1
Physical examination
General physical examination
and auscultation
F Taylor
HISTORY AND GENERAL
OBSERVATIONS
When exploring the history of a patient with suspected
gastroenteric disease the following topics should be
included.
has there been an associated change in the dietary
management?
were there any medications or other treatments
prior to the onset?
is the grazing safe (e.g. check for sandy topsoil,
agrochemicals, poisonous plan ts)?
is the animal's food intake reduced; if so is this
associated with inappetance or evidence of
dysphagia?
is the animal's demeanor normal, depressed,
excitable?
in cases of abdominal pain, was the onset acute and
severe or insidious and low grade; is the pain
continuous or intermittent?
are feces being passed; if so in what volume and
consistency, and with what regularity?
is the worming history suited to the animal's
environment?
has this animal suffered previous episodes; are
other animals in the group affected?
In addition, the age and sex of the patient may help to
narrow the differential diagnoses. For example, neona-
tal foals are prone to meconium retention (day 1) and
systemic infections which may involve the alimentary
tract (days 1-4). Older foals become susceptible to
gastrointestinal parasites and/or gastroduodenal ulcer-
ation, and horses below 3 years of age are more likely to
succumb to intussusception than adults. In stallions, the
possibility of inguinal herniation of the small intestine
should be considered in all cases of colic. In the mare,
uterine torsion in late gestation can produce colic-like
signs, whereas postpartum colic may be associated with
hemorrhage into the broad ligament, or rupture of the
cecum or colon during fetal expulsion.
PHYSICAL EXAMINATION AND
AUSCULTATION
The initial physical examination of a patient with
suspected gastroenteric disease should pay particular
attention to the head and trunk. Additional aids to
physical examination will be required and are outlined
in the latter part of this section.
The head
The rate, regularity, and quality of the pulse are most
easily appreciated at the facial artery as it crosses the
horizontal ramus of the mandible. The rate and
regularity are dictated by the heart (see below), but the
quality will also be influenced by peripheral events. An
increasing pulse rate of deteriorating quality suggests
circulatory compromise and impending shock.
The color of the mucous membranes and the capil-
lary refill time (CRT) reflect the horse's circulatory
3
1 PHYSICAL EXAMINATION
status. The normal appearance is moist and pink and
the normal CRT is less than 2 seconds. The CRT indi-
cates whether perfusion, hydration, and vascular tone
are impaired. Increasing refill times indicate progres-
sively inadequate perfusion and are usually accompa-
nied by dryness and discoloration of the membranes.
The mouth should be examined to detect abnormal-
ities of tooth wear, sharp edges on the cheek teeth, or
other dental or mucosal diseases which may interfere
with feeding.
The thorax and abdomen
Abnormal swellings, particularly of the ventral
thorax and abdomen, may reflect edema associated
with venous and/or lymphatic congestion, or hypo-
proteinemia. Abdominal distention in cases of colic is
frequently a result of tympany.
The heart is auscultated to assess rate and regularity.
Increases in the heart and pulse rate are influenced to
some extent by pain, but most particularly by dehydra-
tion, decreased venous return, and toxemia.
Rapid, shallow respiration can be a feature of pain
and/or metabolic acidosis. Severe gastric distention or
hindgut tympany will exert pressure on the diaphragm
resulting in dyspnea. On rare occasions dyspnea
accompanies rupture of the diaphragm, especially if
the hindgut is prolapsed.
Slight increases in rectal temperature can be associ-
ated with pain, but significant increases suggest infec-
tion. In cases of colic, temperatures in excess of 38.6C
(l0l OF) suggest a differential diagnosis of a systemic
disease for which colic is an early incidental sign, for
example salmonellosis or acute peritonitis. A decreasing
temperature, coupled with a rapid weak pulse, indicates
the development of shock and carries a grave prognosis.
Abdominal auscultation
Abdominal auscultation enables appreciation of gut
activity and its greatest value is in the assessment of
colic. At least four sites should be auscultated: these are
both paralumbar fossae and both sides of the lower
abdomen behind the costal arch.
