Advice needed ASAP for ileus treatment/recovery

Question
QUESTION: I'm writing to you about my poor little Mina again.  She's
the 10-11 year old female who got a mammary tumor removed
about two months ago.  She's unfortunately had a few other
problems since then.

About two weeks ago, her appetite dropped off significantly,
and her droppings were smaller very suddenly.  I took her to
the vet right away, who discovered a molar spur on her back
left molar.  He took care of the molar the next day, but
during the procedure, he found that it had caused an abscess
on the inside of her mouth, and so she was prescribed with
Baytril to take once per day for 2-3 weeks.  I was told to
give her Enercal twice daily until she was eating normally
again, but if she wasn't eating normally in a week, to take
her back.  

She was eating *very* little, and only soft foods.  She
tolerated the Enercal, and she was drinking normally, but
her droppings were either very small or nonexistent.  She
passed some white foamy substance Monday night, so I didn't
want to wait the full week to take her back to the vet.  

I took her back, and he said that if we didn't get her
eating roughage again ASAP, she wasn't going to make it.  
(This was Tuesday of this week.)  On the brighter side, he
said the abscess was gone, and there was still just a bit of
swelling.  He was impressed with how well that healed up for
her.  He said her tummy felt very empty, and there was no
suspicion of a blockage, that her body was just simply
becoming used to not digesting food and so wasn't working
properly.  I pressed him to give her some kind of pain
relief, but he didn't want to.  I've been giving her
simethicone and tummy massages to help her out instead.

I was told to take her home and start force feedings of a
mixture of Enercal, papaya tablet, Laxatone, and yogurt,
mixed with a bit of water.  The mixture makes about 12 ml of
fluid, and I was supposed to give this to her twice a day.  
Mina is only a little under 3 pounds...she just can't take
in that much all at once, so I was spacing the feedings out
throughout the day, giving her about 3 ml at a time, every
few hours.  (Whenever I tried any more than that, she would
refuse to swallow!)  

By the next morning, she was eating romaine lettuce again!  
Over the past 3 days, her appetite has been improving, and
she's been eating a little more each day on her own, mostly
of the romaine lettuce, and tiny amounts of pellets.  She
has no interest in hay right now, and while she wants
treats, I don't want to give her the added sugar.  She's
still drinking and peeing like a champ, and I've been adding
a bit of unflavored Pedialyte to her water.  Last night, she
left me 13 beautiful droppings!  They are still smaller and
harder than her usual healthy ones, but it's a major
improvement over the mucusy and/or lack of droppings she was
producing before.

I read your article on ileus, and it has proved a *major*
help to me over these past two terrifying weeks.  However, I
have a few concerns.  

1.  Mina is perking up a lot, and her energy levels are
almost back to normal, but she's still showing signs of pain
off/on throughout the day.  I want to do everything I can
for her.  Do you have any other suggestions to make her more
comfortable right now until she gets back to feeling 100%
again?

2.  I'm really concerned over this force feed mixture I'm
giving her, as it is packed with sugar, and yogurt.  I've
ordered some powdered probiotic powder, which should arrive
on Monday, and will use that instead.  But what about all
the sugar?  Is it doing harm to her GI system even though it
seems to be helping?

3.  Also concerning the force feed, as her appetite
improves, I was told I can start to slowly taper off the
frequency of the force feedings.  She's getting around 20 ml
a day of this stuff so far, and I'm going to decrease that a
bit today, as she seems to be doing so well.  I'm nervous
about tapering it off too quickly!  Do you have any
suggestions on how to best measure that?

4.  The vet said that the tooth problem is odd because he
examined her teeth when she was in for the tumor surgery on
October 5 and the teeth looked fine.  I understand their
teeth grow pretty fast, but it seems strange such a problem
developed so quickly!  Also, since she never had tooth
issues before, the vet found it odd that she'd develop it so
late in life, and feels that maybe something between the
time of the surgery and now has upset something in her to
make this happen.  He wouldn't elaborate, except to say that
we will be keeping a close eye on her with this from now on.  
Do you have any idea what he could be talking about?  It was
just the one molar, and the wound/abscess was on the inside
of her mouth, completely invisible from the outside.

I'm sorry for the novella here!  I've never had to go
through this with her before, and I know how serious ileus
can be, so I really don't want to mess a single thing up!  
I'd also like to be ready for the tooth problem popping up
again in the future and don't want her to have to go through
this painful ileus again if at all possible!

Thank you so much for your help!

ANSWER: Dear Jennifer,

I'll tackle each question in turn:

1.  Do you have any other suggestions to make her more
comfortable right now until she gets back to feeling 100%
again?

Is she on any pain medication?  Metacam and tramadol can be a godsend in a case like this.  Also, don't forget the simethicone suspension to relief gas pain.  Gentle tummy massage will make her feel a lot better if the source of her pain is her abdomen/GI tract.

2.  But what about all the sugar?  Is it doing harm to her GI system even though it seems to be helping?

It's good to keep her eating *something*, but a slowed GI tract loaded with digestible carbs can be a real gas factory, and that might be why she is intermittently uncomfortable.  Simethicone will help, as will tummy massage.  

Is she producing poops yet?  If not, a shallow enema can work veritable miracles.  Instructions for that can be found in the ileus article.  Just be very, very careful and gentle, never force anything, and NEVER go any deeper than about 1/4" beyond the sphincter with the tip of the ear syringe.

3.  Also concerning the force feed, as her appetite
improves, I was told I can start to slowly taper off the
frequency of the force feedings.  She's getting around 20 ml
a day of this stuff so far, and I'm going to decrease that a
bit today, as she seems to be doing so well.  I'm nervous
about tapering it off too quickly!  Do you have any
suggestions on how to best measure that?

