1 / 30

Case of Inflammatory Bowel Disease, Colic, and intra-abdominal abscess

Case of Inflammatory Bowel Disease, Colic, and intra-abdominal abscess. Naomi Chiero DVM - Intern Mentors: Margaret MacHarg , MS, DVM; John Vacek DVM Kendall Road Equine Hospital (KREH) Elgin, Illinois. Patient Signalment :. history :. 12 year old Thoroughbred Gelding.

aviles
Download Presentation

Case of Inflammatory Bowel Disease, Colic, and intra-abdominal abscess

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Case of Inflammatory Bowel Disease, Colic, and intra-abdominal abscess Naomi Chiero DVM - Intern Mentors: Margaret MacHarg, MS, DVM; John Vacek DVM Kendall Road Equine Hospital (KREH) Elgin, Illinois

  2. Patient Signalment: history: • 12 year old Thoroughbred Gelding • Treated by rDVM previous night for colic (7-2-11) • Initial colic signs treated by trainer with IV Banamine (500mg) • PE: mild tachycardia (44 bpm), passing normal manure • Rectal: Tight band traveling craniodorsally on left side • Abd US: unable to visualize left kidney • Treated with additional dose of IV Banamine (250mg) • In morning continued to show colic signs and referred to KREH Previous history: • Treated at University of Georgia (UGA) one year prior: • Diagnosed with Inflammatory Bowel Disease and Gastric Ulcers • History of chronic weight loss andintermittent colic • Previous treatments include tapering dose of Dexamethasone, dailyomeprazole, anddietary changes.

  3. Inflammatory bowel disease: • Chronic idiopathic disease due to abnormal immune response • Inciting cause is an unknown bacteria, virus, parasite, or dietary antigen • Abnormal immune response causes massive cellular infiltration • Generally the small intestine (SI) is predominantly affected • Chronic cellular infiltrate creates a malabsorption and maldigestion • IBD is further classified based on the type cellular infiltrate • Eosinophilic enteritis– eosinophils and lymphocytes • MEED: multisystemiceosinophilicepitheliotrophic disease – more severe form of disease with multiple organ involvement • Granulomatous Enteritis– lymphocytes and macrophages • Similar to Crohn’sdiease in humans and Johnne’s disease in cattle • Lymphocytic Enteritis– lymphocytes and plasma cells • May be an early form of intestinal lymphosarcoma

  4. Inflammatory bowel disease: • Historical findings in IBD horses • Weight loss or failure to gain weight despite adequate nutrition • Occasional history of chronic diarrhea (when large intestine is affected) • Mild recurrent colic or acute/severe colic requiring surgery • IBD is an uncommon disease of young to middle aged horses • More common causes of weight loss and diarrhea include: Chronic Parasitism Dental Disease Malnutrition Use of NSAIDS Salmonellosis Gastrointestinal ulceration Sand Ingestion • Other less common causes of weight loss and diarrhea include: Neoplasia Chronic Renal Failure Intra-abdominal abscess Infectious anemia Liver Failure Bacterial infection (pneumonia, plueropneumonia, peritonitis)

  5. Inflammatory bowel disease: • Diagnostics for history of Weight loss +/- chronic diarrhea • Thorough history/examination of diet, physical exam, oral exam • CBC and Biochemistry: • IBD cases may have normal CBC or have mild neutrophila, hyperfibrogenemia, and anemia. Biochemistry often shows hypoproteinemia and hypoalbuminemia. • Rectal Exam: • Occasionally thickened loops of SI can be palpated in horses with IBD. • Abdominal and Thoracic Ultrasound: • Ultrasound is helpful to document small intestinal wall thickening. As well as examination of liver, kidneys, colon, and lungs, to rule out other differentials • Abdominocentesis: • Horses with IBD typically have normal peritoneal fluid • Gastroscopy and Duodenal Biopsy: • Confirm or rule out gastric ulcers and collect duodenal biopsy to rule in IBD • Rectal Biopsy: • Can detect evidence of inflammatory disease.

