Thrombelastography in horses with acute gastrointestinal disease

Background: Coagulopathies in horses with gastrointestinal disease are frequently identified and associated with morbidity and fatality. Objective: Determine if thrombelastography (TEG) identifies abnormalities associated with lesion type, presence of systemic inflammatory response syndrome (SIRS), morbidity, and fatality more consistently than traditional coagulation testing. Animals: One‐hundred and one horses examined for gastrointestinal disease and 20 healthy horses. Methods: TEG, tissue factor (TF)‐TEG, and traditional coagulation panels parameters and percentages of horses with coagulopathies were compared for lesion type, presence of SIRS, complications, and survival. Results: Changes in individual parameters and increased incidence of coagulopathies were associated with fatality (R, P= .007; k‐value [K], P= .004; clot lysis [CL]30, P= .037; CL60, P= .050; angle [Ang], P= .0003; maximum amplitude [MA], P= .006; lysis [Ly]30, P= .042; Ly60, P= .027; CI, P= .0004; ≥ 2 TEG coagulopathies, P= .013; ≥ 3 TEG coagulopathies, P= .038; TF‐R, P= .037; TF‐K, P= .004; TF‐CL30, P < .0001; TF‐CL60, P < .0001; TF‐Ang, P= .005; TF‐Ly30, P= .0002; TF‐Ly60, P < .0001; TF‐CI, P= .043; ≥ 1 TF‐TEG coagulopathies, P= .003; ≥ 2 TF‐TEG coagulopathies, P= .0004; prothrombin tme [PT], P < .0001; activated partial throboplastin time [aPTT], P= .021), inflammatory lesions (MA, P= .013; TF‐CL30, P= .033; TF‐CL60, P= .010; TF‐Ly60, P= .011; ≥ 1 TF‐TEG coagulopathy, P= .036; ≥ 2 TF‐TEG coagulopathy, P= .0007; PT, P= .0005; fibrinogen, P= .019), SIRS (MA, P= .004; TF‐CL30, P= .019; TF‐CL60, P= .013; TF‐Ly30, P= .020; TF‐Ly60, P= .010; PT, P < .0001; aPTT, P= .032; disseminated intravascular coagulation, P= .005), and complications (ileus: aPTT, P= .020; diarrhea: TF‐CL30, P= .040; TF‐Ly30, P= .041; thrombophlebitis: ≥ 1 TF‐TEG coagulopathy, P= .018; laminitis: MA, P= .004; CL60, P= .045; CI, P= .036; TF‐MA, P= .019; TF‐TEG CI, P= .019). Abnormalities in TEG and TF‐TEG parameters were indicative of hypocoagulation and hypofibrinolysis. Conclusions and Clinical Importance: TEG identifies changes in coagulation and fibrinolysis associated with lesion type, SIRS, morbidity, and fatality in horses with gastrointestinal disease.     

Factors associated with mortality and morbidity in small intestinal volvulus in horses

OBJECTIVE: To determine historical, physical, and clinical factors that may affect morbidity and mortality in horses with small intestinal volvulus unrelated to other causes (e.g., incarceration, lipoma, etc.). STUDY DESIGN: Retrospective study. ANIMALS: Client-owned horses (115), aged 1 month to 21 years. Methods: Data were obtained from medical records, identified by computer search and manual review. Continuous variables were compared between affected and non-affected horses with Mann-Whitney U-tests and non-continuous variables with Fisher's exact test (2 x 2 tables) or chi(2)-tests (larger tables). Stepwise logistic regression analysis was used to develop a multivariable model of the risk factors, taking account of confounding and interaction. RESULTS: Eighty percent of horses recovered from surgery survived to hospital discharge. Neither age, breed, nor sex was related to mortality. Survivors had a significantly lower heart rate, shorter capillary refill time, and better mucous membrane color. Variables associated with worsening cardiovascular status, increased hemoconcentration, and exudation of cells and protein into peritoneal fluid were significantly associated with non-survival. After recovery from surgery, the most serious complication was colic, which was significantly associated with non-survival (P=.028) as was a second celiotomy (P<.01). Both of these complications were associated with a jejunocecostomy during the first surgery. CONCLUSIONS: Significant differences in the clinical and clinicopathologic signs were identified between survivors and non-survivors. CLINICAL RELEVANCE: These findings can be used to make a scientific assessment of prognosis in the pre-operative, operative, and post-operative management of horses with small intestinal volvulus.     