Two types of sound can be appreciated: weak sounds
associated with localized bowel contractions (mixing
the ingesta), and louder fluid sounds or borborygmi
associated with propulsion of ingesta. Sounds heard in
the right paralumbar fossa reflect ileocecal (and possi-
bly cecocolic) valve activity and differ from sounds
heard at the other sites. Here, a period of silence is
broken once or twice a minute by a sudden rush of fluid
rumbling as secretions from one compartment pass
through the valve and hit the gas-fluid interface of the
next.
4
Increased movement (hyperperistalsis) can be pro-
voked by a simple obstruction in an otherwise healthy
gut. The best example is spasmodic colic in which con-
tinuous sounds, of greater than usual intensity, are
heard at all sites. In contrast, reflex movement is
reduced by inflammation and ischemia. An absence of
sound, or infrequent sounds of reduced intensity, may
therefore be associated with peritonitis or the develop-
ment of gut hypoperfusion during colic. An absence of
sound is also associated with alimentary paralysis as in
postoperative ileus and grass sickness.
The presence of entrapped gas (tympany) is
denoted by low-pitched tinkling sounds which may be
superimposed on other alimentary sounds - as, for
example, in tympany associated with spasmodic colic.
The localization of entrapped gas in a segment of the
large bowel may be appreciated by simultaneous
percussion and auscultation over the abdominal wall. A
resonant 'hollow' sound is audible where a volume of
gas is trapped against the body wall.
Nasogastric intubation
F Taylor
Apart from therapeutic applications, a nasogastric tube
may be used to deliver sugar solutions for absorption
tests, to assess fluid reflux, and to permit decompres-
sion in cases of gastrointestinal obstruction, or (with
care) to indicate the site of esophageal obstruction.
Nasogastric tubes are manufactured in foal, pony, or
horse sizes. Tubes with an additional hole set in the side
of the leading end are recommended and transparent
tubes are preferable since they allow the passage of
fluid to be seen. Because proprietary tubes are not grad-
uated along their length, it is useful to make an indeli-
ble mark around the circumference at a point that will
indicate that the leading end is approaching the
entrance to the larynx or esophagus. This distance is
approximately 30 em for pony tubes and 35 em for
horse tubes.
RESTRAINT
The horse is positioned diagonally in a corner with its
quarters against the wall to restrict backward and lateral
movements. The handler should stand to the left of the
horse's head with his/her back to the horse to minimize
injury if the horse rears. A secure headcollar is essential
but additional restraints will depend upon the horse's
temperament. A horse that struggles during intubation

is more likely to suffer a nosebleed and it is best to apply
a twitch to such patients. Sedation is possible where
clinical circumstances permit, but this will diminish the
swallow reflex as the tube is passed and could affect the
results of an absorption test if intubation is used for this
purpose.
PROCEDURE
The uncoiled tube is draped around the clinician's
neck to prevent it from trailing on the floor; this also
leaves the clinician's hands free to control the tube's
passage. In cold weather a rigid tube should be softened
by passing warm tap water through it. The first 10-
12 ern of the leading end is then coated liberally with a
water-soluble lubricant and the tube is grasped just
behind this point for controlled insertion.
The right-handed clinician will be most comfortable
standing to the right of the horse's head with his/her
back to the horse. The handler should attempt to keep
Figure 1.1 Insertion of a nasogastric tube. The thumb of
the left hand is used to elevate the alar cartilage of the
right nostril and the tube is inserted along the floor of the
open nostril
PHYSICAL EXAMINATION 1
the head in a flexed position and the clinician rests
his/her left hand on the bridge of the nose above the
muzzle. Care should be taken not to occlude the oppo-
site nostril inadvertently. The thumb is then used to ele-
vate the alar cartilage of the right nostril, opening wide
the entrance to the nasal cavity.
The lubricated end of the tube is then placed on the
floor of the open nostril, slightly inclined toward the
nasal septum with its curvature directed downward
(Figure 1.1), and advanced gently so that it follows the
floor of the ventral meatus. The tube's advance is
stopped once its preset mark arrives at the nostril, indi-
cating that the leading end is approaching the larynx or
esophagus. In most cases, onward passage will result in
entry into the larynx and trachea. To avoid this, the
tube should be turned through 90 degrees before being
advanced further. This has the effect of raising the level
of the leading end with respect to the larynx, thereby
bringing it closer to the opening of the esophagus lying
above the larynx.
