Intestinal impactions and obstructions

This article is tagged to be informative to veterinarians too. The information is not a substitute for advice from a veterinarian.

Impactions and obstructions are seen when the intestines get blocked. Leopard geckos are often affected by sand impactions.

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Introduction

An intestinal impaction is where the intestines get filled up. This prevents food from passing, ultimately leading to intestinal obstruction (or a blockage). It results in pain, inability to pass stool, dehydration and a state of shock. When an obstruction is not rectified in due time, the condition can cause permanent damage to the intestines or even lead to death.

Apart from sand impactions, intestinal obstructions in Leopard geckos can also be caused by faecal impactions and foreign body obstructions(62) (e.g. by ingesting large pieces of the substrate), urate masses, neoplasias and non-neoplastic masses. Foreign body obstructions are considered common in Leopard geckos(62).

In theory, sand and any particulate substrate that is small enough and undigestible can be ingested and cause an intestinal obstruction(32). In the case of faecal impactions, the food was either indigestible or, more likely, the intestines were not able to contract properly. Impactions can also be indicative of chronic (long term) dehydration(42).

Intestinal impactions and obstructions in Leopard geckos are important and often complicated conditions to know about. This is an extensive article discussing sand impactions and their prevention in Leopard geckos, foreign body obstructions, faecal impactions, other causes of impactions and obstructions in Leopard geckos, diagnostics and treatment of impactions and obstructions in Leopard geckos, nutritional secondary hyperparathyroidism and choosing the best substrates for Leopard geckos.

Intestinal impactions and obstructions often lead to, the so-called, wasting syndrome where affected Leopard geckos lose weight and/or stop growing. Common signs in Leopard geckos include anorexia (not eating well or eating at all), lethargy (reduced activity), weight loss (e.g. tail getting thinner), a bloated abdomen, darkened intestines (visible from the belly area) and cloacal eversion(30). The abdominal (belly) area is often hard, or something hard in the form of a tube can be palpated (felt with fingers and hands).

Leopard geckos with obstructions are unable to defecate (pass stool). A Leopard gecko should be passing stool at least once a day. Observant owners will be able to identify a potential obstruction early on by looking at the frequency of defaecating (pooping). Regurgitation, dehydration (seen as a wrinkly skin) and cloacal or colonic prolapse are also be seen in some cases.

Diagnostics and treatment of impactions and obstructions in Leopard geckos are best done under the guidance of a reptile-friendly veterinarian.

Sand impactions in Leopard geckos

Sand impactions are commonly seen in pet Leopard geckos. When sand is ingested and not excreted, it will start to build up and fill the intestines — ultimately leading to a blockage. Whether Leopard geckos need sand in their diets, and how much, is uncertain. It is also not exactly known whether Leopard geckos in the wild eat sand or not, but they are commonly seen doing so in captivity.

Pet Leopard geckos will often eat sand (called geophagia), especially when they suffer from certain mineral deficiencies (then called pica). Leopard geckos with sand impactions are also often seen drinking more water and soaking in their water dish.

Risk factors associated with sand impactions in Leopard geckos include:

  • Being kept on sand
  • Seeing eating sand
  • Seeing sand in the faeces
  • Inadequate calcium/vitamin D3 supplementation
  • Being smaller (<15 cm / 6″ in length)(31)
  • Internal and external parasite infestations
  • Obesity

Some authors have found a high incidence of metabolic imbalances, parasite infestations and poor body conditions scores in Leopard gecko with sand impactions. It can, therefore, be argued that poor husbandry and underlying health conditions are also risk factors for sand impactions.

Preventing sand impactions

Leopard geckos ingest sand either directly, or indirectly on feeder insects (e.g. sand that gets stuck to food). Irrespective the reason for ingestion, sand is always found in the stomach and intestines of Leopard geckos with sand impactions. Theoretically, any sand can be the cause of impaction, even commercial and digestible calcium-enriched sands (see later). It is therefore not surprising that the most widely given recommendation to prevent sand impactions in Leopard geckos is to avoid using sand as a substrate.

