EQUINE VETERINARY EDUCATION 1

Equine vet. Educ. (2020)  () -

Clinical Commentary
Expanding the definition of nephrosplenic entrapment
A. Munsterman*
School of Veterinary Medicine, University of Wisconsin, Madison, Wisconsin, USA
*Corresponding author email: amunsterman@[Link]
Keywords: horse; colon; small intestine; gastrointestinal surgery; nephrosplenic

Nephrosplenic entrapment, when defined in equine other studies have noted a prevalence of this condition in
abdominal emergencies, is typically thought of as a the Thoroughbred (Livesey et al. 1988; Baker et al. 2011).
condition affecting the ascending colon (Southwood 2019). Similarly, there may be a predilection for small intestinal
As the colon displaces, the left dorsal and ventral colons entrapment in horses with a large frame. However, the depth
migrate between the spleen and body wall and move of the nephrosplenic space may also be an important factor
dorsally to rest over the nephrosplenic ligament as it courses for retaining viscera in this position (Burba and Moore 1997;
horizontally between the base of the spleen and the left Marien et al. 2001; Ro € cken et al. 2005; Lindegaard et al.
kidney. Nephrosplenic, or renosplenic, entrapment of the 2011). Future investigation of the cause of entrapment may
colon was first described in the literature in 1902 and is a require improved mapping of the topography of this region
common form of large colon displacement (Marek 1902; to further delineate horses at risk of entrapment of any
Hardy et al. 1994; Burba and Moore 1997). However, the portion of the intestine.
ascending colon is not the only portion of bowel that is free Age of the horse has been identified as a significant
to migrate in the abdomen and can potentially reach this variable affecting the long-term outcome after nephrosplenic
space. entrapment of the ascending colon (Nelson et al. 2016).
In this issue of EVE, Gandini et al. (2019) present a case of However, others have not identified this association
a strangulating nephrosplenic entrapment of the jejunum in a (Lindegaard et al. 2011). The median age of horses with
juvenile Thoroughbred gelding. Entrapment of the small nephrosplenic entrapment of the ascending colon has been
intestine has been reported previously in the literature, reported as between 8 and 10.2 years and ranged from
demonstrating that small intestine can move dorsal to the 7 months to 36 years (Barrell et al. 2011; Lindegaard et al.
nephrosplenic ligament, as well as become lodged in this 2011; Nelson et al. 2016; Gillen et al. 2019; Are  valo Rodrıguez
position. Wheat initially described this condition in 1972 and et al. 2019). Horses in the case report by Goodrich et al.
noted both small intestine and small colon can become (1997) describing small intestinal entrapment in the
entrapped in the nephrosplenic space. This report specifically nephrosplenic space were 6 and 14 years of age, whereas
mentions one horse where 5.5 m of small intestine passed the horse in the current report (Gandini et al. 2019) was
through the space; however, further details and the outcome 2 years of age. Similar to ascending colon entrapment, there
of this case are not provided (Wheat 1972). More recently, does not seem to be an age predilection, but the numbers
Goodrich et al. (1997) described two horses in a case report are too low at this time to be definitive. At this time, the long-
with small intestinal nephrosplenic entrapment. In addition, term outcomes of any case of small intestinal entrapment in
the retrospective report by Nelson et al. (2016) noted the the nephrosplenic space has not been reported, therefore
presence of small intestine in the nephrosplenic space as an speculation as to the effect of age on survival cannot be
incidental finding. Finally, a single report of a small intestinal made.
nephrosplenic entrapment resulting in the resection of 1.5 m Transrectal palpation of a taenia band coursing over the
of compromised bowel has been reported (Porzuczek et al. nephrosplenic ligament is a characteristic finding often used
2012). While the incidence of small intestine displaced into to diagnose nephrosplenic entrapment of the ascending
the nephrosplenic space is likely underreported in the horse, colon prior to surgery, with an accuracy between 61.2 and
the concurrent finding of entrapment with clinical signs of 72% (Burba and Moore 1997; Nelson et al. 2016). However,
abdominal disease requiring surgical intervention appears to the potential for misdiagnosis may be high (Gillen et al. 2019),
be rare. especially if the colon is severely distended with ingesta or
Identification of entrapment of the small intestine in the gas, as the nephrosplenic space may not be palpable (Baird
nephrosplenic space prior to surgery appears to be difficult, et al. 1991; van Pelt 1993). The nephrosplenic ligament is also
based on the information currently available. Regarding difficult to palpate in larger horses. The second finding
signalment, in the case report by Goodrich et al. (1997) both common in transrectal palpation of horses with nephrosplenic
horses were Thoroughbreds, similar to the horse presented in entrapment of the ascending colon is that the spleen is often
the case report by Gandini et al. (2019). While a small displaced medial and ventral, due to the weight of the large
number of cases do indicate a trend, the breed predilection colon on the base of the spleen and across the
for these cases of small intestinal entrapment is similar to what nephrosplenic ligament. Similarly, this was reported in one of
has been identified in horses with nephrosplenic entrapment the cases with small intestinal entrapment (Goodrich et al.
of the ascending colon. Warmbloods, Thoroughbreds and 1997). Therefore, the position of the spleen ventral and
geldings are overrepresented when compared to the caudal on rectal palpation may be associated with weight
general hospital population presented for colic (Hofmeister of a portion of the intestinal tract across its base, regardless of
et al. 1998; Lindegaard et al. 2011; Nelson et al. 2016), and the segment of bowel involved.

