Unusual left colon displacement and clockwise torsion in a 10‐month‐old Arab filly: A case report

Abstract

In this case report, we present an unusual clockwise torsion of left colon around mesenteric root in a 10‐month‐old Arab filly, highlighting the clinical presentation, diagnostic approach and successful surgical intervention.

A 10‐month‐old Arab filly weighing approximately 250 kg was referred with signs of acute abdominal pain. The history revealed anorexia, restlessness and severe abdominal pain that had begun the previous day. The local practitioner had previously administered flunixin meglumine, an analgesic, but it proved ineffective in relieving the pain. Upon physical examination, the filly exhibited sweating, a body temperature of 38.5°C, tachycardia (65 beats per minute) and tachypnea (25 breaths per minute). Due to the severity of the colic and the lack of response to the conservative treatments, surgical intervention was deemed necessary. An exploratory midline celiotomy was performed to evaluate the abdominal organs. During the examination, no obvious primary lesions were identified in the evaluated organs. However, a restriction in exteriorizing the left colon's length was observed. Further examination revealed an unusual clockwise torsion of the left colon that displaced in left to the right side around the mesenteric root; thereby, pelvic flexure was located in the normal anatomical position with a short length.

To the best of our knowledge, this is the first reported case of clockwise torsion and an atypical displacement of the left colon in horses. The surgical correction of the displacement was successfully performed. The filly showed improvement post‐surgery and did not exhibit any complications during the recovery period.

This report describes the successful management of colic caused by left colon displacement and clockwise torsion in a filly. Surgical intervention consisting of manual counterclockwise detorsion and careful pushing of the left colons with the pelvic flexure in the craniolateral direction was performed. Successful management of such cases can provide beneficial data for equine veterinarians to consider and manage this as a cause of colic.

1. BACKGROUND

Abdominal pain, commonly known as colic, is a prevalent disorder observed in equine medicine practice (Curtis et al., 2019; Mehdi & Mohammad, 2006). Colic can stem from various causes, with gastrointestinal disease being the most frequent culprit (Curtis et al., 2015, 2019). It is worth noting that colic is a significant contributor to horse mortality rates, often leading to euthanasia or death (Ireland et al., 2011; Tinker et al., 1997) Consequently, prompt veterinary intervention is crucial when dealing with affected horses (Curtis et al., 2019). Among the reported causes of colic in horses is the displacement of the ascending colon (Southwood, 2019). The ascending large colon in horses forms a U‐shaped loop that is partially attached to the dorsal body wall, primarily through the base of the right dorsal colon and right ventral colon (Schummer, 2008). Due to its length and mobility, the large colon is susceptible to displacement (Sasani et al., 2013). Previous studies have indicated that 17%–23% of colic cases are attributed to large colon displacement (Southwood, 2019). It is important to note that large colon displacement is classified as a non‐strangulating injury, which means that it does not cause disruption of blood flow. However, it does obstruct the passage of gas and digesta (McGovern et al., 2012; Southwood, 2019). Typically, large colon displacement occurs in two forms: right dorsal displacement and left dorsal displacement (Southwood, 2019). In right dorsal displacement, the pelvic flexure moves in clockwise and counterclockwise directions. Most cases of displacement occur counterclockwise when viewed from the caudal and ventral aspect of the horse during surgery. However, clockwise displacement is a rare occurrence (Southwood, 2019). When conservative treatments fail to resolve large colon displacements, an exploratory celiotomy becomes necessary to save the lives of affected animals (Southwood, 2019).

In this study, we present a unique case of an Arab filly with clockwise torsion and unusual displacement of the left colon, which was successfully treated through surgical intervention. To the best of our knowledge, this is the first reported instance of such a condition.

2. CASE PRESENTATION

A 10‐month‐old Arab filly weighing approximately 250 kg was presented to the Urmia University Veterinary Teaching Hospital with acute abdominal pain. The filly had a history of being fed alfalfa hay and undergoing daily training for 2 h, with regular anthelmintic treatment. The patient had experienced anorexia, restlessness and severe abdominal pain since the previous day and local practitioner administered flunixin meglumine as routine in practice, which was effective in pain control only for about 2 h. As no improvement in the clinical signs of the colic was observed, the filly was referred to our hospital.

