Gastrointestinal Stasis:

Review and Current Therapy

Colin McDermott, VMD, CertAqV
Exotic and Aquatics Veterinarian
Mount Laurel Animal Hospital

Overview
• Gastrointestinal Stasis- definition
• Physical examination
• Treatment
• Prevention

Gastrointestinal Stasis
• Rabbit Gastrointestinal Syndrome
• SYNDROME
• Not a specific disease unto itself
• Set of clinical signs
• Hyporexia/anorexia
• Decreased fecal production or absence of fecal production
• Downward spiral of discomfort and anorexia
• Species affected
• Rabbits
• Guinea Pigs
• Chinchillas
GI stasis
• Timeframe?
• Varies by species, very general
• Rabbit- 8-12 hours
• Guinea pig- 6-8 hours
• Chinchilla- 8 hours

Unique anatomy
• Dentition

Rabbit Guinea Pig Chinchilla

30 degree angle

Unique anatomy
• Stomach
• Rabbit - pH 1-2
• Guinea pig - pH 2-3
• Ever present fiber mat
• Hair and fiber
Unique anatomy
• Small intestines
• Higher pH than stomach (6.4-7.4)
• Cecum
• ~60% of GI volume
• Fermentive vat of varying bacterial and fungal species
• Cyniciomyces guttulatus yeast- Rabbits

Unique anatomy
• Colon
• Proximal colon
• Passes indigestible fiber
• Retropulses digestible fiber for cecotrophs
• Fusi coli- controls peristalsis
• Descending colon
• Fluid and electrolyte absorbtion
• Goblet cells
• Mucus for cecotrophs

Types of GI stasis
• Mechanical
• True foreign body
• Hairballs (?)
• Pyloric outflow obstruction
• Functional
• More common
• Pyloric outflow obstruction

• Not all stasis is considered equal

Causes of GI stasis
• Primary
• GI pathology
• Secondary
• Extra-GI pathology leading to GI signs

• At its core
• Stress/discomfort
• Inability to eat food for a set period of time
• Downward spiral if not corrected

Physical examination
• History
• Onset of signs
• Diet history
• Triage
• HR, RR, mentation
• Fecal production/appetite history
• Temperature?
• Normal range- 101.3-104 F
• Hypothermia carried a 3x higher risk of death before or within 1 week of discharge
• For each 1 degree C decrease in body temp on admission, odds of death are doubled

J Am Vet Med Assoc. 2016 Feb 1;248(3):288-97. doi: 10.2460/javma.248.3.288

Physical examination
• Borborygmi
• Palpation of GI tract
• Stomach, Cecum, Colon
• Oral examination
• Incisors and cheek teeth
• Other focal sites?
• Feet
• Ears- abscesses
• Eyes- nasolacrimal duct blockages
• Respiratory system- URI, pneumonia
Diagnostic testing
• Radiographs
• Mechanical vs functional ileus
• Stomach size
• Cecum size
• Fecal material present?
• Musculoskeletal pathology
• Arthritis
• Spondylosis
• Pathologic fractures
• Pulmonary disease

Diagnostics
• Bloodwork
• CBC
• Biochemistry
• Renal
• Hepatic
• Other prognostic indicators?

Diagnostics
• Glucose and sodium as prognostic indicators
Physiologic state Glucose (mg/dL) Sodium (mEq/L)
Normal 76-148 136-147
Stressed 144-180 --
Severe disease 360-540 <129 carries a 2.3 times
mortality risk
Diabetes mellitus 540-601 --

Fisher P, Graham J. In: Rabbits In: Carpenter JW, ed Exotic Animal Formulary, 5th ed. St. Louis: Elsevier;2017.
Other diagnostic tools
• Ultrasound?
• CT scan?

GI Stasis
• Examination
• Determine underlying cause
• Stress
• Dental disease
• Underling metabolic pathology
• Inflammation
• Infection

Basis of treatment
• Treatment
• Rehydrate
• Analgesia
• Critical care
• Exercise
GI Stasis
• Rehydrate
• Maintenance fluids- 100-125ml/kg/d
• Peripheral vs GI dehydration
• Assessing dehydration- difficult
• Skin turgor
• Abdominal palpation
• PCV/TS
• Single SC doses of 50-75ml/kg q8-12hr

GI Stasis
• IV fluid therapy
• IV access available?
• Cephalic vein
• Lateral saphenous vein
• Marginal ear vein (NOT CENTRAL ARTERY)
• Intraosseous catheter placement
• Young and more debilitated animals

GI Stasis
• IV fluid basics
• Maintenance requirement of 3-5mL/kg/hr
• 60-90mL/kg for shock
• Divide over 10-15 minute boluses
• Hetastarch
• 5mL/kg IV over 5-10 minutes
• Blood products
• 10-20mL/kg given no faster than 22mL/kg/hr
• Cross matching advised, but no known blood typing
GI Stasis
• Analgesia
• Considerations with anorexia
• PO may not be appropriate if no fecal production
• NSAIDS
• Buprenorphine
• Decreased GI motility with repeated doses?
• Butorphanol
• Hydromorphone
• Tramadol
• Gabapentin
• Lidocaine