Don't force her to eat more than she will readily take.  If she's still eating it readily, then give her as much as she wants.  She will taper off naturally, and when you notice her regular eating is back to normal, you can stop the force feeding.

I wouldn't use a sugar/yogurt goo, though.  Instead, you can make your own emergency food by putting her normal pellets in a bit of warm chamomile tea to "fluff" them, and then add enough water to make a slurry that will pass easily through a wide-bore dropper or syringe.  That will give her more fiber and less sugar, and help speed her recovery.

4.  The vet said that the tooth problem is odd because he
examined her teeth when she was in for the tumor surgery on
October 5 and the teeth looked fine.  I understand their
teeth grow pretty fast, but it seems strange such a problem
developed so quickly!

We have several bunnies (and hares) with malocclusions.  The incisors need to be trimmed once every two weeks, and molars usually need to be addressed once a month, depending on the severity of the individual's problem.

It is quite possible that Mina had the abscess first, and *that* caused the molar spur to develop because the tooth was loose.  If she continues to show signs of pain, the other teeth should be checked for signs of infection, and if she still has problems, the antibiotics might need to be continued.

5. Also, since she never had tooth issues before, the vet found it odd that she'd develop it so late in life, and feels that maybe something between the time of the surgery and now has upset something in her to make this happen.

Late in life is *exactly* when rabbits start to show signs of non-congenital dental problems.  Bone loss (especially in spayed females), infections, other aging processes can cause the molars to become slightly loose in their sockets, and as the bunny chews, they will wear unevenly and develop spurs.  It is not at all unexpected for this to happen once a bunny reaches the age of 5-6 years.  The older the bunny, the more likely s/he'll have acquired dental problems.

6. He wouldn't elaborate, except to say that we will be keeping a close eye on her with this from now on.  Do you have any idea what he could be talking about?  It was just the one molar, and the wound/abscess was on the inside of her mouth, completely invisible from the outside.

It sounds as if your vet is attentive and a great advocate for your bunny.  And yes, it's wise to keep a close eye out for any futher molar problems, as these can quickly elicit GI slowdown and all the problems you just experienced.  The first sign can be as simple as her refusing a favorite treat, or developing picky eating habits.  If you see that, it's time for another molar check.

Hope this helps!

Dana



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

QUESTION: 1.  She isn't on any pain medication.  I did ask the vet to
give her some, but he didn't want to, and urged that the
important thing was to get her appetite going.  I do
understand the importance of that, but I wasn't pleased that
he wouldn't help her with the pain.  Tummy rubs and
simethicone do help her, but it's still so hard to see her
in pain and to know there's nothing else I can do for her.  
:(

2.  She is producing poops.  They are smaller and harder
than her normal healthy ones, but they are coming out pretty
regularly now.  Is it normal for a bunny going through ileus
to feel pain during the passing of poop?  It seems like
she'll be perky, then eat, and then shortly after eating, go
into one of her "trances" where she sits, stares, and grinds
her teeth for awhile, not moving.  After doing this for
awhile, she'll move again, and there's almost always a small
pile of poops left where she was sitting.

3.  Thank you!  I'll take your advice on the force feedings.  
Do you think vegetable baby food or canned pumpkin is ever a
good idea for the force feedings as well?

4.  I think you're right, and that there is something more
to her tooth problem.  She eats some foods normally now, but
she still has trouble with the hard pellets, and seems to be
bugged by those.  She won't touch her hay, and usually loves
that.  She wants romaine lettuce more than anything, and
that does seem to be helping her pass poops more easily.  

5.  Do you think it's at all possible that the pain she felt
from her tumor surgery made her grind her teeth more, and
maybe loosened her molar, thus causing the tooth problem?  
The vet insists that this problem wasn't there at the time
of the surgery, and she really did only show signs of it
recently.  But even with the tooth trimming, something still
seems off.

I've noticed that when she's hunched in pain, she'll start
chattering her teeth rapidly (it's so fast, it's really like
a vibration sound), and then will stop herself with a
strange expression on her face, followed by a sneeze.  The
sneezing only happens when she's grinding/chattering, so I'm
thinking something with her teeth is causing that?  She
doesn't have any nasal or eye discharge--just the sneeze!

6.  He has been great for the most part, but I can't really
call him entirely rabbit savvy as they do tell you to fast a
bunny before surgery.  :(  Still, the closest rabbit savvy
vet on that list is an almost two hour drive from me, so
this guy is my best bet.  I'm mostly happy, I just like to
double check on the things that still concern me, or that he
hasn't answered as thoroughly as I would like.

Thank you so much, once again, for your help!  You are much
more concise and clear in explaining everything, and I feel
like this helps me make sure she gets the best care she can
get!

Answer
Dear Jennifer,

I disagree that the vet you're seeing is your best bet.  Any vet who would refuse pain management for a bunny in this condition is not knowledgeable about rabbit medicine, and I would not take my rabbits to him, period.

If this were my rabbit, I would get in the car and take her to the rabbit savvy vet two hours away.  :(

If your current vet had bothered to read any literature about rabbit medicine or gone to any veterinary meetings where rabbit medicine is discussed, he would not be withholding pain medication.  It is CENTRAL to rabbit medicine to provide pain relief.  In a case like this, I would ask the vet for Banamine.  But if he's unwilling to do that, then metacam and tramadol (both) would help your poor bunny cross that pain hump and start to recover.

Please also consider the enema and subcutaneous fluids to help her hydrate her intestinal contents.  Oral hydration is very important, too.  Enema instructions here:

www.bio.miami.edu/hare/ileus.html

I hope this helps.

Dana