It's an all too familiar story. "My bunny stopped eating, and then she just died." When we ask for details, we often learn that not only did the bunny stop eating, but she had been producing extremely small or even no fecal droppings, or showed symptoms of diarrhea. In reality, true diarrhea is uncommon in rabbits. Runny stool is more commonly due to an imbalance of the normal bacterial and fungal flora of the caecum (the bunny's intestinal "fermentation vat"). The diarrhea is actually liquid, unformed caecotropes--the soft, pungent, normally mulberry-shaped pellet the bunny reingests to obtain essential nutrients. The floral imbalance can be caused by a number of factors, such as the wrong antibiotic (oral penicillins can be deadly to rabbits for this reason!), but is often simply due to an intestine whose normal peristaltic muscular contractions have slowed down or stopped.. This condition is known as GastroIntestinal (GI) stasis, or ileus.
A rabbit's intestine can become static for a variety of reasons, including
Symptoms of GI stasis include very small (or no) fecal pellets, sometimes clinging to the bunny's bottom. In some cases, very small fecal pellets will be encased in clear or yellowish mucous. This indicates a serious problem which must be treated as an emergency.
With GI stasis, the normal, quiet gurgling of the healthy intestine is replaced either by very loud, violent gurgles (gas blorping around painfully!) or a desolate silence. The bunny may become lethargic, have no appetite and may hunch in a ball, loudly grinding his teeth in pain.
Too often, a rabbit suffering from GI stasis is diagnosed as having a "hairball." In reality, an apparent hairball usually is a result of GI stasis--not the cause. A vet who has not palpated many rabbit abdomens may be unfamiliar with the normal, sometimes doughy feel of the healthy rabbit stomach. A doughy stomach is cause for concern only when accompanied by an empty lower GI and symptoms of abdominal discomfort.
Like those of most herbivores, the stomach and intestines of a healthy rabbit are never empty. A rabbit may eat relatively normal amounts of food, almost up to the time the GI shuts down. Because of this, the stomach may retain a large bolus of food when stasis occurs. Unlike the typical cat hairball, which usually consists completely of hair, the mass misdiagnosed as a hairball in a rabbit is usually composed mostly of food held together by hair and mucous. Unless it is allowed to dehydrate into an impassable mass, this bolus of ingesta can be slowly broken down with enzyme supplements and plenty of oral fluids, as will be discussed shortly. However, treating a hairball without addressing the problem of GI stasis will generally be unproductive.
If you suspect that your bunny is experiencing GI stasis, you must take him/her to your rabbit-experienced veterinarian without delay. Tell the vet your suspicions. S/he will probably listen for normal intestinal sounds and palpate the bunny's abdomen. The vet also may wish to take radiographs to see whether the various parts of the digestive tract contain normal ingested matter, feces or foreign objects--or are empty and gassy. The appearance of the digestive tract will help the vet determine whether there is an obstruction and, if so, where it is located.
If an obstruction of any kind is present, the use of intestinal motility drugs (described later) could make the situation worse by pushing it into a narrow area where it completely obstructs the intestine. If the mass is not causing a complete blockage, it is best to consider medical alternatives to surgery. A gastroenterotomy--surgical opening of the stomach--may be performed to remove the obstruction, but rabbits who undergo this procedure have an abyssmally low survival rate. Those who survive the surgery itself often succumb a few days later to peritonitis or other complications, even when under the care of the most practiced, skillful rabbit surgeon. Surgery on the rabbit GI tract should be considered only as a last resort.
If your vet has determined that there is no intestinal obstruction, there are several treatments s/he may wish to use to help your bunny in distress. As always, do not perform any of these procedures or try to administer any of these medicines without the supervision of an experienced rabbit veterinarian.