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Overall, transrectal palpation was nondiagnostic in all contamination. One of the two horses in the report by
three reported cases of small intestinal entrapment found at Goodrich et al. (1997) had an abdominocentesis performed,
surgery (Goodrich et al. 1997; Gandini et al. 2019). In two which resulted in a haemorrhagic splenic puncture. An
horses, transrectal palpation noted small intestinal distention, abdominocentesis was not performed in the current case
consistent with an obstructive lesion. However, due to the report (Gandini et al. 2019), but if abdominal fluid was
degree of small intestinal distention in the current case, obtained, it likely would have assisted in confirming a
Gandini et al. (2019) were unable to palpate the strangulating lesion prior to surgery. When electing to perform
nephrosplenic ligament to identify if the small intestine abdominocentesis, a transabdominal ultrasonographic
travelled dorsal to the structure. In the horse with small examination would allow for identification of the ideal
intestinal distention reported in Goodrich et al. (1997), the location for sample collection to avoid interference by the
spleen was not displaced, and the colon appeared to be spleen.
heading towards the nephrosplenic ligament similar to the At surgery, the authors in the present report (Gandini et al.
classic definition of ascending colon entrapment. However, 2019) diagnosed a strangulating obstruction of the distal
the nephrosplenic ligament could not be palpated to jejunum, caused by nephrosplenic entrapment of the small
confirm entrapment of the colon, and this horse also had intestine by a fibrous band in the caudal aspect of the
moderate small intestinal distention. nephrosplenic ligament. The intestine was deemed nonviable
Ultrasonography has been described as strongly on visual examination, and a jejunojejunostomy was
supportive of the diagnosis of a nephrosplenic entrapment of performed. In the report by Goodrich et al. (1997), the
the large colon when the classic images are obtained intestine in both cases described was deemed viable at
(Santschi et al. 1993; Johnston 1996). The observation of an surgery, with a grade 2 mucosal injury score described
echogenic shadow consistent with the appearance of gas (Freeman et al. 2014). In both of these horses, the bowel
within the colon present between the spleen and abdominal coursed in a cranial to caudal direction; an additional finding
wall has been described as consistent with displacement of in one horse was a concurrent 180 degree volvulus of the
the large colon to the left and dorsal, whereas obliteration of affected jejunum. The nature of the entrapment was not
the view of the left kidney supports the diagnosis of a identified in the current case (Gandini et al. 2019).
nephrosplenic entrapment. Transabdominal ultrasonography Interestingly, in the horses described anecdotally by Wheat
has been reported to have observed distended, amotile (1972) with nephrosplenic entrapment of the small intestine,
loops of small intestine between the spleen and left kidney in the bowel passed in a caudal to cranial direction, contrary to
a single case of small intestinal strangulation in the that reported by Goodrich et al. (1997). Additional cases will
nephrosplenic space (Porzuczek et al. 2012). Therefore, small be needed to further describe this type of small intestinal
intestinal distention in the left dorsal quadrant may support lesion, and any trend in pathogenesis.
the diagnosis of nephrosplenic entrapment, similar to what is A unique aspect of the current report was the decision to
observed in the right dorsal abdomen in epiploic foramen close the nephrosplenic space (Gandini et al. 2019). The
