Disorders of the Cecum

Jan 22, 2013 by

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The healthy functioning of the cecum is critical to the overall health of a rabbit. Gaining an understanding of how this large organ works – and what causes disruption – will help caregivers monitor their rabbits’ health, detect early signs of cecal disorder, and take steps to prevent a bunny’s condition from worsening.

The primary author has a special interest in cecal function because of her rescued rabbits. Most would be considered “special needs,” and it was not uncommon to see them initially producing soft cecotropes. One of them, elderly and very ill, presented with a large soft mass that looked as though it had been dispensed from a soft-serve machine, complete with swirl on the top. Another presented with what is commonly referred to as “cow pile syndrome.” In both cases, the right diet returned them to a level of health that allowed them to live the remainder of their lives as normal rabbits.

Overview of article. This article covers the following topics: How the cecum functions in a healthy rabbit, including indigestible fiber, digestible fiber, and cecotropes. Prevention of cecal disorders. Cecal motility disorders. Signs of three stages of cecal motility disorders, including abnormally soft cecotropes, cecal hypomotility (slowdown), and cecal impaction (stasis). Treatment and prognosis for recovery from cecal motility disorders. Home care of rabbits with cecal motility disorder. Enterotoxemia, including signs, treatment and prognosis, and home care; the disease is related to cecal motility disorders in that it also affects the gastrointestinal tract. Brief mention of cow pile syndrome, which shares some similar signs with cecal disorders, is included at the end of the article.

At the end of the article is a chart that sums up the various disorders and signs.

HOW THE CECUM FUNCTIONS IN A HEALTHY RABBIT

Rabbits have a complex and efficient gastrointestinal (GI) physiology that allows them to digest materials that are indigestible to non-herbivore species. The stomach and small intestine alone are not able to extract all the nutrients from the fibrous plant material that is a rabbit’s primary food source. As a result, the thin-walled cecum – the largest organ in a rabbit’s abdomen – serves as a fermentation chamber, enhancing nutrient retrieval. The cecum is a sizable pouch that has its opening at the junction of the large and small intestines. It uses primarily bacteria, along with some protozoa and fungal (yeast) flora, to convert food into the amino acids, vitamins, and volatile fatty acids needed for a healthy existence.

Indigestible Fiber: Its Key Role

Food that passes into the large intestine (colon) is separated into two parts: indigestible fiber and digestible fiber. Unlike many other species, in which liquid is removed from the contents of the large intestine, the rabbit actually secretes fluid into the upper part of the large intestine to allow sorting of the two fibers. The indigestible fiber stimulates the movement and mixing of the intestinal contents; therefore, fiber must be ingested regularly to keep the digestive system working as it should. The indigestible fiber is collected and then pushed into the second half of the colon where water is removed, leaving the small, dry, nearly odorless fecal pellets that are excreted as waste.

Digestible Fiber and Cecotropes (UK spellings include cecotrophs and caecotrophs)

In contrast, digestible fiber, along with some fluid, is moved backwards from the upper part of the colon into the cecum. (Reference the illustration included in Marinell Harriman’s House Rabbit Handbook.) This material is broken down by the cecal flora, and some of the resulting nutrients are absorbed directly through the thin cecum wall. The remaining material is turned into cecotropes: small packets of tiny-bodied, nutrient-rich flora. (Note that cecotropes are sometimes informally referred to as cecals; however, the word cecal is appropriately used to refer to processes involving the cecum.)

Several hours after eating, contractions of the cecum and colon move the cecotropes out toward the anus. Receiving a neurological signal that the cecotropes are coming, the rabbit turns his attention to the anal area and eats the cecotropes directly (a process called cecotrophy); they are swallowed whole. Few caregivers ever see the cecotropes, as it looks like the rabbit is simply grooming his anal area.

Cecotropes are dark green and have a distinct odor and a small grape-cluster appearance. They are covered in a thin layer of mucus to provide initial protection to the bacteria from the low pH stomach acids. Once eaten, the cecotropes are gradually broken down in the digestive tract and the nutrient-laden cecal flora are assimilated.

Rabbits should always be allowed to eat their cecotropes. These food capsules are not fecal waste; they are a critical part of the diet. Though rabbits are crepuscular (meaning they are most active at dawn and dusk), house rabbits react to variable lighting and their human’s schedule, so they may graze throughout the day and produce cecotropes any number of times. (Thus, they are not really “night droppings” as sometimes thought.)

Healthy rabbits consume all their cecotropes. However, consumption can be influenced by the rabbit’s diet. For example, a protein-rich diet (such as one high in alfalfa) may result in a rabbit ingesting fewer cecotropes; thus, you may find them in the litter box along with regular feces. If cecotropes are not ingested, the rabbit may experience dietary insufficiencies.

Additionally, note that a rabbit may not eat cecotropes due to dental or other oral pain as well as obesity or restricted movement (e.g., spondylosis) that prevents the bunny from physically reaching the anus to eat the cecotropes.

Caregivers may wish to read “Liver (Hepatic) Disease in Rabbits,” which discusses the importance of cecotropes and a healthy liver.

PREVENTION OF CECAL DISORDERS

Before starting the discussion of cecal disorders, it should be noted that caregivers can help protect their rabbits against the diseases, which can be life-threatening. Throughout this article, the important role of diet is mentioned in both the cause and treatment of cecal disorders. Diet is also the best protective measure against all gastrointestinal (GI) tract disease, and that includes disorders of the cecum and enterotoxemia. A rabbit’s diet is ideally composed of high-fiber, low-energy foods.

