Hello, I am Matt Sinnovich, one of the surgeons at the Lipo equine Hospital, and our topic today is colic in our equine patients, a current perspective. Collic is one of the most frequently encountered emergencies in equine practise, and it challenges everyone from recent graduates to university professors. And today, we're basically gonna get into it a little bit, have a look at some of the challenges, and have a look at some of the, Triage of a colicing horse, have a look at emergency stabilisation, when and what to refer.

We're gonna get a little bit into the flesh abdominal ultrasound exam, a quick summary of displacements, which are the most commonly encountered, things you will find on rectal. And then a little brief update on what we think may be the current best practise. Now there's no right or wrong in colic.

And all colics don't necessarily follow the textbook. Everyone is often very, very different. So this is some work or some theorising by, Professor Annie Durham and a couple of us here at the hospital, and kind of how we approach the colic exam.

They're basically three categories of colics, 90 to 95%, which are gonna be simple medical colics, so those are mostly your displacements, with or without gas distention. Those are the ones that are going to need some treatment, but, probably will be OK, and that's, that's the one category you need to identify. A few of them are surgical cases and will require very urgent surgical treatment.

And those are the really important ones to get a handle on. Now, you don't necessarily need a diagnosis for the first two, but you very definitely need to know what category they fall into, whether it's just something you can. Or whether it needs very, very prompt referral.

And then the third category are going to be those that are medical, but may be easier to manage in a hospital situation. So an example of those would be impactions. And as we said there, the aim of the exam really is to identify which category.

The colic falls into, and then what you're gonna do about it. Caric is almost always a disease of the gastrointestinal tract, as well as the cardiovascular system. Now, we always think of just the GI tract, but it actually is the cardiovascular compromise long term that's going to cause the real problems for our patients.

And that's why we always need to evaluate both in this situation. Gastrointestinal disease usually precedes the cardiovascular abnormalities. And if there are concerning gastrointestinal signs, what you don't want to do is wait for cardiovascular signs to develop before you start acting.

And basically, what we mean by that is through pain and endotoxemia, you're gonna end up with other problems. It's the way we go about sort of the routine of the colic assessment in the first instance is obviously observation, and that's often done best from a distance. Now, you're severely colicing horses, not, it's not going to be subtle, but those that are slightly more subtle may stop if you come up to a door.

So it's important often just to let them be, see what they're doing. While that's going on, you can take a history and find out what's been going on from the owner's point of view. Then you want to move on to your exam, and as we said, that's looking at both the cardiovascular system as well as the GI tract and putting the two together to decide where, where you're going with this.

History obviously is very important. Have there been any dietary changes, exercise changes, Dental work, all those sorts of things. Anything change in routine, change in weather, all of these things may contribute to causes of colic.

What you want to do is assess the general state of the horse, how much abdominal distention is there, the characteristics of pain, Is it sweated up? Does it look tachycardia from the outside, before you move on to doing your cardiovascular assessment. And that includes looking at parameters, .

Listed here, so your heart rate, your mucous membranes looking both at the colour and the refill time, peripheral temperature. So just seeing, you know, a quick feel of the of the ears and the legs. Are they cold?

Is there a potential heat in the abdomen, the horse is bleeding out internally, feeling the pulse strength, and then looking at some parameters, like, for example, looking at plasma lactate, which may help guide you in some of your decision making. And in this case, ideally what the aim is, is to identify the potential surgery cases before the cardiovascular system is impaired. Moving on then to the gastrointestinal assessment.

And here, what we're gonna do is look at the horse's behaviour. So obviously, if it's colicing, it's, it's had some, some signs, but to find out what those signs are, sort of how severe they are, what the owner has been noticing, . Another very good indicator of whether a colic is surgical is looking at the response to analgesia.

Very, very bad torsions and a lot of ischemic lesions will not respond to analgesia. Some might, and we'll get into some of those a little bit later in the talk. The other thing is then a rectal exam.

Obviously feel what you can feel. Some things you will be able to palpate, some things you won't. And often what we feel is the, the symptoms of those and we'll get into the most common displacements a little bit later in the talk.

And then moving on to imaging. And basically, in the first instance, and certainly in ambulatory practise and in most hospital settings, that would firstly be ultrasound. And there may be some indication for other imaging such as radio radiography, but we'll again, get into that a little bit later.

And then looking at the peritoneal tap. Now, the 1 to 4 over there are really the key decision makers. The peritoneal tap is not something you're gonna be doing as a standard on the road, but certainly there are instances where that can be very useful and help to guide you, or at least put your mind at rest in a hospital situation.