  6. Presentation to KREH: 7-3-11 • Physical Exam: • Depressed attitude • Tachycardia (60 bpm) • Hypermotileborborygmi • Repeatedly stretching out • Mild pyrexia (102.0°F) • BCS: 2/9 • PCV: 36% • TS: 5.4 g/dL • NG Tube: no net reflux • Rectal: tight band traveling craniodorsally on left side in area of nephrosplenic space • initial diagnosis:Nephrosplenic • Entrapment of large colon

  7. Initial treatment: • Administer Phenylephrine hydorchloride • 20mg Phenylephrine diluted in 60mls of Lactated Ringers Solution and administered IV over period of 5 minutes • Phenylephrine is a vasoconstrictor used in nephrosplenic entrapments to contract the spleen and allow release of entrapment • Jogged patient for 15 min • Maintenance IV Fluids (2-3mls/kg/hr) – Lactated Ringer’s Solution Monitoring: • 2 hours post treatment • Worsening colic signs (progressed from stretching to rolling) • Persistent tachycardia (HR: 56-60 bpm) • Rectal exam: spleen responsive to phenylephrine, but large colon still entrapped with mild-moderate gas distension Exploratory Celiotomyto correct displacement due to persistent tachycardia, level of pain, and poor response to phenylephrine Recommendation:

  8. Surgical findings: • 360° Large Colon Volvulus • Large colon appeared healthy with no vascular compromise • Corrected by de-rotation and gas decompression • Mesenteric abscess located adjacent to proximal ileum/distal jejunum • Abscess appeared thin walled and filled with thin watery fluid • Approximately 40cmx40cmx6cm in size • Inflamed Small Intestine • SI diffusely thickened and inflamed, on cut surface wall thickenss measured ~ 5-7cm. ileum abscess

  9. Surgical Correction: • Resected adhered omentum from abscess • Resected ~60cm section of distal jejunum/distal ileum to remove abscess and minimize risk of rupture • Performed end-to-end Jejunal-ileal anastomosis Gross Pathology: • Abscess Capsule <1mm thick and cavity contained thin, dark serosanguineous fluid with small feed particulates. • Post-operative sample of abscess contents was collected aseptically and submitted for culture and sensitivity.

  10. Post-operative care: • Analgesia • FlunixinMeglumine: 0.5mg/kg IV BID x 2 days, then as needed • Broad Spectrum Antibiotics • Gentamicin sulfate: 6.6mg/kg IV SID x 4 days • Aminoglycoside: gram negative spectrum • Procaine Penicillin G: 22,000IU/kg IM BID x 4 days • β-lactam: covers gram positive and gram negative cocci • Metronidazole: 22mg/kg PO TID x 4 days • Anaerobic spectrum and anti-inflammatory/immune-modulatory affects • Fluid Therapy • Lactated Ringer’s Solution at maintenance dose (2-3mls/kg/hr) • Monitoring q 4 hours • Watch for colic signs, measure vitals, fecal output, and PCV/TP

  11. Lab results: 1 day post-op • CBC • Inflammatory leukogram • Moderate leukopenia with • neutrophiliaand lymphopenia • Suggests inflammatory process • (colic) and possibly infectious agent. • Biochemistry • Mild Hypoproteinemia • Characterized by hypoalbuminemia • Mild Hypocalcemia • Common in many types of colic • Mildly Increased Creatinine • Likely pre-renal due to mild hypovolemia since BUN is normal • Metabolic acidosis and anion gap • Possibly due to lactate production

  12. Further history & University Findings: • Presented to University of Georgia (UGA) July 2010 • History of drastic weight loss over 6 month period and development of foul smelling “cowpie” feces. • Diagnostics and Findings • PE: WNL, except BCS: 2/9 (1015lbs) • Rectal exam: mildly distended and thickened loops of small intestine. • Abdominocentesis: peritoneal fluid WNL • CBC/Chemistry: no significant abnormalities • Gastroscopy/duodenal biopsy: • Stomach: extensive hyperkeratosis, superficial gastric ulceration, and a few deeper bleeding ulcers along the margoplicatus and lesser curvature of the stomach. Grade 2EGUS • Duodenal histopathology: Eosinophilicinfiltrates Grade 2 ulcers

  13. UGA Findings: • Diagnostics and Findings • Abdominal Ultrasound: moderatelythickened stomach wall(13.4mm, normal is < 7.5mm) andincreased thickness of small intestinal wall (5-6mm, normal is < 3mm). Spleen Stomach Stomach with thickened wall Mildly distended & thickened SI