Upon physical examination, the filly exhibited notable signs of severe abdominal pain, including profuse sweating, pawing, abdominal kicking, sitting and standing up, and frequent rolling. Clinical assessment revealed a body temperature of 38.5°C, tachycardia (65 beats per minute), tachypnea (25 breaths per minute) and a capillary refill time of 2 s. The hydration status appeared normal. Auscultation of abdominal borborygmi revealed a large intestinal hypomotility.

To facilitate further diagnostic procedures, the patient was administered xylazine (Rompun, Alfasan) intravenously at a dosage of 1.1 mg/kg. Transrectal examination revealed a distended viscus of the large colon filled with gas and fluid in the pelvic inlet, with the pelvic flexure being impalpable. Nasogastric intubation was performed, and normal gastric fluid content without signs of reflux was observed. Haematology parameters, including complete blood count and total protein, were within normal ranges (Table 1). Abdominocentesis did not reveal any abnormalities in the abdominal fluid, and abdominal ultrasonography failed to provide informative findings. Gastroduodenoscopy using an endoscope did not identify any abnormalities.

TABLE 1.

Complete blood count (CBC), differential count and total protein (TP) of the filly.

Parameter	Measure
WBC (103/µL)	8.5
RBC (106/µL)	9.67
HGB (g/dL)	13.0
HCT (%)	36.5
MCV (fl)	37.7
MCH (pg)	13.4
MCHC (g/dL)	35.6
PLT (103/µL)	165
TP (g/dL)	6.5
Lymph (103/µL)	1.5 (17.9%)
Mon (103/µL)	0.4 (4.9%)
Eos (103/µL)	0.0 (0.3%)
Gran (103/µL)	6.6 (76.9%)

The persistence of severe pain and the lack of improvement with conservative management prompted the decision to proceed with exploratory celiotomy for further evaluation and potential surgical intervention.

2.1. Surgical intervention

The patient underwent jugular vein catheterization using a no. 16 IV catheter. For premedication, xylazine (0.5 mg/kg, IV) and flunixin meglumine (0.5 mg/kg, IV) were administered. Prophylactic antibiotics, penicillin (22,000 IU/kg, IM) and gentamicin (6.6 mg/kg, IV), were administered. The sedated animal was secured on a surgical tilt table, and anaesthesia was induced using a combination of diazepam (0.05 mg/kg, IV) and ketamine‐hydrochloride (2 mg/kg, IV). Endotracheal intubation was performed, and the patient was positioned in dorsal recumbency. Anaesthesia was maintained with isoflurane in oxygen.

The surgical site was meticulously prepared in a sterile manner, and the surgical field was draped using a fenestrated sterile drape over four rectangular drapes. To maintain the patient's condition, intraoperative fluid therapy was initiated with lactated Ringer's solution administered intravenously at a rate of 10 mL/kg body weight per hour. A skin incision, approximately 30 cm in length, was made from the umbilicus towards the xiphoid. Careful dissection was performed through the subcutaneous tissue and the linea alba. The thin retroperitoneal fat and peritoneum were opened after exposing the falciform ligament.

2.2. Intraoperative findings and surgical procedure

To facilitate exploration of the intra‐abdominal cavity, the accumulated gas in the colon was decompressed using a no. 14 needle connected to a suction device. Additionally, a pelvic flexure enterotomy was performed to evacuate excess ingesta. A systematic exploration was carried out to identify the primary lesion. Initially, the primary lesion was not apparent in the evaluated organs; however, there was a limitation in exteriorizing the left colon to its usual length. Careful manipulation of the left side of the body revealed a circular ring structure of the left colon in the vicinity of the mesenteric root. Based on the restricted exteriorization and the observed abnormalities, a torsion of the colon around the mesenteric root was suspected and subsequently confirmed (Figure 1). The left colon was displaced in a clockwise direction and accompanied by torsion.

FIGURE 1.

A) Normal anatomy of the gastrointestinal organs in horse, (B) cecum is shown with red dash lines and mesenteric root with green dash lines, (C) displacement of left colons in the right and cranial direction, (D) torsion around mesenteric root, (E) complete torsion with the left colons in the supposed normal position.

Efforts were made to correct the twisted colons by performing detorsion in a counterclockwise route. Careful manipulation enabled the careful pushing of the left colons with the pelvic flexure in the craniolateral direction to achieve detorsion. Subsequently, the left colons were fully exteriorized and thoroughly examined for possible lesions. Fortunately, due to the prompt referral and surgical intervention, only mild inflammation and hyperaemia were observed in the affected colons (Figure 2). Additionally, the colonic lymph nodes in the twisted region were slightly oedematous and enlarged. The exteriorized colons were returned to their normal anatomical position in the abdominal cavity after copious warm saline lavage.