The discussion below includes information about foods that disrupt the proper working of a rabbit’s GI tract as well as foods that enable it to function as it should. Other causes of cecal disorders (e.g., ingestion of foreign material, antibiotics) are also mentioned, the knowledge about which will help caregivers take proactive steps to protect their rabbits.

CECAL MOTILITY DISORDERS

This section of the article addresses three cecal motility disorders; most disorders of the cecum will eventually lead to dysbiosis (imbalance of the microbial flora in the cecum and GI tract).

When a rabbit’s GI tract works as it should, cecotropes are produced in a rhythmic fashion and consistently eaten by the bunny. However, when the process does not work normally, disruption in cecal motility results. It can be caused by a variety of factors, including pain, toxins (including some antibiotics), ingestion of foreign materials, disorders of other parts of the gastrointestinal tract, and environmental or physical stress (such as extremes of temperature, poor sanitation, and lack of exercise). In addition, our domestic rabbits retain the prey flight-response of their forebears and the stress of real or perceived danger can adversely affect digestion, cecotrope production, and gut motility.

However, the most common cause of cecal motility disorders is food, especially a diet too rich in carbohydrates – including starchy vegetables, fruits, and grains – and lacking in fiber. Dr. Scott Stahl, who treats many rabbits at his exotic animal practice, advises:

Rabbits are herbivorous and their proper diet includes high-fiber, low-energy foods such as grass hay and leafy greens. The importance of fiber cannot be emphasized enough: it’s what is moved into the cecum for fermentation and further digestion, forming into the nutrient food called cecotropes. Fiber affects cecotrope consistency as well as the rabbit’s appetite for them.

 

When a rabbit is fed appropriately, a balance of bacteria in the cecum works slowly to break down fibrous plant foodstuffs, providing volatile fatty acids for energy as well as amino acids, vitamins, and particular enzymes.

 

In contrast, when rabbits are allowed free access to commercial pellets (including those containing dried fruits, grains, and/or legumes) or simple carbohydrate snacks (such as crackers, toast, or cookies), the cecum often can no longer function properly. These high-starch foods – which are also highly fermentable – are quickly broken down by the cecal bacteria, resulting in cecal gas, possible overgrowth of dangerous bacteria, and an imbalance in the delicate cecal flora. An irregular production or abnormal formation of cecotropes is often the result.

 

Maintaining the balance of flora in the cecum is critically important to a rabbit’s health. Dysbiosis can result in problems serious enough to cause illness and death.

Stages and Manifestations of Cecal Motility Disorders

There are various stages and manifestations of cecal motility disorders. Dr. Susan Brown, who has been an exotic animal veterinarian for over thirty years, with a special interest in rabbits, explains:

When cecal dysbiosis occurs, there is often a change in the pH of the cecal contents, thus changing the balance of cecal flora. The timing of contractions in the large intestine is interrupted, resulting in food particles not being sorted and broken down as they should be. The cecum then “dumps” contents randomly instead of producing nicely formed cecotropes. This dumping usually results in relatively formless, “pudding like” cecotropes, often with foul smell. The rabbit is unable to eat them, and they may end up on the floor or pasted to the rabbit’s rear end. It is not known for sure, but there may also not be the normal “brain trigger” to tell the rabbit that the cecotropes are coming.

 

Not all rabbits with cecal dysbiosis will exhibit obvious soft or pudding-like cecotropes. Some rabbits will have a gradual decline in appetite and develop smaller and smaller waste droppings, ending eventually with a complete cessation of food intake and a shutdown (ileus) of the intestinal tract and cecum. Gas will build up, fluid will accumulate, and the rabbit will soon be in a life-threatening situation.

 

Another scenario that occurs less frequently is when a rabbit eats less, then stops eating, producing mucus instead of cecotropes. Eventually the rabbit will also develop a life-threatening ileus, which is the shutdown of movements in the GI tract.

Dr. Tomáš Chlebeček, a companion animal veterinarian who also has a special interest in rabbits, adds this:

In a well-functioning digestive system, simple sugars and starches are removed by the small intestine before the food reaches the cecum. All rabbits have low levels of pathogenic [potentially harmful] bacteria in the cecum. As long as they are eating a low carbohydrate diet, these bacteria are not harmful.

However, if a rabbit eats high-carbohydrate foods, there will be glucose in the cecum, which will allow pathogenic bacteria (primarily Clostridium spp, sometimes E. coli) to flourish and produce toxins that can lead to enterotoxemia, diarrhea, and death.

SIGNS OF THREE STAGES OF CECAL MOTILITY DISORDERS

Three general stages of cecal motility disorders are discussed in this section: abnormally soft cecotropes, cecal hypomotility (slowdown), and cecal impaction (stasis). However, as previously noted by Dr. Brown, a rabbit will not necessarily proceed through each stage.

In addition, cecal motility disorders may be gradual and progressive. Thus, familiarity with the signs of the various stages can be helpful, keeping in mind that there is overlap between the stages and that individuality affects how a rabbit presents with the condition.

Additionally, cecal impaction is different from gastrointestinal (GI) blockage, though some of the signs are similar. Both are life-threatening conditions. The signs for cecal motility disorders are non-specific; they may be indicative of some other problem.

