Primary cecal impactions
In horses with primary cecal impactions, there is a gradual onset of abdominal pain similar to the development of a large
colon impaction. The typical time course is 5-7-days. During this time, veterinarians may use treatments for impactions, such
as intravenous administration of analgesics and nasogastric administration of laxatives such as mineral oil, dioctyl sodium
sulfocuccinae (DSS) or magnesium sulphate (Epsom salts). However, the crucial aspect of management is to differentiate cecal
impactions from large colon impactions. This is because cecal impactions have a propensity to rupture before the development
of severe abdominal pain or systemic evidence of shock, and therefore are best referred as early as possible. The way to differentiate
cecal impactions from large colon impactions is by rectal palpation. Although the cecum will always be on the right side of
the abdomen, large colon impactions can shift from left side of the abdomen to the right side of the abdomen, making this
finding difficult to interpret. However, the cecum is attached to the dorsal body wall by its mesentery, whereas the large
colon is not attached to the body wall at this location. Therefore, the dorsal surface of a right-sided impaction should be
carefully palpated to determine if it is attached to the dorsal body wall. This is not always possible to determine, but can
be palpated in approximately 90% of presented cases. If the impacted viscus is attached to the dorsal body wall, it is best
to assume it is a cecal impaction and offer the client referral. At the referral center, additional medical therapy may be
used, including intravenous fluids. However, in this author's opinion, it is best to take these horses to surgery as it is
difficult to determine the full extent of the impaction and the integrity of the cecal wall from rectal palpation.
Secondary cecal impactions
Secondary cecal impactions are more difficult to detect because they are most frequently noted in postoperative patients.
These horses may display depression and decreased fecal output that may be attributed to the operative procedure rather than
colic. By the time horses with secondary cecal impactions show noticeable signs of colic, the cecum is typically close to
rupture. In some cases, there will be no signs of impending rupture. Therefore, all horses that undergo surgeries where considerable
postoperative pain may develop should have feed intake and manure production closely monitored. Studies have shown that horses
that produce 3 or less piles of manure on a daily basis are at risk of impaction, regardless of perioperative feeding regime.
Such a finding should prompt rectal palpation so that an impaction is not missed. The finding of a cecal impaction should
prompt surgical exploration of the abdomen.
Pain control in horses that have undergone surgery should be managed aggressively. Although the non-steroidal anti-inflammatory
drug (NSAID) phenylbutazone has been implicated in the pathogenesis of cecal impaction, this author's opinion is to aggressively
treat pain, including the use of NSAIDs. The full labeled dose of NSAIDs should be administered pre and postoperative if deemed
necessary. In addition, opiates such as butorphanol, preferably given as a constant rate infusion, can augment pain control.
Although opiates slow intestinal motility, this has not been shown to outweigh the benefit of butorphanol when treating postoperative
pain. Veterinarians should be aware that postoperative pain is not always readily detectable. Subtle signs such as depression,
standing toward the back of the stall, and failure to show interest in other horses or people in the hospital should be taken
into account.