Intra-abdominal adhesions in horses: a retrospective evaluation of repeat laparotomy in 99 horses with acute gastrointestinal disease

The objectives of this study were (1) to determine the prevalence of pathological abdominal adhesion formation following exploratory laparotomy; (2) to establish the site of adhesion formation and its relationship to the initial lesion; (3) to ascertain whether the development of intra-abdominal adhesions decreases long-term survival and (4) to identify risk factors for adhesion formation. Of 1014 horses treated surgically for acute gastrointestinal disease, 113 (10.1%) were subjected to repeat laparotomy, with surgical records available for 99 of these cases. Pathological adhesions were the most common diagnosis at repeat laparotomy (28%), followed by complications associated with the anastomosis (16%). Adhesions were not associated with the site of the primary lesion, resection, or endotoxaemia, consistent with the hypothesis that surgical trauma is the most important stimulus in adhesion formation. Together these findings strongly support the need for pan-abdominal, rather than site-specific adhesion prevention measures in all horses undergoing exploratory laparotomy.     

Pulmonary gas exchange and plasma lactate in horses with gastrointestinal disease undergoing emergency exploratory laparotomy: a comparison with an elective surgery horse population

Objective: To characterize pulmonary gas exchange and arterial lactate in horses with gastrointestinal disease undergoing anesthesia, compared with elective surgical horses, and to correlate these variables with postoperative complications and mortality. Study Design: Prospective clinical study. Animals: Horses undergoing emergency laparotomy for acute intestinal disease (n=50) and healthy horses undergoing elective surgery in dorsal recumbency (n=20). Methods: Arterial blood gas analysis was performed at predetermined intervals on horses undergoing a standardized anesthetic protocol. Alveolar–arterial oxygen gradient was calculated. Predictive factors for postoperative complications and death in colic horses were determined. Results: Arterial oxygen tension (P_aO₂) varied widely among horses in both groups. P_aO₂ significantly increased in the colic group after exteriorization of the ascending colon. P_aO₂ and alveolar–arterial oxygen gradient were not significantly different between groups, and neither were correlated with horse outcome. Arterial lactate in recovery ≥5 mmol/L was associated with a 2.25 times greater relative risk of complications and lactate ≥7 mmol/L was associated with a 10.5 times higher relative risk of death. Conclusion: Colic horses in this population were not more likely to be hypoxemic than elective horses, nor was gas exchange impaired to a greater degree in colic horses relative to controls. Arterial lactate sampled immediately after anesthetic recovery was predictive for postoperative complications and death.     

Heart rate variability after horse trekking in leading and following horses

Horse trekking (HT) is having a stroll on a horse along a walking trail in a forest, field, and/or sandy beach. Generally in HT, horses exercise in tandem line outside the riding facilities. Because the leading horse will be confronted with stressors in the forefront, we hypothesized that the leading horse shows higher stress responses than the following one. In order to verify the hypothesis, we compared short‐term stress responses between each position in six horses. Exercise consisted of 15 min of ground riding and 45 min of HT with walking and trotting. Heart rate variability was analyzed for 5 min at 30, 60, and 90 min after the exercising period. There was no significant difference in heart rate during exercise between leading and following positions. The high frequency / low frequency power band of heart rate variability, an index of sympathetic nervous activity, after exercise, tended to be higher in the leading position than following one (P < 0.1). The result in this study can suggest that the leading horse was in a higher stressed state than the following horse after HT.     

Retrospective evaluation of repeat celiotomy in 53 horses with acute gastrointestinal disease

