EQUINE VETERINARY EDUCATION
Equine vet. Educ. (2017) 29 (7) 385-390
doi: 10.1111/eve.12530
Review Article
Medical management of large colonic impactions
G. D. Hallowell*
School of Veterinary Medicine and Science, University of Nottingham, Sutton Bonington, Leicestershire, UK.
*Corresponding author email: gayle.d.hallowell@nottingham.ac.uk
Keywords: horse; gastrointestinal; pelvic flexure; colic
Summary
Large colonic impactions are a common cause of abdominal
pain in the horse. This review aims to discuss normal function
of the large colon, risk factors for development of colonic
impactions, diagnosis and optimal strategies for management
and prevention based on the evidence available.
Introduction
Large colonic impactions can be either primary or secondary
to other disease processes that have induced hypovolaemia
such as small intestinal strangulating lesions and subacute
equine grass sickness. This article will primarily focus upon
primary colonic impactions. Primary large colonic impactions
are a common cause of mild to moderate abdominal pain in
the horse and generally form gradually leading to the
insidious onset and nature of the clinical signs seen.
Impactions of the large colon generally occur at sites of
luminal narrowing, primarily of the pelvic flexure and right
dorsal colon, but can affect other intestinal sections (White
and Dabareiner 1997).
Aetiology and risk factors
Many risk factors have been proposed, but not proven. A
sudden reduction in exercise, often secondary to
musculoskeletal injuries, is often associated with this condition
(Dabareiner and White 1995). Other factors implicated
include parasite migration affecting gastrointestinal motility,
poor dentition, coarse roughage, especially horses that eat
their straw bed, permanent stabling, oral stereotypies, travel
in the recent past, administration of pharmacological agents
that reduce gastrointestinal motility (Freeman and England
2001; Proudman et al. 2006; Williams et al. 2015) and either
dehydration or hypovolaemia (Hillyer et al. 2002).
The prevalence of colonic impactions with sand is
dramatically affected by geography and soil type as well as
how animals are fed. Some animals also develop a particular
predilection for eating sand, which in most cases will not be
due to a mineral deficiency (Blikslager 2010). It is reported
that fine grain sand generally accumulates in the ventral
colonic segments and coarser grains in the dorsal sections
(Specht and Colahan 1988; Ragle et al. 1989). However,
changes in gastrointestinal motility may also play a role in
sand accumulation. Clinical signs are generally similar to
those with colonic impactions and due to colonic distention
with sand, gaseous distention or inflammation of the mucosa.
Enteroliths leading to ingesta accumulation, usually of the
right dorsal and transverse colonic sections (Lloyd et al. 1987),
are a relatively uncommon cause of obstruction in the UK,
but are more prevalent in other parts of the world. These
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masses are primarily composed of struvite (ammonium
magnesium phosphate) (Blue and Wittkopp 1981) and start
around some small nidus (stone, hair, small bits of rope). As
horses have an abundance of calcium in the gastrointestinal
tract, it is surprising that these masses are not composed of
calcium phosphate (Hassel et al. 2001). However, it is
suggested that there is an excessive solute load of
magnesium in the diet, which may be bound by increased
amounts of intraluminal protein. Thus diets containing large
quantities of alfalfa, which has both a high protein and
magnesium content, may predispose animals to developing
these stones. Miniature horses and Arabians have been
shown to be more susceptible in one study (Cohen et al.
2000). As these stones take some time to develop and cause
obstruction, they are rarely identified in animals less than
4 years of age. These obstructions are usually associated with
mild to moderate, intermittent pain, which may lead to these
animals presenting with chronic or even recurrent abdominal
pain (Lloyd et al. 1987). Management of these cases is
usually surgical, although dietary manipulation is required
post operatively and as such will not be discussed any further.
Faecoliths are a rare cause of colonic impaction,
particularly of the transverse and descending colon. They are
most commonly seen in ponies and foals (McClure et al.
1992) and in older horses secondary to poor dentition and
inappropriate mastication of food material. These animals will
present as with enteroliths, although may also show signs
consistent with tenesmus (Gay et al. 1979).
Other rarer causes of colonic disease resulting in colonic
impactions include adhesions from previous colic surgery or
peritonitis, foreign bodies, which are usually seen in younger
animals and those in the developing world and mural masses
such as abscesses, tumours, granulomas and haematomas.
The cause of the impaction can be due to direct luminal
obstruction or indirectly secondary to a change in colonic
motility.
