Slovenian Veterinary Research 2024  |  Vol 61 No 2 |  137
Secondary Small Intestinal Obstruction 
Associated With an Omental Adhesion After 
End-To-End Jejuno-Ileal Anastomosis in a 
Thoroughbred Horse: A Case Report  
Key words
colic, 
horse; 
jejuno-ileal nastomosis;
omental adhesion; 
small intestinal obstruction
Jungho Yoon1,2, Ahram Kim1, Jongyoung Park1, Young Beom Kwak1, In-Soo Choi2, 
Taemook Park1*
1Equine Clinic, Jeju Stud Farm, Korea Racing Authority, Namjo-ro 1660, Jeju-si, Jeju, 63346, 2College of 
Veterinary Medicine, Konkuk University, Neungdong-ro 120, Gwangjin-gu, Seoul 05029, Korea 
*Corresponding author: taemook@kra.co.kr
Abstract: A 19-month-old female thoroughbred horse presented with a history of acute 
abdominal pain. When the horse was four months of age, she underwent abdominal 
surgery and most of the strangulated jejunum and ileum were resected and anasto-
mosed using an end-to-end technique. Subsequently, the horse was diagnosed with 
an ileal obstruction secondary to an adhesion of the greater omentum, which caused 
a mechanical obstruction of the lumen of the distal ileum. The ileum was released by 
transecting the adhesion and performing an omentectomy. After surgical intervention, 
the horse recovered quickly and was discharged fifteen days after surgery. This case 
report describes an ileal obstruction caused by an omental adhesion that formed after 
a jejunoileal anastomosis in a thoroughbred horse. The clinical, imaging, and surgical 
findings are described.  
Received: 7 August 2023
Accepted: 7 February 2024
Slov Vet Res
DOI 10.26873/SVR-1833-2024
UDC 636.1:616.34-007.272
Pages: 137–42
Case Report
Introduction 
Postoperative intra-abdominal adhesions (PIAs) are com-
plications of abdominal surgery that challenge equine 
surgeons (1). Fibrinous and omental adhesions are con-
sequences of peritoneal inflammation that may remain 
clinically silent or cause complications depending on the 
location and organization (1). Pathological adhesions caus-
ing postoperative abdominal pain and intestinal obstruc-
tion have been reported in 9% to 27% of horses, identified 
at postmortem examinations or during repeat laparotomy 
after abdominal surgery (2). Furthermore, strangulating le-
sions of the small intestine associated with the omental ad-
hesions (OA) occur in 1% of horses undergoing exploratory 
laparotomy for abdominal pain (3). This report describes 
the clinical signs, diagnosis, surgical findings, treatment, 
and follow-up of small intestinal obstruction (SIO) caused 
by an OA after an end-to-end jejuno-ileal anastomosis in a 
horse.
Case Presentation
A 19-month-old female thoroughbred horse, weighing 430 
kg presented with anorexia, signs of abdominal pain, and 
gastric reflux. The horse had undergone abdominal surgery 
at four months of age for a small intestinal volvulus involving 
most of the jejunum, and an end-to-end jejuno-ileal anasto-
mosis was performed (Figure 1). The signs of abdominal 
pain developed the morning of presentation and had not re-
sponded to symptomatic treatment, including nonsteroidal 
anti-inflammatory medication (NSAID; flunixin meglumine, 
1.1 mg/kg IV), fluid therapy (15 litres of Hartmann’s solution 
IV), and gastric decompression through a nasogastric tube. 
On a physical examination, the horse was quiet with a 
heart rate of 48 beats/min, respiratory rate of 15 breaths/
min, and body temperature of 38.5 °C. The abdominal bor-
borygmi was decreased at both sides and capillary refill 
time was delayed (>3 sec) along with congested mucous 
138  |  Slovenian Veterinary Research 2024  |  Vol 61 No 2
membranes. A rectal examination was unremarkable. The 
hematology was within normal ranges. Serum biochemical 
analysis revealed elevated lactate (3.6 mmol/l, reference 
range, 1–1.5 mmol/l), hyperglycemia (156 mg/dl; reference 
range, 65–110 mg/dl), elevated creatinine kinase (2,003 U/l; 
reference range 120–470 U/l), decreased calcium (10.8 mg/
dl, reference range; 11.5–14.2 mg/dl) and globulin (2.7 g/
dl; reference range, 2.7–5.0 g/dl) levels. Abdominal ultraso-
nography revealed duodenal dilation (oval-shaped, 3.78 cm 
× 7.55 cm) with intraluminal fluid accumulation in almost 
the entire duodenal segment on the right side (Figure 2A).
