E-college questions

Question 1

Which of the following support the classification of a non-strangulating large intestinal lesion? (Select all that apply)

Tachycardia with a HR of 70 bpm

Dry pale MM with a CRT of 2.5 sec

Minimal external distension

Large balloon-like structure with tight distension and tight bands on rectal exam.

Mild to moderate pain

Normal abdominocentesis

Answer 1

Minimal external distension

Mild to moderate pain

Normal abdominocentesis

*Expectation:
Mild to moderate pain. HR below about 60-65 bpm. (If moderate to severe pain then more likely to have HR around 70 range. If mild to moderate then about mid 40’s to mid 50’s HR.)

Abdominocentesis normal (if starts becoming abnormal then might see slight TP increase). Maybe mild external abdominal distension with some mild to moderate distension on rectal. Would not expect tight distension. No reflux expected (think: location).

Recall in some of these (from disease section) you may have increased GGT such as in Right Dorsal Displacement.*

Question 2

You evaluate a 9 yr-old Morgan mare with a 10 hour history of moderate colic. CRT and MM within normal limits. Temp= 99.7F, RR 20/min. Borborygmi normal in all quadrants. Reflux: 5 L, pH 8.2. Rectal palpation: moderately distended loops of bandless tubular type structures within the caudal abdominal field. Predict the HR

24

32

44

52

72

80

96

Answer 2

52

*Presented parameters fit with the non-strangulating type disease presentation. And the rectal indicates involvement of the small intestine thus we expect moderate heart rate increase as animal is reasonably painful (thus not within normal range). We would not expect it to be elveated to levels nearing values seen in strangulating lesions.

Thus HR in about 50 range compatible with picture in this case.*

Question 3

You evaluate a 10 yr-old Arabian gelding with a 10 hour history of intermittent pawing, laying down occasionally, persistent walking, and intermittent looking at its flanks. CRT and MM within normal limits. Temp= 100.2F, HR 56 bpm, RR 24/min. Borborygmi are slightly reduced in all four quadrants. Mild amount of acidic reflux found on NG intubation. Transrectal palpationl reveals a large feed filled, moderately indentable, structure running across the pelvic inlet. The ventral aspect of the structure reveals slightly distended sacculations and a thick wide band running horizontally across the pelvic inlet. Classify the colic.

• Non-strangulating large colon disease
• Non-strangulating small colon disease
• Non-strangulating small intestinal disease
• Strangulating small colon disease
• Strangulating small intestinal disease

Answer 3

Non-strangulating large colon disease

All parameters fit with the non-strangulating type disease presentation, and the rectal indicates involvement of the large colon. What is a little different in this case is

• Having to grade the pain. Thus we would qualitfy this as mild to moderate /moderate type pain.
• The palpation transrectally reveals the presence of the large colon running across the pelvic inlet and we can specifically identify structures compatible with the ventral colon.

Question 4

You evaluate a 12 yr-old Paint mare with a six hour history of colic and moderate to severe pain. CRT 3.5 sec and MM congested and dry. Temp= 102.1F, HR 88 bpm, RR 24/min. The horse is stabled at night and pastured during the day. The horse is painful thus 150 mg of xylazine are administered IV to complete the PE. Minimal borborygmi are ausculted in all quadrants. NG intubation reveals 18L of reflux with a pH of 7.8. Upon removal of the reflux the horse gets a little quieter but within 10 minutes is painful enough again to warrant another 150 mg of xylazine IV. Transrectal palpation reveals multiple numbers tightly distended loops of bandless tubular type structures throughout the caudal abdominal field. The second dose of alpha-2 agonist quietens the horse for about 20 minutes, at which point pain signs return and another 100 mg is administered while 10 L of reflux are removed again. Addtional analgesic effect seems to be maintained for approximately 40 minutes at this time. Classify the colic.

• Non-strangulating large colon disease
• Non-strangulating small colon disease
• Non-strangulating small intestinal disease
• Strangulating small colon disease
• Strangulating small intestinal disease

Answer 4

Strangulating small intestinal disease

Parameters fit with strangulating small intestinal disease. Note the abdominocentesis was not performed at this time (what would you expect?). Also note that in a few questions GI auscultation is described. Please recall that borborygmi is the scientific name for gut sounds.

Question 5

In evaluating a severe colic, what would be the first procedure to be performed?

• The abdominocentesis
• The complete physical exam
• The blood work
• The nasogastric intubation
• The transrectal palpation

Answer 5

Nasogastric Intubation

*In assessing equine colic patients it is important to remember that the horse can develop gastric rupture if not decompressed with a nasogastric tube. Typically such “at risk” horses will have HR from 60 bpm or above, and are especially prone if they have significant pain and an elevated HR.