Role of the large colon
In order to fully appreciate the management options for
colonic impactions, it is necessary to understand normal
colonic function, have a basic understanding of the complex
mechanisms involved in normal colonic motility and
appreciate the normal composition of colonic contents.
The large colon of the horse, compared with other
monogastric species, is extremely well developed and has
many functions. It mixes, retains and propulses ingesta. Whilst
the ingesta is within the colon, it undergoes fermentation and
the process is essentially analogous to that which occurs in
the rumen of farm animals. If the horse did not produce large
quantities of volatile fatty acids (VFAs) from the fibre it ingests,
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it would not survive. These VFAs are absorbed through the
caecal and colonic epithelium and are then distributed for
use throughout the body as an energy source. One
significant difference from ruminants is that the large quantity
of microbial protein generated in the equine large colon is
wasted because there is no opportunity for significant
absorption of amino acids. In addition to the generation of
energy, water absorption in the normal horse primarily occurs
in the large colon. Water in the large intestine acts as a
reserve in times of need. In an adult horse a volume of up to
100 l of fluid and associated secretions is absorbed during the
course of the day (Argenzio et al. 1974, 1975; Argenzio and
Clarke 1989).
Large colonic motility
Motility of the large colon is essential for mixing, retainment,
propulsion and retropulsion of ingesta. It depends upon a
complex interaction between neural, hormonal, vascular and
neuromuscular pathways and any disruption to this fine
balance can lead to reduced motility or gastrointestinal
stasis. Regulation of motility requires central, autonomic
innervation and the enteric nervous system (myenteric and
submucosal plexi) (Koenig and Cote 2006). However, control
of intestinal contractility by the enteric nervous system is
independent of the central nervous system (Koenig and Cote
2006). Acetylcholine is the main excitatory neurotransmitter
causing smooth muscle contraction through M-2 type
receptors. Sympathetic stimulation inhibits acetylcholine
release via activation of alpha-2 receptors (Lester et al.
1998). There has been a focus on the pelvic flexure regarding
large colonic motility and it has long been accepted that an
electrical pacemaker exists at the pelvic flexure where the
strong rhythmic contractions of the large intestine begin
(Sellers and Lowe 1986). The pacemaker cells of the
gastrointestinal tract, the interstitial cells of Cajal (ICC)
(Hudson et al. 1999), are responsible for initiating coordinated
gastrointestinal motility (Bortoff 1965; Ward et al. 1997;
Sanders et al. 1999). Reduced myenteric neuron densities in
the large intestine have been identified in horses with
gastrointestinal obstructive disorders, including impactions,
when compared with normal horses (Schusser and White
1997; Schusser et al. 2000) as have ICC density (Fintl et al.
2004).
Large intestinal contents
The large intestinal contents contain fibrous material
suspended in water. The size of the fibrous material depends
upon the type of fibre ingested and degree of mastication.
One experimental study found that high grain diets led to
dehydrated contents of the right dorsal colon when
compared with fibre-based diets (Lopes et al. 2004a), which
may be due to promotion of water absorption from colonic
contents secondary to activation of the renin-angiotensin-
aldosterone system post prandially (Clarke et al. 1990),
coupling of absorption of VFA with sodium and water
(Argenzio et al. 1977) or fibre holding water within the
gastrointestinal tract (Warren et al. 1999). The amount of
water that the fibre is contained within is dependent upon
fluid intake, but also upon how much of that water is
absorbed to maintain normal systemic hydration.
© 2016 EVJ Ltd
Management of large colonic impactions
The microbiota
There is currently a lot of interest in the gastrointestinal
microbiota, its specific composition and potential
consequences of change regarding gastrointestinal disease
(Schoster et al. 2014). The colon contains bacteria, protozoa
and fungi. Changes in composition will affect the efficiency
of fibre fermentation and locally production of certain
byproducts such as lactic acid and local changes in pH can
affect local motility as is well documented in the rumen of
farm animals (Enemark 2008). Low faecal pH has been
identified in horses on a high carbohydrate diet (Sykes et al.
2013) and thus may play a role in motility disorders in the
horse and warrants further evaluation.