  14. UGA Findings: • Diagnostics and Findings • Fecal egg count, fecal sand test, & Salmonella PCR: all negative • Glucose Absorption Test: Adequate • Serial PCV/TS: • Packed cell volume remained WNL • Total solids were persistently low (avg. 5.5g/dL) • Final Diagnoses: • Inflammatory Bowel Disease (Eosinophilic enteritis) • Hallmarks of IBD that were found in this case include: • Chronic weight loss in spite of adequate nutrition • Chronic diarrhea • Thickened loops of small intestine detected through rectal examination and abdominal ultrasound • Duodenal biopsy revealing eosinophilic infiltrates • Persistent hypoproteinemia with low-normal albumin • Grade 2 Equine Gastric Ulcer Syndrome

  15. UGA Treatment & Recommendations: • Gastric Ulcers • Sucralfate: 20mg/kg PO QID x 2 weeks • Omeprazole: 4mg/kg PO SID x 28 days • Inflammatory Bowel Disease • Fenbendazole: 10mg/kg PO SID x 5 days • Ivermectin: 200ug/kg PO once • Dexamethasone: • Week 1 - 46mg (0.1 mg/kg) IV for 7 days, • Week 2 - 46mg (0.1 mg/kg) PO for 7 days, • then ~25% tapered dose each week • Week 3 – 36mg (0.08mg/kg) PO for 7 days • Week 4 – 26mg (0.06mg/kg) PO for 7 days • Week 5 – 16mg (0.03mg/kg) PO for 7 days • Week 6 – 8mg (0.02 mg/kg) PO for 7 days until recheck • Feeding Recommendations • Free choice orchardgrass and alfalfa hay • 6-12 hours daily pasture turn out • Nutrena XTN 2lbs 4 times a day • Assure Guard (3/4 scp BID daily) & Assure Plus (1 scp SID daily x 2weeks)

  16. UGA Recheck: • Findings and Diagnostics – August 2010 • PE: WNL, BCS: 3/9 (1168lbs – weight gain of 153lbs in 4 weeks) • Ultrasound: Sm. Intestinal wall thickness: 4mm (improved from 5mm) • Gastroscopy: 2 superficial linear ulcers and mild hyperkeratosis present in the non-glandular portion of the stomach. Grade 1 ulcers. • Total Protein: 6.1g/dL(previous avg. of 5.5g/dL) • Albumin: 3.3g/dL (previously 2.2g/dL) • Treatment and Recommendations • Omeprazole: 4mg/kg PO SID x 14 days, then 2mg/kg SID x 7 days, followed by 1mg/kg maintenance dose. • Recommend giving full 4mg/kg dose 3 days prior to and for duration of any stressful event, diet change, or trailering. • Dexamethasone: 8mg (0.02 mg/kg) PO EOD x 2 weeks, then discontinue. May have to continue therapy if relapse occurs.

  17. KREH 7-4-11 Patient Progress: • Patient recovered well from surgery. All physical parameters WNL within 24 hrs of surgery. • Maintained on IV fluids for first 48hrs • Fasted first 12 hours post-operatively • Gradual re-introduction of feed starting with Equine Senior mashes, then grazing. Introduced incremental amounts of soaked hay 5 days post-op • 5 days post-op switched to oral antibiotics • Trimethoprim/sulfamethoxazole: 30mg/kg PO BID x 6 days July 6th July 12th • July 10th – July16th • Patient had mild intermittent colic episodes approximately EOD. • Initial colic episodes treated with Flunixinmeglamine and feed removal, each episode milder and resolved with hand walking only. • Visible weight gain

  18. Which disease came first? • Inflammatory Bowel Disease or Intra-abdominal abscess: • The mesenteric abscess was present for unknown amount of time, could have been present during previous work up at University and gone undetected. • Intra-abdominal abscesses can cause chronic weight loss and intermittent colic. • Abscess could be inciting cause of abnormal immune response creating inflammatory bowel disease. • Testing hypothesis: • To test the hypothesis it was decided to not restart steroid treatment. • If patient improved the abscess may have been inciting cause of IBD and the disease process may resolve with removal of inciting cause. • If patient does not improve then… • Abscess could be unrelated incidental finding • Abscess is inciting cause but IBD now chronic sequelarequiring treatment • GI ulceration/perforation and abscess formation could have resulted from high steroid doses used to treat IBD. OR