Although this is the safest route, not all Leopard geckos will actively eat sand. Various literature sources give guidelines on reducing the risk of pica. Also, empirical data suggests that it is possible that Leopard geckos might only prefer certain colours of sand(29).

If an owner does decide to use sand as a substrate, it is recommended that fine sand is used(32). Play sand is considered less desirable to eat when compared with calcium-enriched sand and is considered safer than coarse grains(32). Silica sand should be avoided.

Whenever sand is used as a substrate, owners need to be mindful of its possible effects and know what to look for. The most obvious way to identify geophagia is by seeing it happen. Droppings can also be evaluated regularly to see if it contains sand (e.g. by mixing it with water in a test tube(34) or glass container). Early signs of anorexia and/or abdominal distention may prevent a full impaction(34).

Other ways to prevent sand impactions in leopard geckos include:

  • Using a feeding platform or a deep food bowl(32)
  • Supplying adequate food
  • Supplying the correct vitamin/mineral supplementations

To minimise this risk of indirect ingestion of sand, feeder insects can be fed in a separate enclosure or they can be placed in a feeding container(32) or on a platform. By supplying the correct, and enough food, most healthy, adult Leopard geckos should be able to pass small quantities of sand(29). In addition to improving health, vitamins and minerals — especially calcium/vitamin D3 combinations, are also believed to reduce the urge to obtain calcium from sand.

Foreign body obstructions in Leopard geckos

Albeit less frequent than sand impactions, obstructions caused by larger objects are also seen in Leopard geckos. These type of obstructions, usually called foreign body obstructions, are either caused by indirect or accidental ingestion of a large piece of substrate. Foreign bodies cause obstructions by either getting stuck somewhere in the intestines or by cutting into the intestinal lining — causing pain and reluctancy to defaecate.

Foreign body obstructions in Leopard geckos can be prevented by using non-particulate substrates, using feeding platforms and by supplying enough food feeding frenzies can be prevented.

Faecal impactions in Leopard geckos

Another cause of intestinal impactions in Leopard geckos is faecal impactions. Although less commonly seen, they can also be life-threatening in Leopard geckos and is worth mentioning. A faecal impaction (also called faecal obstipation or simply constipation) is when the stool becomes so hard that it cannot be excreted. Reasons for this include food items that are either too large or that is difficult to digest, severe intestinal parasite infestations, dehydration, low environmental temperatures, accidental ingestion of fibrous substrates (e.g. peat/sphagnum moss) and intestinal stasis as a result of nutritional secondary hyperparathyroidism (see later)

Overfeeding and/or feeding too many hard-to-digest, or too large, feeder insects (e.g. grasshoppers and Superworms) can cause impactions and obstructions.

Parasite infestations (e.g. pinworms, hookworms and roundworms) can either cause physical damage to the intestines or become so abundant that they prevent food from passing.

Other causes of impactions and obstructions in Leopard geckos

Other causes of impactions and obstructions in Leopard geckos include urate masses, neoplasias (benign cancers, rare) and other types of masses. Urate masses have been reported in many lizards species and are when large urate crystals get stuck in the colon (large intestines) and block their passage.

Urate crystals are a mixture of uric acid and water. Unlike mammals, reptiles excrete nitrogen (a waste product) as uric acid, and not (watery) urea. Uric acid is produced in the kidneys from nitrates and is excreted into the colon(43) (lower part of the large intestine). When it is excreted it is often seen as the solid, whitish/yellowish semi-solid pieces that are attached to faeces. Incorrect husbandry (e.g. too little water, low humidity, small enclosure size, too high temperatures) and obesity are often blamed for obstructions caused by urate masses(43).

