GastroIntestinal Stasis, The Silent Killer
Department of Biology
University of Miami
Coral Gables, FL 33124
GastroIntestinal Stasis, The Silent Killer
It's an all too familiar story. "My bunny stopped eating, and then she just died."
When we ask for details, we often learn that not only did the bunny stop eating, but she had been producing extremely small or even no fecal droppings, or showed symptoms of "runny stool." True diarrhea (unformed, liquid fecal matter) is uncommon in rabbits. The runny stool sometimes misidentified as "diarrhea" in rabbits is more often composed of unformed, almost-liquid cecotropes.
Rabbits produce two types of pellets: fecal pellets (left in the litterbox) and cecotropes (soft, pungent, normally shaped like a cluster of grapes and reingested by the rabbit to obtain essential nutrients). Liquid or mushy cecotropes can result from an imbalance of the normal bacterial and fungal flora of the cecum (the bunny's intestinal "fermentation vat"). The floral imbalance can be caused by a number of factors, such as the wrong antibiotic (oral penicillins and lincosamine antibiotics can be very dangerous to rabbits for this reason!) or a diet too rich in digestible carbohydrates and too low in crude fiber. Often, however, it is caused by a slowing of the normal peristaltic muscular contractions which push food and liquids through the intestines. The slowdown or cessation of peristalsis of the intestine is known as gastrointestinal (GI) stasis or ileus.
What Causes GI Stasis?
A rabbit's intestine can become static for a variety of reasons, including (1) stress, (2) dehydration, (3) pain from another underlying disorder or illness (such as gas, dental problems, infections, or urinary tract disorders) (4) an intestinal blockage or, (5) insufficient dietary crude fiber. Left untreated, the slowdown or complete cessation of normal intestinal movement (peristalsis) can result in a painful death, in a relatively short period of time. If your rabbit stops eating or producing feces for 12 hours or more, you should consider the condition an EMERGENCY. GET YOUR BUNNY TO A RABBIT-SAVVY VETERINARIAN IMMEDIATELY.
An intestinal slowdown can cause ingested hair and food to lodge anywhere along the GI tract, creating a potential blockage. Also, because the cecum is not emptying quickly enough, harmful bacteria such as Clostridium species (related to the ones that cause botulism and tetanus) can proliferate, their numbers overwhelming those of the normal, beneficial bacteria and fungi in the cecum. Once this overgrowth occurs, gas emitted by the bacteria can cause extreme pain. Some Clostridium species also produce potentially deadly toxins. It is the liver's job to detoxify these poisons, at a high cost to that all-important organ. Damage to the liver can be a serious--even life-threatening--side effect of GI stasis.
How Can GI Stasis be detected?
Symptoms of GI stasis include very small (or no) fecal pellets, sometimes clinging to the bunny's bottom. In some cases, very small fecal pellets will be encased in clear or yellowish mucus. This potentially serious problem (enteritis, an inflammation of the intestinal lining) should be treated as an emergency.
With GI stasis, the normal, quiet gurgling of the healthy intestine may be replaced either by very loud, violent gurgles (gas moving around painfully!) or silence. The bunny may become lethargic, have no appetite and may hunch in a ball, loudly crunching his teeth in pain.
GI Stasis and the "Hairball" Myth
Sometimes, a rabbit suffering from GI stasis is diagnosed as having a "hairball." In reality, an apparent hairball usually is a result of GI stasis--not the cause. A vet who has not palpated many rabbit abdomens may be unfamiliar with the normal, sometimes "doughy" feel of the healthy rabbit stomach. A "doughy" stomach is usually cause for concern only when accompanied by an empty lower GI and symptoms of abdominal discomfort.
Like those of most herbivores, the stomach and intestines of a healthy rabbit are never empty. A rabbit may eat relatively normal amounts of food, almost up to the time the GI tract shuts down. Because of this, the stomach may contain a large bolus of food when stasis occurs. Unlike the typical cat hairball, which usually consists entirely of hair, a mass misidentified as a "hairball" in a rabbit is usually composed mostly of food held together by hair and mucus. Such a bolus, even if it is dehydrated and unable to pass out of the stomach when initially found, usually can be broken down slowly with plenty of oral fluids and even enzyme supplements, if the vet deems them necessary. However, if the mass is there as a result of chronic GI stasis, simply treating the mass without addressing the GI stasis will be unproductive in the long term.