Fifty-three of 648 horses (8.2%) treated surgically for acute gastrointestinal obstruction were subjected to repeat celiotomy. Forty horses (75%) recovered from anesthesia after repeat celiotomy, and 26 horses (49%) were discharged from the clinic. Excluding two horses lost to follow-up, 10 of 51 horses (20%) survived long term. Horses subjected to repeat celiotomy had a significantly lower long-term survival rate than horses subjected to a single celiotomy. Twenty-eight horses had mechanical obstructions, and 22 had functional obstructions at the second surgery. Significantly more horses with mechanical obstructions recovered from anesthesia, but there was no difference in short-term or long-term survival. Seventy-seven percent of horses were subjected to two celiotomies without being discharged from the clinic between procedures. The intervals between primary and repeat celiotomies ranged from less than 24 hours to 4 years, with 89% of them being less than 2 months. Horses with functional obstructions at the second surgery had a significantly shorter interval between surgeries than horses with mechanical obstructions. Twenty-three horses had sequelae of the primary celiotomy, 19 had progression of their original disease, 8 had recurrence of the same condition, and 3 had unrelated problems. Intestinal ischemic necrosis was the most common diagnosis at repeat celiotomy, and small intestinal obstruction by adhesions was the second most frequent.     

Initial investigation of mortality rates and prognostic indicators in horses with colic in Israel: A retrospective study

Reasons for performing study: Initial assessment of the mortality rates and prognostic indicators in horses with colic presented to a referral hospital in Israel. Objectives: To determine mortality rates and to identify potential prognostic indicators in horses undergoing treatment for colic. Methods: The medical records of 208 colic cases were reviewed and mortality rates calculated including 95% confidence intervals. Mortality rates in surgical cases were calculated separately for strangulating and nonstrangulating lesions as well as for lesions of the large and small intestines. Potential prognostic indicators were identified and evaluated by Student's t test or X² test, where appropriate. Those found to be significant (P<0.05) were evaluated in 2 logistic regression models; one including all horses with colic and one for surgical cases only. Results: The overall mortality rate was 51/208 (25%); 5/72 (7%) in medically treated cases, 46/136 (34%) in surgical cases, 30/50 (60%) in strangulating lesions and 15/85 (18%) in nonstrangulating lesions, 17/27 (63%) in cases involving small intestinal lesions and 28/108 (26%) in cases with large intestinal lesions. Clinical parameters found to be significantly associated with death by univariate analysis were medical/surgical treatment, location of lesion, severity of lesion, mucous membrane colour (MM), capillary refill time (CRT) and heart rate. Using a multivariate logistic regression model, including all cases, medical/surgical treatment, CRT and MM were found to be prognostic indicators and when using the surgical cases alone, only CRT and lesion severity remained related to mortality. Conclusions: Mortality rates were similar or better than those previously reported in most cases, however, studies from the USA and the UK published better success rates for small intestinal surgeries. Cultural attitudes toward euthanasia may be associated with mortality rates. Potential relevance: These results assist clinicians in providing an immediate prognosis based on clinical findings at presentation and contribute to an international database that may aid future research in improving treatment of colic.     

Clinical findings in 10 horses diagnosed with monorchidism following exploratory laparotomy or standing laparoscopic surgery

Monorchidism describes the complete absence of one testis and is rare in horses. This study reports the clinical findings in 10 horses diagnosed as monorchids by standing laparoscopy or exploratory laparotomy. Hospital records for all horses undergoing cryptorchidectomy (2000–2016) in four centres were reviewed from which horses diagnosed with monorchidism were identified. Surgery was by either standing flank laparoscopy or an inguinal exploration and subsequent exploratory laparotomy under general anaesthesia. Ten horses were diagnosed as monorchids, five by laparoscopy (one bilateral laparoscopy) and five by laparotomy. Nine horses had a normally descended scrotal testicle, which was also removed at surgery. The right testicle was absent in three horses, and the left testicle was absent in seven horses. Anatomical findings were recorded in each case; the vaginal process was present in all horses, ductus deferens and epididymis were present in 80% of horses and the ligament of the tail of the epididymis and testicular vessels were present in 50% of horses. Laparoscopy allowed easy identification of spermatic structures enabling a prompt diagnosis of monorchidism. In conclusion, when monorchidism occurs, most other associated spermatic structures are likely to be present. A diagnosis of true monorchidism is reliant on hormonal testing and absence of testicular tissue on histopathology and so some of these horses may strictly be somewhere on the spectrum of testicular degeneration. This information is particularly useful in the surgical situation when it is not clear whether the testicle is present or not.     