Abnormally Soft Cecotropes

Although appetite and activity level may appear normal, the caregiver may notice the following signs in addition to the abnormally soft, possibly gooey, cecotropes:

  • Irregular cecotrope production (in number and timing)
  • Occasional mucus from the anus (without the usual accompanying cecotropes)
  • Inflammation around anal area (due to accumulation of cecotropes)
  • Gradual weight loss
  • Poor coat (e.g, scruffy, sparse, dull)

The term “poopy butt” is often used to describe a rabbit who excretes soft stools that soil the hind end. However, this messiness is not generally caused by fecal matter but is due to liquid or malformed cecotropes matting the fur. The mucous covering of the cecotropes makes them sticky and hard to remove.

Cecal Hypomotility (Slowdown)

As already stated, not all rabbits with a cecal motility disorder will present with pudding-like cecotropes. It may be that a rabbit reacts with loss of appetite and subsequent slowdown of gut motility, which leads to the life-threatening shutdown of both the intestinal tract and the cecum.

In addition to inappropriate diet, cecal slowdown may be caused by ingestion of a foreign material such as cat litter (e.g., wheat, corn, clay), bulk-forming products such as psyllium, carpet material, seeds, or dried legumes. In addition to causing imbalance, some of the materials absorb water, which is crucial to the working of the cecum and upper part of the colon. Regardless of origin, unhealthy or foreign materials can become lodged in the cecum or they may create cecal imbalance. In addition, toxins such as heavy metal or inappropriate antibiotics can cause cecal flora changes.

When the cecum cannot empty properly, it no longer functions normally. The rabbit will start to become dehydrated.

Cecal hypomotility (slowdown), which can lead to serious problems, results in fewer cecotropes – something not easily observed by the caregiver. Signs to watch for include those listed above for obviously soft cecotropes as well as:

  • Decline of normal appetite and water intake
  • Picking at food; dropping uneaten food
  • Smaller and fewer fecal pellets

Another sign may be lumps in the cecum; however, a rabbit-knowledgeable veterinarian should make this determination. Extreme caution needs to be taken when feeling the internal organs of a rabbit with a potential cecal problem because the thin-walled cecum could be bruised or ruptured with overly aggressive palpation.

Cecal Impaction (Stasis)

If cecal hypomotility is allowed to continue, the cecum will become impacted – the contents will become dehydrated and there will no longer be the normal mixing and movement of material in and out of the cecum. This condition results in a serious imbalance of the cecal flora, and the rabbit becomes gravely ill. Cecal impaction (confirmed with radiographs) will result in a slowdown and subsequent stasis of the GI tract.

Not every rabbit will exhibit all of the following advanced signs (some of which also apply to intestinal obstruction):

  • Dehydration
  • Complete loss of appetite (anorexia)
  • Cessation of cecotropes
  • Cessation of fecal output
  • Silent gut or excessive gut sounds
  • Pain (due to build-up of gas)
  • Low body temperature
  • Weight loss
  • Distended abdomen

Note that abdominal abnormalities (e.g., shape, distension) can be caused by something other than cecal impaction, for example, certain cancers as well as liver and cardiac diseases.

TREATMENT AND PROGNOSIS FOR RECOVERY FROM CECAL MOTILITY DISORDER

Treatment and Prognosis for Recovery: Abnormally Soft Cecotropes

Treatment for a cecal motility disorder that manifests as abnormally formed cecotropes is based on the appropriate diet for a rabbit. Dr. Brown advises:

A diet that most closely approximates that of a wild rabbit is healthiest for domestic rabbits. Unlimited grass hay and a measured amount of green leafy vegetables should be offered daily. Processed pellets are unnecessary for most rabbits if they eat quality mixed grass hay and a variety of leafy green foods.

 

If a rabbit with soft cecotropes is overweight, it’s safe to discontinue feeding pellets only if he or she is freely eating grass hay. However, if the rabbit is not eating hay or not eating it in the quantity needed, then a gradual reduction in the quantity of processed pellets is necessary to prevent hepatic lipidosis. If the pellets are alfalfa-based, they should be replaced by grass-hay-based pellets as soon as possible. This can be done by mixing the two types and gradually reducing, then removing, the alfalfa-based pellet. In all cases, high carbohydrate or sugary snacks (e.g., grain-based foods or cereals and fruit, both dried and fresh) should be discontinued immediately.

If the rabbit has overly soft cecotropes and the problem is diet-related, the prognosis for recovery is excellent as long as dietary guidelines are followed. Dr. Brown offers this:

My experience with several hundred rabbits who have had pudding-like cecotropes – but were otherwise active, alert, and medically normal – is that feeding a diet of only grass (not alfalfa) hay usually turns them around in a week. If the problem has been going on for months or the rabbit doesn’t browse the required amount of hay (making it necessary to feed some pellets), then the turn-around time may be longer.

 

Once the rabbit stops producing the obvious soft cecotropes for a full week – meaning his body is now producing cecotropes normally – I gradually add in one leafy green food every three days until the rabbit is eating a nice variety. Ideally, I like to have the rabbit eating three or more different types of leafy green foods during the week (the more fibrous greens rather than soft salad greens).

