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F
eline idiopathic megacolon is characterized neuromuscular disorders. Previous investigations
by generalized colonic dysfunction mani- by Washabau et al1,2 using in vitro isometric
festing as severe colonic dilation and fecal stress measurements of colonic smooth muscle
impaction. Clinical signs commonly include segments revealed that cats with idiopathic di-
anorexia, weight loss, vomiting, and dyschezia; lated megacolon developed less isometric stress
physical examination classically reveals a large in circular and longitudinal smooth muscle in
amount of very firm feces palpable within the response to neurotransmitters, membrane depo-
colon. Diagnostic investigation is aimed at rul- larization, and electrical field stimulation com-
ing out underlying problems that could cause pared with healthy controls. These findings were
colonic stricture and/or obstruction (see box on associated with decreased myosin light-chain
page 659). Once this has been done, medical phosphorylation, suggesting a disturbance of
management with dietary modification and intracellular calcium mobilization2 and signify-
administration of laxatives, enemas, and/or pro- ing that feline idiopathic megacolon is a general-
motility agents may be effective. Patients refrac- ized dysfunction of colonic smooth muscle.
tory to medical therapy may benefit from Thus colonic motility may be augmented with
surgical intervention via subtotal colectomy. therapeutic intervention designed to stimulate
colonic smooth muscle.
PATHOPHYSIOLOGY
Feline idiopathic megacolon has traditionally DIAGNOSIS
been attributed to primary Constipation is defined as “a condition in
Send comments/questions via email to neurogenic and degenerative which bowel movements are infrequent or
editor@CompendiumVet.com incomplete”; severe constipation is often
or fax 800-556-3288. *Drs. Byers and Sanders are cur- referred to as obstipation.3 Obstipation implies
rently collaborating with and are
Visit CompendiumVet.com for supported, in part, by Animal
permanent loss of colonic motility, and when
full-text articles, CE testing, and CE Clinical Investigation, LLC, obstipation results in dilation or hypertrophy of
test answers. Bethesda, MD. the colon, the condition is called megacolon.3
To diagnose feline idiopathic megacolon, the following must be eliminated from the list of diagnostic
differentials: systemic disturbances, mechanical obstructions, and obvious functional abnormalities.
vention. Often, a combination of dietary modification, Pharmacia and Searle; 7.5 to 15 mg IV bid) because of
laxatives, enemas, and/or colonic prokinetic agents is potential anaerobic bacterial translocation with colonic
effective therapy. Studies12,13 have shown that dietary handling during digital extraction. Warm water or 0.9%
supplementation with short-chain fatty acids improves saline mixed in a 50:50 combination with a water-based,
colonic smooth muscle contraction in both cats and sterile bacteriostatic surgical lubricant may be infused
dogs. Hospitalization for intravenous fluid therapy to into the colon while the fecal mass is manually reduced
correct dehydration and electrolyte derangements as via abdominal palpation. Laxative and/or prokinetic
well as to evacuate impacted feces is typically required in therapy may be instituted once the fecal mass has been
cases of obstipation and megacolon. adequately removed.
Rectal suppositories (see box above) are available to Lactulose is a hyperosmotic laxative and is perhaps
manage mild constipation, but their use requires an the most frequently used medication in treating idio-
amenable pet and compliant pet owner. Suppositories pathic megacolon (see box on page 661). The organic
may be used alone or in conjunction with oral laxative acids produced from lactulose fermentation stimulate
therapy. Mild to moderate or recurrent episodes of con- colonic fluid secretion and propulsive motility. 14
stipation may require administration of enemas and/or Another example of a hyperosmotic laxative is polyeth-
manual extraction of impacted feces. Several types of ylene glycol, and some researchers report 15 anecdotal
enema solutions (see box at top right) are available; success with the use of this medication. Bulk-forming
agonists may stimulate both colonic and cardiac 5-HT4 nist at 5-HT 1D receptors on enteric cholinergic
receptors.17–21 Cisapride (from compounding pharma- neurons.14 Tegaserod has definite prokinetic effects in
cies) is a substituted piperidinyl benzamide serotonin the canine colon, but the mechanisms responsible for
receptor agonist,22 and in vitro studies23,24 showed that tegaserod-induced canine colonic propulsion are
this medication stimulates feline colonic smooth muscle unknown.27 Effects of tegaserod have not been reported
5-HT receptors to promote propulsive motility. This in cats, and further studies are needed before the drug
medication has also been shown to cause prolongation should be considered in the medical treatment of feline
of the QT interval and slowing of cardiac repolarization idiopathic megacolon.