Retrospective Study: The association of blood lactate concentration with outcome in dogs with idiopathic immune‐mediated hemolytic anemia: 173 cases (2003–2006)

Objective – To determine the association of blood lactate with outcome and response to transfusion therapy in dogs with idiopathic immune‐mediated hemolytic anemia (IMHA). Design – Retrospective study. Setting – Urban veterinary small animal emergency hospital. Animals – One hundred and seventy‐three client‐owned dogs with IMHA. Interventions – None. Measurements and Main Results – Serial blood lactate concentration, therapeutic interventions, and outcome were recorded. Nonsurvivors were defined as those that died or were euthanized. One hundred and thirty‐three dogs (77%) survived, 35 (20%) were euthanized, and 5 (3%) died. One hundred forty‐five dogs (84%; 145/173) had a lactate concentration above the laboratory reference interval [0.46–2.31 mmol/L] on presentation. Blood lactate at presentation was higher in the nonsurvivors (median 4.8 mmol/L; 0.5–13.6) compared with survivors (median 2.9 mmol/L; 0.3–13.2) (P<0.01). All dogs presenting with hyperlactatemia that normalized (<2.0 mmol/L) within 6 hours of admission survived, whereas, 71% of dogs that had a persistent hyperlactatemia at 6 hours survived (P=0.034). Lactate was positively correlated with age, BUN, and alkaline phosphatase, and inversely correlated with PCV. Receiver operating curve analysis for lactate concentration at admission as a test for outcome had an area under the curve of 0.69 with an optimal lactate cutoff concentration of 4.4 mmol/L correctly predicting outcome 73% of the time (sensitivity 60%, specificity 77%). Conclusions – Lactate concentration at presentation was significantly higher in nonsurvivors than survivors. Lactate was significantly correlated with previously reported outcome variables but lactate concentration at admission, as a predictor for outcome was less than optimal. However, serial lactate concentration measurements may be more predictive as patients with persistent hyperlactatemia 6 hours after admission were less likely to survive. Prospective studies evaluating serial lactate concentration while controlling for other variables may provide further insight into lactate measurement as a prognostic indicator in animals with IMHA.     

Clinical evaluation of serum alcohol dehydrogenase activity in horses with acute intestinal obstruction

Objectives – To measure serum alcohol dehydrogenase (ADH) activity in horses with acute intestinal obstruction and to determine the diagnostic and prognostic utility of this analyte. Design – Prospective observational study. Setting – University Veterinary Hospital. Animals – Thirty healthy horses (control group) and 77 horses with acute intestinal obstruction, including 36 horses with nonstrangulating obstruction (23 with left ventral colon impaction and 13 with left dorsal displacement [G1], 22 with small intestinal strangulation [G2], and 19 with colon torsion [G3]). Interventions – Serum ADH activity was assayed spectrophotometerically in all horses. Serum lactate concentration and hepatic enzyme (aspartate aminotransferase, gamma‐glutamyl transferase, glutamate dehydrogenase) activities were measured using an automatic analyzer. Measurements and Main Results – The median [interquartile range] serum ADH activity in healthy horses was 10.5 [8.7 – 11 U/L]. ADH activity was significantly increased (P<0.05) in G1=16.5 [13.8 – 18 U/L], G2=40 [20 – 74.9 U/L], and G3=63.2 [40 – 78 U/L] compared with healthy controls. Aspartate aminotransferase and glutamate dehydrogenase activities were also significantly increased in G3 in comparison with controls. ADH activity was correlated with serum lactate concentration in G1 and G3, respectively (P<0.01, r=0.55 and 0.8). Other liver enzymes did not show any significant correlation with lactate. ADH activity was directly related to the probability of strangulation; odds ratio=1.11. ADH activity >20 U/L had 80.6% specificity and 80.5% sensitivity for discriminating horses with strangulating obstruction. Twelve horses euthanized before surgery were excluded from the outcome analysis. Increasing ADH activity was associated with nonsurvival; odds ratio=1.03. ADH activity <80 U/L had 94.44% specificity and 66.67% sensitivity for survival. Conclusion – Serum ADH activity may be a useful clinical parameter in detecting intestinal strangulation in horses and may provide some prognostic value in horses with acute intestinal obstruction.     