 

It can take up to two months for the cecal flora to completely return to normal, particularly if the rabbit has had abnormal cecotropes for weeks or months prior to treatment. I advise my clients to never feed any high-carbohydrate (especially grain-based) foods again. If pellets are to be eventually introduced, I recommend that only grass-hay-based (not alfalfa-based) pellets be fed on a very limited basis; the food should be devoid of grains. Some rabbits can be successfully fed small amounts of dried or fresh fruit if they are introduced gradually, with the cecotropes remaining normal. However, if soft cecotropes are produced again within twelve to twenty-four hours of the introduction of any food into the diet, immediately discontinue that food.

 As already noted, a gradual change in pellet amount or kind (alfalfa-based to grass-hay-based) may have to be done gradually to prevent hepatic lipidosis. For additional information, reference “Liver (Hepatic) Disease in Rabbits,” posted on this website.

Treatment and Prognosis for Recovery: Cecal Hypomotility

Treatment for the early stage of cecal hypomotility (slowdown) leading to impaction is much the same as for ileus, the cessation of GI tract movement. Unfortunately, the rabbit may not always be brought to the animal hospital early in the condition. Dr. Bill Guerrera, who treats many rabbits from the Colorado House Rabbit Society, shares his experience:  

At first, the rabbit may act very normal and is eating and drinking. The condition may involve only a slight decrease in size and/or frequency of stool production, and gut sounds may be normal. Because he’s active and alert, the caregiver often assumes the rabbit’s health is okay.

 

Contents of the cecum are normally semifluid. So when I palpate doughy contents in the cecum instead, my diagnostics may include radiographs and blood work to assess the severity of the situation. I also want to rule out other systemic illness or disease. Though it’s not always possible to determine the initial cause of cecal hypomotility, successfully returning the rabbit to health hinges on stimulating the gut to work again.

 

In the early stages of cecal hypomotility, the rabbit is usually healthy enough to be at home, and he’s generally less stressed there as well. Before the rabbit is dismissed from the hospital, sterile fluids are given subcutaneously to help soften the mass and get it moving. I work out a treatment protocol for the caregiver that includes additional hydration if necessary, and some caregivers are skilled in giving fluids at home. I also provide guidelines for a diet that is high in fiber and water content (Oxbow Critical Care™ is a popular choice). Current research indicates that return to health hinges on fluids and fiber.

 

If there are signs of pain, I prescribe meloxicam (Metacam®), a COX-2 selective NSAID [nonsteroidal anti-inflammatory drug]. Prokinetics (motility drugs) may be considered, though scientific trials are lacking; opinions on which drugs are most effective vary. Some veterinarians may prescribe probiotics for rabbits on antibiotics for extended periods of time, but the efficacy of presently available probiotics is currently unknown.

 

Because cecal impaction is a serious threat, I want to see the rabbit respond to treatment within twenty-four hours. If there is no improvement or if the rabbit’s temperature drops, it’s vital to reexamine the situation.

 

If the rabbit’s digestive system is responsive, I like to perform a recheck within the week to make sure the cecum is emptying. If it empties and the flora balance is restored, the prognosis for the rabbit is very good. I encourage the client to give the recovering rabbit gentle tummy massages and to allow him to be active.

For additional information on healing touch, reference the following two articles, “Deepening the Bond: How to Connect with Your Rabbit through Massage” and “Tellington TTouch for a Happy and Healthy Rabbit.”

Treatment and Prognosis for Recovery: Cecal Impaction

If a rabbit is not treated early, the caregiver will suddenly notice changes in the rabbit’s behavior and responsiveness. Because cecal impaction and intestinal obstruction share some of the same signs, it’s critical that the veterinarian determine the cause of the rabbit’s problems to ensure correct treatment and follow-up.

Cecal impaction is extremely serious. Though the rabbit may look fat, due to abdominal distension, he or she may be very emaciated and most likely unable to absorb the nutrition needed to maintain health. Acute dehydration may lead to additional problems. Dr. Chlebeček explains:

When a rabbit is severely dehydrated, the peripheral circulation shuts down in order to maintain circulation to internal organs and the brain. That means that subcutaneous fluids are not absorbed quickly enough to do much good. Administration by IV (intravenous, by vein) or IO (intraosseous, into the bone marrow, e.g., of the femur) gets fluids into a severely dehydrated or otherwise critically ill rabbit.

An analgesic for pain will also be required. Some individuals feel Banamine® (flunixin meglumine) is superior for GI pain. It is an injectable that can be given orally if mixed with something palatable. However, the drug is not without significant risks, as Dr. Chlebeček mentions:

Banamine® has a negative effect on prostaglandins, which are necessary for rabbits to make cecotropes and to get them out of the cecum. In addition, the drug can destroy the stomach lining and damage the kidneys, especially in a dehydrated rabbit. When there is dehydration and shutdown, buprenorphine (an injectable morphine derivative) may be more appropriate. (Meloxicam works well in well-hydrated rabbits.)

This negative effect on prostaglandins, a group of hormone-like substances, is an important consideration. Derived from amino acids, they affect a wide range of the rabbit’s physiological functions, including metabolism, smooth muscle action, and nerve transmissions.

Cecal impaction does not mean a rabbit cannot recover. Dr. Guerrera says that he’s had success emptying the cecum:

Fluids are critical to the working of the cecum, so hydration is the key. Fiber is second in importance. Cecal contents have to be softened up, and then fiber helps get things moving again.

 

These rabbits may have a chronic history of misshapen stool, but once the impaction is relieved I’ve seen rabbits return to living an active, normal life. I like to monitor them closely because once the cecum has been stretched, it potentially loses tone and is more flaccid than it should be.