Various types of abdominal neoplasias can also cause impactions and obstructions. Neoplasias originate from the uncontrolled/abnormal growth of cells. Benign neoplasias (meaning they are more commonly expansive in nature, i.e. they form large masses) cause obstructions by narrowing the luminal (inside) space of the intestines. Obstructive neoplasias can either originate from the intestines itself or organs other than the intestines (e.g. liver, kidneys, bladder, etc.). Non-neoplastic, non-urate masses such as granulomas can also cause intestinal obstructions.

Diagnosing impactions and obstructions in Leopard geckos

When an impaction or obstruction is suspected, it is best to consult a reptile-friendly veterinarian. Veterinarians are equipped with radiograph facilities and will be able to do the best possible assessment.

Abdominal palpation (feeling with fingers and hands) together with the clinical signs and patient history can be diagnostic of sand impactions and foreign body obstructions. Radiographs will be able to confirm the diagnosis, aid with diagnosis milder cases, distinguish between impactions and obstructions, and give an indication of the cause and its severity.

In addition to this, radiographs will also assess the bone density of the patient — which, in combination with a proper patient history, is often used to diagnose nutritional secondary hyperparathyroidism (metabolic bone disease — see later). One, or sometimes two, properly positioned radiographs will be taken — one from the top/bottom and sometimes one from the side. Sand and other mineral-based materials will be radiopaque/radiodense (showing up white).

Additional contrast studies, ultrasonography, oral endoscopy and computed tomography (CT scans) might have to be used to diagnose neoplasias and non-mineral-based materials. One study showed the use of a CT scan in an unsedated Leopard gecko to diagnose a urate obstruction(41).

In order to get a holistic medical picture of the patient, the clinician will often also recommend stool testing. Apart from containing sand or undigested food, testing of stool samples can also diagnose intestinal parasites (e.g. helminths, Cryptosporidium and other protozoa) which also needs to be addressed.

Treatment of impactions and obstructions in Leopard geckos

There is a couple of options when it comes to the treatment of impactions and obstructions in Leopard geckos. Milder impactions will often respond to home treatment, but valuable time might be wasted in the case of failure. After making a diagnosis and doing a thorough medical workup, the attending veterinarian will be able to discuss additional treatment options.

Mild, moderate and severe impactions/obstructions will often respond to different treatments. Critically ill patients need to be stabilised first and treatment options should be catered appropriately. Each patient will have its own, unique recommended treatment plan. The treatment options and the outcome will depend on the body condition score (the weight) of the affected Leopard gecko, whether it is an impaction or obstruction, its cause, its degree and duration and the presence of concurrent medical conditions (see later).

Intestinal impactions and obstructions can be classified according to its severity — i.e. mild, moderate or severe. Although present, some impactions will be non-complicated (without causing problems). Obstructions are more often classified as severe.

Patients with a poor body condition and concurrent conditions such as nutritional secondary hyperparathyroidism (see later) and/or cryptosporidiosis are often diagnosed with complicated, more severe impactions and have smaller chances of recovery. At some point, especially if finances are a concern, the Leopard gecko is too debilitated, there is no response to initial treatment or after-care is impractical, many owners opt for euthanasia.

Without a diagnosis, home treatment can be attempted if the affected Leopard gecko is still eating. Commonly recommended home treatments include water baths and the administration of stool softeners and lubricants.

Mild impactions in Leopard geckos will often go unnoticed and cause no visible harm. The presence of foreign material is still abnormal. While the patient is still eating and is sufficiently hydrated, home treatment (as above) it is often enough to stimulate normal stools. Stool softeners, intestinal lubricants and motility modifiers [See ref. 23 for dosages] can also be used. Incorrect husbandry and concurrent diseases should still be investigated and rectified.

Moderate, non-complicated impactions will often need rehydration, water baths, stool softeners and lubricants, enemas and monitoring. Stomach and assist feeding will also be required if appetite hasn’t returned a couple of days after the patient has been sufficiently rehydrated.