A. Abdominal massage.This may sound strange, but one of the single most effective ways to stimulate a lazy gut into action is with gentle massage. Place the bunny on a secure countertop on a towel, making sure he can't jump down and hurt himself. With your hands and fingertips, gently massage the abdomen. Knead as deeply as the bunny will allow, but back off immediately if he expresses pain. A rabbit's internal organs are very delicate; care must be taken to avoid bruising them and making the situation worse. After a bit of manual massage, try an electric vibrating massager. This seems to be even more effective than manual massage, and it's worthwhile to invest in some type of massager with a large, flat surface that can be held against the bunny's tummy for relatively long periods. Press the massager firmly against the abdomen, start on low and work your way up. The bunny may be a bit taken aback at first, but almost every bunny on whom we have tried massage has settled down and enjoyed the soothing vibrations. In addition to stimulating the muscles, the massage seems to help break up gas bubbles and ease colic. Massage as long and as often as the bunny will allow and enjoy.
B. Petroleum-based laxatives(Laxatone, Petromalt, mineral oil) do not affect intestinal motility, but may help to slide dry, impacted matter through the intestine more easily when used in conjuction with intestinal motility drugs. Whereas flavored remedies in a tube are often preferred by the bunny, some vets believe that their higher viscosity may actually contribute to holding a mass of impacted food together. Unscented, laxative grade mineral oil is less viscous, and may be more effective. Petroleum-based laxatives should not be given daily or long term, as they can strip the intestine of important, fat-soluble vitamins. Note that some very experienced rabbit vets believe that these products are of no use whatsoever in treating GI stasis.
C. Simethicone (liquid, pediatric suspension or tablets) is essential for the relief of gas pain which usually accompanies ileus. This substance has no known drug interactions, is not absorbed through the intestinal lining and acts only on a mechanical principle: it changes the surface tension of the frothy gas bubbles in the gut, joining them into larger, easier-to-pass bubbles. Simethicone is practically inert, and is safe to give, even as a precaution. A farting bunny is a happy bunny!
A. Oral fluids are essential for hydrating intestinal contents which may have formed a hard mass and be nearly impossible to pass. Water is fine, but unsweetened Pedialyte, an electrolyte drink designed for human infants (and available in the infant section of the grocery store), is even better. Avoid any fluids containing large amounts of sugar (even Gatorade), as these can exacerbate the overgrowth of harmful bacteria in the caecum.
B. Force feeding. Anorexia can rapidly cause gastric ulcers and liver deterioration in rabbits. Even 12 hours without eating is cause for concern. Keep the bunny eating! One quick and easy recipe is to heat about 1/2 cup of Pedialyte or chamomile tea and soak 2 - 3 tablespoons of pellets in it until they're soft and fluffy. Mix the pellet fluff with vegetable baby food or canned pumpkin until it forms a somewhat liquid paste (you may need to add more liquid). Allow to cool before using a large-bore feeding syringe (available at most pharmacies) to deliver the goods. Insert the tip of the syringe into the space behind the incisors and squeeze gently sideways to avoid squirting food down the trachea. Give only 1-2 cc at a time, allowing the bunny a chance to chew and swallow. Aspiration of food could be life threatening, so do this with great care!
C. Caecotropes from a healthy rabbit, although difficult to obtain, are an ideal way to re-establish normal caecal flora in a compromised rabbit. If your rabbit is producing runny stool, and you can get healthy caecotropes, you can feed them to the sick bunny in a bit of baby food, mushed banana or papaya. Don't expect it to be easy. No one appreciates being fed someone else's poop!
D. Unlimited grass hay. If the rabbit won't eat timothy, oat, brome or other grass hays, you may have to resort to alfalfa (which is too rich in protein, calories and calcium for everyday use), since this is an emergency. Even if you have to feed it strand by strand, get the bunny eating hay. The long fibers help push impacted matter through the digestive tract and also stimulate the intestinal muscles into normal action. (Of course, your bunny should always have unlimited, fresh grass hay available!)
E. Fresh, wet, leafy vegetables. The fiber and moisture in fresh vegetables will also help stimulate the intestine. Kale is a good choice. If the rabbit refuses to eat, try fragrant, fresh herbs such as mint, basil, dill, cilantro, tarragon, sage, fennel, parsley and others. You just never know which herb will stimulate the appetite, so it's best to have a variety on hand.