It's something we do very, very routinely, and there are various ways of doing that, one with a teat cannula or otherwise free hand with a needle. . And then moving on, obviously, the, the rest of the assessment is auscultation.

Now, that's very important and some, and we, we always do it, but it's probably low value on your diagnostic criteria list for the fact that it's gonna tell you that there's motility or not motility. And motility and assess essentially be better assessed with imaging with, with ultrasound than than anything else. And then nasogastric intubation, so stomach decompression, which often will help relieve some of the pain and stop some of the catastrophic consequences of colic-like stomach ruptures.

So looking at the behaviour, what we're looking at there for and it's a wide list of behaviours that are put down as colic. Obviously, there's the classic grimacing, lip curling, flank watching and stretching, in appetences, kicking at the abdomen. But some of them may be Just intermittent.

So in the early stages, it may just be intermittent scraping. It may be pacing. Sometimes it's just slight sweating or even persistent sweating, and that may then build up to persistent scraping, recumbency, rolling, or buckling at the knees in pain.

So the next step is looking at the response to initial analgesia. Now, we don't want to do this necessarily until we've completed our exam, because analgesia in the horse prior to getting all of your parameters and completing the full exam may mask some things. But what you do want to do is once you're at that point of going, OK, we don't think this is a a violent that needs referring in the first instance, and we're gonna see our response to analgesia.

What you're gonna reach for is A number of many reasonable choices. In the first instance, what we generally rely on are NSAIDs, so phenylbutisone, metamazole, basal scopolamine, not butyl scopolamine, sorry, buscopan, and flunexin. And then there are a number of alpha 2s as well.

So xylazine can often be used to aid in the exam if the horse is very, very uncomfortable or non-compliant. And then we're talking about other. Other alpha 2s, such as damidine and remiphidine.

Those are, are fairly well known and fairly well used. And my advice to you would be to use agents that you are comfortable with and you know the sort of expected response to. You don't want to be caught up by not knowing what to expect, and then you're going and you're going, well, it hasn't responded to analgesia, if you're just given at a very low dose of something, for example, just some Buscopan Coke.

In a horse that's maybe slightly more painful than that. Then moving on to the rectal exam, and everyone has a standard approach to how they do that. My advice again would be to develop a standard approach and go from there.

Mine, as I was taught it, was to always start dorsally at the aorta and then rotate clockwise around, identifying anatomy as I go. So starting at the top with the aorta, then moving. To the base of the scum, following the seal bands down, looking ventrally where you're going for any gas distension, any tenial bands, anything along those lines, palpating the pelvic flexure if it's present, then moving across to the left to the spleen and coming back round up towards nephrosplenic ligament and nephrosplenic space there.

Now we're gonna play one of my favourite games, which is name that band. This is basically a short summary of large colon displacements. The large colon has a lack of mesenteric attachment, and this means it's freely mobile and able to displace.

Now, in the normal horse, there is longitudinal shortening of the left colon, and the contractions of the longitudinal layers move along the pelvic flexor towards the diaphragm. This is followed by backward movement towards the pelvis during relaxation. So anything that alters this motility pattern, which is initiated the pelvic flexure pacemaker, may lead to displacements and torsion.

And generally, this is often diet-related, and that's why it's important to find out about any changes in the diet, or in the weather, etc. Where soluble and insoluble carbohydrates may have changed. So those two make up the components of most equine or normal equine diets.

Insoluble carbohydrates are digested by microbial fermentation. The production of volatile fatty acids is then absorbed for energy production. It's the excess soluble carbohydrates that tend to cause alterations in the microbial population.

So that's your grains and and pulses in the hard feed. And what that then does is causes excessive fermentation, which may lead to gas distention and subsequent displacement. So how do we classify our large colon displacements?

Now this is just large colon displacements. We generally have, we talk about them left and or right, and we'll go into what that means in in a bit. But left dorsal displacements of the large colon are what we would classly refer to as nephrosplenic entrapment or renal splenic entrapment if you're in the states.

And then versus right dorsal displacement, which is to the opposite side. Non-strangulating bulbulus may also be classified as a displacement, . And then the large colon may adopt a location in between any of these, and the exact description of the displacement can be difficult.

So although we talk about them as a classical one unit, they aren't always, that isn't always the case. Here is a video just of a left dorsal displacement taken off the glass horse in the University of Georgia, just to show you the movement as it goes across there. So that's the spleen and the large clone displacing above and up over it into the space between the spleen and the.