Surgical intervention is indicated for severe impactions, obstructions, neoplasias and cases where initial treatment was unsuccessful in allowing gut passage. It is done under general anaesthesia using a procedure called an exploratory celiotomy.

Emergency surgery might be indicated, but carries a poor prognosis (chances of survival) in non-stabilised and emaciated Leopard geckos. The surgical outcome is also dependant on the chronicity of the condition and viability of the intestines. Many owners elect to euthanase instead of surgical treatment. Surgery might also be required to reduce certain prolapses.

Water baths

In the case of impactions and urate masses, Leopard geckos can be bathed/soaked twice a day in chin-deep water for 30 minutes at a time. The water temperature needs to be similar to that of the enclosure (25–30 ºC / 77–86 ºF(23), use a thermometer) and the soaking container must be deep enough to prevent escape. Mildly dehydrated Leopard geckos can also be stimulated to drink water this way. When the Leopard gecko is defaecating it is a good sign. Care needs to be taken not to allow the head of the Leopard gecko to go below the level of the water.

Leopard gecko water bath

Soaking can assist in loosening impactions and urate masses. By doing so, the Leopard gecko will also be moving around which will have a stimulating effecting on the intestines. During these periods, gentle massages of the abdominal area might assist even more. Batching also often stimulates drinking. Image by adyn02llee

 

Stool softeners and lubricants

Stool softeners and intestinal lubricants (also called wetting agents) aids in the softening of stool creating and/or making their passage smoother, thus lessening the discomfort of defaecating (pooping). Some of them work by acting as surfactants that reduce the surface tension and allowing intestinal fluids and fatty substances to penetrate the faeces, while others serve purely as lubrication.

Commonly used wetting agents include petroleum jelly/mineral oil or medicinal liquid paraffin. Both these agents should be mixed with an equal amount of water or better, an electrolyte solution before being administered by gavage (‘tubing’) at a dosage of 20-30 ml/kg per 24 hours(23).

A syringe attached to a small diameter soft-tipped feeding tube is pushed through the mouth, down the oesophagus (gullet) to about a third of the length of the Leopard gecko’s body where the medicine is slowly injected. Their effect should start to be visible between one and three days and the can be used in combination with enemas (see below).

Care must be taken as both these medicines can cause regurgitation and aspiration into the lungs. Appropriately diluted (1:20 to 1:30) Dioctyl Na Sulfosuccinate is also popularly recommended(23), but also needs to be used with caution(44).

Tube-feeding a Leopard gecko

Anorexic (non-eating) Leopard geckos with intestinal impactions and obstructions might need nutritional support in the form of stomach feeding (tube-feeding). Image © Renier Delport

Rehydration

Hydration should be addressed before feeding commences, even if it takes days(38). In cases where assist drinking is unsuccessful or impractical, mild (<5%) to moderately (<8%) dehydrated patients can be treated with subcutaneous (SC) fluids. Severe dehydration (>8%) should be treated with intracoelomic (ICo) and intraosseous (IO) fluid administration.

Pre-warmed (25–30 ºC / 77–86 ºF(23)) crystalloids such as isotonic balanced fluids (e.g. 0.9% physiologic saline, Plasma-Lyte A, Normosol-R and Lactated Ringers solution)(38) can be used by injecting it under the skin on the lateral sides over the chest area. SC injections should be divided over 2 or 3 evenly spaced boluses(40)Maintenance fluids (calculated as ~10-30 ml/kg/day(23)(37)(42) or 2.5-3.5% of BW per day(40)) plus rehydration fluids need to be given. Rehydration fluids are calculated as:

hydration deficit (percentage decimal) x body weight (kg) x 1000 ml

and should be given over a period of 48 to 96 hours(42). A 50-gram adult Leopard gecko that is 10% dehydrated will need about 1 ml of maintenance fluids per day and an additional 5 ml replacement fluids over 2-4 days. This means the daily requirements will be about 2 ml for the first 4 days.