F. Lactobacillus acidophilus is not normally a member of the rabbit's intestinal ecosystem, but we have noticed that a good dose of dried Lactobacillus powder (available at health food stores in powder or capsules) seems to help the rabbit survive the crisis until the intestine starts moving again. No one knows why, but it helps. Use non-diary powder--NOT yogurt. The milk sugars and carbohydrates in yogurt may promote harmful bacterial overgrowth.
Probiotic pastes such as Benebac are available at feed stores, and might also be helpful. Products designed for horses are generally safe and possibly effective for rabbits.
G. Enema. It may be helpful to administer an enema of warm, clean water and a very small bit of unscented, laxative grade mineral oil. Be sure to consult your veterinarian for instruction before trying this procedure. We adminster the enema with a pediatric rubber ear bulb/syringe. A 5 lb rabbit can safely be given 10-15 ccs of liquid enema. Mix the water and oil well. Place the bunny on her back, well supported so she doesn't kick. Gently insert the lubricated tip of the syringe into the anus, about 1/2 - 1 deep. (Note: if you are not sure which orifice is the right one, the anus is the one that winks back at you when touched.) Be gentle. NEVER FORCE ANYTHING! Slowly empty the bulb and let the bunny remain on her back for at least 30 seconds, to allow the liquid to travel up the tract a bit. You may need to gently hold the anus closed to avoid a fountain.
An enema delivers liquid to the source. It can help hydrate hardened, dehydrated fecal matter in the lower GI, even when subcutaneously administered fluids don't seem to help.
A. An intestinal motility agent, such as cisapride (= Propulsid) or Reglan will help get a static intestine moving again, as long as your veterinarian has determined that there is no intestinal obstruction. Both of the aforementioned drugs are safe and effective for rabbits. Cisapride, a more recently developed drug, has fewer potential side effects than Reglan, and can safely be used long term. It may take as long as two weeks on these drugs before the intestine is fully motile again, and patience and careful nursing for the duration is essential. In severe cases of GI stasis, both drugs can be used simultaneously. Because they work on different areas of the digestive tract (Reglan on the upper GI and cisapride primarily on the lower GI), they may have a synergistic effect. Recall: if there is an intestinal obstruction, these drugs should not be used, as they could make the situation worse. This is why it is imperative that you not take matters into your own hands. Have an experienced rabbit vet diagnose the problem and prescribe proper treatment!
B. Cholestryramine (Questran) is a granular resin with a high affinity for negatively charged, hydrophobic compounds, of which Clostridium spiroformes toxins are one type. This product is used primarily to reduce serum cholesterol in humans, and is available at most pharmacies. If the rabbit has mucousy stool, there is a good possibility that Clostridium bacteria are proliferating and producing potentially lethal exotoxins. Questran will absorb these and be passed out harmlessly in the feces. Questran should be suspended in a generous amount of liquid and administered orally: because of its hydrophilic properties, it can dehydrate intestinal contents if given with insufficient water. Questran does not affect the action of the intestine; it is not absorbed by the body. Rather, it works directly upon the contents of the gut. We believe this substance has helped save the lives of many rabbits suffering from a severely inflamed intestine simply by sequestering toxins and buying time while gut motility medications and other treatments get the intestine moving again. It is very safe, used as directed.
C. Subcutaneous Lactated Ringers Solution will not only keep the bunny well hydrated, but will also make sure the electrolytes are balanced. Administration of subcutaneous LRS--even if the rabbit does not feel dehydrated to the touch--can help to re-hydrate food masses lodged in the intestine, and make the bunny feel better in general. A dehydrated rabbit will feel tired and ill, and may not have as much will to fight as one who is well-hydrated. Rabbits in GI stasis tend to be both anorectic and unwilling to drink, so it is a good idea to administer subcutaneous fluids as a precaution, unless the rabbit has known kidney or heart malfunctions.
D. Enzymatic digestive aids can be helpful in loosening and softening an impacted mass of food and hair (which, we remind you, is usually a symptom, not the cause of the problem!). Proteolytic (protein-dissolving) enzymes may be of either plant or animal origin. Papain (found in papaya) and bromelain (found in pineapple) may help to break down mucous binding an obstruction, thus allowing it to slowly break up and pass. However, there is no evidence to suggest that these enzymes break down keratin, which is the main protein component of hair. Both papain and bromelain are available in powdered form at most health food stores, and should be reconstituted in water or Pedialyte shortly before use to ensure maximum potency. Papaya tablets are little more than a sugary treat: they contain very little active enzyme.