The kidney. Now it comes round to the back so you can see it accordingly, and that's classically what you'll feel as it drops down on your rectal. You're gonna feel those tight bands of the colon heading up towards the nephrosplenic space.

There's some discussion about what the difference is between a left dorsal displacement and a nephrosplenic entrapment. And classically, it's thought that when the colons exist between the spleen and the body wall, that is just a left dorsal displacement. However, when they are physically in the nephrosplenic space, that is when you have an entrapment.

The thought behind this is that you get, again, excessive gas formation within the left colon, with or without a change in motility that causes the left colon to displace laterally to the spleen, and then it migrates its way up dorsally into the space. In most cases, you get a ventromedial rotation, so that the left dorsal colon rotates eventuallyr versus the left ventral colon. Why do right dorsal displacements happen?

We think it's thought to be initiated by a retropulsive movement of the pelvic flexure. So you get migration of the left colon, cranial, and then to the right abdominal quadrant, until the right ventral and dorsal colons are located between the spleen and the body wall. The colon can also rotate on its long axis, resulting in variable degrees of venous congestion, and also means that you can get various different different patterns of displacement as well.

So over there on the left is your basic sort of normal position of the colon. And the middle one is your most common direction where the migration of the pelvic flexure is in a counterclockwise direction when viewed from caudal and ventral. And less commonly, you can get an ascending colon developing in the right dorsal space and characterised by a clockward migration of the pelvic flexure when views from caudal and the ventralal aspects.

And this is taken from a surgery textbook. Again, just a quick representation of the difference between right doors displacements on the left and and left do displacements on the right, which is a bit confusing, I know. But looking at the horse, that would be kind of how you would do it, and the variations between them as we've kind of gone through now.

As we said, the colon can also turn on its own axis, anything from 90 to 270 degrees, resulting invariabilities of lack of venous access or venous congestion. And these are generally classified as non-strangulating vuluses. The most common way is shown over there, so you can have The most common is the dorsal medial torsion, but you can also have a ventrolateral, and that's kind of how it would sit in the abdomen as as with the whole standing.

This is again just a sort of representation of what happens as that sort of necross and where it would sit in the abdomen and the development of a large colon bulbulus. Right, moving on then to more of our diagnostic assessment and the gastrointestinal assessment. And indications for using X-rays, we said, are often limited, but often very useful and false.

And that can be plus minus having a an enema or a contrast enhancement. We can also use positive contrast or negative contrast in the stomach. And certainly milk acts as a contrast and folds in the stomach, and that can be very, very useful.

The other place where radiographic guidance or radiographic assessment is useful is in measuring sand impactions and sand associated colics. And there's a radiograph on the left of a ventral abdomen showing quite a large beach of sand, in the ventral colon. More commonly, we use ultrasound, and one of the protocols that's been developed is the flash scan, and we'll get onto that in a minute.

But here is just a picture of some distendant small intestines. So this is something you don't want to see on your colic exam as you're starting with ultrasound. Most of us have access to an ultrasound, or I would hope we do.

And I think it's one of the important skills to develop is becoming competent and confident in using your ultrasound machine for all sorts of things. It's relatively non-invasive, and it's a very good indicator of, of many things. The more you use it, the better you, the better you will become at it, and the more adept you will become at assessing things.

So in an acute colic case, there was a protocol which is called the Fat localised abdominal Sonography of horses. And there is this very specific protocol. So the diagrams on the left or the right there, sorry, show the two sides of the horse, and the way through which you work.

So they're labelled 1 through 6 over there. And basically, it's a targeted ultrasound protocol which will essentially maximise the detection of surgical abnormalities, shown to be similarly efficacious when used by inexperienced operators with and the average time takes 10 to 11 minutes. So that's pretty quick to assess an abdomen just in a number of windows.

And things you're looking for there are distended small loops of intestine and abdominal free fluid. That is the reference for anyone who wants to go find the original paper. Very good reading, quite acise paper, and some good pictures.

So, if you aren't familiar with it, I would advise that you go and familiar familiarise yourself with it, and then get practising, but we'll go through it very quickly here. So the first window that we look at is the ventral abdomen. These are slides from a very good imager and credit to Lucy Meehan for them.

But here we have the probe on the ventral abdomen, and then we move that probe cordially, so starting quite cranial ventrally and looking for fluid pockets. What you will find is that normally you have colon wall and spleen against the ventral body wall. Anything abnormal would be things like excessive free fluid or distended loops of intestine in this region.

