PROBLEM SOLVING APPROACH TO THE RABBIT CASE
JOANNA HEDLEY
The domestic rabbit (Oryctolagus cuniculus) originated from the European wild rabbit. Many
different breeds and colours have been developed so appearances can be variable, however
even these pet rabbits retain the wild instincts of a prey animal. Consequently, they
commonly hide signs of pain or disease which can make diagnosing and treating their
problems a challenge. Any sign of illness or abnormal behaviour could indicate a serious
underlying problem and rabbits are commonly presented to the veterinary clinic in a critical
condition.
Any sick rabbit should be seen as soon as possible even if clinical signs appear minor. A full
husbandry and diet history should be taken, in addition to a normal medical history, as
husbandry and diet deficits are a common cause of medical problems. Observation from a
distance is an important part of physical examination, as rabbits will often hide their signs on
the consult room table. A full physical examination should also include listening for gut
sounds and checking the teeth with an otoscope.
Diagnostic approach
Every veterinary surgeon has their own methods of dealing with the cases which are
presented to them. For example, in small animal practice when working with commonly seen
species such as dogs and cats, similar presentations may be seen repeatedly and in many
cases, the experienced clinician may be able to quickly “match” the presentation with the
most likely diagnosis and treat appropriately. This pattern recognition approach however
relies on having encountered this presentation previously, as well as reaching a correct
diagnosis each time, so can be an error-prone method for the less experienced clinician. This
approach may also be ineffective when faced with less common or more complex disorders
or those with fewer “typical” clinical signs. Instead in recent years, problem based clinical
reasoning has become a popular approach. The logic is that each of the patient’s problems are
assessed separately in a structured way before deciding if they all originate from the same
underlying cause. There are several stages to this process as can be demonstrated by looking
at how it can be applied to some common presentations in rabbits.
The dyspnoeic rabbit
1. Define the problems
Rabbits with respiratory disease may present with a number of problems, but it is easiest
to start by examining the most specific problem initially. For example if presented with a
lethargic, inappetant, dyspnoeic rabbit, dyspnoea is the most specific clinical problem to
investigate.
2. Define the body system affected and how it is involved
Dyspnoea is usually linked with the respiratory system but this is the stage to determine
whether this is due to a primary problem of that system or a secondary problem due to
other factors. For example, is the dyspnoeic rabbit suffering from a primary respiratory
problem, a cardiac problem or actually dyspnoeic due to another factor such as pain, heat
stress or a mass restricting ventilation? Sometimes this may be obvious on history and
clinical examination or alternatively further diagnostics may be necessary to confirm.
However if performing diagnostics at this point, they can be targeted to answer a set
question (e.g. Is this a respiratory or non-respiratory problem?) rather than a general
screen, increasing the chance of selecting the most appropriate diagnostic test to obtain
and be able to interpret useful results.
3. Define the location
Having determined the body system involved, the next stage is to determine the location
within that body system. For the rabbit, this may be determining whether a respiratory
problem involves the upper or lower respiratory system or both. This may be obvious on
history taking and clinical examination or further diagnostics may be necessary, but
again, this helps us target use of diagnostics. For example, taking a deep nasal swab may
be helpful if an upper respiratory problem is suspected, but is unlikely to yield useful
information if this is primarily a lower respiratory problem.
4. Define the lesion
Once the location of a problem is determined, the final stage is to identify the underlying
pathological lesion. Is the pathology due to an infectious, inflammatory, traumatic, toxic,
degenerative or neoplastic cause? Having localised the problem the differential list is
generally much shorter and the appropriate resources can be used to logically identify the
final underlying cause or combination of causes. We may not always get a full
histopathological diagnosis in every case but aim to reach an understanding of the most
likely cause based on more than random guesswork.
Following this approach, treatment may be selected based on the most likely cause. For
example, for a rabbit with an upper respiratory tract infection, the most common pathogen
involved is Pasteurella multocida. This would ideally be confirmed on culture, but in many
cases, this bacteria can live as part of the commensal respiratory tract flora and only causes
problems when the animal is under stress, has concurrent disease or is immunocompromised
for another reason. Environmental factors such as inadequate ventilation, poor hygiene or
overcrowding may also contribute. It is always important therefore to address not just the
most obvious cause of an infection, but also any predisposing factors to treat the problem
holistically and prevent signs recurring again in future. More specific treatment may include
antibiotics (ideally based on culture, but otherwise tetracyclines or trimethoprim-
sulphonamides are appropriate first-line choices), anti-inflammatories, nebulisation and
mucolytics.