An exploratory laparotomy was performed under general 
anesthesia. Antibiotic treatment included procaine peni-
cillin G plus dihydrostreptomycin suspension (0.06 ml/kg 
IM, PPS injection, Daesung microbiological labs, Euiwang, 
Korea), gentamicin sulfate (6.6 mg/kg IV, Eagle gentamy-
cin injection, Eaglevet, Seoul, Korea). NSAID was not given 
due to the administration prior to referral. The horse was 
premedicated with detomidine (0.02 mg/kg IV, Provet 
Detomidine®, Provet, Istanbul, Turkey). General anesthesia 
was induced with diazepam (0.1 mg/kg IV, Samjin pharm, 
Seoul, Korea) and ketamine (2.2 mg/kg IV, Yuhan Ketamine, 
Yuhan, Seoul, Korea) and maintained with isoflurane (Ifran, 
Hana pharm, Hwaseong, Korea) in oxygen through a closed 
circle ventilation system after endotracheal intubation. 
After clipping and aseptic preparation, a ventral midline in-
cision was made. The abdominal exploration revealed the 
small intestine to be fluid-distended, which was related to 
the ileal obstruction (Figure 2B). The lumen of a segment 
of distal ileum was narrowed by a circumferential adhesion 
of the greater omentum, which caused a mechanical ob-
struction (Figure 3A). The cecum and large colon distal to 
the ileum collapsed with few palpable contents (Figure 2B). 
The ileum was released through a transection of the ad-
hesion and omentectomy using a blunt dissection and an 
ultrasonic surgical instrument (Medisonic DU-137, Daiwha, 
Wonju, Korea) (Figure 3B, 3C). After the adhesionolysis, the 
remaining small intestine was inspected grossly. The col-
or of the small intestine improved, and good motility was 
Figure 1: Detailed small intestine found on the first surgery at four-month of age. The strangulated small intestine was identified (A, B; arrowheads) and 
end-to-end jejuno-ileal anastomosis was performed (C; arrows)
Figure 2: Ultrasonographic image (A) and gross appearance (B) of the distended small intestine in this study. (A) The duodenum was markedly dilated 
(oval-shaped, 3.78 cm × 7.55 cm) with an intraluminal fluid accumulation. The image was obtained from the right abdomen; RDC, and right dorsal colon. 
(B) The whole of the small intestine was grossly fluid distended which was related to the ileal obstruction
  Slovenian Veterinary Research 2024  |  Vol 61 No 2 |  139
observed throughout the intestine. The fluid distension was 
relieved by stripping the small intestinal contents into the 
cecum. Serosal scarring and adhesions were noted at the 
anastomotic site of the previous surgery (Figure 3D). Prior 
to closure, the abdominal cavity was lavaged with 15 L of 
heparinized saline (5,000IU/L). The linea alba, subcutane-
ous tissues, and skin were closed routinely.
Postoperatively, the horse recovered uneventfully from an-
esthesia. Postoperative medications included a continu-
ous infusion of lidocaine (1.3 mg/kg IV as a bolus followed 
by a 0.05 mg/kg/min infusion) for the first 12 hours, flu-
nixin meglumine (1.1 mg/kg IV once daily, Finadyne, MSD, 
France), procaine penicillin G (22,000 IU/kg IM once daily, 
PPS injection, Daesung microbiological labs, Euiwang, 
Korea), gentamicin sulfate (6.6 mg/kg IV once daily, Eagle 
gentamycin injection, Eaglevet, Seoul, Korea), famoti-
dine (0.3 mg/kg IV twice daily, Gaster, Dong-A ST, Seoul, 
Korea), and omeprazole (4 mg/kg PO once daily, Abgard, 
Abler Pharmaceuticals, Houston, TX, USA) were adminis-
tered for five days. Maintenance intravenous fluid of lac-
tated Ringer’s solution (60ml/kg/day) was infused for five 
days. After confirming the absence of complications such 
as postoperative ileus, gastric reflux, dehydration, and di-
arrhea, the infusion was discontinued. The horse showed 
hypocalcemia and hyperkalemia pre- and postoperatively 
(Table 1). Calcium gluconate (0.1 ml/kg of the 45% solution) 
and 50% dextrose were added to the fluid to improve the 
electrolyte imbalances. Food was re-introduced 24 hours 
postoperatively. Initially, the horse was provided with 0.5 
kg of fresh grass four times daily, with a steady increase in 
the volume of feedings. Grass hay (0.5 kg, four times daily) 
was added to the fresh grass 48 hours after surgery and 
increased gradually to the full ration over the next five day. 