Your vet may wish to try a more powerful, animal-derived enzyme product such as Viokase, which contains pancreatic enzymes to break down proteins, amylases to break down indigestible carbohydrates and lipases to break down fats. Although these enzymes may be better at breaking up an obstruction composed of ingested matter, they should be used with caution, as they can burn the esophagus and cause several days discomfort in an already sick bunny!
E. B-complex vitamins, administered orally or injected, may help stimulate the appetite. It is vital to keep the bunny eating, even if you must force-feed. Anorexia can rapidly result in gastric ulcers and serious liver degeneration.
F. Antibiotics. Some vets routinely prescribe antibiotics for a rabbit suffering from GI stasis, either to combat the overgrowth of Clostridium spp. (Flagyl) or to prevent secondary bacterial infection in the compromised rabbit (e.g., Baytril). While we appreciate such cautionary measures, we note that unnecessary use of antibiotics is a prime reason that so many resistant strains of bacteria are evolving even as we speak. Unless the rabbit shows signs of bacterial infection (which may be the reason the intestine shut down in the first place), we urge a conservative approach: don't use antibiotics unless they are absolutely necessary. The abovementioned medications and treatments should be enough to get the rabbit's intestine working again.
A. Analgesics are extremely important for a rabbit suffering the abdominal pain of GI stasis. Banamine, a product approved for use only in horses, has been used extensively on rabbits with excellent results. Although some species suffer gastric ulcers when given banamine, we have anecdotal evidence of rabbits on Banamine for several weeks, suffering no apparent side effects. Torbugesic, an opioid analgesic, provides excellent pain relief at relatively low doses, but it may have the undesirable side effect of slowing down intestinal motility.
We also have had excellent success at relieving colic pain and inflammation of the intestinal lining with sulfasalazine, a combination sulfa antibiotic and non-steroidal anti-inflammatory compound. Sulfasalazine works topically to reduce intestinal inflammation. Both banamine and sulfasalazine have a twofold benefit: not only do they relieve pain, they also help reduce enteric toxins generated by harmful bacteria. Barium may also be useful as an intestinal tonic to relieve pain and help stimulate peristalsis, but its action is slow compared to that of the aforementioned analgesics.
It is absolutely essential that the caretaker faced with a rabbit in GI stasis be patient, allowing the treatments and medications to work. Rabbits are easily stressed, and excessive handling should be avoided. It may take several days before any fecal pellets are seen, and it may take two weeks or more on intestinal motility agents and therapy before the intestine is moving normally again. We have had one case in which a rabbit produced no fecal pellets for 14 days, but finally did respond to gentle, consistent administration of the above treatment regimen. Patience and persistence are key!
Do not make more trips to the veterinarian's office with the rabbit than absolutely necessary. Increased stress will only slow recovery. Whenever possible, administer medications at home, where the rabbit feels safe and secure. Every bunny parent should have a stethoscope (not necessarily an expensive one) to monitor intestinal sounds. The gradual return of gentle gurgling is a very good sign: once this begins, the rabbit is on the road to recovery, even if fecal pellets don't begin pouring out the chute. Administration of intestinal motility agents, gentle massage and supportive care as listed above should be continued, and gradually tapered as fecal pellets slowly begin to come through the system.
Do not be alarmed if the first batch of fecal pellets are small, hard and misshapen. This is to be expected. Also do not be surprised if the rabbit produces a small bunch of pellets, nothing for a day, and then a bit more. The intestine sometimes seems to regain its function in fits and starts, rather than all at once. Consistent, gentle nursing and reduction of stress are essential at this time.
