5-10,12 3407 IN-DEPTH: ULTRASOUND OF THE THORAX AND ABDOMEN C O L O R Fig. 3. Normal anatomy of the left paralumbar fossa. Fig. 4. Sand accumulation in the colon. tion and diagnosis of strangulating and nonstrangu- lation lesions of the small intestine. Each region and subregion of the abdomen is examined ultra- sonographically, and the detection of either large small intestine that are secondary to the primary intestine and/or small intestine is recorded. Im- problem (colonic enterolith). The gold standard for ages of the small intestine (jejunum) and duodenum the detection of an enterolith in the large colon is are measured for diameter and wall thickness. abdominal radiographs. In the author’s opinion, The detection of intestinal motility is recorded. colonic enteroliths are not detectable with abdomi- Small intestinal motility is defined as contraction nal ultrasound. and subsequent distention of the small intestinal walls with a change in luminal diameter. In some Horses With Peritonitis, Ruptured Intestines, Abdominal horses with small intestinal lesions, there is com- Fluid Analysis plete absence of small intestinal motility. Abdominal ultrasonography of a horse with perito- Additionally, the nephro-splenic space (left PLF l nitis will usually show several slightly distended and left PLF 2) is evaluated for either a left dorsal loops of small intestine with a very thickened small colon displacement or a nephro-splenic entrapment of the large colon. The left intercostal spaces (ribs 10 to 13) are also evaluated for possible distention of the stomach with fluid (gastric reflux). Horses With Sand Accumulation in the Colon (Sand Colic) Abdominal ultrasonography of a horse with sand colic usually will not show any distended, amotile loops of small intestine. Some horses with sand colic may show signs of minimally distended small intestine loops filled with fluid or ingesta, which are subsequent to the primary sand colic problem. The gold standard for the detection of sand in the F4 large colon is abdominal radiography (Fig. 4). Ab- dominal ultrasound of a horse with sand accumula- tion in the colon will reveal the large colon wall in the ventral region to appear “brighter” and more hyperechoic. This ultrasonographic finding is re- lated to the ultrasonographic reflection of the sand F5 particles (Fig. 5). C O Horses With Large Colon Enteroliths and/or Small Colon L Enteroliths O Abdominal ultrasonography of a horse with a large R colon enterolith or small colon enterolith usually will not show any distended or amotile loops of small Fig. 5. Ultrasonographic view of the large colon wall in the intestine but may show minimally distended loops of ventral region showing evidence of sand in the colon. AAEP PROCEEDINGS ր Vol. 58 ր 2012 13 Orig. Op. OPERATOR: Session PROOF: PE’s: AA’s: 4/Color Figure(s) ARTNO: 1st disk, 2nd beb spencers 7 F1-3,5-10,12 3407 IN-DEPTH: ULTRASOUND OF THE THORAX AND ABDOMEN C O L O R Fig. 6. Slightly distended loops of small intestine with very thickened intestinal wall, indicative of peritonitis. F6 intestinal wall (Fig. 6). The small intestinal motility may vary. The thickened loops of small intestine are usually best visualized in the ventral or inguinal re- C gions.
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