 

Rabbits who have had cecal impactions in the past are more likely to develop problems in the future: the cecum may fill up again. Proper nutrition is a must for these rabbits to decrease the probability of recurrence.

There are times when the cecum does not empty and the rabbit is in a life-threatening situation. Dr. Guerrera offers:

Though I’ve seen rabbits with distended cecum and cecal hypomotility go for months without apparent clinical signs – they are eating, active, and maintaining weight – there generally comes a downturn. I become very concerned when a rabbit is not responding to treatment and starts to have diarrhea, lethargy, and weight loss.

 

Sometimes the cecum will not empty. The decision to go to surgery is never easy. For most veterinarians, surgery into the cecum is the last resort; thus, it is carried out primarily on critically ill patients. The cecum itself is a paper-thin bag of bacterial contamination and does not hold sutures well. Even if surgery is successful, there is always a risk of postoperative sepsis [life-threatening internal infection]. The technically difficult procedure on a critically ill patient equals a poor success rate. If the rabbit does survive the surgery, there is a chance the cecum may not return to normal function. I would also have concern about the long-term prognosis for the rabbit.

HOME CARE OF A RABBIT WITH CECAL MOTILITY DISORDER

A rabbit who has any signs of cecal motility disorder should be checked by a veterinarian experienced with rabbits to make sure there is no underlying disease. Since the condition can also result from other stress factors, a careful review of known stressors will aid the caregiver in making necessary changes to the rabbit’s environment. Any change to the rabbit’s environment, even something as seemingly simple as a change in routine, can potentially result in health problems.

The information contained in the sub-section immediately below applies to the whole of this section, though a veterinarian may provide specific guidelines for feeding pellets and leafy greens, depending on the condition of a rabbit.

Home Care: The Rabbit with Abnormally Soft Cecotropes

When a bunny has soft, poorly formed cecotropes, it is recommended that caregivers discuss the daily feeding regimen with a veterinarian who is knowledgeable about the appropriate diet before making major changes.

If the rabbit who has gooey cecotropes grazes freely on hay throughout the day, Dr. Brown’s guidelines (provided above) will help clear up a diet-related problem. Dr. Angela Lennox, who has practiced exotic animal medicine exclusively for more than twenty years and is past president of the Association of Exotic Mammal Veterinarians, concurs:

Hay drives the gastrointestinal tract. I have seen soft mushy cecotropes cured with a temporary all-grass-hay diet, then reintroduction of limited leafy greens, so many times that I’m convinced of this care regimen.

However, if quality grass hay is unavailable or if a rabbit only nibbles hay or doesn’t seem to like it at all, the rabbit has to be treated differently, as Dr. Brown indicates:

Rabbits who do not freely graze on hay can be maintained on grass-hay-based pellets and leafy greens. However, some rabbits who are producing abnormal cecotropes will not completely return to normal if fed any pellets, even grass-hay-based. This may be due to a starch or protein content in the pellet that is still too high for that individual rabbit.

 

Caregivers can usually entice their rabbits to eat hay by offering variety and interest, perhaps sprinkling on an aromatic cooking herb for example. Though long-fiber hay is preferable, timothy-based hay cubes are an option.

Offering a variety of grass hay (timothy, orchard, brome, oat) may create interest and is healthiest for most adult rabbits. Note that alfalfa is often mixed in with orchard grass, so it is wise to ask about content before purchasing. Good quality hay should be fed in long-fiber form (i.e., not cubed or chopped up) whenever possible. If you have a rabbit who refuses hay, query rabbit-savvy people about their successes in getting a rabbit to eat it. Dr. Chlebeček cautions that overfeeding pellets and other treats (including fruits and high-sugar vegetables such as carrots) generally results in poor hay consumption.

For those rabbit guardians who are concerned that leafy vegetables may be the cause of abnormal cecotropes, Dr. Brown advises that true vegetable intolerance is rare. Dr. Lennox offers additional explanation:

A rabbit who doesn’t seem to do well with green leafy vegetables may have a genetic intolerance. However, problems are most often caused by previous damage from chronic inappropriate diet and lack of exercise. The focus should be on coarse fibrous plant materials [grass hay].

After the rabbit stops producing the pudding-like cecotropes and green leafy vegetables are reintroduced, Dr. Brown recommends that high-fiber greens (e.g., kale) be included in the selection because of their vitamin content, especially Vitamin C. Softer greens (e.g., romaine lettuce) and cooking herbs such as parsley and mint add variety. Freshly pulled grass (not clippings) and some other native plants (e.g., dandelion greens) that are free of fecal and chemical contamination can also be fed; they have the added benefit of being more fibrous than store-purchased greens.

If the rabbit won’t eat large amounts of hay and holds out instead for the greens, Dr. Lennox advises caregivers to reduce the quantity of greens. Grass hay is most important for the health of the rabbit.

Home Care: The Rabbit with Cecal Hypomotility

Dr. Guerrera’s home-care program for a rabbit suffering from early-stage cecal hypomotility includes fluids and a diet high in fiber. He monitors the rabbit very closely and asks the client to regularly weigh the bunny.

To help move contents out of the cecum, very gentle massage to the belly may be beneficial, depending on the condition. However, extreme caution is necessary so as not to damage or rupture the cecum.

