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Equine July/August 2008 (Vol 3, No 6)

Managing Pain Associated with Colic

by Anthony Blikslager, DVM, PhD, DACVS

    Abstract

    Colic is one of the most frequent disease syndromes encountered in horses (affecting about 10% of horses annually) and the single largest cause of mortality (causing death due to complications in approximately 1% of horses annually). Fortunately, the vast majority of horses that suffer from colic can be medically managed without the need for intensive therapy or surgical intervention. Nevertheless, it is critically important that veterinarians be knowledgeable about how to manage abdominal pain to provide rapid and effective treatment of equine patients suffering from colic and to instill confidence in horse-owning clients. Because colic presents as an emergency, practitioners must commit to memory dosages of effective analgesics and be able to rapidly improvise if a particular analgesic is ineffective.

    In addition to developing an approach to management of abdominal pain in horses, it is also worthwhile to consider what colic is and what varying degrees of pain indicate in terms of the need for referral for potential surgery. Although most horses with colic have gastrointestinal (GI)-associated pain, a number of other body systems can trigger signs of colic, including the urogenital and respiratory tracts. Regardless of the cause of colic, referral for potential surgery is indicated when colic is unresponsive to analgesia.

    Diagnostic Criteria

    Historical Information

    Gender: Risk factor for certain diseases.

    • Male horses—Inguinal hernia.
    • Mares—Large colon volvulus or displacement just before and after foaling.
    • Geldings—Pedunculated lipoma.

    Age: Some diseases are more common at particular ages.

    • Foals, weanlings, and yearlings—Less likely to have colic.
    • Neonates—Increased risk of meconium impaction.
    • Weanlings and yearlings—Prone to ileocecal intussusception.
    • Horses older than 12 years—More likely to have strangulating lipomas.

    Breed Predisposition:

    • Arabians—Found to have a higher risk of colic in some studies.
    • Male Standardbreds, Saddlebreds, Tennessee walking horses, and Warmbloods—More prone to inguinal hernias.
    • Paint foals from overo mares—Can have a recessive genetic trait that causes aganglionosis of the intestine, which causes functional obstruction.

    Owner Observations:

    • Initial observations (before colic is noticed) often include depression, poor appetite, decreased frequency of defecation, lagging behind the herd, and more frequent recumbency.
    • It is important to document colic duration and the amount of pain:
      — Long period of mild pain—More likely to be a simple obstruction.
      — Severe colic with rapid progression—More likely to be due to a strangulating lesion or severe distention.
    • Owners often know about changes in diet, environment, activity, transport, or treatments that may be related to the horse's colic. A thorough history is imperative to ferret out these seemingly innocent changes.
    • Exposure to toxic compounds can cause colic, and owners should be questioned about this possibility.

    Other Factors:

    • Evidence of trauma to the head or body may indicate a previous episode of severe colic.
    • Recurrent colic after feeding grain may indicate colic from gastric ulcers.
    • Severe pain changing to depression is often the result of a gastric rupture or enteritis with endotoxemia. Some strangulating diseases (e.g., strangulating lipoma) can mimic these clinical signs.
    • Administration of excessive medication, exposure to sand or fine gravel, excessive feeding of grain, poor forage quality, and inconsistent feeding or exercise routines are all suspected of increasing the risk of colic.
    • Prior surgery for colic often increases the risk of future colic due to adhesions or mesenteric constriction.

    Physical Examination Findings Indicative of the Degree of Abdominal Pain

    Increased Heart Rate (>48 bpm)

    • Increases in heart rate in the early stages of colic (first 1 to 3 hours) tend to indicate the degree of abdominal pain.
      — Normal heart rate: Mild pain.
      — 50-65 bpm: Moderate pain. — 65-80 bpm: Severe pain.
      — >80 bpm: Excruciating pain.
    • Increases in heart rate in the later stages of colic are more likely to be associated with the degree of endotoxemic shock.
      — 50-70 bpm: Moderate shock.
      — 70-90 bpm: Severe shock.
    • Horses with severe pain, particularly those with a large colon volvulus, may have a paradoxically low heart rate (possibly associated with an increase in vagal tone).

    Increased Respiratory Rate (>16 respirations/min)

    • Indicative of pain during the early stages of colic.
    • Associated with abdominal distention during the later stages.

    Facial Trauma

    Horses that have had progressive signs of abdominal pain typically have increasing degrees of facial trauma, particularly around the eyes.