If you suspect that your bunny is experiencing GI stasis, you must take him/her to your rabbit-experienced veterinarian without delay. Tell the vet your suspicions. S/he will probably listen for normal intestinal sounds and palpate the bunny's abdomen. The vet also may wish to take radiographs (x-rays) to see whether the various parts of the digestive tract contain normal ingested matter, feces or foreign objects--or are empty and gassy. The appearance of the digestive tract will help the vet determine whether there is an obstruction and, if so, where it is located.
If a true intestinal obstruction (almost always accompanied by severe bloating and acute pain) is present, the use of intestinal motility drugs (described later) could make the situation worse by pushing the blockage into a narrow area where it completely obstructs the intestine. However, if the mass is not causing an acute, complete blockage, medical alternatives to surgery should be considered first. A gastrotomy--surgical opening of the stomach--may be performed to remove a gastric obstruction, but rabbits who undergo this procedure have an abysmally low survival rate. Those who survive the surgery itself often succumb a few days later to peritonitis or other complications, even when under the care of the most practiced, skillful rabbit surgeon. Surgery on the rabbit GI tract should be considered only as a last resort.
Can GI Stasis Be Successfully Treated?
If your vet has determined that there is no intestinal obstruction, there are several treatments s/he may wish to use to help your bunny in distress. As always, do not perform any of these procedures or try to administer any of these medications without the supervision of a veterinarian experienced with rabbit disorders and treatments.
I. Mechanical Treatments
A. Abdominal massage.
A rabbit's internal organs are very delicate; care must be taken to avoid bruising them and making the situation worse. After a bit of manual massage, try an electric vibrating massager. This seems to be as effective as manual massage, and it's worthwhile to invest in some type of massager with a large, flat surface that can be held against the bunny's tummy for relatively long periods. Press the massager firmly against the abdomen, start on low and work your way higher. The bunny may be a bit taken aback at first, but almost every bunny on whom we've tried massage has settled down and enjoyed the soothing vibrations. In addition to stimulating the muscles, the massage seems to help break up gas bubbles and ease colic. Massage as long and as often as the bunny will allow and enjoy.
C. Monitoring Body Temperature.
Of utmost importance is careful monitoring of body temperature via (plastic, unbreakable) rectal thermometer. Normal rabbit body temperature ranges from about 101o - 103o F. A higher temperature may indicate either stress or an infection, the latter requiring immediate veterinary attention. A temperature lower than 101oF is of even greater concern than a mildly elevated temperature. Abnormally low body temperature (hypothermia) may indicate shock or septicemia, a bacterial infection that has entered the bloodstream. A rabbit with a temperature lower than 100o F should be considered an extreme emergency. Pack the rabbit with warm water bottles wrapped in towels and get him to your rabbit-savvy veterinarian immediately. Medications often will not be effective when given to a rabbit suffering from hypothermia, so the first step in saving your bunny's life is to get his body temperature back into normal range. Warm water bottles and warmed subcutaneous fluids can be used to achieve this end, but it can take an hour or more if the bunny is severely hypothermic.
Before you attempt to perform an enema on your rabbit, please ask your veterinarian to instruct you in this process during a regular office visit. Don't wait for an emergency to learn how to do this. If you cannot reach your vet when your bunny is in stasis, you will be out of luck!
We administer the enema with a pediatric rubber ear bulb/syringe. A 5 lb rabbit can safely be given 10-15 cc's of liquid enema. Mix the water and oil well. Place the bunny on her back, well supported so she doesn't kick. Gently insert the lubricated tip of the syringe into the anus, no deeper than 1/2 - 3/4 inch. (Note: if you're not sure which orifice is the right one, the anus is the one that winks back at you when touched.) Be gentle. NEVER FORCE ANYTHING! Slowly empty the bulb and let the bunny remain on her back for at least 30 seconds, to allow the liquid to travel up the tract a bit. When you allow the bunny to flip back into normal position, gently lift her hindquarters a couple of inches (firmly supporting the spine!) so that the liquid travels up the GI tract. You may need to gently hold the anus closed to avoid a fountain.