via blockade of the rapid component of the delayed rec- Prucalopride (R093877, Janssen, LP) is a partial benz-
tifier potassium channel in humans, 18–20 and these amide agonist at 5-HT4 receptors but has no effect at
Procedure for Subtotal Colectomy38,39 other 5-HT receptors.14 Prucalopride stimulates giant
migrating contractions in dogs, frequently causing defe-
• Position the patient in dorsal recumbency.
cation within the first hour after administration.28,29 This
• In a routine manner, shave and drape the ventral medication also increased defecation within a similar
abdomen for aseptic surgery.
time period in healthy cats with no alteration of fecal
• Monitor the patient’s cardiovascular status (i.e., consistency. 29 To date, prucalopride has not been
temperature, heart rate and rhythm, respiratory rate,
approved for use in the United States.
blood pressure, end-tidal carbon dioxide)
continuously during the entire anesthetic period. Misoprostol (Cytotec, Searle) is a prostaglandin E1
analogue shown to reduce the incidence of NSAID-
• Provide appropriate intraoperative fluids (typically,
induced gastric injury. 30,31 An in vitro study revealed
isotonic crystalloid administered at 5–10 ml/kg/hr).
that misoprostol stimulates feline colonic smooth mus-
• Create a ventral midline celiotomy from cranial to cle contraction.32 However, to our knowledge, in vivo
the umbilicus to the pubis.
studies have not been conducted.32 Erythromycin has
• Thoroughly explore the abdomen. been shown to decrease in vitro canine colonic transit
• Harvest appropriate samples (tissue biopsy time33; however, this medication has no effect on feline
specimens, fluids) from other abdominal organs colonic smooth muscle and thus is not indicated to
before incising the gastrointestinal tract. treat feline constipation or obstipation and/or mega-
• Isolate and pack off the colon with laparotomy pads colon.34 Metoclopramide HCl (Reglan, Wyeth-Ayerst)
moistened with sterile 0.9% sodium chloride. and domperidone (Motilium, Janssen, LP) are
• From the surgical site, digitally manipulate fecal dopaminergic (D) antagonists with peripheral proki-
material within the colonic lumen. netic effects and central antiemetic effects at D2 recep-
• Occlude the colonic lumen using noncrushing tors.14 Metoclopramide antagonizes enteric cholinergic
clamps (Doyen forceps). neurons via 5-HT3 receptors and is also a 5-HT4 ago-
• Double-ligate only the short vasa recta vessels nist, whereas domperidone has antagonistic activity at
supplying the segment to be resected, helping to α2- and β2-adrenergic receptors.35 Although these med-
ensure that the caudal mesenteric, cranial rectal, left, ications enhance gastric motility, they have a negligible
middle, and right colic vessels are intact to maximize effect on colonic transit time, which minimalizes their
blood supply to the anastomosis site. use in treating constipation or obstipation and/or
• Transect the distal colon 2–4 cm cranial to the megacolon.14,30
pubis.
• 3-0 or 4-0 absorbable suture is preferred for SURGICAL MANAGEMENT
colectomy; however, if the patient is Cats with a history of chronic constipation refractory
immunocompromised and/or hypoalbuminemic, to appropriate medical therapies may require surgical
a nonabsorbable suture should be used.
intervention. Many surgical techniques for the manage-
ment of feline idiopathic megacolon have been
described, including coloplasty and partial or subtotal
colectomy.36 Partial colectomy involves removal of only
the dilated and atonic segment of colon at the time of
surgical exploration 37; grossly normal tissue is not
resected. Partial colectomy has fallen out of favor
because differentiation between normal and abnormal
tissue based on gross appearance at the time of surgery
is impossible. A study36 demonstrated that the entire
colon is likely histologically affected and any amount of
colon remaining following subtotal colectomy may con-
tinue to dilate, potentially resulting in recurrence of
Surgical area on a cat before subtotal colectomy. clinical signs. Thus failure to resect a significant length
Note the profound colonic distention.
of grossly normal-appearing colon may result in thera-
peutic failure.36
12. Rondeau MP, Meltzer K, Michel KE, et al: Short chain fatty acids stimulate 37. Holt DE, Brockman D: Large intestine, in Slatter D (ed): Textbook of Small
feline colonic smooth muscle contraction. J Feline Med Surg 5(3):167, 2003. Animal Surgery, ed 3. Philadelphia, WB Saunders, 2003, p 665.