An abdominal bandage was maintained for two weeks. 
Probiotics (Lactobacillus spp., Enterococcus spp., and 
Saccharomyces boulardii) were added to the feeding dur-
ing hospitalization. Short periods of hand-walking and graz-
ing were allowed two or three times daily.
Serial ultrasonography revealed no small intestinal dilation 
and normal intestinal motility. Serial hematology showed el-
evated serum amyloid A (SAA; 2,063 mg/l; reference range 
< 20 mg/l), creatinine kinase (CK, 4,892 U/l; reference range 
Figure 3: Identification of omental adhesion (A), adhesionolysis (B, C), and remnant secondary adhesion (D) in this study. (A) The distal ileum is encircled 
by the adhesion of the greater omentum. Both the mechanical obstruction and partial strangulation were caused by adhesion. (B) Omentectomy was 
performed using blunt dissection and an ultrasonic surgical instrument. (C) Resected omentum and relieved small intestines. The color and movement 
of the intestines gradually returned to normal. (D) Remnant adhesion at the anastomotic site of the previous surgery
140  |  Slovenian Veterinary Research 2024  |  Vol 61 No 2
120–470 U/l), aspartate aminotransferase (AST, 1,750 U/l; 
reference range 175–340 U/l), and mild electrolyte imbal-
ances (hypocalcemia and hyperkalemia) but the levels re-
turned to the normal ranges with postoperative treatment 
within two weeks (Table 1). There was mild edema around 
the abdominal incision, but this resolved. During hospital-
ization, the horse showed no signs of abdominal pain and 
a good appetite. The staples were removed from the ab-
dominal incision on day 15 after surgery and the horse was 
discharged. Follow-up at 1 year after surgery the horse re-
mained healthy without any clinical signs of gastrointesti-
nal disease.
Discussion
Postoperative intraabdominal adhesions are not an uncom-
mon complication consequence of abdominal surgery (4, 
5). Normally, the fibrinolytic capacity in the peritoneum ex-
ceeds the coagulation response so, abdominal adhesions 
do not occur under normal conditions (4). An imbalanced 
fibrinolytic system induced by specific causes, such as 
surgery and inflammation, damage to the mesothelial layer 
of the intestine, and reduced fibrinolytic activity, increases 
the risk of PIA (6). The earlier development of clinical ad-
hesions is related to a poorer prognosis for survival (5). 
In equine medicine, adhesions are more often associated 
with surgical trauma rather than the site of the primary le-
sion, resection, or endotoxemia (7). Pathological adhesions 
causing postoperative abdominal pain and intestinal ob-
struction have been reported in 9% to 27% of horses (2), 
and small intestinal strangulating lesions associated with a 
greater omentum were present in 2.3% (32/1413) of horses 
undergoing exploratory laparotomy for abdominal pain (3). 
The potential causes of SIO in horses include peduncu-
lated lipoma, herniation, epiploic foramen entrapment, 
incarceration within a mesenteric or omental rent, gastro-
splenic ligament entrapment, volvulus, and adhesions (5). 
In the present case, based on the physical examination and 
blood analysis, differential diagnoses were listed as small 
intestinal enteritis, impaction, obstruction, and strangulat-
ing intestinal lesions. The horse showed a sudden onset of 
gastric reflux and hyperlactatemia, associated with small 
intestinal ileus and poor tissue perfusion, respectively. 
Furthermore, ultrasonographic duodenal dilation, delayed 
CRT, color change of the mucous membranes, and hypo-
calcemia supported the differential diagnosis. Given the 
clinical findings, small intestinal strangulation and obstruc-
tion were considered as the likely cause, and OA-associated 
SIO was confirmed during surgery. 