WE DO NOT RECOMMEND THAT A CATHETER BE USED TO DELIVER AN ENEMA. The rabbit's lower GI tract is extremely delicate and fragile, and it is distressingly easy to perforate the rectum or small intestine, with disatrous results. The ear syringe works well, and is far safer than inserting a catheter deep into the lower GI tract.
An enema delivers liquid to the source. It can help hydrate hardened, dehydrated fecal matter in the lower GI, even when subcutaneously administered fluids don't seem to help. The very presence of the warm liquid also seems to stimulate the muscles of the lower GI tract.
E. Petroleum-based laxatives: use with caution.
Note, however, that if the intestinal contents are severely dehydrated and brick-hard (yes, we have seen this!), a coating of vaseline-like substance over them will merely impede their re-hydration and make it more difficult for the mass to break up and begin passing normally. For this reason, it is probably wise to concentrate on re-hydrating the intestinal contents before using petroleum-based laxatives, if they are to be used at all.
Note also that whereas malt-flavored remedies in a tube are often preferred by the bunny, some vets believe that their higher viscosity may actually contribute to holding a mass of impacted food together, especially if the intestinal contents are dehydrated. Unscented, laxative grade mineral oil is less viscous, and may be more effective. Always administer such substances with care so that the bunny does not aspirate (inhale) any. Petroleum-based laxatives should not be given daily or long term, as they can impede the absorption of important, fat-soluble vitamins.
II. Non-prescription supportive measures
A. Oral fluids
B. Force feeding.
Insert the tip of the syringe into the space behind the incisors and squeeze gently sideways to avoid squirting food down the trachea (windpipe). Give only 1-2 cc at a time, allowing the bunny time to chew and swallow. Aspiration of food can be life threatening, so do this with great care!
C. Unlimited grass hay.
D. Fresh, wet, leafy herbs.
E. Lactobacillus acidophilus
Probiotic pastes such as Benebac are available at feed stores, and also might be helpful. Products designed for horses are generally safe and possibly effective for rabbits.
Also, because the normal cecotrope is coated with mucus that protects the bacteria while they travelthrough the stomach, mashing the cecotropes into a pellet mush might well render them useless. Given time and the proper supportive care, your rabbit will be able to re-establish a healthy cecal flora on his own, without the stress of being force fed foreign cecotropes.
However, if you and your vet absolutely insist on trying this, you can obtain cecotropes from a donor rabbit by diapering the donor, or briefly placing an E-collar on him/her during the late afternoon when cecotrophy usually occurs. Don't use the E-collar if the donor rabbit seems very stressed or upset by it. (You don't need two rabbits suffering from GI stasis!)
III. Prescription/veterinary treatments
A. An intestinal motility agent,
It may take as long as two weeks on metaclopramide and/or cisapride before the intestine is fully motile again, and patience and careful nursing for the duration are essential. In severe cases of GI stasis, both drugs can be used simultaneously. Because they work on different areas of the digestive tract, they may have a synergistic effect.
Conventional wisdom holds that if there is a possibility of an intestinal obstruction, these drugs should not be used. However, more and more rabbit-savvy veterinarians are noting that unless there is a problem with the pyloric valve or an acute and true blockage of the stomach, motility drugs generally do not make the problem worse. So far, there is no consensus on this aspect of the problem, and it will be up to your veterinarian (and you, as your bunny's health advocate) to determine the course that seems right for your bunny. Once again, it is imperative that you not take matters into your own hands. Have an experienced rabbit vet diagnose the problem and prescribe proper treatment!
B. Subcutaneous Fluid Therapy.
A dehydrated rabbit will feel tired and ill, and may not have as much will to live as one who is well-hydrated. Rabbits in GI stasis tend to be unwilling to eat or drink, so it may be a good idea to administer subcutaneous fluids as a precaution, unless the rabbit has known kidney or heart malfunctions, or other problems that your vet will be able to determine that would contradict administration of subQ fluids.
As with the enema described previously, you should be able to do this procedure at home. But do not wait for an emergency to learn how to do it. Have your vet teach you how to administer fluids during a regular office visit. It could save your bunny's life.