Enemas

Impactions that ends in the distal (furthest) parts of the colon can be loosened or broken down using enemas. This is done by gently inserting a small diameter, soft-tipped stomach tube into the vent area and carefully flushing with lukewarm water. The water can also be combined with a wetting agent. Some authors prefer to stimulate activity directly after the enema(43). One or multiple enemas might be required to be effective. Enemas that are done directly before or after a water bath or 24 hours after using a wetting agent can prove more efficient.

Concurrent conditions and consequences

Concurrent conditions and consequences of impactions/obstructions also need to be addressed. Concurrent conditions that that are often seen with impactions and obstructions include poor body condition (weight loss), internal and external parasite infestations, obesity and nutritional secondary hyperparathyroidism (see later).

Pinworms and other nematodes are popularly treated with febendazole [See ref. 23 for dosages].

Consequences of intestinal impactions and obstructions include weight loss, prolapses and bacterial infections. Cloacal or colonic prolapses, occasionally seen secondary to intestinal obstructions, needs to be reduced. Prolapses are also often seen in the case of pinworm infections in Leopard geckos. Mild prolapses can be manually reduced under anaesthesia. Severe prolapses need surgical intervention (see earlier). Secondary bacterial overgrowths can be identified on faecal wet preparations and are often treated with Metronidazole(43) [See ref. 23 for dosages].

Nutritional secondary hyperparathyroidism (MBD)

Nutritional secondary hyperparathyroidism, also known as calcium deficiency and metabolic bone disease (MBD) is often diagnosed, or at least suspected, in patients with impactions and obstructions. MBD, associated with geophagia (eating of sand) and pica (sand hunger), can be an underlying cause and/or contributing factor to impactions. Whether this is the case of not, it is often seen concurrently with impactions.

Sand eating is seen in Leopard geckos with various degrees of MBD. When the body is deficient in calcium, Leopard geckos often resort to eating sand to try to fill the gap. Calcium is also required for muscles in the intestines to contract, therefore its deficiency can lead to intestinal stasis (the inability to do so properly).

Together with large quantities of indigestible sand, various degrees of calcium deficiencies can result in the inability of sand to move through the digestive system. Leopard geckos with severe metabolic bone disease are also less active, which can lead to insufficient stimulation for the intestines to contract.

Metabolic bone disease can be prevented in healthy Leopard geckos by dusting feeder insects with commercial calcium/vitamin D3 supplementation.

With or without an aggressive individualised patient treatment plan, addressing both MBD and an impaction, the outcome is usually grave.

Choosing the best substrate

Many cases of intestinal impactions and obstructions are caused by ingesting substrate. The substrate (or bedding) is the layer that is placed on the floor of the Leopard gecko’s enclosure. There are many options available to Leopard gecko owners, but safety with regards to their ingestion should take priority over aesthetics. Theoretically, any substrate that can be ingested and is not digested can cause intestinal impactions and obstructions.

Commonly used substrates that should be avoided with Leopard geckos include sand, fine gravel, wood chips, crushed walnut shells, eggshells, fine grade bark, perlite, corn cob and alfalfa pellets. If an owner insists on using sand for its natural appeal, coarse grade sands, silica sand and calcium-enriched sands should be avoided.

Calcium carbamate and other calcium-rich sands (e.g. Calcisand, Calci Sand, Calci-Sand, Vita-Sand) are popularly used but is often seen causing sand impactions in Leopard geckos. Even though they are marketed as “digestible” sands, they can stay in the intestines long enough to cause impactions.

Safe substrates for Leopard geckos include paper(unprinted news, brown, butcher, kitchen roll(32)), paper towel, carpet, plastic foam mats, Astroturf, clay mixtures and large pieces of slate rocks and aquarium stones(30).

Conclusion

Leopard geckos with compactions and obstructions are often presented to veterinarians for treatment. Following the correct husbandry guidelines can reduce the risk of it happening, but being overcautious is preventative.

References

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