entrapment (Scharner et al. 2002). Future cases that include authors indicated that they suspected that the horse had
these tools in the diagnostic work-up may be able to better undergone repeated nephrosplenic entrapments, resulting in
provide a presurgical picture of these unusual nephrosplenic inflammation and the formation of adhesions that caused the
entrapments. small intestinal strangulation. While this horse had no history of
Further diagnostics are often recommended to help previous colic, one gelding in the report by Goodrich et al.
identify the cause and severity of gastrointestinal disease in (1997) was noted to have frequent, mild episodes of colic,
acute colic. Nasogastric intubation was performed in all three which were responsive to treatment with flunixin meglumine
horses in these case reports (Goodrich et al. 1997; Gandini alone. None of the horses in these case reports were
et al. 2019) but was negative for net gastric reflux in two diagnosed with a left dorsal displacement or nephrosplenic
horses. Reflux is often variable in horses with nephrosplenic entrapment prior to the surgery for small intestinal
entrapment of the ascending colon and may be associated entrapment.
with either severe colon distention or displacement of the Recently, it has been reported that closure of the
colon between the stomach and the liver (Milne et al. 1977; nephrosplenic space was found to reduce the risk of
Van Pelt 1993). However, net nasogastric reflux more often reoccurrence of colic after diagnosis of nephrosplenic
results from small intestinal obstruction and will vary entrapment (Nelson et al. 2016; Are  valo Rodrıguez et al.
depending on the site and severity of the obstruction and 2019). Are valo Rodrıguez et al. (2019) noted that in 42 horses
duration of the lesion. Therefore, the presence of net reflux is where closure of the nephrosplenic space was performed,
often not able to definitively distinguish between the type of the odds of recurrent colic were significantly lower in horses
entrapped bowel. with laparoscopic closure of the nephrosplenic space
Abdominocentesis can be effective as a tool to further (OR = 0.325, P = 0.02) compared to horses without closure. In
evaluate nephrosplenic entrapment of the ascending colon, addition, when colic was observed post-surgery, none were
as it is often clinically normal and indirectly supports this confirmed as a left dorsal displacement of the large colon.
diagnosis. However, ischaemic necrosis of the entrapped While the evidence is supportive, these findings must be
colon has been described, indicating a role in diagnosis and considered in light of the fact that these are owner
prognostication (Huskamp and Kopf 1980; Foerner 1982; Testa observations in a follow-up period spanning 11 years. Similar
and Hilbert 1987). One observation in horses with observations were reported by Nelson et al. (2016) in 29
nephrosplenic entrapment of the ascending colon is that horses with closure of the nephrosplenic space, with 86% of
ventral displacement of the spleen may make it difficult to owners reporting less frequent colic signs than before surgery,
obtain a diagnostic peritoneal fluid sample without and 97% reporting no further episodes of nephrosplenic
accidental trauma to the spleen, resulting in blood entrapment. While a history of colic was not identified in the

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current case (Gandini et al. 2019), the closure of the Gillen, A.M., Munsterman, A.S. and Hanson, R.R. (2019) Evaluation of
nephrosplenic space may help to prevent reoccurrence of phenylephrine and exercise with or without trocarization for
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1111/eve.13206

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