And as you go back, you may also get them in the groyne region, and that's often where they're more commonly sit. So there you go, and there's a couple of examples of excessive free fluid. You can see the the viscera floating in a hypoechoic fluid.

In the case of a heme abdomen, what you may do as well is get swirling or speckling. And in some cases, if you have a rupture, there may also be an increase in ecogenicity as food content is, visible in the abdomen. Next, you want to look at the gastric window.

So you're looking on the left there between intercostal spaces, 10 to 13. And what you can do here is assess the size of the stomach, from its cordal border, which should be sitting between the intercostal spaces, 1113. If it stretches back past 14, then that means it's enlarged.

The other way to do this is to count the number of rib spaces in which the gastric window is visible. And generally we say sort of anything below 5 is not distended, but if you're talking 567 or 8, then you, you probably are on the edge of what is normal. And that can be because of either a functional obstruction or more commonly because of the small intestine having a an obstruction or vascular compromise of sorts.

So there we have a normal view of the stomach, . Closely followed by distended stomachs. That one on the left was taken from the 16th intercostal space.

And the one on the right, as you can see there against the spleen, there's a very speckled fluid-filled stomach. And that will be distended as well. The 3rd and 4th windows of the splenorenal windows and coming down towards the mid abdomen as seen by the probe on the right picture there.

Assessing whether the kidney and spleen are in contact with the dorsal aspect of the abdomen, and then to be sure that you don't have any gas cut off there. So if you can physically see that, you can 100% say that there is no, Nephrosplenic entrapment, there may still be guts between the spleen and the and the body wall, but if you can visualise the kidney, then there is no gut in that space. You also on the left flank want to look for distention of the small intestine.

There we have the normal view of the kidney and spleen sitting flesh. Moving on to the 5th 1 is the duodenal window. So, the duodenum is relatively fixed along the right body wall, and there are two places that it's easy to see.

One is through the liver at about 13th or 14th intercostal space, where it sits between the right dorsal colon and liver. And then you can usually see the, the duodenum contracting there. And then the second place you're gonna find it is at the ventral aspect of the right kidney.

And that's just a representation of it there. So you can see the duodenum may contract down quite small and then open up and it should be motile and contract tile and be closing down. So you may need to keep your probe in that position for a couple of seconds or up to a minute just to see it contract and move.

That's fairly abnormal, with some thickened duodenum setting up there. So detection of distended small intestine and free abdominal fluid is a very important marker for decision making with respect to surgery. DSI has had a positive predictive value of 89% for a surgical lesion and a negative production value of 82%.

And this was through inexperienced operators as well as experienced operators. The flash scan has also been assessed in ambulatory practise. And this was a good study, small numbers, but a, a fairly good study in an ambulatory practise.

And here they just had wireless, ultrasound, which was connected to a phone and or a tablet. But they still had Pretty good outcomes there with, a large number of horses being diagnosed with surgical lesions. And, those included epilo for arm entrapment, strangulating lipomas, small colon infections.

And then there were a number that they could assess, and, about 56% that were medical management. Moving on then with the gastrointestinal assessment. So talking about peritoneal taps.

This generally, as we said, is indicated in inconclusive cases or in hospital environments, . Where it's very, very often indicated is to assess things like hemoperitoneum, or if you think you have had a rupture, so the top right picture there is not an enterocentesis, that was a rupture. The top left picture there can just show you inadvertent splenic penetration as well.

Generally, if you get orange to red fluid, that's fairly pathonemonic for a vascular compromise of the intestine, and that usually is a very strong indication for surgery. In some, what you're expecting on your peritoneal tap is a nice clear yellow straw coloured, fluid, and if you have it in a tube, you should be able to read a newspaper or read writing through it. You don't want anything that's particularly cloudy.

And that may give you some reassurance if it is normal. And if it is abnormal, it may also push your decision for surgery. Now, there is a picture on the bottom right there taken at surgery of a needle stick where the needle had grazed the small intestine.

During the peritoneal tap. It did have a pedunculated lipoma, that horse, and part of that was resected. But just to be aware that it is not a, an innocuous procedure and it can also cause enterocentesis or other problems with it.

So one of those things not to attempt by yourself the first time, but rather find an experienced colleague to guide you through it. . But that being said, it is, does offer very useful information and is often something that that we certainly we do very frequently in a hospital setting.

Let's move on to the auscultation part, what does it all mean, really. The general rule is that quiet is bad and noisy is probably good or better. But it is, however, unreliable.