13. McManus CM, Michel KE, Simon DM, et al: Effect of short-chain fatty 38. Fossum TW: Surgery of the digestive system, in Fossum TW, Hedlund CS,
acids on contraction of smooth muscle in canine colon. Am J Vet Res Hulse DA, et al (eds): Small Animal Surgery, ed 2. St. Louis, Mosby, 2002, p
63(2):295, 2002. 398.
14. Washabau RJ: Gastrointestinal motility disorders and gastrointestinal proki- 39. Colopy-Poulsen SA, Danova NA, Hardie RJ, et al: Managing feline obstipa-
netic therapy. Vet Clin North Am Small Anim Pract 33(5):1007, 2003. tion secondary to pelvic fracture. Compend Contin Educ Pract Vet 27(9):
15. Guilford WG: Motility disorders of the bowel, in Guilford WG, Center SA, 662–670, 2005.
Strombeck DR, et al (eds): Strombeck’s Small Animal Gastroenterology, ed 3. 40. Sweet DC, Hardie EM, Stone EA: Preservation versus excision of the ileo-
Philadelphia, WB Saunders, 1996, p 538. colic junction during colectomy for megacolon: A study of 22 cats. J Small
16. Riemann JF, Schmidt H, Zimmermann W: The fine structure of colonic sub- Anim Pract 35:358–363, 1994.
mucosal nerves in patients with chronic laxative abuse. Scand J Gastroenterol 41. Bright RM, Burrows CF, Goring R, et al: Subtotal colectomy for treatment
15(6):761, 1980. of acquired megacolon in the dog and cat. JAVMA 188(2):1412–1416, 1986.
17. Prins NH, Akkermans LM, Lefebvre RA, et al: 5-HT(4) receptors on
cholinergic nerves involved in contractility of canine and human large intes-
tine longitudinal muscle. Br J Pharmacol 131(5):927, 2000.
ARTICLE #3 CE TEST
18. Enger C, Cali C, Walker AM: Serious ventricular arrhythmias among users
of cisapride and other QT-prolonger agents in the United States. Pharma- This article qualifies for 2 contact hours of continuing CE
coepidemiol Drug Safety 11(6):477, 2002. education credit from the Auburn University College of
19. Di Diego JM, Belardinelli L, Antzelevich C: Cisapride-induced transmural Veterinary Medicine. Paid subscribers may purchase
dispersion of repolarization and torsade de pointes in the canine left ventric- individual CE tests or sign up for our annual CE
ular wedge preparation. Circulation 108(6):1027, 2003.
program. Those who wish to apply this credit to fulfill state
20. Cubeddu LX: QT prolongation and fatal arrhythmias: A review of clinic
implications and effects of drugs. Am J Ther 10(6):452, 2003. relicensure requirements should consult their respective
21. Fasth S, Hedlund H, Hulten L, et al: The effects of 5-hydroxytryptamine on state authorities regarding the applicability of this program.
large intestinal motility and blood flow in the cat. Acta Physiol Scand To participate, fill out the test form inserted at the end of
118(4):329, 1983. this issue or take CE tests online and get real-time scores at
22. Plumb DC: Plumb’s Veterinary Drug Handbook, ed 5. Ames, IA, Blackwell CompendiumVet.com.Test answers are available online
Publishing, 2005, pp 143–173, 236–239.
free to paid subscribers as well.
23. Hasler AH, Washabau RJ: Cisapride stimulates contraction of idiopathic
megacolonic smooth muscle in cats. J Vet Intern Med 11(6):313, 1997.