Gentle pressure by the leading end against the
esophageal opening will then cause the tube to be
admitted by a swallow. If the tube is accidentally passed
into the larynx, it should be withdrawn to the nostril
mark, given an additional 90 degree turn to raise the
leading end higher, and advanced again. Alternatively,
if gentle pressure meets total resistance the tube is with-
drawn 2-3 cm and gently readvanced in the hope of
provoking a swallow.
If this maneuver fails on 3-4 occasions, the operator
should suspect that the end is pushing against the
pharyngeal recess above both the larynx and the
esophagus. In this instance the leading end is lowered
by turning the tube back through approximately
90 degrees before being advanced again.
CHECKING THE POSITION OF THE TUBE
The commonest error is to pass the tube into the larynx.
In this instance air can be blown or sucked through the
tube without resistance and shaking the larynx will pro-
duce a palpable 'rattle'. If the tube is clean, then unto-
ward effects are unlikely - it is simply withdrawn and
repositioned. When entering the esophagus, there is
often an accompanying swallow which may be repeated
on the downward passage of the tube. Successful intu-
bation is indicated by an increase in the resistance to
passage (esophageal tone) and the appearance of a
swelling in the upper third of the left jugular groove
which moves down the neck following the line of the
esophagus. In addition, there is resistance to air being
sucked through the tube due to esophageal collapse at
the leading end. Alternatively, a short, sharp blow of air
5
1 PHYSICAL EXAMINATION
down the tube produces a momentary inflation of the
esophagus which is seen in the left jugular groove; this
is a useful test if a distinct swelling has not been seen to
travel down the jugular groove.
Once satisfied that the tube is correctly placed the
clinician can advance it to the stomach. There is usually
an audible release of gas as the tube enters the stomach
and gaseous 'bubbling' sounds can be heard when
listening at the open end of the tube.
TUBE WITHDRAWAL
Any fluid medication which has been given by tube and
which is occupying its dead space should be blown
through to the stomach before removal. Failure to do so
may result in inhalation of spilt fluid as the tube is with-
drawn over the larynx. Thereafter, the tube should be
withdrawn slowly and carefully. Particular care should
be taken not to rush out the last 50 ern, otherwise
trauma to the highly vascular nasal mucosa may result
in a nosebleed.
Rectal examination
POE Mueller
INTRODUCTION
The rectal examination is one of the most important
and helpful diagnostic techniques for evaluating adult
horses with abdominal disease. It is frequently essential
in evaluating the need for surgery in horses with acute
abdominal pain (see Chapter 9). Rectal examination
may be used to identify
position of intestinal segments
distention of bowel
abnormalities of bowel wall thickness
mesenteric lymphadenopathy
mesenteric pain
abnormal masses such as tumors, abscesses,
intussusceptions, foreign bodies
excessive abdominal fluid
pneumoperitoneum
bowel rupture
cranial mesenteric arteritis/aneurysm
rectal perforation.
In addition, palpation of other intra-abdominal organs
is possible, including the urinary bladder, uterus and
ovaries, left kidney, and spleen.
6
TECHNIQUE
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When performing a rectal examination, proper
restraint is of the utmost importance to insure the
safety of the horse and the examiner. Inadequate
restraint may result in iatrogenic rectal perforation, a
potentially fatal complication of rectal examination, or
serious injury to the examiner. Horses with signs of
unrelenting abdominal pain should be sedated with an
alpha, agonist agent such as xylazine (0.3-0.5 mg/kg
i.v.), detomidine (7-10 !lg/kg i.v.) or romifidine
(40-120 !lg/kg i.v.). For more profound sedation, and
to reduce the chance of the horse kicking, the alpha,
agonist may be combined with butorphanol (20 !lg/kg
i.v.). A nose twitch should always be used to control the
patient and promote relaxation of the rectum.
Adequate lubrication ofthe examiner's hand and arm
is necessary to minimize irritation to the rectal mucosa.
Hydrated methylcellulose and mineral oil are the most
commonly used lubricants. Initial introduction of the
examiner's hand through the anal sphincter is often met
with great resistance. This should therefore be per-
formed with a slow and steady motion. The fingers and
thumb of the hand should be kept together, in an
extended position throughout the entire examination.