There can be exceptions to a horse having significant reflux in the absence of a HR over 60 bpm. This is especially true when monitoring current colic cases (example post-op colics or DPJ cases during thereapy) whose HR go from 44 into the 50’s. This change is likely reflect the development of increased accumulation of fluid in the stomach (without having an associated obvious changes in level of pain, and with a HR less than 60 bpm).*

Question 6

You evaluate a 5 yr-old Thoroughbred mare with a six hour history of colic. CRT and MM within normal limits. Temp= 100.3F, HR 44 bpm, RR 24/min. The horse is stabled at night and pastured during the day. Borborygmi normal in all quadrants. No reflux found on NG intubation however there were mild to moderately distended loops of bandless tubular type structures within the caudal abdominal field. Classify the colic.

• Non-strangulating large colon disease
• Non-strangulating small colon disease
• Non-strangulating small intestinal disease
• Strangulating small colon disease
• Strangulating small intestinal disease

Answer 6

Non-strangulating small intestinal disease

All parameters fit with the non-strangulating type disease presentation. And the rectal indicates involvement of the small intestine. It is interesting in this case that there is no reflux. However please recall that dependent on the timing and severity in non-strangualting disease of the SI (thus partial obstruction) it can take some time for reflux to develop in these cases.

Question 7

Which of the following evaluations should always be performed prior to the transrectal palpation.

• Abominal ultrasound
• Abdominal auscultation
• Heart rate
• Nasogastric intubation
• Temperature

Answer 7

Temperature

*The temperature should always be performed before the palpation as this latter procedure will introduce air in the rectum and rectal dilation which will make it difficult to get an accurate reflection of the temperature. This can be a significant parameter in many cases, and the information would be delayed in such an instance.

The NG intubation would be significant in view of the severity of the case. It is basically unrelated to the transrectal palpation, and relates to overall sequence of procedures in any given case.*

Question 8

Which of the following support the classification of a strangulating small colon lesion? (Select all that apply)

• Tachycardia with a HR of 70 bpm
• Dry pale MM with a CRT of 2.5 sec
• Minimal external distension
• Large balloon-like structure with tight distension and tight bands on rectal exam.
• Mild to moderate pain
• Normal abdominocentesis
• Serosanguinous abdominocentesis with normal WBCs and elevated protein
• Large volume alkaline reflux

Answer 8

Tachycardia with a HR of 70 bpm

Minimal external distension

*Expectation
Moderate, moderate to severe or severe pain. HR more likely to be around 70 or above range.

Maybe mild external abdominal distension ( depends on severity of distension, time) with tight distension of tubular loops (sausage type loops) with a band on trans-rectal palpation.

Abdominocentesis serosanguinous: tycpical TP, WBC and RBC all increased to same degree at same time.

No reflux expected (think: location).

Silent abdomen in most cases, but this can depend on time of evaluation compared to time of lesion.*

Question 9

Which of the following support the classification of a non-strangulating small intestinal lesion? (Select all that apply)

• Tachycardia with a HR of 70 bpm
• Dry pale MM with a CRT of 2 sec
• Minimal external distension
• Large balloon-like structure with tight distension and tight bands on rectal exam.
• Mild to moderate pain
• Normal abdominocentesis
• Serosanguinous abdominocentesis with normal WBCs and elevated protein
• Large volume alkaline reflux

Answer 9

Dry pale MM with a CRT of 2 sec

Minimal external distension

Mild to moderate pain

Normal abdominocentesis

Expectation

• Mild to moderate pain. HR more likely to be between 36-60 or so range.
• Maybe mild external abdominal distension (depends on severity of distension, time) with mild to maybe moderate distension of tubular bandless structures (sausage type loops) on trans-rectal palpation.
• Would not expect change in abdominocentesis unless was progressive, and then would expect increase in TP first (then WBCs then later RBCs as progresses further).
• Reflux expected however may not be very large volume, takes time to develop and would be expected to be progressively increasing dependent on persistence of lesion, thus in these cases variable reflux.
• Abdominal auscultation variable, likely normal to maybe some generalized decrease in borborygmi.

Question 10

Which of the following support the classification of a strangulating large colon lesion? (Select all that apply)

• Tachycardia with a HR of 70 bpm
• Dry pale MM with a CRT of 2.0 sec
• Minimal external distension
• Large ballon-like strucutre with tight distension and tight bands on rectal exam.
• Mild to moderate pain
• Abdominocentesis: yellow fluid with Tp = 2.9 g/dL and WBC = 23,000
• Large volume reflux with pH of 6.2

Answer 10

Tachycardia with a HR of 70 bpm

Large ballon-like strucutre with tight distension and tight bands on rectal exam.

