A Left Displaced Abomasum in a Calf Due to a Liver Abscess Kathleen Laux Dr. Kyla Ortved
Senior Seminar Paper Cornell University College of Veterinary Medicine
September 9, 2009
Left displaced abomasum, liver/umbilical vein abscess

Abstract Darcy, a 4.5 month old red and white Holstein heifer, presented to Cornell
University on April 11, 2009 with a 10 day history of inappetance and episodes of bloat. Problems on her physical examination included: tachycardia, dehydration, a distended left paralumbar fossa, bilateral ventral abdominal distention, fluid succussion on her left, and a left sided ping. Blood work showed a mature neutrophilia and slightly increased liver enzymes. Ultrasonography showed findings consistent with a left displaced abomasum and an intra-abdominal abscess. Surgery was elected for Darcy and she received antibiotics and a fluid bolus before surgery. Her surgery included body wall marsupialization of her intra-abdominal abscess and a midline abomasopexy. Additional antibiotics following surgery in the hospital and at home resolved Darcy’s abscess. Marsupliazation and antibiotic therapy led to complete resolution of Darcy’s abscess. Signalment and Case History
Darcy, a 4.5 month old red and white Holstein heifer, presented to the Cornell University Farm Animal Hospital on April 11, 2009 for evaluation of bloat of approximately 10 days duration. Darcy was in an individual pen in the calf barn for her first 9 weeks of life and was growing well. She continued to do well a week and a half after being weaned and was then moved to group housing with 5 other calves in the calf barn. Since then she had become progressively inappetant and intermittently bloated. Physical Examination
On presentation, Darcy was quiet but alert and responsive. She was recumbent in the trailer but able to rise and ambulate into the hospital. She was approximately 8-10% dehydrated with sunken eyes and a prolonged skin tent; however, her mucus membranes
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were moist and pink. She was tachycardic with a heart rate of 100 beats per minute. Her respiratory rate (24 breaths per minute) and temperature (102F) were both within normal limits. The calf appeared distended in the left abdomen and a ping could be elicited on the left at the level of the 9-13th intercostal spaces consistent with a left displaced abomasum. Cardiothoracic auscultation was unremarkable and the remainder of her physical exam was unremarkable. Problem List
Darcy’s problems after physical examination included: dehydration, tachycardia, left paralumbar fossa distention, bilateral ventral abdominal distention, left fluid succussion, and a left sided ping. Differential Diagnoses
Differential diagnoses for Darcy’s clinical signs included: left displaced abomasum, rumen bloat, and vagal indigestion. Vagal indigestion secondary to bronchopneumonia has been reported in calves due to inflammation of the thoracic portion of the vagus nerve. Ancillary Tests
A complete blood count revealed a mature neutrophilia (14,000cells/uL) consistent with chronic infection and an elevated hematocrit (64%) and a total protein (7.2g/dL) consistent with dehydration. Serum biochemistry revealed mildly elevated liver enzymes (SDH=89g/dL and LDH=116g/dL) but was otherwise within normal limits.
Abdominal ultrasonography was performed to help make a definitive diagnosis on Darcy. Ultrasonography can be used to assess the size, position, and contents of the
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abomasum. In a left displaced abomasum, the abomasum is seen between the left abdominal wall and the rumen. It will contain fluid ingesta ventrally and a gas cap dorsally. Occasionally, the abomasal folds can be seen in the ingesta (Braun). Darcy’s ultrasound did reveal a left displaced abomasum as well as a large mass in the right cranioventral abdomen that was consistent with an abscess. The mass had a thick capsule with fluid of mixed echogenicity. Since 80% to 90% of left displaced abomasums are diagnosed in the transition period occurring between 2 weeks prepartum and 2 to 4 weeks postpartum it is thought that Darcy’s abscess played a role in her left displaced abomasum. This transition period has an increased risk factor due to lower ruminal fill, reduced forage to concentrate ratio resulting in decreased ruminal motility due to increased volatile fatty acids, and increased incidence of other post partum disorders such as ketosis, retained placenta, metritis, and hypocalcemia (Shaver). It is possible that the abscess contributed to decreased rumen motility and decreased ruminal fill due to the space it occupied which lead to her left displaced abomasum. Additional Problem List
Ancillary tests on Darcy revealed abnormal ultrasound findings, a mature neutrophilia, and increased liver enzymes. Differential Diagnoses
Darcy’s ancillary tests helped to narrow down the differential diagnosis to a left displaced abomasums and an intra-abdominal abscess. Treatment
Omphalitis in calves usually occurs as a consequence of ascending bacterial infection during the first few days of life. Poor obstetric hygiene, faulty husbandry, and
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deprivation or delayed administration of colostrum increases the risk for omphalitis. Surgical intervention is usually needed when the infection becomes sequestered in an insufficiently draining abscess (Steiner et al). Exploratory ceiliotomy in dorsal recumbency was elected in Darcy’s case and she was administered procaine penicillin (22,000U/kg SC q12h) and ceftiofur (2.2mg/kg IV q12h) for their antimicrobial effects and flunixin meglumine (1.1mg/kg IV q24h) for analgesia. Darcy was also bolused 2L of plasmalyte prior to surgery.