Blood glucose in horses with acute abdominal disease

BACKGROUND: Hyperglycemia in critically ill humans is associated with increased glucose production and insulin resistance and is associated with death. This might also be true in horses presenting with acute abdominal disease. HYPOTHESIS: Throughout hospitalization, hyperglycemia will be common in adult horses presenting with acute abdominal disease. Hyperglycemia will be associated with a worse prognosis for survival to hospital discharge. ANIMALS: Two hundred sixty-nine adult horses with acute abdominal disease. METHODS: Observational retrospective study. Records were reviewed for 269 horses that had glucose data analysed and recorded at the time of hospital admission: 154 horses had a first sample after admission; 110 horses at 24 hours after admission; 74 horses at 36 hours after admission; and 49 horses at 48 hours after admission. Logistic regression analyses were performed to investigate the association of glucose concentrations with survival, in addition to the association of glucose concentrations with surgical, small intestinal, strangulating lesions, and lesions requiring a resection. RESULTS: Of 269 horses presenting with acute abdominal disease, 50.2% had blood glucose concentrations greater than the reference range (75.6-131.4 mg/dL); 0.4%, below the reference range; and 49.4%, within the reference range at admission. Of 269 horses, 2.3% had blood glucose concentrations below the reference range at some point during the first 48 hours of hospitalization, all of which had strangulating intestinal lesions. Horses that did not survive to hospital discharge had a higher mean blood glucose concentration at admission; at the first sample after admission; at 24, 36, and 48 hours after admission; and higher maximum and minimum blood glucose concentrations in the first 24 hours after admission. CONCLUSIONS AND CLINICAL IMPORTANCE: Derangements of blood glucose concentration are common in horses with acute abdominal disease. Hyperglycemia is much more common than hypoglycemia in these animals. Hyperglycemia in the first 48 hours of hospitalization is associated with a worse prognosis for survival to hospital discharge.     

Association between hypercoagulability and decreased survival in horses with ischemic or inflammatory gastrointestinal disease

Background: Coagulopathies are common in horses with ischemic or inflammatory gastrointestinal (GI) disturbances. There is indirect evidence suggesting that early stages of these diseases are characterized by hypercoagulability (HC). Hypothesis/Objectives: HC, assessed via thromboelastography (TEG), is common in horses with ischemic or inflammatory GI diseases. The degree of HC is correlated with nonsurvival and thrombotic complications. Animals: Thirty client‐owned horses with ischemic or inflammatory GI disease, 30 client‐owned horses with nonischemic or inflammatory GI disease, and 30 healthy horses (control group). Methods: Prospective, observational clinical study. TEG profiles of 30 horses with ischemic or inflammatory GI disease were obtained on admission and 48 hours after admission, and these were compared with profiles from 30 horses with nonischemic or inflammatory GI disease and 30 healthy controls. Prothrombin time (PT), activated partial thromboplastin time (aPTT), antithrombin activity (AT), and D‐Dimer concentrations were also determined in horses with GI disease. Results: Horses with ischemic or inflammatory GI disease had shorter R times compared with healthy horses (14.8 ± 8.3 versus 22.8 ± 12 minute; P= .011). However, changes were subtle and TEG profiles did not resembled those obtained from animals or humans presumed to be hypercoagulable. Although conventional coagulation testing supported the presence of HC (decreased AT and increased D‐Dimer concentrations), TEG and coagulation abnormalities were rarely found in the same horses and the methods were not statistically related. Conclusions and Clinical Importance: There is evidence of HC in horses with GI disease but techniques for diagnoses require refinement.     

Fecal alpha1-proteinase inhibitor concentration in dogs with chronic gastrointestinal disease

Background: Fecal α₁‐proteinase inhibitor (α₁‐PI) clearance is a reliable, noninvasive marker for protein‐losing enteropathy in human beings. An assay for use in dogs has been developed and validated. Objective: The aim of this study was to evaluate fecal α₁‐PI concentration in dogs with chronic gastrointestinal disease, compared with healthy dogs, and to assess its correlation with serum albumin concentration. Methods: Fecal samples were collected from 2 groups of dogs. Group 1 consisted of 21 clinically healthy client‐owned dogs without signs of gastrointestinal disease. Group 2 consisted of 16 dogs referred for investigation of suspected gastrointestinal disease. On the basis of gastric and duodenal biopsies, group 2 was further subdivided into dogs with normal histology (n = 9) and those with histologic abnormalities (n = 7: inflammatory bowel disease, n = 3; lymphangiectasia, n = 4). An ELISA was used to measure α₁‐PI concentrations in fecal extracts. Results: Fecal α₁‐PI concentrations, expressed as μg/g of feces, were not significantly different between groups 1 and 2 as a whole. However, fecal α₁‐PI concentrations (median, minimum‐maximum) were significantly higher in dogs with gastrointestinal diseases associated with histologic abnormalities (60.6 μg/g, 7.4–201.7 μg/g) compared with dogs with normal histology (3.8 μg/g, 0.7–74.0 μg/g) and control dogs (9.9 μg/g, 0.0–32.1 μg/g). There was no significant correlation between fecal α₁‐PI and serum albumin concentrations in dogs with gastrointestinal disease. Conclusions: Increased fecal α₁‐PI concentration may signal the need to obtain gastrointestinal biopsies for a final diagnosis. Fecal α₁‐PI concentration may be a useful test for early detection of protein‐losing enteropathy before decreases in serum albumin concentration can be detected.     