Diagnosis
For the majority of colonic obstructions, the mainstay for
diagnosis will be based on history, signs of abdominal
pain, reduced faecal output and presence of a smooth
distended viscus running laterally in front of, and ventral to
the pelvis in the case of pelvic flexure impactions and
potentially in other anatomical locations for other areas of
obstruction. Diagnosis of other forms of obstruction,
particularly with sand, will also be aided with history and
geographical location. Other diagnostic aids for sand
impactions include auscultation, where some clinicians
advocate being able to ‘hear’ the sand, which sounds
like the sea crashing on the beach, faecal sedimentation
and radiographic assessment (Ragle et al. 1989). There is
controversy regarding the value of ultrasonography; some
have found that it aids in identification, whereas others
have not and have reported that it does not provide
information regarding the amount of sand present
(Korolainen and Ruohoniemi 2002; Hotwagner and Iben
2008). In animals that live in areas where sand ingestion is
likely, there appear to be poor ‘cut-offs’ between normal
and likely affected animals. Enteroliths and faecoliths may
be detectable on rectal examination, but abdominal
radiography may be beneficial to identify these
obstructions, especially in smaller cases.
Assessment of hydration status
One of the key assessments undertaken in the horse with
abdominal pain is of hydration status and this is going to
have a significant impact on the most appropriate
management of horses with colonic obstruction. The majority
of horses that present with colonic impaction are neither
hypovolaemic nor dehydrated. Hypovolaemia is defined as a
loss of circulating volume, resulting from both water and salt
loss. Clinical signs of hypovolaemia include tachycardia,
increased capillary refill time, haemoconcentration
(increased packed cell volume and total solids), increased
lactate concentrations, reduced urine output and
concentrated urine (USG >1.040). Dehydration is defined as a
loss of total body water and is much more challenging to
quantify. Clinical signs of dehydration include decreased
bodyweight (not helpful clinically, but used experimentally),
sunken eyes, increased skin tent over the upper eyelid and
tacky mucous membranes. Dehydrated animals are always
hypernatraemic.
G. D. Hallowell
Overall aims of treatment of colonic impactions
The overall aims of treatment are to provide analgesia,
correct any fluid deficits present, resolve the impaction and
then identify any potential risk factors to prevent these from
developing again.
General management of colonic impactions
Although withholding food is likely to reduce gastrointestinal
motility (Jones et al. 1991), in the short-term it prevents the
impaction from growing any larger and also provides
the opportunity for enterally-administered products to reach
the impacted colon. Food should be withheld until there is
evidence that the impaction has resolved. As discussed
above, these animals are variably painful, but are likely to
require some parenteral nonsteroidal anti-inflammatory
agents, which will have direct benefits for managing pain
and indirect benefits in that a less painful animal will have
reduced activation of the sympathetic nervous system, which
itself is likely contributing to gastrointestinal stasis (Koenig and
Cote 2006). Alpha-2 agonists are known to reduce
gastrointestinal motility in normal horses, but will provide
analgesia for the duration of their sedative actions (Valverde
2010). In the author’s opinion, products containing
N-butylscolopamine are not warranted for the treatment of
colonic impactions as they have a short duration of action,
reduce gastrointestinal motility and on their own have no
intrinsic analgesic activity. Other analgesic agents have
variable effects on gastrointestinal motility in normal animals,
but no studies have been undertaken to address the effects
of these drugs on motility in experimentally or clinically
affected animals with intestinal obstruction. Turning horses out
into small paddocks in order that they gently ambulate may
be appropriate and beneficial in some cases (Williams et al.
2015), but these animals should not be lunged or ridden. For
further information on analgesics for horses with abdominal
pain, see Michou and Leese 2012.
Fluid therapy – intravenous, enteral or both?
If the horse has clinical signs consistent with hypovolaemia,
which is rare, then the animal needs intravenous (i.v.) fluid
therapy to restore circulating volume (Corley 2008). In the
hypovolaemic horse, in order to protect the vital organs,
blood flow is diverted from the gastrointestinal tract. Once
blood flow is reduced, so too is gastrointestinal motility and
absorption. In addition, hypovolaemia manifests as variable
obtundation, which ultimately results in a reduced thirst drive
(Corley 2008). It is for this reason that using oral fluid therapy
in hypovolaemic animals is unsuccessful at best and
detrimental in certain scenarios. If the horse has no fluid
deficits, or shows signs only of dehydration, then it will be
more clinically and cost effective to manage the horse with
enteral fluids (Hallowell 2008). Absolute contraindications
would include ileus and subsequent excessive nasogastric
reflux.
Experimental (Lopes et al. 2002; Lester et al. 2013) and
clinical studies (Hallowell 2008; Monreal et al. 2010) have
shown that correction of large colonic impactions is more
effective using enteral than parenteral fluids unless significant
haemodilution occurs. The reported parenteral fluid rates
required to hydrate impactions is not only expensive but
387
results in significant haemodynamic changes (Lopes et al.