Darcy was given 5mg of xylazine to cast her down for surgery, as well as 3mg of butorphanol for pain, and an additional 4mg of xylazine during the surgery. She was placed in dorsal recumbency and her legs were tied to keep her in this position. Darcy was aseptically clipped, prepared, and draped for both a midline and right paramedian incision. An inverted L block was performed using lidocaine. An 8cm midline incision was made through her skin subcutaneous tissues, and linea alba using a 10 blade. Her peritoneum was then opened using mayo scissors. Upon opening her abdomen, a gas filled abomasum was visible. The abomasum had returned to its normal position by putting Darcy on her back. The abomasum was deflated using gas suction on a 14 gauge needle. Intra-abdominal palpation revealed a large, firm mass (approximately 10cm in diameter) in the right cranioventral abdomen. The mass was attached to the lateral body wall by fibrous adhesions and firmly attached to the right caudodorsal liver. The mass was aspirated in order to determine its contents and purulent material was extracted that was submitted for aerobic and anaerobic cultures.
An 8cm right paramedian incision was made in order to marsupialize her abscess to the outside of her body. The skin, rectus abdominus muscle and internal sheath were
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incised with a 10 blade. The area was bluntly dissected to find the abscess capsule and the right milk vein was ligated before incising the abscess. The outer capsule of the abscess was sutured using a simple continuous pattern to the internal sheath of the rectus and rectus muscle using 0 and #1 Monocryl. The abscess what then drained using a 10 blade and approximately 2L of pus drained from the site. The abscess was lavaged with saline and then the inner capsule was sutured to the skin wall using #1 Monocryl in a simple continuous pattern interrupted at either end of the elliptical incision. An abomasopexy was then performed using the midline incision by incorporating the seromuscular layer of the abomasum into the closure of the internal rectus sheath and muscle using #2 PDS in a simple continuous pattern. The external rectus sheath was closed with #2 Vicryl. The skin was then closed in a simple continuous pattern with #1 Supramid. Darcy recovered and stood quickly after surgery and was taken back to her stall.
The exact origin of the abscess is not known but possibilities include: seeding of the liver via the umbilical vein when the calf was younger, gastrointestinal puncture, or a primary liver abscess. However, a study regarding marsupialization of umbilical vein abscesses showed that moving the umbilical vein cranially by extending the ceiliotomy incision rather than by translocation of the umbilical tissues to a right paramedian position greatly reduces the risk of contamination of the abdomen (Steiner et al). However, this was not an option in Darcy due to her left displaced abomasum which compounded the situation. The abscess needed to be marsupialized in the right paramedian site due to its location and to keep the midline incision clean in order to
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perform an abomasopexy. The abomasopexy could not be performed in its usual right paramedian location due to the abscess. Outcome
Post-operative management included administration of intravenous fluids supplemented with potassium chloride and calcium as needed in order to maintain hydration and normal electrolyte values. The antibiotics were also continued. The marsupialization site was also flushed with dilute betadine and the skin around the site cleaned as needed. The marsupialization study also showed that repeated flushing of marsupialized abscesses with diluted iodine solution under pressure produces serious complications in calves younger than 2 months of age. When flushed under pressure the bacteria and iodine enter systemic circulation causing an anaphylactic reaction and bacteremia. However, omphalophlebitis seems to be sealed off from systemic circulation in calves older than 2 months old. Lavage of a marsupialization site in calves younger than 2 months old should be carried out with the suction tip technique. However, this technique prolongs the amount of time the site needs to be flushed. Flushing with either technique should be continued until the egress solution remains clear for at least 3 days (Steiner et al).