Once the hand is through the anal sphincter the feces
within the rectum are evacuated. The amount and con-
sistency of fecal material in the rectum should be noted.
Absence of fecal material, or the presence of dry, fibrin
and mucus-covered feces is abnormal and is consistent
with delayed intestinal transit. Fetid, watery fecal mater-
ial is often present in horses with colitis. Large amounts
of sand within the feces may be indicative of a sand
impaction or sand-induced colitis. After evacuation of
feces from the rectum, intrarectal administration of
50-60 ml of 2% lidocaine via a 60 cc catheter tip syringe
(alternatively a soft tube such as an intravenous exten-
sion set connected to a regular syringe can be used) may
help promote further rectal relaxation and reduce strain-
ing. The syringe may also be used to administer addi-
tionallubrication into the rectum at this time.
The examiner's arm is then re-introduced into the
rectum and advanced slowly and steadily as far as com-
fortably possible. The arm is left in this position without
excessive movement for 20-30 seconds. In most cases
this initial delay in internal palpation will allow the rec-
tum to relax around the examiner's arm, facilitating a
more thorough palpation of the more cranial aspects of
the abdomen. Initial examination of the caudal aspects
of the abdomen with a half-inserted arm is not recom-
mended because it usually results in straining and
excessive peristaltic contraction of the rectum. This pre-
cludes a safe and thorough examination of the more
cranial abdominal contents.
 PHYSICAL EXAMINATION 1
The most severe complication associated with rectal mesenteric stalk
palpation is iatrogenic perforation of the rectum (see ventral cecal tenia (no tension)
Chapter 16). Although rare, tears usually occur dorsally cecal base (empty)
between the 10 o'clock and 12 o'clock positions. Most pelvic flexure (Figure 1.2).
rectal tears can be avoided by proper restraint, ade-
Normally, the duodenum and remaining small intes-
quate lubrication, and a steady and careful palpation
tine are too soft and relaxed to be identified unless an
technique. If a peristaltic contraction or increased resis-
underlying abnormality exists.
tance is felt during examination, the hand should
The spleen is located in the left dorsal abdomen.
immediately be withdrawn from the rectum to avoid
The caudal edge of the spleen is palpable against the
potential rectal injury as the descending colon can tear
body wall. The nephrosplenic ligament can be palpated
as it contracts on the examiner's hand.
coursing from the head of the spleen, to the right, to
The exact sequence of abdominal structures pal-
the caudal pole of the left kidney. Immediately dorsal to
pated during rectal examination may vary from practi-
the ligament is the renosplenic space. Three to four fin-
tioner to practitioner. Regardless of the sequence, the
gers may be placed in the renosplenic space. The cau-
examination should be performed in a consistent, sys-
dal pole of the left kidney is palpable just to the right of
tematic manner to assure a complete and thorough
the spleen; it may not be possible to reach the kidney in
examination and minimize the chance of missing a
some large horses. Moving the arm to the right and cra-
lesion. The author prefers a clockwise approach, start-
nially along the dorsal midline, the aorta, duodenum,
ing with the spleen in the left dorsal abdominal quad-
and mesenteric stalk may be palpated. The pulse in the
rant. This is followed by examination of the right dorsal,
aorta is easily palpable; the duodenum is identified as a
right ventral, and left ventral quadrants. The pelvic
small intestinal structure perpendicular and attached to
canal and more caudal structures are then examined
just before removal of the hand from the rectum.
In general, palpable characteristics of the abdominal
contents and viscera are often helpful in identifying the
particular segment of the intestine involved in horses
with colic. Severe gas or ingesta-distended intestine,
tight mesentery or tenia (bands), or thickened or turgid
intestine are indicative of intestinal obstruction or
strangulation. Free peritoneal gas or crepitus within the
intestinal wall is usually indicative of intestinal rupture.
A gritty or granular texture of the peritoneal cavity is
indicative of intestinal rupture with contamination of
the serosal and peritoneal surfaces with ingesta. It
should be emphasized that rectal examination findings
should always be interpreted in conjunction with the
physical examination and laboratory findings.