2002). A more recent study supported previous findings in that
i.v. fluids administered at 3 times maintenance requirements
were no more efficacious and might be associated with
adverse physiological findings after withdrawal, whilst boluses
of water administered nasogastrically can be used to restore
intestinal water with minimal adverse effects (Lester et al.
2013). Another experimental study proposed that the main
effect of a selection of oral fluids that were compared was
activation of the gastrocolic reflex following filling of the
stomach (Freeman et al. 1992).
In clinical cases with colonic impactions, resolution rates
were fastest in those that received 5 doses of isotonic
electrolyte solutions every 30 min or hourly when compared
with those that received fluids every 2 h or i.v. Complication
rates were similar between groups, but severity of abdominal
pain was greatest in those treated every 30 min (Hallowell
2008). A similar clinical study demonstrated that 99% of large
colon impactions (n = 78) were effectively treated with
enteral fluids with a resolution time of under 24 h (Monreal
et al. 2010), which is similar to the previous clinical study
described above (Hallowell 2008), with no difference in
resolution time when i.v. fluids were administered concurrently
(Monreal et al. 2010).
Enteral fluid administration
Enteral fluids can be delivered in the form of water from a
bucket, via an indwelling narrow nasogastric tube to allow for
continuous administration of enteral fluids or a conventional
nasogastric tube providing intermittent fluid administration.
Fluids provided in the stable can be simply water alone or
combined with a second bucket containing either
electrolytes or sweetening agents such as fruit juice or
molasses to encourage increased water intake. Some horses
will select oral fluids containing electrolytes when they have
specific derangements, whereas others will not. Fluids with
electrolyte supplementation should be isotonic (i.e. 9 g NaCl/l
of water or equivalent), or they will not be consumed.
Intermittent fluid administration via nasogastric tube allows
the clinician to have complete control over the amount and
timing of fluids administrated. The stomach tube can be left
in and capped to prevent air entering the stomach or
removed after each fluid administration. This approach can
lead to worsening of signs of abdominal pain due to gastric
and small intestinal distention and as such should be
monitored for signs of abdominal pain.
Continuous enteral fluid therapy prevents the abdominal
discomfort seen with intermittent fluid administration. This is
relatively easily undertaken either using commercially
available enteral fluid therapy kits or equine nasogastric
feeding tubes. As these tubes are thin, it is prudent to ensure
they are positioned in the oesophagus, which may require
endoscopy or radiography. They need to be appropriately
secured and a muzzle will help to prevent horses rubbing
them out. Clean, but nonsterile, coiled fluid administration
sets and i.v. fluid bags can be used to hold the water or
electrolyte solutions.
A maximum intermittent rate of enteral fluids would be
6–8 l for a 500 kg horse (approximately 1.5 l/100 kg) at no less
than 30 min intervals. Checking for nasogastric reflux prior to
the next dose is essential. The maximum rate usually possible
for continuous administration would be 5 l/500 kg/h (1 l/
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388 Management of large colonic impactions

100 kg/h) and maximum rates should be 10 l/500 kg/h (2 l/ a)

100 kg/h) (Corley 2008).

Fluids used enterally

A variety of enteral fluids are administered to manage
colonic impactions. These include water, hypotonic or
isotonic fluids supplemented with electrolytes (e.g. sodium
chloride and potassium chloride) and also hypertonic
magnesium sulphate. Hypotonic fluids given enterally are
absorbed from the proximal gastrointestinal tract, whereas
isotonic fluids are more likely to remain within the
gastrointestinal lumen and thus hydrate the colonic contents
(Lopes et al. 2004a,b). b)
Magnesium sulphate is used enterally as a cathartic
agent as an initial treatment for large colonic impactions.
Initial use of 0.5 g/kg bwt is recommended diluted in water.
Doses up to 1 g/kg bwt can be used, but can result in
hypermagnesaemia and repeated administration of this
product is not recommended as it can lead to signs
associated with magnesium toxicity. These include
tachycardia, increased respiratory rate, sweating,
hyperexcitability, muscle tremors, flaccid paralysis and
recumbency. Magnesium sulphate is not as effective
experimentally at increasing colon water content when
Fig 1: Two photographs of some hard faecal balls immersed in
compared with a balanced electrolyte solution, but does water (a) and liquid paraffin (b) for 24 h. The faeces in the water
increase the water content of faeces in the small colon (a) has dissipated into the solution, whereas the faecal balls in
(Lopes et al. 2004b), so may be of value for primary small liquid paraffin (b) are still hard and solid and remained this way
colon impactions. for a further 6 days (images courtesy of Dr M. Bowen).