C. Cholestyramine (Questran)
D. Enzymatic digestive aids
If a hair/food mass proves particularly stubborn, even after rehydration efforts and plant enzymes have been tried, your vet may wish to try a more powerful, animal-derived enzyme product such as Viokase, which contains pancreatic enzymes to break down proteins, amylases to break down indigestible carbohydrates and lipases to break down fats. Although these enzymes may be better than bromelain or papain at breaking down an obstruction composed of ingested matter, they should be used with great caution, as they can burn the esophagus and cause temporary (two or three days) discomfort in an already sick bunny. If Viokase is to be used, it may help to administer just enough pediatric simethicone or laxative grade mineral oil to coat the esophagus for a moment just before the enzyme solution is given.
E. Appetite stimulants.
F. Antibiotics: Use with caution, if at all.
IV. Pain Relief: The key to keeping the bunny fighting to live.
The importance of analgesia to a rabbit's recovery cannot be overstated. A rabbit suffering from GI stasis will sometimes just seem to give up and die, possibly because of the sometimes extreme abdominal pain. Although officially approved only for use in horses, flunixin meglumine (Banamine) is an excellent NSAID (non-steroidal anti-inflammatory drug) for use in rabbits. Although this drug can produce gastric ulcers in some species, substantial anecdotal evidence (involving many hundreds of rabbits over a period of many years) suggests that Banamine is tolerated well by rabbits, even when administered daily for several weeks. We have observed no adverse side effects from Banamine in our rabbits, some of whom have had to receive it daily for a week or longer.
Meloxicam (metacam) and Rimadyl (carprofen) are other NSAIDs which have been used with good results in rabbits.
Torbugesic, an opioid analgesic, provides good pain relief at relatively low doses. Although some practitioners fear that an opioid might contribue to GI slowdown, pain can certainly do the same. We have used opiods repeatedly in cases like this, with good results. We also have had success at relieving colic pain and inflammation of the intestinal lining with sulfasalazine, a combination sulfa antibiotic and NSAID compound. Sulfasalazine works topically to reduce intestinal inflammation.
Barium also may be useful as an intestinal "tonic" to relieve pain and help stimulate peristalsis, but its action is slow as compared to that of the aforementioned analgesics. As always, your veterinarian is the one best able to decide which type of pain relief is appropriate for your rabbit, given the specific conditions of his/her illness.
V. The Road to Recovery: Reduce Stress. ("If it ain't broke, don't fix it.")
It is essential that the caretaker faced with a rabbit in GI stasis be patient, allowing the treatments and medications to work. Rabbits are easily stressed, and excessive handling should be avoided. It may take several days before any fecal pellets are seen, and it may take two weeks or more of motility therapy before the intestine is moving normally again. We know of one case in which a rabbit produced no fecal pellets for 14 days, but finally did respond to gentle, consistent administration of the above treatment regimen. Patience and persistence are key.
Do not make more trips to the veterinarian's office with the rabbit than absolutely necessary (the stress of travel can slow recovery), but DO contact your veterinarian frequently to report on progress and any changes. Whenever possible, administer medications at home, where the rabbit feels safe and secure.
While you are treating your sick bunny, NEVER separate him/her from his/her bonded partner(s). The stress of separation itself can make the problem worse. We have known bunnies who seemed at death's door to recover when they were provided with the love and constant attention of their bonded mate. If your bunny does not have a mate, it is even more important that you, his best friend, show him a great deal of calm attention and affection during his ordeal. Rabbits seem to understand when they are being fussed over, and it may help them recover more quickly to know that they are not being abandoned in their misery. But do this within reason. Many a rabbit can sense a caregiver's fear for his safety, and this in itself can cause stress. Visit and love your bunny, but also give him time to himself to recover.
Every bunny parent should have a stethoscope (not necessarily an expensive one) to monitor intestinal sounds. The gradual return of gentle gurgling is a very good sign: once this begins, the rabbit is on the road to recovery, even if fecal pellets don't begin pouring out the chute. Administration of intestinal motility agents, gentle massage and supportive care as recounted above should be continued, and gradually tapered as fecal pellets slowly begin to come through the system.
Do not be alarmed if the first batch of fecal pellets is small, hard and misshapen, and even accompanied by some mucus. This is to be expected. Also do not be surprised if the rabbit produces a small bunch of pellets, nothing for a day, and then a bit more. The intestine sometimes seems to regain its function in fits and starts, rather than all at once. Consistent, gentle nursing and reduction of stress are essential at this time.