RECTAL PALPATION OF THE NORMAL

HORSE

In the normal horse, moist, soft fecal balls should be

present in the rectal ampulla. The descending colon is
easily identifiable in the caudal abdomen. It contains
multiple, distinct fecal balls and is freely movable within
the abdomen. Other intra-abdominal structures palpa-
ble in the normal horse starting in the left dorsal
abdominal quadrant, and progressing in a clockwise
direction include
caudal border of the spleen
nephrosplenic (renosplenic) ligament
caudal pole of the left kidney
Figure 1.2 Caudal view of a standing horse demonstrating
abdominal structures that are palpable in the normal
horse during rectal examination. Starting in the left dorsal
abdominal quadrant, and progressing in a clockwise
direction, palpable structures include: caudal border of
the spleen, renosplenic ligament, caudal pole of the left
kidney, ventral cecal tenia, cecal base, and the pelvic
flexure

7
1 PHYSICAL EXAMINATION
the mesenteric stalk. The mesenteric stalk is usually pal-
pable as a sheet of tissue, with a pulse that is only occa-
sionally palpable. In large horses it may not be possible
to reach far enough to palpate the root of mesentery.
Continuing to move in a clockwise direction, the
base of the cecum is palpable in the right dorsal abdom-
inal quadrant. Depending on the amount of ingesta in
the cecum, it mayor may not be palpable. The ventral
and sometimes medial cecal tenia are usually palpable
by moving the hand laterally and caudally, hooking the
tenia with the tips of the examiner's forefingers. These
bands usually course in a dorsocaudal to ventrocranial
direction, just to the right of the midline. Because the
majority of the body and apex of the cecum are beyond
the examiner's reach, the tautness of the ventral and
medial cecal tenia is used as an indicator of the amount
of ingesta within the cecum. Normally the cecal tenia
should be loose and easily movable. With increased
amounts of ingesta in the cecum, the tenia become
more taut. Pain elicited upon palpation of the ventral
or medial cecal tenia may be associated with tension of
the ileum or its mesentery. This has been associated
with pain originating from the ileum and its vascula-
ture, such as occurs with entrapment of the ileum in the
epiploic foramen. The duodenum is attached dorsal to
the base of the cecum, but is normally too soft and
relaxed to be palpable. It may, however, sometimes be
palpable as it distends during a peristaltic contraction.
As the hand is moved ventral and caudal to the
pelvic brim, fecal balls in the small colon are usuallyeas-
ily identified. Small intestine is not usually felt unless it
contracts, when it may be palpable as a tight tubular
structure.
Moving caudally and to the left side, the pelvic flex-
ure mayor may not be palpable in the caudal left
abdomen, depending on the amount of ingesta within
the large colon. If the pelvic flexure and left dorsal
large colon are palpable, they may be identified by soft
ingesta, and the absence of the tenia and haustra (sac-
culations). The adjacent left ventral colon contains sim-
ilar contents and has two free tenia and haustra. The
tenia should course in a cranial-to-caudal direction,
from the left caudal abdomen to the left cranial
abdomen (Figure 1.2). The left dorsal colon does not
have haustra and contains only one mesenteric tenia.
Additional structures in the caudal abdomen
included in a complete rectal examination include:
bladder, uterus and ovaries in the mare, the aortic
bifurcation, and the internal inguinal rings in the
stallion. The inguinal rings are identified just cranial,
lateral, and slightly ventral to the iliopectineal emi-
nence of the anterior brim of the pelvis. In stallions, the
inguinal rings are large enough for insertion of a finger.
If the testis or epididymis has descended, the ductus
deferens is palpable in the caudomedial aspect of the
ring. In geldings, the inguinal ring is palpable as only a
slight depression and decreases in size with age.
BIBLIOGRAPHY
Rectal examination
KopfN (1997) Rectal examination of the colic patient. In
Current Therapy in Equine Medicine 4th edn, N E Robinson
(ed.). W B Saunders, Philadelphia, pp. 170-4.
White N A (1998) Rectal examination for the acute abdomen.
In Current Techniques in Equine Surgery and Lameness 2nd
edn, N A White and] N Moore (eds). W B Saunders,
Philadelphia, pp. 262-70.