  19. Patient Progress: 7-11-11 • CBC/Chem • Normal lymphocyte count – discontinue anitbiotics • Persistent hypoproteinemia (5.5 g/dL) and hypoalbuminemia(2/7 g/dL) • Abscess Culture & sensitivity • 1 Isolate: Escherichia coli • Sensitive to Gentamicin, Penicillin, and Tribrissin 7-18-11 July 6th • Discontinued all medications • Diet consisting of: • 1 flake soaked grass hay 6x/day • 2lbs XTN 6x/day (12lbs total) • Turned out to graze 1-2hrs/day • Significant visible weight gain, BSC 3/9 • Discharged from hospital: • Continue current diet, slowly decreasing frequency of feedings • Stall rest with 2-3hrs/daily turn out for 3 weeks, then return to normal turn-out • Recheck in 60-90 days July 18th

  20. KREH 8-16-11 REcurrent Colic: • History after discharge • 1st week: regular improvement with good appetite and weight gain. • 2nd week: small decline in attitude and appetite • 3rd & 4th week: management changes led to return of appetite • Today: horse colicky, trying to lay down/roll • no improvement with 1 dose (500mg) of Flunixinmeglamine. • Presentation • BAR, comfortable, passed normal manure in trailer • PE: WNL, except hypermotileborborgymi & BCS 2/9 • *Recurrent weight loss despite adequate diet* • PCV: 32% TS: 4.8g/dL*TS rechecked* • Nasogastric Tube – no net reflux • Rectal exam: gas distension of large colon and cecum, with large colon palpated medial to spleen, no tight bands palpated. • Initial Diagnosis: Nephrosplenic Entrapment

  21. Recurrent Colic: • Initial Treatment: • Placed jugular catheter • Administered 20mg Phenyleprhine (same as prev. described) • Patient jogged for 15 min – passed large amount of gas • Remained comfortable with no further colic signs • 6hrs later re-introduced small amount of feed • Lab Results: • Mild leukopenia with near normal differential • Persistent and worsening hypoproteinemia/hypoalbuminemia • Mild hypocalcemia

  22. Which disease came first? • Inflammatory Bowel Disease or Intra-abdominal abscess: • Previous Hypothesis: Abscess is inciting cause of an abnormal immune response creating inflammatory bowel disease and disease will resolve if remove inciting cause. • Results: • Poor Clinical Response… Recurrent Weight Loss Recurrent Colic Persistent Hypoproteinemia Persistent Hypoalbuminemia • “If patient does not improve then…” • Abscess may be secondary incidental finding • Abscess is inciting cause but IBD now chronic sequela requiring treatment • GI ulceration/perforation and abscess formation could have resulted from high steroid doses used to treat IBD. • Don’t know which scenario is true. However, solution is the same no matter the cause, need immunosuppressive treatment for IBD.

  23. Repeat diagnostics for IBD? Repeat diagnostics for IBD were offered to client: • Rectal Examination and CBC/Biochemistry were already performed • Abdominocentesis, Gastroscopy/Duodenal biopsy, Glucose absorption test were denied due to previously confirmed results and cost of tests. • An abdominal ultrasound was performed: • Slightly increased amount of abdominal free fluid observed • Small intestine with normal motility and appearance were observed with normal to mildly increased wall thickness (2.9 – 4.1mm)

  24. Initiate Treatment for IBD • Immunosuppressive Steroid Treatment: Moderate steroid dose was chosen since cause of abdominal abscess remains unknown and risk of GI ulceration. • Dexamethasone: • 12mg (0.025mg/kg) IM SID x 2 days • 10mg (0.02mg/kg) IM SID x 4 days • 10mg IM EOD x 7 days • 10mg PO TIW x 30 days • Immunomodulatory Supplement: • 4Life Transfer Factor Livestock Stress Formula: • 1 Scoop PO SID • Transfer Factor is a vitamin, mineral, electrolyte, and probiotic supplement that also contains transfer factors. Transfer Factors are immune-modulatory molecules extracted from cow colostrum and egg yolks that are said to promote immune function • Anecdotal improvement in animals with immune related diseases such as melanomas and hypersensitivities.