Expectation

• Moderate to severe pain. HR above 60-65 bpm. (If moderate to severe pain then more likely to have HR around 70 range. If severe then in 80s to 90s.)

Abdominocentesis abnormal expect WBC, TP and RBC increase all to same degree at same time). Likely significant external abdominal distension with significant (tight) distension on rectal.

No reflux expected (think: location).

Question 11

You evaluate a 3 yr-old Appaloosa gelding with a 2 hour history of severe colic. CRT: 2.5 sec, congested membranes and MM tachy. Temp= 99.7F, HR = 88 bpm, RR 28/min. Borborygmi decreased in all quadrants. Rectal palpation: multiple tightly distended loops of banded tubular type structures. Predict the reflux

• 2 L pH 8
• 8 L pH 8
• 20 L pH 6.2
• none

Answer 11

None

Question 12

You evaluate a 17-yr-old Quarter Horse mare with an 8 hour history of moderate colic. CRT: 3.5 sec, congested membranes and MM tachy. Temp= 102.3F, HR = 96 bpm, RR 30/min. Borborygmi decreased in all quadrants. Reflux 22 L pH 8.1. Animal repeatedly treated with xylazine and stays pain free for longer periods with repeated dosages. The horse is progressively depressed. Predict the rectal palpation.

• moderately distended tubular structures with a band
• moderately distended large ballon like structure located in right dorsal quadrant
• tightly distended large balloon like structure with multiple wide flat badns filling the caudal abdomen
• tighly distended sausage like structures without a band
• moderatley distended sausage like structures without a band

Answer 12

moderatley distended sausage like structures without a band

Explanation:

*All parameters fit with the strangulating type disease presentation. Findings of reflux and distension under abdomen support small intestinal involvement, thus should be sausage-like structures without a band.

Severity of distesion in this case would be moderate as fever, response to refluxing, depression support aneterior enteritis/ DPJ. We expect lesser severity of distension in general in these cases compared to true strangulation.*

Question 13

The small colon is ausculted in quadrant/(s)_______.

Answer 13

A

Question 14

In the normal horse you expect to hear 2-3 contractions every 1-2 minutes in quadrant/(s) _______.

Answer 14

B

Question 15

The small intestine is ausculted in quadrant/(s)_______.

Answer 15

A

Question 16

The large colon is ausculted in quadrant/(s)_______.

Answer 16

C, D

Question 17

Which of these differentials should present as “what looks like” non-strangualting SI disease?

• Small intestinal adhesions (Yes, adhesions typically present with a non-strangulating picture.)
• Epiploic foramen entrapment (Strangulating obstruction)
• Pedunculated lipoma
• Duodenitis proximal jejunitis (Inflammatory disease thus presents as strangulating)
• Ileal impaction (Typically presents as non-strangulating disease, as it is a non-strangulating true obstruction.)
• Ascarid impaction (Typically presents as strangulating due to necrosis and inflammation of GIT wall caused by death of the parasites. The disease itself is a non-strangulating true obstruction.)
• Gastrosplenic ligament entrapment (As with other SI incarcerations, this typically presents as with strangulating picture.)

Answer 17

Small intestinal adhesions (Yes, adhesions typically present with a non-strangulating picture.)

Ileal impaction (Typically presents as non-strangulating disease, as it is a non-strangulating true obstruction.)

Question 18

Which of the following diseases likely will not have the multiple/many loops of SI noted on rectal as we would expect in classic SI strangulating cases?

• Pedunculated lipoma
• Gastrosplenic ligament entrapment
• Epiploic foramen entrapment
• Diaphragmatic hernia
• Mesenteric rent

(Select all, if any, that apply)

Answer 18

• Gastrosplenic ligament entrapment
• Epiploic foramen entrapment
• Diaphragmatic hernia

Explanation:

Usually the reason there are “less loops” palpable include:

1. Very cranial lesions, so not as much SI will distend due to the shorter segment cranial/orad to site of obstruction.
2. Tract pulled forward in the abdomen thus out of reach, less palpable in caudal abdomen.

Also want to consider that, as with all cases, time plays a factor and full distension might not be present in very early stages of disease (not a judgement/assessment expected of you at this time).

Question 19

In which of the following diseases would we not find what is expected on abdominocentesis given the clinical presentation?