Statistically, significant associations between the PIA rate 
and the following factors were identified in previous stud-
ies: surgical techniques, perioperative medications, and 
protective tissue coating solutions (1). Among the surgical 
techniques available, omentectomy has been advocated to 
reduce PIA (1, 3). In the present case, an omentectomy was 
not performed at the first abdominal surgery. As shown in 
this study, the omentum may lead to OA-related SIO, and 
omentectomy may be effective in preventing OA lesions. 
Broad-spectrum antimicrobials, NSAID, prokinetic agent, 
and intraperitoneal heparin were administered peri- and 
postoperatively in this study to minimize peritoneal and 
serosal inflammation. In addition, protective tissue coating 
solutions, such as hyaluronic acid (HA) and carboxymethyl-
cellulose (CMC), resorbable membranes, and postoperative 
Table 1: Postoperative blood examination results obtained while hospitalized. The factors important for a prognosis evaluation and out of the normal 
range were specified. Blood biochemical analyses were performed using the VS2 (Abaxis, USA) for CK, AST, TBIL, BUN, Creatinine, Calcium, and 
Potassium; the Accutrend Plus (Roche, Germany) for Lactate; and the Solo (EuroLyser, Austria) for SAA
Reference 
range Preoperation Day 1 Day 2 Day 3 Day 4 Day 5 Day 7 Day 11
SAA (mg/l) < 20 NA 2,063 1,912 1,502 1,112 NA 116.7 < 10
CK (U/l) 120–470 2,003 4,892 4,106 2,186 1,283 956 524 317
AST (U/l) 175–340 399 1,458 1,750 1,531 1,486 1,258 960 655
TBIL (mg/dl) 0.5–2.3 1.8 3.4 3.0 1.7 1.7 1.4 1.0 0.8
Lactate 
(mmol/l) 1–1.5 3.6 2.8 2.1 2.1 1.5 1.1 NA NA
BUN (mg/dl) 7–25 23 15 11 12 13 14 12 14
Creatinine 
(mg/dl) 0.6–2.2 1.5 1.1 1.1 1.0 1.2 1.2 0.7 1.0
Calcium (mg/
dl) 11.5–14.2 10.8 10.6 12.3 12.5 12.7 12.4 12.0 11.8
Potassium 
(mEq/L) 2.5–5.2 3.8 4.5 5.8 6.0 5.7 4.7 4.3 3.3
SAA, serum amyloid A; CK, creatinine kinase; AST, aspartate aminotransferase; TBIL, total bilirubin; BUN, blood urea nitrogen NA, not available
  Slovenian Veterinary Research 2024  |  Vol 61 No 2 |  141
abdominal lavage could have been used to prevent postop-
erative adhesions (1). 
Lidocaine was administered postoperatively (1.3 mg/kg 
IV as a bolus followed by a 0.05 mg/kg/min infusion) and 
was discontinued after confirming that the horse showed 
no signs of postoperative ileus, including gastric reflux on 
nasogastric intubation and abnormalities on abdominal ul-
trasonography. The horse showed no abdominal pain with 
normal intestinal borborygmi and good appetite toward to 
the hang hay nets outside the stall. Lidocaine is often used 
clinically as a constant rate infusion (CRI) for its potential 
analgesic, anti-inflammatory, and prokinetics properties 
(2). Although the prokinetic efficacy of lidocaine is still con-
troversial (2, 8), there are evidence that lidocaine improves 
postoperative reflux, hospitalization duration, time to the 
first fecal passage, and survival rate (9-12). In a meta-anal-
ysis of the recent literature, the use of lidocaine in horses 
undergoing gastrointestinal surgery for the small intestinal 
disease was associated with an increased survival rate (8). 
In addition, surveys showed that most (79%) ECVS/ECEIM 
and 68% of ACVS/ACVIM, and ACVECC diplomates use li-
docaine to treat postoperative ileus (13, 14). 
On admission, the horse showed elevated serum CK and 
AST concentrations pre- and postoperatively (Table 1). 
Elevated CK and AST activities in horses with colic are 
frequently associated with muscle trauma caused by ly-
ing down, thrashing, rolling, and trailering to hospitals (15). 