PLEASE RESIST THE TEMPTATION TO FORCE ADDITIONAL, AGGRESSIVE TREATMENT ONCE THE RABBIT BEGINS TO RECOVER. RECOVERY FROM GI STASIS IS SOMETIMES MADDENINGLY GRADUAL. [We know of one instance in which a rabbit was starting to produce fecal pellets and showing signs of recovery, but the veterinarian overseeing the case insisted on anesthetizing the rabbit to perform oral gavage, enemas with an extension tube and vigorous abdominal massage. Despite advice to the contrary, this veterinarian believed that the mass in the stomach could not possibly pass without such treatment. Tragically, the rabbit died. Necropsy revealed a ruptured liver. We cannot help but wonder whether excessive handling and the unnecessarily aggressive treatments contributed to, or even caused this rabbit's demise.]
VI. MOST IMPORTANT OF ALL: Backtracking to the CauseRemember: Ileus is not an illness in and of itself. It is a SYMPTOM of an underlying disorder that has caused the bunny enough stress or pain to cause the GI tract to slow down or stop. Hence, ileus may be your first clue that something else is wrong that needs proper diagnosis and treatment.
Once your bunny is recovering from the immediate GI stasis threat, it's time to look for the ultimate cause of the problem.
DO NOT wait for an emergency to find a veterinarian who is experienced and good with rabbits. Unfortunately, many emergency clinics will not even see rabbits, let alone know how to properly care for one in acute distress. A veterinarian who treats a rabbit as if s/he were a dog or cat might do more harm than good. Plan now and avoid heartache later! Find a good rabbit vet in your area via the House Rabbit Society Veterinarian Listings.
VII. Prevention: The Best Medicine
The best cure for GI stasis is prevention. Be sure your rabbit companion gets plenty of dietary fiber from fresh grass hay. Feed high fiber (22% or higher crude fiber) pellets. Be sure your rabbit is drinking sufficient water to keep ingested food hydrated and moving smoothly. It helps to offer at least 4 cups of fresh, wet leafy greens per 5 lbs. of rabbit daily. And don't forget that regular exercise not only keeps the skeletal muscles strong: it also keeps the smooth muscles of the intestines well-toned and active.
Regular visits (including a molar check!) to your rabbit-experienced veterinarian will ensure that your bunny pal doesn't develop health problems that go undetected. Once such a problem becomes serious, it may manifest itself as GI stasis.
So here's to healthy peristalsis! May your home be blessed with great, big, healthy piles of gorgeous bunny poops. All in the litterbox, of course.
copyright July 1997 - Dana Krempels
Revised: June 2005
This article is dedicated to Alex, who died because no one attending him recognized the symptoms of ileus before it was too late. Alex, I wish I had known then what I know now. But your life and untimely passing inspired this article, which I hope will save the lives of other rabbits.
The author gratefully acknowledges the assistance of Mary Cotter, Ed.D. and Susan Kelleher, D.V.M., for their input and feedback.
I also thank George Flentke, Ph.D. (University of Wisconsin Pharmacology Dept.) for information on the pharmaceuticals named in this article. I thank Mary Cotter, Ed.D. for her contribution to treatment protocols and for her editorial expertise. I also thank Kevin Johnson for his support and editorial expertise.
The treatments and protocols outlined in this article were developed after discussions with many veterinarians familiar with the condition of ileus in rabbits. In particular, I wish to thank (in alphabetical order) Thomas Goldsmith, D.V.M., Jeff Jenkins, D.V.M, Susan Kelleher, D.V.M. and Maya Menchaca, D.V.M. Also, several experienced, knowledgeable rabbit rescuers have contributed hints and tips for home treatments. Of these contributors, Mary Cotter Ed.D. has been an invaluable resource and constant inspiration.
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THE TREATMENTS AND PROTOCOLS DESCRIBED HERE ARE SUBJECT TO CONSTANT REVISION AND IMPROVEMENT AS NEW INFORMATION BECOMES AVAILABLE. NEW INFORMATION ON TREATING ILEUS POSTED HERE WILL NOT BE INCLUDED IN "PIRATED" VERSIONS POSTED ELSEWHERE!
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