It's very variable. It depends on horses, if they've been sedated, if they've had, other medications like Buscopan, etc. And there's often there's actually been shown to be a very poor correlation between gut sounds and motility.

It may be more accurate to actually assess your motility using your ultrasound. Next is looking at gastric decompression. This should always be performed if you have distended small intestine.

Now, whether that was palpated or imaged, or when you have moderate to severe and unresponsive pain, usually require a syphon, and so a tube or a pump. Generally in Research and sort of textbooks, more than 2 litres of spontaneous reflux. So if you're putting fluid in to create a cipher, you need to keep account of how much you've put in, and take out what you've taken out and do some subtraction to work out how much you've actually gained.

But generally, the thought is that more than 2 litres is indicative of some reflux, but many horses can fill up a couple of buckets, and then you'll see they often feel quite quite a lot more comfortable thereafter. It's putting it all together, what are the criteria for a surgical referral? Generally, the highly indicative criteria are moderate to severe pain that does not respond to analgesia.

We all get very excited about heart rates and all sorts of things, but we can have horses with low heart rates that are just perpetually painful. And that doesn't matter what the heart rate is or the PCV or any of those things. If you're not getting a response to your analgesia and the horse is becoming unsafe, it is very definitely time to start having a conversation about surgery.

Positive ultrasound findings. So what does that mean, you know, the DSIs that we've spoken about, then a positive peritoneal tap, so having a serious sang ones peritoneal tap. Slightly more moderate, moderate indicators are positive rectal findings, so DSI's on rectal or tight gassy bands.

Copious reflux, which could still be an enteritis or some other things, but definitely pushing towards wanting to have a conversation about a referral and or surgery. And then any sort of signs of cardiovascular shock, where you think fluid therapy may be indicated. So what you do wanna do in the ongoing management, and now that you've gone through all of your assessment is to get chatting to the owners early and have that discussion about whether, if you think this is potentially surgical, is there an option for a referral, and start getting them thinking about.

That owners are very often in a high stress state during colic, it's a, it's a very emotive time for them as well for as for everyone else involved. It's usually out of hours. There's a lot of logistics to be handled.

And the sooner you get onto those conversations, the better for you, and often the better for the horse. Many people want to route march horses to stop them from being recumbent. And the reason they, they're not going to twist because they are rolling.

They are, they are rolling because they are already twisted. So if a horse is recumbent and it's lying down and it isn't damaging itself, then let it be, it probably is a lot more comfortable in that position. By lying upside down, it takes some of the strain off the misen tree, and helps with some of the vascular compromise in, in many cases.

Different story if they're thrashing around and actually traumatising themselves because of the pain. But definitely if they are quiet, it's not a, it's it's not bad to leave them recumbent. You can also attempt to decompress the stomach in cases of severe pain.

As we said, gastric distension can cause severe pain, and it also is a, a risk for rupture. Practise your ultrasound. Use the flash scan if you're not comfortable with it.

Read up on it. There are a number of, as I said, the, the original paper and there are a number of follow-up papers post, looking at all sorts of variables with it. You can use it even with a a not great ultrasound machine.

You don't need a big vivid or a fancy GE machine to, to assess the whole. Abdomen or whichever you prefer. There are a number of handheld ones available.

And certainly they can do a good job. And the limiting factor really, in many instances is just the operator. So become experienced with what you're doing, and you'll find your results improving.

What you don't want to do is repeatedly administer analgesia, particularly if surgery is an option. You don't want to leave the decisions too long, and which can be making contingency plans. So that, that early referral is really, really, really important for, optimising outcomes, as well as patient satisfaction and client satisfaction.

You don't also want to have to walk and lunch them excessively, certainly not on the yard. Using ACE and giving things like mineral oil, unless, unless you have good evidence of, of impaction and, and maintaining it. ACE obviously may upset some of your cardiovascular functions, and mineral oil, if you're not quite sure where it's going, has, has risks that are probably better or probably outweigh the benefits.

To move on then to the third sort of type of case, which, as we said, you can kind of manage. What we're generally talking about there are impactions. Now, these can be managed in the yard, but often are more effectively managed in a hospital for, for a number of reasons.

Most commonly we get pelvic flexureactions. I think that's what 90% of them will be. Less commonly, we can have small colon and rectumactions or cecalactions.

That's a more common sequela of orthopaedic pain or a postoperative complication, although there are primary sealactions that are often seen on the continent. Also more common on the continent than here. And then gastric compaction again, which is, is fairly uncommon, but it may also be associated with displacements, .