24. Washabau RJ, Sammarco J: Effects of cisapride on feline colonic smooth 1. Which pedigree is not overrepresented for hav-
muscle function. Am J Vet Res 57(4):541, 1996. ing feline idiopathic megacolon?
25. Gintant GA, Limberis JT, McDermott JS, et al: The canine Purkinje fiber: a. Domestic Shorthair
An in vitro model system for acquired long QT syndrome and drug-induced b. Maine coon
arrhythmogenesis. J Cardiovasc Pharmacol 37(5):607, 2001.
c. Domestic Longhair
26. Hall JA, Washabau RJ: Diagnosis and treatment of gastric motility disorders. d. Siamese
Vet Clin North Am Small Anim Pract 29(2):377, 1999.
27. Nguyen A, Camilleri M, Kost LJ, et al: SDZ HTF 919 stimulates canine
colonic motility and transit in vivo. J Pharmacol Exp Ther 280(3):1270, 1997. 2. Which condition does not cause hypertrophic
28. Briejer MR, Prins NH, Schuurkes JA: Effects of the enterokinetic prucalo-
megacolon?
pride (R093877) on colonic motility in fasted dogs. Neurogastroenterol Motil a. pelvic fracture malunion
13(5):465, 2001. b. hypokalemia
29. Rondeau M, Meltzer K, Washabau RJ: Prucalopride, a 5-HT4 agonist stimu- c. pelvic canal stenosis
lates canine and feline colonic smooth muscle contraction. Proc 20 th d. luminal obstruction
ACVIM:761, 2002.
30. Bauer RF: Misoprostol preclinical pharmacology. Dig Dis Sci 30(11
suppl):118S, 1985.
3. _____________ laxatives enhance lipid absorption
and impair colonic water absorption by altering
31. Sakamoto C: The role of mucoprotective drugs in gastric ulcer treatment:
With [specific] reference to their effect on gastritis mucosa. Nippon Rinsho miscibility of water and lipid in ingesta.
62(3):566, 2004. a. Hyperosmotic
32. Mosenco A, Meltzer K, Kennedy D, et al: Prostanoids stimulate duodenal b. Bulk-forming
and colonic smooth muscle contraction. Proc 21st ACVIM:1021, 2003. c. Emollient
33. Chiba T, Thomforde GM, Kost LJ, et al: Motilides accelerate regional gas- d. Lubricant
trointestinal transit in the dog. Aliment Pharmacol Ther 14(7):955, 2000.
34. Depoortere I, Peters TL, Vantrappen G: Distribution and characterization of 4. ___________________ is a potentially adverse car-
motilin receptors in the cat. Peptides 14(6):1153, 1993.
diac side effect of cisapride.
35. Washabau RJ, Holt DE: Diseases of the large intestine, in Ettinger SJ, Feld-
man EC (eds): Textbook of Veterinary Internal Medicine, ed 6. St. Louis, Else-
a. Ventricular tachycardia
vier, 2005, pp 1400–1406. b. Prolongation of the QT interval
36. White RN: Surgical management of constipation. J Feline Med Surg 4(3): c. Atrial standstill
129–138, 2002. d. Left anterior fascicular block
5. H2 antagonists stimulate in vitro feline colonic 8. Which may not be used as an enema?
muscle stimulation via a. a 50:50 ratio of water or saline plus a water-based
a. suppression of parietal cell activity. lubricant
b. inhibition of tissue acetylcholinesterase. b. dioctyl sodium sulfosuccinate
c. stimulation of enterochromaffin cells. c. glycerin
d. direct stimulation of myenteric plexi. d. lactulose
6. The preferred surgical treatment of idiopathic 9. During deobstipation, stimulation of the colonic
megacolon is afferent nerves may stimulate
a. coloplasty. a. extensor rigidity.
b. subtotal colectomy. b. vomiting.
c. partial colectomy. c. dysuria.
d. total colectomy. d. panniculus reflex.
7. Which is not a reported metabolic cause of 10. The preferred administration route for lubricant
colonic dysfunction? laxatives is
a. hyperphosphatemia a. oral.
b. hypokalemia b. intravenous.
c. hypercalcemia c. per rectum.
d. dehydration d. subcutaneous.