The rabbit in “gut stasis”
Reduced faecal output is one of the most common reasons for a pet rabbit to be presented in
practice and is often accompanied by reduced appetite and described as the rabbit being in
“gut stasis”. It is important to appreciate that gut stasis in a rabbit is only a clinical sign, not a
diagnosis and often occurs as a consequence of another problem. Common causes of “gut
stasis” include stress, primary gastrointestinal disease, dehydration, toxin ingestion, dental
disease and any cause of pain or systemic disease to name but a few. In presentations such as
these, a logical problem solving approach can therefore be particularly useful to help the
clinician concentrate on the most likely causes.
1. Define the problems
Is faecal output reduced or completely absent? Are there any changes in appetite and if so
was it the reduced faecal output or reduced appetite which occurred first or were they
both noticed simultaneously? If reduced appetite was the predominant sign, was this a
reluctance or inability to eat? An inability to eat usually indicates underlying dental
disease or sometimes another oro-facial lesion whereas a reluctance to eat has many more
potential causes.
2. Define the body system affected and how it is involved
Primary gastrointestinal disease should be strongly suspected if there is:
History of poor diet / dietary change
An abnormality is palpable in the gut, e.g. foreign body
The onset of gut stasis preceded any development of signs of malaise – depression
and/or anorexia
Secondary gastrointestinal disease may be suspected if there is:
An obvious source of pain, e.g. dental disease
Other clinical signs, e.g. drinking excessively
3. Define the location
If a primary gastrointestinal problem is suspected, the next stage is determining which
part of the gastrointestinal tract is primarily affected. This may be by abdominal palpation
or may need to be confirmed by imaging.
4. Define the lesion
Ideally at this point the problem will have been localised and the lesion can be identified.
Dental lesions for example can usually be easily localised and treated. In some other
cases however, confirming a definitive diagnosis would require exploratory surgery
which may not be possible or even desirable for every rabbit in “gut stasis”. In these
cases, it is more important to work through the logical steps to exclude all except the most
likely cause or causes in this multifactorial problem.
A problem solving approach will help determine both the most likely cause of the “gut stasis”
and whether medical or surgical treatment will be required. Stabilisation will be critical for all
cases. This may need to include supplementary warmth, fluid therapy, nutritional support and
analgesia +/- prokinetics. More specific treatment can then be given depending on suspected
diagnosis.
The rabbit with urinary incontinence
Urinary incontinence is a common condition in rabbits and differentials include cystitis,
urolithiasis / “sludgy urine syndrome”, renal disease, spinal disease, prostatic disease,
neoplasia and Encephalitozoon cuniculi infection.
1. Define the problems
Owners often struggle to define true urinary incontinence in a rabbit. Animals may be
presented for inappropriate urination habits or urine-soaked fur around their perineum.
Careful history taking and examination may be needed to determine if this is true urinary
incontinence or just inappropriate urination? Is the bladder fully emptying or just
overflowing? Is the rabbit straining to pass urine at times? Does the urine have a normal
appearance? Are there any other specific problems such as excessive drinking?
2. Define the body system affected and how it is involved
Are the signs due to primary urinary system pathology or could they be secondary to
pathology elsewhere in the abdomen or disease of the neurological or musculoskeletal
system? An abnormal appearance to the urine may be visualised or the kidneys or bladder
may feel abnormal on palpation leading to suspicion of a primary urinary problem.
Alternatively the animal may be struggling to move or groom normally leading to
suspicion of primary neurological or musculoskeletal disease.
3. Define the location
If a primary urinary system problem is suspected, the next stage is determining which part
of the urinary tract is affected. X-rays are usually the first step, ideally accompanied by
ultrasound.
4. Define the lesion
Ideally at this point the problem will have been localised and the lesion can be identified
and treated. If renal dysfunction is suspected then further urinalysis and bloodwork
including E. cuniculi serology may be helpful.
The approach to treatment of these cases will vary considerably depending on the underlying
cause, but supportive treatment such as analgesia and treatment of any secondary dermatitis
should be provided. Owners may also have to be prepared that in many cases, rabbits may
need long-term assistance with grooming and to monitor for signs of flystrike.