NSAIDs
• Caution with:
• Renal/hepatic insufficiency
• Severe dehydration
• Concern for GI disease/ulceration
• Gastric dilation
• Pyloric outflow obstruction

NSAIDs
• Meloxicam
• PO or SC/IM
• Palatable oral formulation
• Doses 0.5-1.5mg/kg/d PO SID-BID
• Some safety studies available
• Give in conjunction with fluid resuscitation
NSAIDs
• Flunixin megulamine
• PO, IM, IV dosing
• Caution with long term use (no more than 3 days)
• Carprofen
• Listed in formulary for osteoarthritis
• Ibuprofen
• Increased GI side effects, not recommended

Opiods
• Buprenorphine
• Partial mu agonist
• Effects on GI transit time?
• Onset of action -30-60 min
• Moderate duration of action- 6-12hr
• Mild sedative effect
• Guinea pigs- transmucosal appears to be effective at higher doses
• Buprenorphine SR
• Evaluated in NZ white rabbits

Opiods
• Butorphanol
• Partial opiate agonist/antagonist
• Mild sedative, short acting (2-4 hr), minimal analgesia
• Hydromorphone
• Mu receptor agonist
• More potent pain control
• Nausea?
Other pain medications
• Tramadol
• Questionable efficacy in rabbits, oral dosing (small study size)
• Unable to determine analgesic effects at high doses in chinchillas
• Gabapentin
• No published studies
• Lidocaine CRI
• Reduced MAC of isoflurane under anesthesia
• Better post operative outcome compared to buprenorphine with respect to
fecal output, food intake, and glucose concentrations following OVH

GI Stasis
• Critical care
• Assist feedings
• Critical care for herbivores
• 15-20mL/kg q4-6hr until eating
• More art than science
• Mixtures with water, natural fruit juice, Ensure
• Emeraid for Herbivores
• Pellet/greens/hay blenderized mash

GI Stasis
• Exercise
• Encourage movement with feedings
• Stimulating GI motility
Adjunct therapies
• All additional therapies should be dependent on the situation and
underlying cause

Motility agents
• Metoclopramide
• Blocks dopamine in the chemoreceptor trigger zone
• Increase tone and amplitude of gastric contractions, increases duodenal and
jejunal peristalsis
• Cisapride
• Upper GI prokinetic
• Increases gastic emptying via increase of Ach at myenteric plexus
• Side effect- Torsades de pointes arrhythmias experimentally and clinically in
people. Experimentally induced in rabbits
• Trimebutine
• Not available in the US

Other GI agents
• Famotidine
• Histamine H2 receptor antagonist
• Reduces acid content in stomach
• Ranitidine
• Histamine H2 receptor antagonist
• Reduces acid content in stomach
• Simethicone (Gas X)
• Detergent based breakdown of gas bubbles
• May be more helpful in guinea pigs and chinchillas, antecdotally
Appetite stimulants
• Cyproheptadine HCl
• Midazolam
• Vitamin B complex

• No controlled studies on efficacy

Antibiotics?
• Rare indications
• Use your PE and diagnostics as a guide
• Urinary tract disease
• Oral ulceration/dental abscessation
• Respiratory disease
• URI
• Pneumonia
• Vestibular disease
• Otitis media/interna

Additional support
• Thermal support
• Temperature based

• Midazolam
• Anxiolytic
• Appetite stimulant?

• Maropitant citrate (Cerenia)

• Anti-inflammatory in other species
• Targets visceral pain in other species
• Potent anti-nausea effects in other species
• No controlled studies in small mammals
Additional support
• Laxatives
• For use in mechanical obstructions?
• Pineapple juice
• Bromelain- enzymatic degredation of hair
• Questionable at best
• Increasing sugars in diet
• Massage
• Possible help in the right hands, movement of GI tract
• Risk of trauma

Other therapies
• GI surgery
• For true mechanical obstructions
• High post op mortality
• Case selection bias?
• Rapid adhesion development
• Post op functional/mechanical stasis

Measuring treatment success

• Time in stasis = time in recovery
• Refilling an empty tank
• Time to urination
• First fecal pellets
• 12-18 hours?
Now what?
• When stable, look for primary causes
• Sedated oral examination
• More advanced diagnostics
• CBC/Chem
• Radiographs
• CT
• Ultrasound

Summary
• GI stasis as a syndrome, while common, can be induced by various
underlying etiologies
• Rely on your PE and diagnostics to guide your clinical decisions
• Temperature
• Core treatments:
• Rehydrate
• Analgesia
• Critical care
• Exercise
• Other therapies based on PE and diagnostics