constant gas pain - surgery?!

Question
QUESTION: Dear Dana,
I wrote to you a few months ago about BB who has been getting very frequent gas episodes which started 6 months ago. Three months ago we put her on a hay and pellet diet (cut out all veg), the loud gut sounds disappeared and the episodes became less frequent but in the last month or so they have become more frequent again. She looks miserable most evenings now (she sleeps all afternoon), lying in litter tray, pressing belly to floor, not eating. I give her simethicone, belly rubs (although she only tolerates it for 5 minutes, hates being picked up) and usually after a few hours she will start eating a bit.
When she is not in pain, BB is a happy bunny and she has had normal droppings throughout all of this.
We had an x-ray in March and 3 x-rays of the skull (to make sure again there are no dental problems) and abdomen last week. The vet can't see anything abnormal. We had a blood test in March (results below), apparently normal apart from high potassium), fecal float last month (results below), also apparently normal.
There is some white stuff in BB's urine but if she had bladder sludge presumably that would show up on the x-ray? I think she doesn't drink enough and now she doesn't get veg...
The vet has now put her on gut motility drugs (Zantac and metoclopramide) as well as liquid paraffin but I doubt it's doing any good and I am worried about using these drugs in any case.
I am told that the next thing would be surgery (!) which I'm really worried about. They think there may be impactions. Would impactions show up in an ultrasound?
I want to do whatever I can to avoid surgery. Is there anything else that should be tested/done before we resort to surgery? I can't really understand why surgery when we don't know for sure there is an impaction/foreign object and if so where it is.
Please help, I am desperate and totally exhausted after 6 months of this.
Many thanks!
Best wishes,
Diane
         BIOCHEMISTRY
Total Protein          56          g/L          (49.0-71.0)
Albumin          37          g/L          (27-50)
Globulin          19          g/L          (15.0-33.0)
Albumin/Globulin          1.95         ratio
Total Bilirubin          5          umol/L          (2.6-17.1)
ALT          57          IU/L          (27.4- 72.2)
Alkaline Phosphatase         35          IU/L          (0   -150  )
Urea          8.0          mmol/L          (6.14-8.38)
Creatinine          89          umol/L          (44.2-229)
Calcium          3.57         mmol/L          (3.0-4.20 )
Phosphorus          * 0.87         mmol/L     Low  (1.0-1.92)
Glucose          6.9          mmol/L          (4.2  -7.8  )
Cholesterol          0.9          mmol/L          (0.207-2.538)
Amylase          * 139          IU/L       Low  (300 - 1500)

Sodium          141          mmol/L          (138-150)
Potassium          * 7.6          mmol/L     High (3.3-5.7)
Chloride          112          mmol/L          (92-120)

         HAEMATOLOGY
Red cell Count          5.53         10^9/ml         (4.0 -7.0 )
Haemoglobin          11.8         g/dl          (10.0 -15.0 )
PCV          35.8         %          (31   - 45  )
MCV          64.7         fl          (60   - 69  )
MCH          21.3         pg          (19   -22   )
MCHC          33.0         g/dL          (33.0 -48.0 )
WHITE CELL COUNT          6.52         10^6/ml         (5.2  -10.0 )
Neutrophils          * 29.9%  1.95  10^6/ml    Low  (2.1  - 8.1 )
Lymphocytes          61.5%  4.01  10^6/ml         (2.0  -8.6  )
Eosinophils          0.8%  0.1   10^6/ml         (0  -0.8  )
Basophils          4.4%  0.3   10^6/ml
Monocytes          3.4%  0.2   10^6/ml         (0.1  - 1.8 )
         Erythrocytes appear normal.
         Leukocytes appear normal.
         Mild neutropenia
         Small clot in EDTA.

Faecal Analysis
McMaster          <100 Ova/Gram (none seen)
Starch granules          Not seen
Fat globules          Not seen
Faecal Bacteriology
Salmonella          Not isolated
Campylobacter          Not isolated
Other organisms          Scant growth of Enterococcus sp. cultured after 48
         hours incubation.

ANSWER: Dear Diane,

My big question is:  What could possibly be gained by surgery?  One simply does not do exploratory surgery on rabbits.  You might as well just euthanize.  :(  The suggestion of exploratory surgery makes me wonder if the vet you are seeing is more familiar/experienced with dogs and cats, in which exploratory surgery is not as much of a big deal.

I would strongly suggest you get your bunny to a very rabbit-savvy vet.  If possible, if you are close enough to get there, Dr. Frances Harcourt-Brown.

Dental problems often do not show up on radiograph, and especially molar spurs.  Those need to be seen visually with an otoscope.  Please see:

http://www.bio.miami.edu/hare/dental.html

The spurs can be subtle, and an inexperienced vet might not think they are problematic.  But if the *rabbit* thinks they are, then case closed.  Some rabbits are just more sensitive to mouth pain than others.

You can find Dr. Harcourt-Brown's contact information here:

http://any-uk-vet.co.uk/harcourt-brown/index.htm

If she is too far from you, she may be able to recommend a rabbit-savvy vet who can help you closer by.  

I hope this helps.

Dana




---------- FOLLOW-UP ----------

QUESTION: Dear Dana,
Thanks for your fast response. I was/am extremely reluctant to go along with the surgery suggestion.
The vet has checked the teeth 3 or 4 times now - with an otoscope - and they are fine.
I wish I lived near Dr. Harcourt-Brown but it is just too far. But I will email her and ask her to recommend someone. Thanks for the encouragement.  
My vet has been in touch with a top rabbit vet (advisor to the rabbit welfare association). He thought low phosphorus might indicate EC. He seems to be suggesting ultrasound to look for partial obstruction, neoplasia or abscessation of gut or adhesions (from spay). Apparently a laporoscopy or laporotomy (please, no!) might be necessary to find out what's going on. What would you do? Go for the ultrasound? Or MRI? Do you think it makes sense to continue with the gut motility drugs and liquid paraffin? How long for?
Many thanks for your help!
Best wishes,
Diane

Answer
Dear Diane,

The vet may have checked the teeth, but may also not know what to look for.  Buccal spurs can be quite subtle, but quite painful.  Check out the illustration on the web site I sent:

http://www.bio.miami.edu/hare/dental.html

I cannot see any justification for surgery.  What would the vet hope to see or accomplish?  Rabbits form adhesions if you SNEEZE at them, so this could just make things worse.  If this were my rabbit there is NO WAY I would allow an exploratory surgery.  There are just too many reasons to say NO.

Low phosphorus can be an artifact.  We've never seen it associated with any pathology, and I think the vet might just be guessing at this point.  

Ultrasound sounds reasonable, as long as you have someone who's very good at interpreting the images.  But just say NO to surgery.

As for GI motility drugs, I hardly ever use them any more.  Instead, we use an enema to trigger GI motility, and it works like a charm.  NO French catheters!  Just a shallow insertion (1/4") into the anus and gentle expression of lukewarm water with a lubricated ear syringe/bulb like this:

   http://tinyurl.com/lwfvsyg

Works like a charm!  I'm going to be producing a video of the procedure soon, since it is so freakin' useful.  Simethicone is also good.y

Hope it works for you.

Dana