Evidence of hepatic and metabolic changes associated 
with CK and AST in surgical colic patients has also been 
reported (16). The horse in this study showed a significantly 
higher CK value postoperatively (Table 1). This was possibly 
attributed to the decreased renal and intestinal blood flows, 
which were less than 50% of the awake value during deep 
anesthesia, causing significant CK and AST elevations on 
the day after anesthesia (17, 18). 
In addition to the anti-inflammatory and prokinetic drug 
use, supportive care was conducted to enhance the post-
operative prognosis. Maintenance intravenous fluid of 
lactated Ringer’s solution was infused for five days. The 
horse showed hypocalcemia and hyperkalemia pre- and 
postoperatively (Table 1). Calcium gluconate and 50% dex-
trose were added to the fluid to improve electrolyte imbal-
ances. The horse received probiotics (Lactobacillus spp., 
Enterococcus spp., and Saccharomyces boulardii) for nor-
mal microbial flora restoring and protective benefits of in-
testinal pathogenic bacteria. Gastric protectants, such as 
omeprazole and famotidine, were administered after sur-
gery to prevent gastric ulcers. Hospitalized colic patients 
are frequently at increased risk of developing gastric ulcers 
associated with the administration of NSAID and treatment, 
stress, and feed deprivation (19). The highly effective treat-
ment of gastric ulcers using omeprazole is well described 
(2, 19). The anti-ulcer medication was discontinued after 
restoring normal feeding and appetite with no gastric re-
flux. Although gastric protectants were used to prevent 
postoperative gastric ulcers in this study, the potential risks 
associated with omeprazole administration, such as re-
bound gastric hyperacidity at the time of discontinuation, 
decreased calcium absorption during administration, and 
gastrointestinal toxicity related to the concurrent adminis-
tration with NSAIDs, have been suggested (20).
Conclusions
This case report describes a secondary SIO associated 
with an OA after end-to-end jejuno-ileal anastomosis in 
a thoroughbred horse. The obstruction was surgically re-
solved by transecting the adhesion and performing an 
omentectomy. These findings highlight the importance of 
recognizing and addressing OA as a potential cause of SIO 
after intestinal surgery in horses, underscoring the impor-
tance of preventing postoperative adhesions and applica-
tion of appropriate surgical techniques.
Acknowledgements
The authors thank all KRA staffs who participated in this 
study.
Conflict of Interest. The authors declare no conflicts of 
interest. 
Author contributions. Conceptualization: J Yoon, and T 
Park; Data curation: J Yoon, A Kim, YB Kwak, and J Park; 
Formal analysis: J Yoon; Resources: A Kim, and J Park; 
Supervision: I-S Choi, and T Park; Validation: J Yoon, I-S 
Choi, and T Park; Visualization: J Yoon; Writing-original 
draft: J Yoon; Writing-review & editing: J Yoon, YB Kwak, 
and T Park.
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Primer sekundarna obstrukcije tankega črevesa, povezane z adhezijo 
omentuma po jejuno-ilealni anastomozi pri čistokrvnem konju 
J. Yoon, A. Kim, J. Park, Y. B. Kwak, I.S. Choi, T. Park   
Izvleček: 19 mesečna čistokrvna kobila je imela akutno abdominalno bolečino. Pri starosti 4 mesecev so ji med abdomi-
nalno operacijo odstranili večino zadrgnjenega jejunuma in ileuma, ki so ju anastomozirali s tehniko konec s koncem. 
Pri kobili so nato diagnosticirali obstrukcijo ileuma kot posledico adhezije velikega omentuma, ki je vodila v mehansko 
zaporo lumna distalnega ileuma. Ileum je bil sproščen s prerezom adhezije in izvedbo omentektomije. Po kirurškem 
posegu je kobila hitro okrevala in bila po petnajstih dneh odpuščena iz veterinarske oskrbe. Ta klinični primer opisuje ob-
strukcijo ileuma zaradi adhezije omentuma po jejuno-ilealni anastomozi pri čistokrvni kobili. Opisani so klinični, slikovni 
in kirurški izvidi. 
Ključne besede: kolika; konj; jejuno-ilealna anastomoza; adhezija omentuma; obstrukcija tankega črevesa