  25. Patient Progress: • Feeding during hospitalization • Free choice grass hay fed 6x/day • 2lbs XTN and 1lb Equine Senior 6x/day • 2-3 hours daily turn-out/grazing • Documented weight gain over two week period • Weight Tape 8/17: 1,003 lbs. • 8/29: 1,049 lbs • Feeding Recommendations • Free choice grass hay • Minimum 3-4 hours daily pasture turn-out • Grain: Transition to Buckeye EQ8 Gut Health • 3.5lbs fed 3x/day (10-11lb total/day) • High fat, low carbohydrate feed withhighly digestible fiber and live probiotic • Fat Supplement: Buckeye Ultimate Finish 40 • 2oz/day for 7 days, then increase to 4oz/day • Highly palatable fat supplement with omega 6 and omega 3 fatty acids • Discharged 8/31, recommend recheck in 30 days August 29th

  26. Recheck Exam: 10-14-11 • Current Medications: • Dexamethasone 10mg (0.02mg/kg) PO TIW • 1 Scoop Transfer Factor PO SID • BCS: 4.5/9 Weight Tape: 1126 lbs. • Abdominal Ultrasound: • Normal loops of small intestine visible with normal motility. Wall thickness: 3-4mm, diameter: 2-3cm • PCV/TS: 32% / 6.0 g.dL • Recommendations: • Decrease Dexamethasone to 6mg (0.01mg/kg) PO TIW • Continue Transfer Factor 1 Scoop PO SID • Continue previous feeding instructions • Recheck in 3 months

  27. Recheck Exam: 3/23/12 • Current Medications: • Dexamethasone 6mg (0.01mg/kg) PO TIW • 1 Scoop Transfer Factor PO SID • BCS: 7/9 Weight Tape: 1238 lbs. • Abdominal Ultrasound: WNL, SI wall thickness: 2-3mm • PCV/TS: 35% / 5.8 g.dL • Recommendations: • Transfer Factor 1 scp PO SID • Decrease feed or increase work • Continue tapering Dexamethasone dose • 6mg PO Mon/Fri and 4mg Wed x 30 days • 6mg PO Wed and 4mg Mon/Fri x 30 days • 4mg PO Mon/Wed/Fri x 60 days • 4mg PO Mon/Fri for maintenance • Recheck in 4-5 months or if clinical signs return

  28. Inflammatory bowel disease Prognosis: • Historical long-term prognosis is guarded to grave. • However, with appropriate treatment long-term improvement and recovery has been reported.

  29. References & further reading: Abutarbush, S. M., & Naylor, J. M. (2005). Comparison of surgical versus medical of nephrosplenic entrapment of the large colon in horses: 19 cases (1992-2002). JAVMA, 227(4), 603-605. Baker, W. T., Frederick, J., Giguere, S., Lynch, T. M., Lehmkuhl, H. D., & Slone, D. E. (2011). Reevaluation of the effect of phenylephrine on resolution of nephrosplenic entrapment by the rolling procedure in 87 horses. Veterinary Surgery, 40(7), 825-829. Buchanan, B. R., & Andrews, F. M. (2003). Treatment and prevention of equine gastric ulcer syndrome. Veterinary Clinics of North America: Equine Practice, 2003(3), 575-597. Kalck, K. A. (2009). Inflammatory bowel disease in horses. Veterinary Clinics of North America: Equine Practice, 25(2), 303-315. Mair, T. S., & Sherlock, C. E. (2011). Surgical drainage and post operative lavage of large abdominal abscess in six mature horses. Equine Veterinary Journal, 43(Suppl. 39), 123-127. Schumacher, J., Edwards, J. F., & Cohen, N. D. (2000). Chronic iodiopathic inflammatory bowel diseases of the horse. Journal of Veterinary Internal Medicine, 14, 258-265.

  30. Acknowledgments: Thank you to: Dr. Margaret MacHargfor surgical correction of case, mentorship of medical management, and case report assistance. Dr. John Vacekfor assisting in initial case work up and continued mentorship. Dr. Elizabeth Pollakfor case anesthesia and assistance with patient care. Dr. Megan Coveyoufor case referral and continued patient care. Drs. Erin L McConachie, Michelle Barton, and Kelsey Hart forconsultationandinitialdiagnosisatthe University ofGeorgie College VeterinaryMedicine.

More Related