During the next 48 hours, Darcy became more alert with an excellent appetite. The abscess continued to drain and the skin around the abscess was cleaned every 4 hours. Intravenous fluid therapy was discontinued on April 12, 2009. The anaerobic culture came back as a Fusobacterium species and the aerobic culture was Actinomyces pyogenes and Enterobacter cloacae. Darcy was continued on her same antibiotics since these bacteria were susceptible to those drugs. On April 13, 2009, Darcy was quiet, but
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alert and was chewing her cud, eating hay and had passed formed, dark manure overnight. Her physical exam and vital parameters were all within normal limits. Her abomasopexy site appeared to be healing well, with a normal amount of post operative edema, but no heat or discharge. The marsupialization site was noted to have significant swelling and heat with a malodorous discharge. It continued to drain and be flushed and Darcy continued on antibiotics and flunixin meglumine. On April 14, 2009, Darcy was bright and alert and had eaten and passed normal manure overnight and was drinking well from her electrolyte bucket. The marsupialization site continued to drain but the swelling and heat had decreased from the day before. Her intravenous catheter was removed and she was discharged to the care of her owners.
Darcy was sent home on ceftiofur (2.2mg/kg SC BID for 10 days) and procaine penicillin (10mL SC BID for 10 days). She was also given one last dose of flunixin meglumine the following morning orally. The owners were also responsible for continuing to flush the marsupialization site with 120mL of sterile saline twice a day. The owners were also warned that Darcy was at risk of developing internal adhesions in her abdomen due to the inflammation associated with the abscess, as well as an increased risk of her abomasopexy site becoming infected due to its close proximity to the abscess marsupialization site. Follow-Up Upon talking to the owners in the fall Darcy went on to thrive after her surgery. She was housed separately for two months following the surgery and then rejoined the other heifers on pasture. Her abomasopexy site healed without problems and her marsupialization site is healed with a small lump in the area as the only reminder. Darcy
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started to grow well again and is the same size as her fellow heifers. She has shown no signs of colic, bloat, or inappetance since her surgery. Discussion Techniques to Fix Left Displaced Abomasums: A Comparison Right Paramedian Abomasopexy
The cow is sedated with 20-40mg of xylazine intravenously and then placed in dorsal recumbency. A right paramedian ceiliotomy is performed and the abomasum is decompressed using gas suction and then placed in its correct anatomical position. A 6cm portion of the greater curvature of the abomasum is incorporated into the closure of the internal rectus sheath with #1 Supramid in a simple continuous pattern. Care is taken to not penetrate the mucosa of the abomasum. The rectus muscle is closed with chromic gut in a simple continuous pattern and the external rectus sheath is closed with #2 Vicryl in a simple interrupted pattern. The subcutaneous tissue is closed with 2-0 catgut in a simple continuous pattern and then the skin is closed with #1 Supramid in a Ford interlocking pattern (Fubini et al). Right Paralumbar Fossa Omentopexy
A right paralumbar fossa ceiliotomy is performed and the abomasum identified. The abomasum is decompressed and returned to its normal position. A fold of the greater omentum is identified 5cm caudal to the pylorus and incorporated into the closure of the transversus abdominus muscle using #1 Supramid in a simple continuous pattern. The muscle layers are closed with #2 catgut in a simple continuous pattern and then the skin is closed with #1 Supramid in a Ford interlocking pattern. A study comparing the right paramedian abomasopexy and the right paralumbar fossa omentopexy showed a higher
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milk yield for the abomasopexy group one month after the surgery. However, after this time there was no difference between the two groups in respect to milk production, reproductive performance, number of postoperative complications, and survival in the herd (Fubini et al). Toggle Pin Suture Technique (TPS)
Cows with small gas-filled abomasum, ventral edema, or concurrent diseases (such as hypocalcemia, retained fetal membranes, metritis, mastitis, and ketosis) are not good candidates for TPS. The ideal candidate for this procedure is one that has been off feed for less than 24 hours. The equipment required for this technique includes a trocar/cannula and toggle sutures. One will also need at least two assistants (Newman et al).