• Pedunculated lipoma
• Gastrosplenic ligament entrapment
• Cecocolic intussusception
• Epiploic foramen entrapment
• Mesenteric rent
• Diaphragmatic hernia
• Jejuno-ileal intussusception
• Inguinal hernia

(Select all, if any, that apply)

Answer 19

• Cecocolic intussusception
• Epiploic foramen entrapment
• Mesenteric rent
• Diaphragmatic hernia
• Jejuno-ileal intussusception

Explanation:

*Consider what abdominocentesis changes are expected in each case. In addition, ask: is the compromised intestinal tract contiguous with the peritoneum?

The one which might have been an issue in the responses might be the inguinal hernia. In this case though the compromised gut might be external to the abdomen, the scrotal area is small and the effused fluid would easily perfuse into the abdomen. Thus as the area is not all that sequestered, we ususally are able to see abdominocentesis fluid changes as expected for the rest of the clinical picture.*

Question 20

Match the following diseases to their appropriate risk factor.

: Bermuda grass hay die

: Old age

: Previous abdominal surgery

: Cribbing

: Fecal consistency changes

» 1 : Adhesions» » 2 : Pedunculated lipoma » 3 : Ileal impaction»4 : Intussusceptiont 5 : Epiploic foramen entrapment (EFE)

Answer 20

: Bermuda grass hay diet » 3 : Ileal impaction

: Old age » 2 : Pedunculated lipoma

: Previous abdominal surgery » 1 : Adhesions

: Cribbing » 5 : Epiploic foramen entrapment (EFE)

: Fecal consistency changes » 4 : Intussusception

Question 21

For which of the following GI diseases is tapeworm infestation possibly a risk factor?

• Pedunculated lipoma
• Cecal impaction
• Ileocecal Intussusception
• Epiploic foramen entrapment
• Cecocolic intussusception
• Spasmodic colic

(Select all if any that apply)

Answer 21

• Cecal impaction
• Ileocecal Intussusception
• Cecocolic intussusception
• Spasmodic colic

Explanation

Tapeworms located at the ileocecal junction are implicated predominantly in motility alterations in this GI location.

1. Thus some cases of cecal impaction which can result from local motility alterations might be related to such an infestation.
2. As well it has been documented that spasmodic colic seems to be closely associated to tapeworm infestation.
3. Intussusceptions, which might relate to fecal consistency changes, might alternatively be due to aberrant motility patterns as a result of tapeworm infestation.

Question 22

You evaluate a 12 yr-old Paint mare with a six hour history of colic and moderate to severe pain. CRT 3.5 sec and MM congested and dry. Temp= 102.1F, HR 88 bpm, RR 24/min. The horse is stabled at night and pastured during the day. The horse is painful thus 150 mg of xylazine are administered IV to complete the PE. Minimal borborygmi are ausculted in any quadrant. NG intubation reveals 18L of reflux with a pH of 7.8. Upon removal of the reflux the horse gets a little quieter but within 10 minutes is painful enough again to warrant another 150 mg of xylazine IV. Transrectal palpation reveals multiple numbers tightly distended loops of bandless tubular type structures throughout the caudal abdominal field. The second dose of alpha-2 agonist quietens the horse for about 20 minutes, at which point pain signs return and another 100 mg is administered while 10 L of reflux are removed again. Addtional analgesic effect seems to be maintained for approximately 40 minutes at this time. What is the likely diagnosis?

• Small intestinal adhesions
• Epiploic foramen entrapment
• Pedunculated lipoma
• Duodenitis proximal jejunitis
• Ileal impaction

Answer 22

Duodenitis proximal jejunitis

Explanation

Parameters fit with “what looks like” strangulating small intestinal disease (thus eliminating option E) and, more specifically, fit with inflammatory disease. Therefore DPJ is the most likely diagnosis. Notice we do not have all of the criteria but we do have the two most significant ones, which should make us question the presence of a true strangulating SI lesion.

Question 23

In this case (DPJ) what are the expected abdominocentesis findings? (check all, if any, that apply)

• Clear yellow fluid
• Red-tinged fluid
• Opaque white fluid
• Elevated WBCs
• Decreased WBCs
• Increased protein
• Decreased protein

Answer 23

Red-tinged fluid, Increased protein

Explanation

*We would expect a serosanguinous abdomonocetesis (red-tinged fluid) with significantly increased protein in the absence of any significant change in WBCs (WBCs thus would be exepcted to be within normal range).