Regarding diet, Dr. Guerrera adds:

The faster the rabbit returns to eating grass hay, the better. If I suspect a nutritional cause, I usually have caregivers slowly introduce green leafy vegetables one at a time every three to five days. If a rabbit prefers greens over hay or is not eating enough hay, then I advise caregivers to be very restrictive with greens. In all cases, the emphasis remains on high quantities of quality grass hay.

Home Care: The Rabbit with Cecal Impaction

A rabbit who suffers from cecal impaction generally will not be returned home until he is no longer in critical condition. Your veterinarian will provide the at-home treatment plan.

Since stress often plays a role in both gastric and cecal stasis, as a preventive measure the guardian should protect the bunny from items that could increase the likelihood of intestinal problems: house plants (many are toxic), cat litter, cat and dog foods, and foreign materials (such as carpet fibers) that a rabbit might chew and ingest. In addition, having a furred companion aids rabbits when they are ill and helps reduce boredom in healthy rabbits, reducing the desire to chew (and potentially reducing ingestion of harmful substances).

ENTEROTOXEMIA

Enterotoxemia, a life-threatening disease, results from toxins produced by specific bacteria that overgrow in a rabbit’s GI tract. These toxins are absorbed into the bloodstream and affect many organs in the rabbit’s body, often resulting in death in a very short time. Young rabbits, especially those newly weaned, are especially susceptible to the disease when they are fed a high-starch diet because their digestive system does not yet have the normal amounts of microbial flora, as does that of a healthy adult rabbit. However, Dr. Brown advises that any rabbit, especially those fed a high-starch or high-sugar diet or those on inappropriate antibiotics, can develop enterotoxemia.

Essentially, the disease is a poisoning of a rabbit’s system, and it is caused by the overgrowth of pathogenic bacteria, notably Clostridium spiroforme and E. coli. As noted previously by Dr. Chlebeček, all rabbits house low levels of pathogenic bacteria in their body. In a healthy rabbit, the organisms live in the intestinal tract without causing problems. However, under certain conditions the microorganisms proliferate, producing rapid onset of severe illness.

Diet plays a major role in setting up conditions favorable to the pathogenic bacteria. Dr. Stahl mentioned that high-starch or refined carbohydrate foods (e.g., crackers, cereals, bananas) are highly fermentable. Pelleted foods that are cereal-based or that contain grain fall into this category (read the label). Rapid fermentation in the cecum upsets the pH, creating an environment more hospitable to dangerous bacteria. Compounding the problem is the lack of fiber; the rabbit is not eating enough grass hay, which means that the cecum does not empty as it should.

Thus, poor diet plays a major role in the disease. Stress and inappropriate antibiotics may also be factors. Dr. Brown shares additional information:

Anytime the pH of the cecum is altered, a rabbit is at risk for enterotoxemia. Though the condition can affect more than the cecum, the cecum is key in the initiation of the disease. Clostridium and E. coli produce toxins that are absorbed through the cecal wall, essentially poisoning the body.

 

Inappropriate diet is certainly a major factor, and in young rabbits it is the most prevalent cause of enterotoxemia. Stress, including pain, can be a contributing factor because acute stress can upset normal flora balance and gastric function. Antibiotics can also put a rabbit at high risk, especially oral administration of those contraindicated for them, such as clindamycin, erythromycin, penicillins, or cephalosporins. It must be noted that although the disease can cause rapid decline, when enterotoxemia is caused by inappropriate antibiotics, whether administered as a single dose or more long-term, a rabbit may not succumb until many days after the administration of the medication. Therefore, the cause of death may not be obvious.

 

Rabbits have a very high mortality rate with this disease, and it can happen very suddenly. The more chronic form of it is mucoid enteropathy. This painful, life-threatening condition, also caused by imbalance of the cecal flora, results in an impacted cecum. Fecal pellets are generally absent; instead, the rabbit produces and eliminates excessive amounts of mucus.

Signs of Enterotoxemia

A rabbit with enterotoxemia may exhibit signs of:

  • Pain (e.g., hunched appearance, inability to stretch out; unmoving; teeth grinding)
  • Soiled hindquarters
  • Depression; lethargy
  • Anorexia
  • Weight loss
  • Abdominal distension
  • Diarrhea (brown or greenish brown; watery); may contain blood and/or mucus.  Mucoid enteropathy results in excessive mucus.
  • Dehydration
  • Hypothermia and shock

Signs such as diarrhea, hypothermia, and shock are very serious. Some rabbits may look healthy, but succumb rapidly. Death from enterotoxemia can result within hours.

Treatment and Prognosis for Recovery from Enterotoxemia

A rabbit exhibiting signs listed above needs emergency treatment; it is likely he will require hospitalization. Emergency treatment generally includes stabilization of the rabbit’s temperature, subcutaneous or intravenous fluids, pain medication, prokinetics (motility drugs), and syringe-feeding of a high-fiber food (e.g., Critical Care™). There are anecdotal reports about the positive effects of probiotics, and a veterinarian may incorporate them into the treatment plan.

If the rabbit is young, the chances for recovery are not as good, especially if the bunny is newly weaned and exhibiting the most serious signs of the disease. Adult rabbits are somewhat less likely to succumb to the disease, especially if treated early, put on the appropriate diet, and any inappropriate antibiotic is stopped. A low-stress environment is also beneficial.