FIGURE 2.

Intraoperative appearance of the left colon and its mesentery following correction of the torsion. Note the hyperaemia and oedema in the mesentery.

The surgical incision was closed in three layers. The linea alba was closed using polyamide suture materials (Nylon, no. 1, Supa, Karaj, Iran) in multiple cruciate patterns. The subcutaneous layer was sutured using a subcutaneous pattern with polyglycolic acid suture materials (PGA, no. 1, Supa, Karaj, Iran), and the skin was sutured in a cruciate pattern using the same polyamide suture materials. The horse recovered from anaesthesia without any complications. Postoperative antimicrobial treatment consisting of penicillin‐G potassium (22,000 IU/kg, q 24 h, IM) and gentamicin (6.6 mg/kg, q 24 h, IV) was administered for 5 consecutive days. Pain management postoperatively involved the administration of flunixin meglumine (1.1 mg/kg, q 24 h, IV) for 3 days. The horse remained hospitalized for 5 days following the surgery. A 2‐week follow‐up revealed no complications related to the surgical incision, and the horse showed improvement. No long‐term complications were observed during the 18‐month post‐discharge period.

3. DISCUSSION AND CONCLUSION

This report presents a case of clockwise torsion and unusual displacement of the left colons in an Arab filly, which is a rare occurrence. Previous studies have primarily focused on right and left dorsal displacements of the large colon (Auer & Stick, 2018). The exact aetiology of large colon displacement in horses remains unknown, although several hypotheses have been proposed in previous research. These hypotheses include changes in gastrointestinal motility due to alterations in the pacemaker cells of the pelvic flexure, excessive consumption of fermentative carbohydrates leading to gas accumulation and alterations in microbial flora (Whyard & Brounts, 2019). However, in the case presented here, there were no reported changes in husbandry or dietary management.

Typically, right dorsal displacement of the large colon occurs when the pelvic flexure retroflexes and the left colon migrates cranially, positioning itself between the cecum and the right body wall (Auer & Stick, 2018; Whyard & Brounts, 2019). Left dorsal displacement, on the other hand, involves the left colons moving dorsally towards the spleen, and nephrosplenic entrapment may occur (Albanese & Caldwell, 2014). The left colon displacement observed in the current case differs from previously reported studies. In this case, the pelvic flexure and left colons were displaced to the right and cranial direction. Subsequently, they twisted from the right to the left side, around the mesenteric root, in a clockwise direction. Therefore, during the intra‐abdominal exploration, the twisted colons appeared to be in their normal anatomical position, and only the pelvic flexure and left colons could not be fully exteriorized to their usual length.

Torsion of the large colon around its mesentery is considered large colon volvulus. Strangulation volvulus occurs when rotation is ≥360° (Auer & Stick, 2018). Knowles et al. (2009) reported colonic volvulus with defects of the mesenteric attachments in a yearling Friesian colt. They found a torsion of the thickened colonic mesentery (Knowles & Mair, 2009). In agreement with the reported case of Knowles et al., in the present case, torsion around mesenteric root had occurred.

In cases of right and left dorsal displacement of the large colon, conservative treatments are typically recommended before considering surgical interventions (Auer & Stick, 2018). For right displacement, conservative management includes food restriction, fluid therapy, analgesia and light exercise. Trocarization of the large colon may also be performed to decompress gas distention (Auer & Stick, 2018). In cases of left dorsal displacement and nephrosplenic entrapment, medical management involves withholding food, fluid therapy, the administration of analgesic drugs, phenylephrine injection and rolling to attempt to replace the displaced colon to its normal position (Auer & Stick, 2018). Conservative medical management is generally effective when a diagnosis of right or left dorsal displacement of the large colon is presumed. However, in the present case, conservative management, including the administration of systemic analgesic agents, was not successful in alleviating pain, and the underlying cause of the abdominal colic could not be identified. Therefore, an exploratory celiotomy was performed to diagnose and address the primary issue.