A series of three half-hitches should be placed onto the cow in order to effectively cast it. The cow should then be rolled clockwise into dorsal recumbency. The cranial right paramedian are should be ausculted for a ping. Clipping and local anesthetic are not always performed. Local anesthetic may be contra-indicated in some cases because it may allow enough time for gas to escape from the abomasum allowing the abomasum to move dorsally away from the ventral body wall and therefore inability to place the TPS. Both the right and left paramedian areas should be ausculted for pings. The presence of a ping in both areas indicates that the abomasum is still displaced. Shaking of the abdomen usually helps the abomasum to correct itself. The person’s hand is placed palm down with the lateral tip of the fifth finger touching the cow’s xiphoid process and the thumb pointing caudally in a sagittal plane. The junction between the thumb and index finger marks the spot for placement of the first TPS. During placement of the first TPS the
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thumb can be placed over the trocar in order to reduce loss of free gas. The second TPS should be placed 4 to 8cm cranial to the first TPS. Correct placement of the TPS into the abomasum can be verified by the characteristic smell of the abomasum and the fluid pH test which should be acidic. After placement of the second TPS as much free gas as possible should be removed from the abomasum. The two TPSs should then be tied to each other with gauze or a stent under the suture. A vertical distance of 6 to 8cm between the suture knot and skin is recommended in order to decrease the risk of abomasal fistulation. The cow should then be rolled counterclockwise and allowed to stand (Newman et al).
Identification of any underlying diseases (ketosis, retained fetal membranes, metritis, and mastitis) is very important because the presence of these diseases is associated with a poorer outcome for the TPS procedure. Further research is needed in order to tell if antibiotics post-procedure are beneficial in cases of uncomplicated LDAs. Misplacement of either TPS can result in either a partial or complete pyloric outflow obstruction. Prompt intervention is necessary to reduce the risk of permanent obstruction. Also, cellulitis may develop at the site of the suture placement. Supportive therapy after TPS correction such as intravenous ceftiofur hydrochloride, 50% dextrose, calcium borogluconate, hypertonic saline, vitamin B12, and dexamethasone may improve the outcome. The TPS should be removed after 2 to 3 weeks (Newman et al).
A success rate of 73.3% in a first study and 88% in a second study where achieved for the TPS. Potential drawbacks of the TPS include: lack of opportunity to explore the abdominal cavity, no visual control of repositioning and fixation of the abomasum, high recurrence of the condition, local or diffuse peritonitis, and abomasal
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fistulation. All though these complication rates are low these complications are sufficiently severe to drastically decrease milk production or cause premature removal of the cow from the herd. Pyloric outflow obstructions have also been reported to occur after TPS (Newton et al).
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References Braun U. Ultrasonography in gastrointestinal disease in cattle. Vet J 2003: 166(2): 112124. Fubini SL, Ducharme NG, Erb HN, Sheils RL. A comparison in 101 dairy cows of right paralumbar fossa omentopexy and right paramedian abomasopexy for treatment of left displacement of the abomasum. Can Vet J 1992: 33: 318-324. Newman KD, Harvey D, Roy JP. Minimally invasive field abomasopexy techniques for correction and fixation of left displaced abomasum in a dairy cow. Vet Clin Food Anim 2008: 24: 359-382. Shaver RD. Nutritional risk factors in the etiology of left displaced abomasums in dairy cows: a review. J Dairy Sci 1997: 80: 2449-2453. Steiner A, Lischer CJ, Oertle C. Marsupialization of umbilical vein abscesses with involvement of the liver in 13 calves. Veterinary Surgery 1993: 22:3: 184-189.
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