Home Care of a Rabbit with Enterotoxemia

A diet high in fiber and low in starch and sugars will be critical in returning the rabbit to health. The caregiver can best protect the bunny by feeding that same diet for the rabbit’s lifetime. As noted early in this article, grass hay plays a pivotal role in moving food through a rabbit’s digestive system, and so an unlimited amount of fresh grass-hay is recommended on a daily basis.

Caregivers can also help reduce a rabbit’s stress by discerning what causes anxiety or fear. Helping a bunny to feel safe and protected includes building trust, proper handling, good location of the rabbit’s house, safe play and exercise time, and proper introductions to other people and animals (including other rabbits). If the situation involves kits, removing baby rabbits from the mother is stressful for them all.

Caregivers can become knowledgeable about drugs considered safe for rabbits by perusing articles on this website, including where to find additional medical information.

ADDITIONAL CONSIDERATIONS

As already noted, diet plays a critical role in the proper functioning of the cecum, and veterinary guidelines can help return a rabbit to health. There are additional articles and FAQ sheets on this website that pertain to diet and other aspects of rabbit health. Working with your veterinarian to individualize your bunny’s diet – based on age, weight, health, and activity level – will help ensure his or her wellbeing.

Caregivers may want to consider supplementing their rabbit’s care with alternative therapies, some of which are addressed in separate articles posted on this website. There are times when combining the expertise of both standard and alternative treatments offers the best supportive care.

When researching complementary treatments, be aware of training and qualification requirements and give careful consideration to the health, nature, and needs of your rabbit. Be clear and realistic about your expectations and goals for treatment, which should prioritize your rabbit’s comfort and quality of life.

CHART: SIGNS OF DISORDERS OF THE CECUM

The chart below, based on information presented in this article, is for reference purposes only. Cecal motility disorders and enterotoxemia require the attention of a veterinarian to ensure proper diagnosis and treatment.

The differences in rabbit behavior (both when healthy and when ill) as well as the varying ways in which rabbits present signs of illness or injury emphasize the importance of familiarity with your own bunnies. It is beyond the scope of this article to address all cecal disorders.

 

   Cecal Motility Disorder: Abnormally   Soft Cecotropes Cecal Motility Disorder: Hypomotility  (Slowdown/Imbalance)  Cecal Motility   Disorder: Impaction Enterotoxemia
General Behavior   Normal behavior and activity levels   (e.g., alert, inquisitive, active) Varying behaviors, from deceivingly normal (active, alert) to lethargic and depressed Critically ill: lethargic, unresponsive. Behaviors signaling pain (see below) Critically ill: depressed, lethargic. Behaviors signaling pain (reference below)
Appetite   Normal Decreased appetite; may exhibit pickiness (e.g., may eat leafy greens but not pellets). If not given enough fresh hay, may chew on paper, wallboard, etc. Anorexia: complete loss of appetite Anorexia: complete loss of appetite
Water Consumption Normal consumption Decreased water consumption; start of   dehydration Cessation of water consumption; acute dehydration May be very thirsty but too weak to drink well; may “drape” over the water bowl. Acute dehydration
Cecotropes  Irregular production in timing and   number; abnormally soft, pudding-like, malformed Fewer in number; may be abnormal in shape None; complete cessation of cecotrope production None; complete cessation of cecotrope production
Fecal Pellets Generally normal Reduced number of fecal pellets, which may be harder/drier, with sharp edges No fecal output; possible watery discharge (true diarrhea, which is different from runny cecotropes) Enterotoxemia: true diarrhea: watery,   greenish brown to brown; may contain blood. Mucoid enteropathy: usually no fecal waste
Mucous Discharge Occasional mucus from anus without the usual accompanying cecotropes Occasional mucus from anus without the usual accompanying cecotropes Possible mucous discharge Enterotoxemia: Possible mucous   discharge. Mucoid enteropathy: excessive mucus.
Body Weight Weight loss (may look fat due to   abdominal abnormality; reference below); emaciation Weight loss (reference “Abdominal   Abnormality” below)
Pain: Presence and Signs of Periodic pain from gas. May exhibit mild to moderate pain (e.g., less active) Periodic pain from gas. May exhibit mild to moderate pain (e.g., less active) Severe abdominal pain due to gas accumulation. Hunched, reluctant to move, perhaps teeth grinding/chattering Hunched, reluctant to move, perhaps teeth grinding/chattering
Body Temperature Normal Initially may be normal but likely to drop as condition worsens Low (hypothermia) Low (hypothermia)
Abdominal Abnormality None Lumps in cecum may be felt with gentle palpation (caution: cecum easily bruised/ruptured; rabbit-savvy veterinarian should make this determination) Enlarged, distended (can be very large) due to gas from GI shutdown. “Doughy” contents in cecum felt with gentle palpation (caution: cecum easily bruised/ruptured; rabbit-savvy   veterinarian should make this determination) Distended abdomen (cecum full of fluid and gas)
Additional Signs Inflammation around anal area due to   accumulation of cecotropes In early stages behavior may be deceivingly normal Silent gut or excessive gut sounds “Water sloshing” sounds from liquid-filled cecum; soiled hindquarters

 

COW PILE SYNDROME

Cow pile syndrome, named for its most visible characteristic, may result from a combination of factors, including genetic, environmental, and dietary. Though not a medically recognized condition, brief mention is included because of some of the similarities with cecal motility disorders.