    Abnormal Mucous Membrane Color

    • Pale pink mucous membrane color typically indicates vasoconstriction in response to pain-associated sympathetic tone and early endotoxemia.
    • Red or purple mucous membranes, especially a dark red "toxic" ring around the upper incisors, are indicative of progressive endotoxemic shock (in order of increasing severity: red, light purple, dark purple).

    Abnormal Frequency of Auscultable Gut Sounds

    • Increased frequency of gut sounds ("spasmodic colic") may be associated with abdominal pain during the early stages of colic.
    • Decreased frequency of gut sounds is recognized during the later stages of colic and is associated with ileus or progressive intestinal obstruction.

    Laboratory Findings

    Initially, a painful, hypovolemic horse has an increased packed cell volume (e.g., >50%) and an increased total protein concentration (e.g., >8.0 mg/dL). A patient with a compromised, devitalized bowel (e.g., volvulus) shows a decrease in total protein concentration (e.g., 5.0 to 6.0 mg/dL) over time because of protein leakage into the abdomen. Obviously, these levels will decrease even more if the patient is given IV fluids. The key point is that packed cell volume and total protein can give important clues as to the duration and severity of the intestinal lesion.

    Differential Diagnosis

    The large majority of horses that exhibit signs of colic have GI-associated pain. However, diseases of other body systems can result in signs that closely resemble colic:

    • Reproductive tract complications in mares (uterine tear, uterine rupture, uterine torsion, ovarian artery hemorrhage).
    • Urinary obstruction (ureteral, cystic, or urethral calculus).
    • Biliary obstruction.
    • Pleuropneumonia.
    • Neurologic disease that causes abnormal mentation.
    • Exertional rhabdomyolysis.

    Treatment Recommendations

    Initial Treatment

    Colic will resolve in many cases before the veterinarian arrives at the farm. In horses that are actively showing signs of colic, the degree of pain should be assessed (see box 1 and box 2). The more severe the signs of colic, the more difficult the pain will be to manage.

    If possible, take a thorough history and complete a physical examination before administering analgesics. If the horse is in too much pain to allow these procedures to be completed, attempt to at least obtain information on the cardiovascular status of the horse by assessing mucous membrane color, capillary refill time, and the heart rate. These will give pertinent information on the severity of pain and systemic shock if obtained prior to administration of an analgesic and may allow more appropriate use of medications (Table 1).

    For horses with mild or moderate colic, administer a short-acting, potent analgesic that will control pain but allow an estimate of the severity of the colic episode (based on the speed of recurrence of signs of colic).

    Choices of short-acting, potent analgesics include:

    • Xylazine (0.3-0.5 mg/kg IV).
    • Butorphanol (0.01-0.02 mg/kg IV).
    • A combination of xylazine and butorphanol.

    Commit dosages for an average-size horse (990 to 1100 lb [450 to 500 kg]) to memory:

    • Xylazine (150 to 250 mg IV; 1.5 to 2.5 mL of 100 mg/mL concentration).
    • Butorphanol (5 to 10 mg IV; 0.5 to 1.0 mL of 10 mg/mL concentration).
    • Combination of xylazine and butorphanol (e.g., 1.5 mL of xylazine + 0.5 mL of butorphanol), which may be mixed in the same syringe and administered IV.

    Short-acting agents can be administered as needed (up to every 15 minutes), but they have a cumulative effect on the systemic condition of the horse:

    • Xylazine is an α2-agonist that causes bradycardia, transient hypertension, and sweating in addition to sedation (depending on the degree of pain present).
    • Butorphanol is an opiate that has mild excitatory effects, including coarse muscle tremors and increased sensitivity to environmental stimuli.
    • Butorphanol is usually given in combination with xylazine to reduce excitatory effects of butorphanol.
    • Other opiates, including pentazocine, meperidine, and morphine, may be administered. However, excit­atory signs are more severe, particularly with morphine, so pretreatment with sedatives is critical.
    • These agents are appropriate in treating horses with mild, moderate, or severe signs of colic. However, they may fail to control signs of severe colic.

    If administration of a short-acting analgesic relieves signs of colic for the duration of the veterinary visit (approximately 1 hour), a dosage of a long-acting, moderate-strength analgesic can be administered to ensure that the horse will remain comfortable. Choices of long-acting, moderate-strength analgesics include NSAIDs (see box 3 and box 4):

    • Flunixin meglumine (1.1 mg/kg IV q12h).
    • Ketoprofen (2.2 mg/kg IV q24h).