If there is any increase in WBC of abdomonocestesis in these cases, it would not be “in-line” with degree of change in protein (it would be typically minimal, not to same degree).*

Question 24

You evaluate a 8 yr-old Thoroughbred mare found in the morning, with facial abrasions and severly thrashing. She is presented to your referral hospital. PE: CRT 3.5 sec and MM congested and dry. Temp= 101.7F, HR 88 bpm, RR 24/min. The horse is stabled at night and pastured during the day. The horse is painful thus 150 mg of xylazine are administered IV to complete the PE. NG intubation reveals 20 L of reflux with a pH of 7.9. Upon removal of the reflux the horse gets a little quieter but within 10 minutes is painful enough again to warrant another 150 mg of xylazine IV. Abdominal auscultation reveals a silent abdomen.Transrectal palpation reveals multiple numbers of tightly distended bandless tubular type structures throughout the caudal abdominal field. The second and third dose of 150 mg of xylazine quietens the horse for about 10 minutes each. Which of the following parameters are indicative of a diagnosis of DPJ? (Select all, if any, that apply)

• The transrectal palpation
• The reflux
• The response to refluxing
• The temperature
• The response to analgesia

Answer 24

The temperature

Explanation

*The only parameter in this case that would increase the index of suspicion of the presence of DPJ is the temperature (fever).

All others are most indicative of a true strangulating lesion of the small intestine. The reflux would be the same for both so it does not indicate a DPJ per se.*

Question 25

You evaluate a 8 yr-old Thoroughbred mare found in the morning, with facial abrasions and severly thrashing. She is presented to your referral hospital. PE: CRT 3.5 sec and MM congested and dry. Temp= 101.7 F, HR 88 bpm, RR 24/min. The horse is stabled at night and pastured during the day. The horse is painful thus 150 mg of xylazine are administered IV to complete the PE. NG intubation reveals 20 L of reflux with a pH of 7.9. Upon removal of the reflux the horse gets a little quieter but within 10 minutes is painful enough again to warrant another 150 mg of xylazine IV. Abdominal auscultation reveals a silent abdomen.Transrectal palpation reveals multiple numbers of tightly distended bandless tubular type structures throughout the caudal abdominal field. The second and third dose of 150 mg of xylazine quietens the horse for about 10 minutes each. Which of the following recommendations would be included in the therapeutic plan for this horse at this time?

• Administer flunixin meglumine
• Administer IV fluids
• Place in a stall and check Q 1hr for changes
• Reflux Q 1hr
• Administer IV endoserum
• Administer IV lidocaine

(Select all, if any, that apply)

Answer 25

• Administer flunixin meglumine
• Administer IV fluids
• Reflux Q 1hr
• Administer IV endoserum
• Administer IV lidocaine

Explanation

You would institute all of the listed treatments except placing the animal in the stall and assessing hourly. Although you would continue to monitor this animal it is unclear at this time that it is a DPJ case. You would want to see the pain relieved for more significant periods of time, quite soon after this initial evaluation, before you would be comfortable it is a DPJ case. If, over the next half hour to hour, the horse continues to get relief only for 10 or so minutes at a time with each dose of xylazine, it is much less likely to be a DPJ case and surgical exploration would thus be recommended .

Question 26

You evaluate a 10 yr-old Arabian gelding with a 10 hour history of intermittent pawing laying down occasionally, persistent walking and intermittent looking at its flanks. CRT and MM within normal limits. Temp= 100.2F, HR 56 bpm, RR 24/min. Borborygmi are slightly reduced in all four quadrants. Mild amount of acidic reflux found on NG intubation. Transrectal palpation reveals a large, feed filled, moderately indentable structure running across the pelvic inlet. The ventral aspect of the structure reveals slightly distended sacculations and a thick wide band running horizontally across the pelvic inlet. Which of the following differentials would you consider?

• Sand impaction
• Bermuda grass hay impaction
• Entrolithiasis
• Left dorsal displacement
• Pelvic flexure retroflexion
• Right dorsal displacement

Answer 26

• Sand impaction
• Entrolithiasis
• Pelvic flexure retroflexion
• Right dorsal displacement

Explanation

*Of the differentials all would be included, EXCEPT the Bermuda grass hay impactionThese could be associated with a large colon impaction presentation (as we have in this case scenario), however Bermuda grass ha is associated with an ileal impaction.

If we look more deeply however we would eliminate the LDD as we do not have a transrectal palpation compatible with this diagnosis in this particular case. We would also eliminate the pelvic flexure retroflexion for the same reason. If you recall the image shown in class the pelvic flexure would be located forward on the left, thus the large colon would not be expected to be traversing across the pelvic inlet in that case.

This particular option (pelvic flexure retroflexion) was added to round out the picture in these cases and for your consideration, but you would not be required to make such a subtle determination in an exam case.*