Determining whether a rabbit is suffering from a condition that affects the cecum or colon requires the skill of an experienced rabbit veterinarian. The caregiver can assist in the process by providing astute and accurate observations about the problem. Additional factors aid in the diagnostic process, including the history of medications, description of the diet (including dates and details of change), any possible foreign materials ingested and date of occurrence(s), and stress factors. Regardless of the condition, appropriate diet plays a crucial role in the recovery and health of the rabbit.

 

by Marie Mead with Drs. Susan Brown, Tomáš Chlebeček, Bill Guerrera, Angela Lennox, and Scott Stahl

© Copyright 2013 by Marie Mead. Used by permission. All rights reserved.

I wish to extend my sincere gratitude to Drs. Susan Brown, Tomáš Chlebeček, Bill Guerrera, Angela Lennox, and Scott Stahl for sharing their expertise in this article. Warm thanks also to Cheryl Abbott, Sandi Ackerman, Heidi Anderson, Dr. Stephanie Crispin, Gary McConville, and Karen Witzke for their review of and suggestions for this article.  – Marie Mead

Marie Mead has been involved in various capacities with animal rescue, advocacy, and education for over twenty years. She has made a home with special-needs rabbits and other animals, all of them rescues. Author (with collaborator Nancy LaRoche) of Rabbits: Gentle Hearts, Valiant Spirits – Inspirational Stories of Rescue, Triumph, and Joy, Marie has also written rabbit-related stories and articles for other publications. Additional writings have covered topics such as aging and the environment.

Susan Brown, DVM is the founder and former owner of Midwest Bird and Exotic Animal Hospital (originally in Westchester, Illinois) and the current owner of Rosehaven Exotic Animal Veterinary Services and The Behavior Connection (North Aurora, Illinois). She is coauthor of Self-Assessment Color Review of Small Mammals and author of numerous lay and professional writings on rabbit medicine and care; she has also lectured extensively in the United States and Europe. She is involved in exotic animal care at rescue organizations and shelters. Utilizing the principles of behavior and training, she is teaching ways for people to live in harmony with their companion animals.

Tomáš Chlebeček, DVM is a former aerospace engineer who became a veterinarian as a result of his association with the Colorado House Rabbit Society. He received his degree from Colorado State University in 1999 and practiced at the Makai Animal Clinic in Kailua, Hawaii, before moving to the Czech Republic.

Bill Guerrera, DVM has always been interested in avian/exotic animal care and received his degree from Colorado State University. He has worked at the Denver Zoo, has presented various veterinary topics to local groups, and is a published author of several animal field studies. He practices at The Animal Doctor in Colorado, where sixty percent of his patients are rabbits, including many from the Colorado House Rabbit Society. Dr. Guerrera also manages an online subscription-based website for people with veterinary-related rabbit questions: http://bunnyhopline.com.

Angela Lennox, DVM, Dipl ABVP (Avian) is a 1989 graduate of Purdue University, has practiced exotic animal medicine exclusively since 1991, and is the owner of Avian & Exotic Animal Clinic of Indianapolis (Indiana). As adjunct professor at Purdue University, she teaches both veterinary and veterinary technician students. Dr. Lennox is the author of numerous professional articles, coauthor of Clinical Radiology of Exotic Companion Animals, and editor of the Rabbit and Rodent Dentistry Handbook. She is past president of the Association of Exotic Mammal Veterinarians and has lectured extensively both nationally and internationally. She currently lives near Indianapolis with her husband of more than 20 years and four daughters.

Scott J. Stahl, DVM, DABVP-Avian graduated from the Virginia-Maryland Regional College of Veterinary Medicine in 1989 and is currently an adjunct professor in avian and exotic animal medicine there. He is the owner and director of Stahl Exotic Animal Veterinary Services (SEAVS) in Fairfax, Virginia (near Washington, DC). He has authored numerous book chapters and articles on avian and exotic animal medicine and surgery.

BIBLIOGRAPHY

My sincere thanks to the veterinarians named in this article for sharing their expertise during personal interviews and in subsequent feedback. In addition to House Rabbit Handbook: How to Live with an Urban Rabbit, the following list of publications, although by no means comprehensive, may assist those who desire additional research.

  • BSAVA Manual of Rabbit Medicine and Surgery. Anna Meredith and Paul Flecknell (Eds.)
  • Clinical Radiology of Exotic Companion Mammals. Vittorio Capello and Angela Lennox
  • Color Atlas of Small Animal Anatomy: The Essentials. Thomas O. McCracken and Robert A. Kainer with David Carlson
  • Exotic DVM (journal)
  • Exotic Pet Behavior: Birds, Reptiles, and Small Mammals. Teresa Bradley Bays, Teresa Lightfoot, and Jorg Mayer
  • Ferrets, Rabbits, and Rodents: Clinical Medicine and Surgery. Katherine E. Quesenberry and James W. Carpenter
  • The 5-Minute Veterinary Consult: Ferret and Rabbit. Barbara L. Oglesbee
  • Journal of Exotic Pet Medicine
  • Notes on Rabbit Internal Medicine. Richard A. Saunders and Ron Rees Davies
  • Rabbit and Rodent Dentistry Handbook. Vittorio Capello with Margherita Gracis
  • Rabbit Medicine & Surgery. Emma Keeble and Anna Meredith
  • Textbook of Rabbit Medicine. Frances Harcourt-Brown