    NSAIDs may be used once for initial treatment of mild or moderate colic. Careful veterinary monitoring is necessary to ensure that additional intervention, if warranted, is promptly initiated. NSAIDs must be given according to a strict schedule to avoid signs of toxicity. These agents should not be readministered at less than the prescribed interval if they fail to relieve signs of colic.

    • Flunixin meglumine (500 mg IV; 10 mL of 50 mg/mL concentration). Flunixin meglumine may be administered more frequently at a reduced dosage (0.25 mg/kg IV q8h [125 mg for a 500-kg horse]) to control mild pain or treat signs of endotoxemia.
    • Ketoprofen (1 g IV; 10 mL of 100 mg/mL concentration).

    Severe Colic

    Controlling signs of severe colic is challenging and requires a slightly different approach. Initial management of pain is similar to that of treatment of mild or moderate colic (including determining the heart rate prior to administration of a potent, short-acting analgesic). If xylazine and/or butorphanol has no effect when repeatedly administered IV and signs of abdominal pain remain violent, administration of detomidine (0.01 to 0.02 mg/kg IV) and referral to an equine hospital should be considered. Butorphanol can be readministered with detomidine.

    Commit the dosage of detomidine for an average-size horse (990 to 1100 lb [450 to 500 kg]) to memory:

    • Detomidine (5 to 10 mg IV; 0.5 to 1.0 mL of 10 mg/mL concentration) with or without butorphanol (0.01 to 0.02 mg/kg IV).

    If detomidine is required to manage severe pain, refer the horse as rapidly as possible rather than waiting to see if pain recurs. This is because detomidine, a potent α2-agonist, can mask severe pain for prolonged periods. Use of detomidine may be reserved for horses that are severely painful and that require a long trailer ride to a referral facility.

    If the signs of colic are so violent as to prevent safe IV administration, an increased dose of xylazine (1.1 mg/kg) or detomidine (0.02 mg/kg) may be administered IM. The general rule is to double the IV dose. Expect a longer duration of effect with the IM route.

    Alternative/Optional Treatments

    • N-butylscopolammonium bromide (Buscopan, Boehringer Ingelheim) is an antispasmolytic that is particularly effective for horses with undiagnosed excessive motility (spasmodic colic; 0.3 mg/kg IV once, given slowly). However, it also transiently elevates the heart rate for approximately 20 minutes, which can be disconcerting but should not deter veterinarians from using this medication in the correct circumstances (spasmodic or gas colic). The medication is combined with dipyrone in other countries, including those in the European Union. Dipyrone is an NSAID that inhibits a cyclooxygenase isoform (COX-3) that is localized to the central nervous system. This inhibition provides relatively low-level but perceptible pain control. In the United States, one alternative is to use Buscopan in combination with a low dose of an NSAID (e.g., flunixin meglumine 0.25 mg/kg IV) to obtain similar mild analgesic effects. Veterinarians also report that Buscopan substantially reduces rectal tone, making palpation easier to perform.
    • A new NSAID, firocoxib (Equioxx, Merial; 0.1 mg/kg PO q24h), is now available. It is selective for COX-2, which is largely responsible for pain and inflammation. Because COX-1 is responsible for physiologic functions such as gut barrier function, firocoxib is, in theory, safer than NSAIDs that inhibit COX-1 and COX-2. This is the premise behind the human NSAID COX-2 inhibitor celecoxib. Side effects led to the withdrawal of rofecoxib from the human market; however, they included heart attacks that are very rare in horses because the blood supply to the heart is different in horses than in people. Firocoxib comes only in a paste formulation; nonetheless, it could be used in horses with colic as an alternative NSAID that would, in theory, have fewer GI side effects. Because firocoxib must be given orally, horses with reflux are not candidates for receiving this drug, and the onset of action is slower than that of drugs that are administered IV (e.g., flunixin meglumine).
    • The age-old management technique of walking horses with colic helps prevent horses from rolling and traumatizing themselves. In addition, this technique allows owners to take part in managing abdominal pain.
    • More efficacious analgesics will continue to become available. For example, medetomidine is more potent than detomidine.
    • Acupuncture has been advocated as a potential therapy for abdominal pain but is unlikely to reduce signs of acute colic.

    Supportive Treatment

    A nasogastric tube should be inserted to check for reflux. If there is no reflux, many patients benefit from nasogastric administration of one of the following laxatives:

    • Mineral oil (2 L in 6 to 8 L of water) or
    • Dioctyl sodium sulfosuccinate (180 to 240 mL in 1 gal of water) or
    • Magnesium sulfate (1 g/kg in 4 L of water)

    Fluids may be administered via nasogastric tube or IV, depending on the severity of dehydration and the presence of nasogastric reflux.