And found in there. Generally, what we're gonna do here is intravenous or fluids and that may be either intravenous or intragastric, or a combination of both, depending on what the horse will tolerate. Now, there are commercially available systems for intragastric fluid therapy, but these can be made up.

There is just an image showing the catheter placed correctly, so that's just been scoped to be sure that the catheter is in the right place, can also be x-rayed or ultrasounded to see that it is sitting in the right place, and then fluid can be administered at a constant rate infusion orally. There also is other methods of doing it, so it can be done either as intragastric as an infusion. If you don't want to leave an indwelling tube in, you can tube it every couple of hours and provide boluss.

And then we can also use rectal fluids as well, although that is, and there's good absorption for rectal fluids and good evidence for its efficacy, but they are used far less commonly. So just a brief sort of sum up of the exam and the rest, you don't necessarily need a very specific diagnosis and very commonly we don't come up with a very specific diagnosis. But what you do need to decide is if this is a simple medical colic that can be managed fairly easily, if it's surgical colic and is going to need referral, or if it's an imp impaction type that you can manage, hopefully on a yard or the the owner doesn't want necessarily want referral.

In which case, for your simple ones you're gonna go with some type of analgesia and monitor the response to it, take the food away, and get and kind of see where you get to with that. If it's a surgical colic, get it to a referral centre as soon as. And then for inactions, fluid therapy, and generally intragastric is, is the way that we go for there.

If in doubt, phone your local referral centre for advice. It's what they do. There will always be a person available.

We're generally very happy to take calls, advice calls, just talk through situations, give advice, etc. And if you have a good relationship with a referral centre, that's worth it. Weight in gold, and always very, very useful.

If in doubt, decompress the stomach anyway. If you spend some time, leave the tube in for a minute or two while you do some other things, and try again. It may be the difference between a horse living and dying on, on its way to a, a referral centre.

Flu Flunex and melamine, there's a lot of debate about whether it should be given or shouldn't be given in the first instance, and there's some very strong opinions about it. We tend to stick with enolbutazone in the first instance, but if you are all at all uncertain, definitely reach for the flunexin. It's something that can be used.

And it, again, providing analgesia on a welfare ground is, is very, very important. Starting things like antibiotics or IV fluids prior to referral, It's usually better to expedite travel, to try to get them to a referral centre as soon as possible before they deteriorate. Although if you think they cannot safely travel and you've had a discussion with the referral centre, it may be a case of starting the administration of IV fluids and or antibiotics on the farm.

And then, and what may actually probably be more useful, and if you're comfortable with doing it, is getting an aseptic catheter placement and certainly while the horse is cardiovascularly stable, and to get IV access, that can be worth its weight in gold. So if that is something you're comfortable with, again, in discussion with your referral centre, may be useful to expedite travel prior to referral and get a catheter in rather than wasting time with fluids, etc. When it could be travelling and getting there for the surgery that it needs.

Again some of the up to-date research, there is a very good international equine colic research symposium that happens yearly, obviously with COVID, etc. It's it's skipped a couple of years, but it's a very interesting forum with some very good speakers. So if you do want to have a look at more stuff on this topic, my suggestion would be to go have a look through the abstracts there.

There's some very interesting talks, some very Scientific based evidence, sort of some of the best that we have. There's some far out there things, but that's and and future work, which is is interesting to know, but maybe not so practical. But certainly there's a lot of epidemiological stuff such as this where looking at how case presentations and outcome have changed, and sort of owners' perceptions of colics, there's a lot of stuff on whether colic surgery is too expensive and the owner perceptions of outcome, etc.

Also having a look at some other Variables and looking at them, can we do better with the point of care evaluation. So this comes out of the University of Penn, and they were looking at intestinal strangulation, because that's obviously an important cause of death in horses and working out if there were parameters that could help with identifying early strangulation. The things they looked at here were PCV, which had an odds a positive odds ratio, rectal temperature age, and then glucose concentration, which isn't something we do so much over here.

But generally, there are point of care variables that can be done on the yard, which may help predict one of those as well as SAA, but certainly, there's, there's some good research out there on that if you want to go into all of those. And then as you said, also looking at things like the flash abdominal ultrasonography, and that's something that I think should very definitely be used in first opinion practise. Thank you very much for that.

I hope you've enjoyed it. I hope it has been useful. As I said, the best advice I can give you is to have a good relationship with a referral centre.

If you're at a referral centre, read up lots, and get good with your ultrasound. And otherwise, thank you very much.