Please resist the temptation to force additional, aggressive treatment once the rabbit begins to recover. Recovery from GI stasis is sometimes maddeningly gradual. We know of one instance in which a rabbit was starting to produce fecal pellets and showing signs of recovery, but the veterinarian overseeing the case insisted on anesthetizing the rabbit to perform oral gavage, enemas with an extension tube and vigorous abdominal massage. Despite our advice to the contrary, this veterinarian believed that the mass in the stomach could not possibly pass without such treatment. Tragically, this rabbit died. The autopsy revealed a ruptured liver. We cannot help but wonder whether excessive handling and the unnecessarily aggressive treatments contributed to, or even caused this rabbit's demise.
Once you and your bunny have defeated the GI stasis threat, it's time to look for the cause of the problem. Does your rabbit get insufficient fiber in her diet? Are you giving her too many starchy treats? Does she have overgrown molars or an abscessed tooth? Does she have an underlying infection or illness that's causing enough stress to shut down her intestine?
A rabbit's stress organ system is its digestive tract. GI stasis may be your first clue that something else is wrong. If the rabbit does not seem fully normal, even after the GI is moving well again, its time to do some bloodwork, radiographs (don't forget the head!) and other additional diagnostics as deemed necessary by your rabbit-experienced veterinarian.
During recovery from GI stasis, careful monitoring of body temperature (use a plastic thermometer, which cannot break off in the rectum) will allow the caretaker to tell whether the rabbit is homeostatically stable. Normal rabbit body temperature ranges from about 101o - 103oF. A higher temperature may indicate either stress or an infection, the latter requiring immediate veterinary attention. A temperature lower than 101oF is actually of greater concern than a mildly elevated temperature. Abnormally low body temperature may indicate shock or septicemia: a bacterial infection that has entered the bloodstream. A rabbit with a temperature lower than 100oF should be considered an extreme emergency. Pack the rabbit with warm water bottles wrapped in towels and get to the emergency clinic immediately!
The best cure for GI stasis, of course, is prevention. Be sure your rabbit companion gets plenty of dietary fiber from fresh grass hay. Feed high fiber (22% or higher crude fiber) pellets. Be sure your rabbit is drinking sufficient water to keep ingested food hydrated and moving smoothly. It helps to offer at least 4 cups of fresh, wet leafy greens per 5 lbs. of rabbit daily. And don't forget that regular exercise not only keeps the skeletal muscles buff and strong: it also keeps the smooth muscles of the intestines well-toned and active. Regular visits to your rabbit-experienced vet will ensure that your bunny pal doesn't develop health problems that go undetected. Once such a problem becomes serious, it may manifest itself as GI stasis.
So here's to healthy peristalsis! May your home be blessed with great, healthy piles of gorgeous bunny poops. All in the litterbox, of course.
Dana Krempels, Ph.D. is a faculty member of the University of Miami Biology Dept. Susan Kelleher, D.V.M. received her veterinary degree from the University of Tennessee School of Veterinary Medicine and is the exotics expert at the Hollywood Animal Clinic, Hollywood, FL. We are grateful to George Flentke, Ph.D. (University of Wisconsin Pharmacy Dept) for his review and information on the pharmaceuticals named in this article and to Kevin Johnson for his editorial expertise. The treatments listed are based on information and protocols suggested by many veterinarians and experienced rabbit rescuers.
For more information, and for referral to a veterinarian who is an expert in rabbit medicine, you may call or e-mail one of Rabbit Rescue volunteers or visit the home page of the House Rabbit Society. A link to veterinary referrals in all 50 states, Canada and Europe is listed on the first page. Please DO NOT allow a vet--however wonderful s/he is with dogs and cats--to treat your rabbit if s/he is not well-versed in the specifics of rabbit medicine. It could be fatal to your rabbit!
The House Rabbit Handbook by Marinell Harriman is an excellent source of information on rabbit care. It is available for less than $10 at most major bookstores. If your bookstore does not carry it, please ask them to order it for you: ISBN 0-940920-12-3.
If you're online, you may wish to join EtherBun, a free listserve devoted to the health, care, behavior and biology of companion rabbits. For more information on EtherBun, visit http://fig.cox.miami.edu/Faculty/Dana/ether.html.
by Dana Krempels, Ph.D.
