I04

EQUINE COLIC 11 Equine vet. J., Suppl. 32 (2000) 1 D4- 107

The medical management of eight horses with Grade 3 rectal tears

T. S. MAlR

Bell Equine Veterinary Clinic, Mereworth, Kent ME18 5GS, UK.

Keywords: horse; rectal tear; Smal colon; peritoneal cavity

Summary Eight horses with Grade 3b rectal tears of the peritoneal part of the rectum or small colon were treated by a combination of medical therapy and dietary manipulation. All of the horses developed septic peritonitis during the course of treatment. Medical therapy consisted of a combination of penicillin, gentamicin and flunixin meglumine administered parenterally, metronidazole administered orally and liquid paraftin administered by nasogastric tube. Some horses also received fluid and electrolyte therapy i.v., plasma and heparin i.v. All horses were maintained on a laxative diet. Six of the 8 horses recovered. Duration of therapy in the horses that survived was between 2 and 7 weeks. Three of the 6 horses that recovered developed a rectal diverticulum, which did not appear to cause any subsequent medical problems. In the 2 horses that died, the Grade 3 rectal tear progressed to a Grade 4 tear with subsequent faecal contamination of the abdomen. Manual evacuation of the cavity of the rectal tears during treatment and size of the tears were identified as possible causes for the progression of the disease in these 2 horses. Introduction
Horses with traumatic and obstructive diseases of the rectum and distal small colon are difficult to treat surgically because of limited access to these areas. Rectal tears are usually iatrogenic, occurring most commonly as a complication of manual palpation per rectum (Arnold et al. 1978; Stauffer 1981; Spensley et al. 1985; Sayegh e f al. 1996). They may also arise, less commonly, as a result of enema administration, especially in foals (Keller and Horner 1985), dystocia and breeding accidents (Arnold et (11. 1978; Guglick et al. 1996). Complications associated with rectal tears that occur caudal to the peritoneal reflection (i.e. in the retroperitoneal part of the rectum) include cellulitis, perianal fistulae and formation of a rectal diverticulum (Sayegh et al. 1996; Mazan 1997). Tears involving the intraperitoneal part of the rectum or small colon are potentially more serious and may result in septic peritonitis, which can be life-threatening. Rectal tears are classified according to the layers of the rectal wall that are disrupted (Arnold et (11. 1978). Grade 1 tears involve disruption of only the mucosa (with or without the submucosa). Grade 2 tears involve only the muscularis. Grade I and 2 tears usually heal with conservative treatment. Grade 3 tears involve the mucosa, submucosa and muscularis, and may result in the formation of a serosal diverticulum (Grade 3a), or they may

enter the dorsal mesentery (Grade 3b). The intact serma or mesorectum of Grade 3 tears prevents faeces from entering the peritoneal cavity, but bacterial contamination of the cavity occurs rapidly, resulting in septic peritonitis (Watkins et al. 1989).Tears that perforate all layers of the rectum and extend into the peritoneal cavity are classified as Grade 4. Grade 4 tears result in faecal contamination of the peritoneal cavity and death. Grade 3 tears may progress to Grade 4 due to rupture or necrosis of the Serosa or mesentery. Recommended treatments for horses with Grade 3 rectal tears include primary closure (Arnold and Meagher 1978; Speir:; e f al. 1980; Watkins et al. 1989; Stewart and Robertson 1990; Wilson and Stone 1990; Sayegh et al. 1996), implantation of a temporary indwelling rectal liner (Taylor et al. 1987; Watkins et al. 1989), temporary diversion of faeces via a loop or end colcstomy (Freeman et al. 1992a,b; Blikslager et al. 1995; Sayegh et al. 1996),or laparoscopic repair (Brugmans and Deegen 1998). Each of these surgical procedures has advantages and disadvantages. The prognosis for horses with Grade 3 rectal tears is guarded. In a report of 42 horses with Grade 3 or 4 tears, mortality rate was 64% (Arnold et al. 1978). Horses with Grade 3b rectal tears had a better prognosis for survival than did those with Grade 3a tears in this study. However, in another review of 35 horses affected by a rectal tear, horses with Grade 31, tears had a worse prognosis for recovery than did those with Grade 3a tears (Watkins et al. 1989). First aid measures undertaken at the time of initial diagnosis had a marked influence on the outcome in this study. This report reviews the case details and outcome of 8 horses with Grade 3b rectal tears that received medical treatment only.

Materials and methods

The case details of 8 mature horses with iatrogenic rectal tears that were treated by medical therapy only were reviewed. These horses were examined by the author over a 12 year period (1986-1997). During this period a further 6 horses with other forms of rectal tears were diagnosed; these included 4 with Grade I rectal tears (all recovered following medical treatment) and 2 with Grade 4 rectal tears (both died). The location and severity of the rectal tears were determined in each case by careful digital palpation per rectum with an ungloved and well-lubricated hand, with the horse sedated and after administration of epidural anaesthesia. In 3 horses (Cases 5, 6 and 8) the tear was also evaluated by fibreoptic endoscopy. All horses had samples of peritoneal fluid obtained for cytology on