Balanced electrolyte solutions can be made from sodium
chloride and combined sodium and potassium chloride
(LoSalt) with approximately 5 g of each per 1 l of water and
the author has found these to be effective, even in Oral glucose in fluids does not provide sufficient nutrition
longstanding, severe large colonic impactions. Other to be valuable in horses and glucose and glycine containing
formulations have been shown to be effective that also add fluids in an experimental diarrhoea model resulted in
sodium bicarbonate, but these are less easy to remember incomplete fluid absorption (Ecke et al. 1998).
and formulate in general equine practice. If only using In summary, enteral fluids can be beneficial for treatment
sodium chloride, add a maximum of 9 g/1 l of water. of large colonic impactions and electrolyte supplementation,
but are not appropriate for hypovolaemic animals or those
with gastrointestinal ileus.
Products not recommended for enteral
administration
Management of horses following colonic
Mineral oil can be used as a marker of gastrointestinal transit impactions
(18 h to anus if transit time is normal). For impactions, it works
its way around as well as hindering water penetration (Fig 1). For some horses the cause of a colonic impaction is clear.
Based on no benefit of using this product in the scientific The horse has been stabled following a musculoskeletal injury,
literature, increased cost over water and the likely fatality if has competed on a warm day and/or been travelled, or for
this product is inadvertently administered into the horse’s some other reason diet or water intake has been modified
lungs (Metcalfe et al. 2010) means that it is not (Hillyer et al. 2002), but for others it may be necessary to
recommended for treatment of large colonic impactions. further evaluate management practices in order to prevent
Dioctyl sodium sulphosuccinate is a detergent that recurrence in the future.
should penetrate impacted faecal material by affecting Horses that have had one or multiple colonic impactions
surface tension, thus allowing water to enter the faeces. should have their anthelmintic regime evaluated. This
Care should be taken as a three-fold overdose is fatal includes considering the pharmacological agents
(Moffat et al. 1975) and also increases absorption of mineral administered and at what frequency, methods used to
oil so should not be administered concurrently. There is no reduce pasture contamination and faecal worm egg counts.
benefit of this over water based on an experimental study Faecal worm egg counts have to be interpreted with caution
comparing faecal output and composition (Freeman et al. as many of the clinical signs associated with endoparasitic
1992). disease are seen in the prepatent period and worm egg
Sodium sulphate is an even more potent cathartic than counts do not always correlate with worm burden. In
magnesium sulphate, but consistently causes hypernatraemia addition, the current recommendations (Nielsen et al. 2013)
and hypocalcaemia and is therefore not recommended are to perform modified faecal worm egg counts (Proudman
(Lopes et al. 2004b). and Edwards 1992), which have a high specificity.

© 2016 EVJ Ltd

G. D. Hallowell
A dental examination should be performed in horses
treated for a colonic impaction, particularly if regular dental
work in that case is not undertaken by the clinician
personally. The author has seen several horses that have
presented with recurrent colonic impactions which on dental
examination have smooth dental arcades from overzealous
use of power rasps, likely leading to a reduction in forage
breakdown.
The majority of horses are fed a balanced diet, but in the
author’s opinion, excessive carbohydrates or particularly
coarse forage may increase the likelihood of colonic
impactions (Hillyer et al. 2002).
Stereotypies, particularly crib-biting and wind-sucking,
have been associated with the development of colonic
impactions. However, it has been shown that there is minimal
aerophagia associated with these stereotypies (McGreevy
et al. 1995). Stereotypies in the author’s opinion could be
thought of as ‘coping’ mechanisms and thus their association
with abdominal pain is likely due to increased sympathetic
nervous system activation and reduced dietary intake
leading to changes in gastrointestinal motility. However,
simply stopping horses performing these stereotypical
activities is likely to lead to more, rather than less ‘stress’ and
sympathetic activation. As such, it is imperative to try and
manage these horses in an optimal environment, taking into
consideration group dynamics when at pasture, amount of
time stabled and at pasture and optimising what is preferred
and carefully managing travel to and attendance at
competitions.
Conclusions
In conclusion, large colonic impactions are a common cause
of abdominal pain in the horse. Many of the risk factors have
been identified, but further evaluation of the effects of
intestinal pH and changes in the microbiota are warranted.
As well as correction of impactions with isotonic enteral
electrolyte solutions, consideration of management practices
is also warranted.
Author’s declaration of interests
No conflicts of interest have been declared.
Ethical animal research
Ethical review not applicable for this review article.
Source of funding
None.
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