Heart rate variability parameters of myxomatous mitral valve disease in dogs with and without heart failure obtained using 24-hour Holter electrocardiography

Time-domain heart rate variability (HRV) parameters and the correlation between echocardiography and Holter examinations in dogs with myxomatous mitral valve disease (MMVD) were determined. Holter examination was also performed at different time frames: an entire 24-hour period, a four-hour period during sleep, and a four-hour period while awake. Ten healthy (control group) and 28 MMVD dogs, 15 with and 13 without heart failure, were evaluated. The SDANN (sd of the mean normal RR intervals for all five-minute segments during 24-hour Holter) and pNN(50) (percentage of differences between adjacent normal RR intervals that are >50 ms computed over 24-hour Holter) variables were significantly lower in the dogs with MMVD heart failure. The differences in HRV between the groups were only detected during the 24-hour evaluation period (P<0.05). There were high correlations (canonical analysis) between Holter and echocardiography examinations when considering pNN(50), SDANN, and LA/AO (left atrial to aortic root ratio) (r=0.92; P<0.05), indicating that both are important in evaluating MMVD dogs. SDANN and pNN(50) are measures of parasympathetic control of the heart, and thus, it is possible to infer that the MMVD dogs exhibit parasympathetic withdrawal during the development of heart failure.     

Subnormal concentrations of serum cobalamin (vitamin B12) in cats with gastrointestinal disease

The present study sought to determine the spectrum of diseases associated with subnormal concentrations of serum cobalamin in cats undergoing investigation of suspected gastrointestinal problems. The solid-phase boil radioassay (RA) for cobalamin employed in the present study was immunologically specific, precise, and accurate, with a sensitivity of 15 pg/mL. The RA yielded results that strongly correlated with those obtained by bioassay (Spearmann rho = .805; P < .0001), although the absolute values were lower for the RA. Forty-nine of 80 serum samples submitted during the period of January 1996-January 1998 had cobalamin concentrations below the reference range for healthy cats (range 900-2,800 pg/mL; mean +/- SD, 1,775 +/- 535 pg/mL; n = 33). Cats with subnormal cobalamin concentrations (mean +/- SD; 384 +/- 272 pg/mL, range 3-883 pg/mL) were middle-aged or older and were presented for weight loss. diarrhea, vomiting, anorexia, and thickened intestines. Definitive diagnoses in 22 cats included inflammatory bowel disease (IBD), intestinal lymphoma, cholangiohepatitis or cholangits, and pancreatic inflammation. Serum concentrations of cobalamin were particularly low in cats with intestinal lymphoma, three-fifths of whom also had subnormal serum concentrations of folate (< 9 ng/mL). The simultaneous presence of disease in the intestines, pancreas, or hepatobiliary system in many cats made it difficult to determine the cause of subnormal cobalamin concentrations. The circulating half-life of parenteral cyanocobalamin was shorter in 2 cats with IBD (5 days) than in 4 healthy cats (12.75 days). The presence of subnormal serum concentrations of cobalamin in 49 of 80 cats evaluated suggests that the measurement of serum cobalamin may be a useful indirect indicator of enteric or pancreatic disease in cats. The rapid depletion of circulating cobalamin in cats suggests that cats may be highly susceptible to cobalamin deficiency. However, the relationship of subnormal serum cobalamin concentrations to cobalamin deficiency and the effect of cobalamin deficiency on cats remain to be determined.