Surgical intervention is warranted when conservative treatments fail or in cases of severe and uncontrollable pain and deteriorating cardiovascular parameters (Albanese & Caldwell, 2014). Ventral midline celiotomy is the most commonly used approach for surgical treatment as it provides optimal exposure and direct visualization of abdominal organs. Additionally, exploratory celiotomy allows for the identification of any concurrent undiagnosed disorders (Albanese & Caldwell, 2014). During surgery, the surgeon should carefully examine all normal anatomical landmarks in the colon and cecum after correcting the displacement. The presence of abnormal anatomical landmarks may indicate persistent displacement (Auer & Stick, 2018). Minimally invasive surgical options, such as standing flank laparoscopic‐assisted correction, may also be considered for left dorsal displacement and epiploic foramen entrapment (Muňoz & Bussy, 2013). In the presented case, the displacement and torsion of the left colons were surgically treated using a ventral midline celiotomy approach.

In general, the prognosis for horses with right or left dorsal displacement of the colons is reported to be excellent. However, the recurrence of the condition has been observed in some cases (Auer & Stick, 2018). The choice between medical and surgical treatments cannot be directly compared due to limited available literature. Surgical procedures can be expensive for the owner and are not recommended as the initial treatment option for mild cases. Therefore, conservative management is typically attempted first, and surgery is considered in cases that do not respond to conservative measures (Albanese & Caldwell, 2014). A study conducted by Baker et al. (2011) compared the survival rates of horses treated via surgery vs. those treated with rolling (with or without phenylephrine administration) in 87 horses. The survival rate for surgically treated horses was approximately 94%, whereas the success rate for rolling was 58%. However, it should be noted that horses unresponsive to rolling ultimately underwent surgery, resulting in a reported survival rate of 98% for these horses (Baker et al., 2011). Another study by Lindegaard et al. (2011) reported a survival rate of 80% for surgically treated cases compared to a 96.5% survival rate for conservatively managed cases (Lindegaard et al., 2011). The authors suggested that the lower survival rate in surgically treated cases could be attributed to their poor general condition prior to surgery.

Furthermore, a recent report described complications following unsuccessful treatment with phenylephrine in a case of nephrosplenic entrapment of the large colon, including haemoptysis, pulmonary oedema and epistaxis (Quesada et al., 2022). Therefore, rolling with phenylephrine administration may carry certain risks and potential complications. In the present case, surgical intervention was effective in resolving the left colon displacement, and no related complications were observed during the follow‐up period.

4. CONCLUSION

The achievement of pain relief through conservative measures is an important indicator for the surgeon to decide on the need for surgical intervention. If pain persists despite conservative management, surgical intervention should not be delayed. In the presented case, prompt surgical intervention was beneficial in treating the left colon displacement.

AUTHOR CONTRIBUTIONS

Saeed Azizi responsible for performing surgical procedures; decision for the type of surgical intervention; conception and design of the work; conducted the study; revising and final approval of the version to be published; Ramin Mazaheri‑Khameneh monitoring perioperative procedures; decision for the type of surgical intervention; conception and design of the work; revising and final approval of the version to be published; Farshid Davoodi responsible for postoperative management; drafting the manuscript; preparing figures; revising and final approval of the version to be published; Mohammad Mahdi Gooran responsible for postoperative management; drafting the manuscript; Seyed Siavash Ghoreishi responsible for performing surgical procedures; revising and final approval of the version to be published; Nima Mozaffari responsible for postoperative management; revising and final approval of the version to be published; Bahram Dalir‐Naghadeh Diagnosis of the disorder, drafting the manuscript, revising and final approval of the version to be published.

CONFLICT OF INTEREST STATEMENT

The authors declare that they have no conflicts of interest.

FUNDING INFORMATION

No funds were received for the present study.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

Research Ethics Committee of Urmia University (IR.URMIA.REC) declared that no formal ethics approval was required in this particular case as it is not experimental and it is a case report. The filly in this study underwent surgical procedures with the written consent of its owner.

PEER REVIEW

The peer review history for this article is available at https://publons.com/publon/10.1002/vms3.1481.

Azizi, S. , Mazaheri‐Khameneh, R. , Davoodi, F. , Gooran, M. M. , Ghoreishi, S. S. , Mozaffari, N. , & Dalir‐Naghadeh, B. (2024). Unusual left colon displacement and clockwise torsion in a 10‐month‐old Arab filly: A case report. Veterinary Medicine and Science, 10, e1481. 10.1002/vms3.1481

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available from the corresponding author upon reasonable request.