    The level of dehydration can be based on the duration of a skin tent (by pinching a fold of skin on the neck) and the degree of enophthalmos (sinking of the eye into the orbit as a result of dehydration of periorbital fat; Table 2). To determine the fluid deficit of the horse, multiply the percentage of dehydration by the body weight in kilograms. For example, a 500-kg horse that is 6% dehydrated has a 30-L fluid deficit. Administration of at least half of the deficit is required to have a noticeable clinical effect. Additional signs of dehydration include abnormal mucous membrane color and prolonged capillary refill time.

    Dehydration of less than 5% to 6% cannot be detected using physical parameters. Horses that are 8% to 10% dehydrated tend not to benefit from oral fluids because of the extent of dehydration and reduced GI motility.

    Horses should have all feed withheld while they are actively showing signs of colic and for 4 to 6 hours following resolution of colic.

    Patient Monitoring

    Physical signs of abdominal pain (e.g., pawing, sweating, rolling) should be monitored continuously for the first hour following initial treatment, then every hour for approximately 4 to 6 hours (preferably in a controlled environment such as a stall).

    In some horses that are stoic, the degree of pain can be determined only by monitoring the heart rate. Therefore, the heart rate should also be monitored every hour for the first 4 to 6 hours following initial treatment.

    In addition, horses should be monitored for dehydration by evaluation of skin tent, enophthalmos, mucous membrane color, and capillary refill time.

    Milestones/Recovery Time Frames

    Response to analgesic treatment includes:

    • Progressive decrease in physical signs of pain.
    • Progressive decrease in heart rate.
    • Return of normal appetite.

    Response to fluid therapy includes:

    • Progressive decrease in the duration of a skin tent.
    • Progressive decrease in capillary refill time.
    • Progressive improvement in mucous membrane color.

    Treatment Contraindications

    • Excessive or too-frequent dosing of NSAIDs (including administration of more than one NSAID at the full dose at one time).
    • Excessive treatment of horses with mild colic (e.g., use of detomidine or excessive use of an NSAID that may mask further signs of colic when xylazine may suffice).
    • Nasogastric administration of any medication or fluids in a horse that is actively refluxing.
    • Spasmolytic, parasympatholytic agents such as atropine (these agents dramatically exacerbate signs of colic). The best option for treatment of suspected increased motility is Buscopan.

    Prognosis

    Favorable Criteria

    (Indicating the horse can be managed without referral)

    • Response to analgesic treatment.
    • Normal heart rate.
    • Passage of feces.

    Unfavorable Criteria

    (Indicating the need to refer for possible surgery)

    • Poor response to analgesic treatment (particularly if there is no response to detomidine).
    • Escalating heart rate or persistently elevated heart rate.
    • Signs of abdominal pain in the presence of abnormal findings, including abnormal mucous membrane color, abnormal rectal palpation findings (Box 5), or nasogastric reflux.

    Betley M, Sutherland SF, Gregoricka MJ, et al. The analgesic effect of ketoprofen for use in treating equine colic as compared to flunixin meglumine. Equine Pract 1991;13(6):11-16.

    Blikslager AT. Do we need cyclooxygenase-2 inhibitors in equine practice? Compend Contin Educ Pract Vet 1999;21(6):548-550.

    Little D, Brown SA, Campbell NB, et al. Effects of the cyclooxygenase inhibitor meloxicam on recovery of ischemia-injured equine jejunum. Am J Vet Res 2007;68(6):614-624.

    Moore RM. Nonsteroidal anti-inflammatory drugs. In: White NA, Moore JN, eds. Current Techniques in Equine Surgery and Lameness. Philadelphia: WB Saunders; 1998:25-30.

    White NA. Analgesia. In: White NA, ed. The Equine Acute Abdomen. Philadelphia: Lea & Febiger; 1990:154-159.

    Zimmel DN. Management of pain and dehydration in horses with colic. In: Robinson NE. Current Therapy in Equine Medicine. Philadelphia: WB Saunders; 2003:115-120.

    Updated by the author and reprinted with permission from Standards of Care: Equine Diagnosis and Treatment 2001;1.2:7-11.

    Downloadable PDF

    aDr. Blikslager discloses that he has received financial support from Novartis, Merial, Boehringer-Ingelheim, and Sucampo and that he is a board member of Morris Animal Foundation.


    References »

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