Poopy Butt / Cecal Disbiosis

Cecal impaction is different from gastrointestinal (GI) blockage, though some of the signs are similar. Both are life-threatening conditions. There are generally three stages involved in cecal motility disorders: abnormally soft cecotrophes, cecal hypomotility (slowdown), cecal impaction (stasis). Cecal motility disorders may be gradual and progressive, however a rabbit will not necessarily proceed through each stage. The signs for cecal motility disorders are also non-specific; they may be indicative of some other problem.

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 sizeable 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 fibre and digestible fibre. 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 fibres. The indigestible fibre stimulates the movement and mixing of the intestinal contents; therefore, fibre must be ingested regularly to keep the digestive system working as it should. The indigestible fibre is collected and then pushed into the second half of

Digestible Fibre and Cecotrophes
In contrast, digestible fibre, along with some fluid, is moved backwards from the upper part of the colon into the cecum. 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 cecotrophes: small packets of tiny-bodied, nutrient-rich flora. (Note that cecotrophes are sometimes informally referred to as caecals; 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 cecotrophes out toward the anus. Receiving a neurological signal that the cecotrophes are coming, the rabbit turns his attention to the anal area and eats the cecotrophes directly (a process called cecotrophy); they are swallowed whole. Few caregivers ever see the cecotrophes, as it looks like the rabbit is simply grooming his anal area.

Cecotrophes are dark green and have a distinct odour 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 cecotrophes are gradually broken down in the digestive tract and the nutrient-laden cecal flora are assimilated.

Rabbits should always be allowed to eat their cecotrophes. These food capsules are not faecal 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 cecotrophes any number of times. (Thus, they are not really “night droppings” as sometimes thought.)

Healthy rabbits consume all their cecotrophes. 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 cecotrophes; thus, you may find them in the litter box along with regular faeces. If cecotrophes are not ingested, the rabbit may experience dietary insufficiencies.

Additionally, note that a rabbit may not eat cecotrophes 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 cecotrophes.

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-fibre, 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 three cecal motility disorders; most disorders of the cecum will eventually lead to disbiosis (imbalance of the microbial flora in the cecum and GI tract).

When a rabbit’s GI tract works as it should, cecotrophes 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, cecotrophe 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 fibre.

Stages and Manifestations of Cecal Motility Disorders
When cecal disbiosis 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 cecotrophes. This dumping usually results in relatively formless, “pudding like” cecotrophes, 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 cecotrophes are coming.

Not all rabbits with cecal disbiosis will exhibit obvious soft or pudding-like cecotrophes. 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 cecotrophes. Eventually the rabbit will also develop a life-threatening ileus, which is the shutdown of movements in the GI tract.

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, diarrhoea, and death.

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, cecotrophes:

- 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 faecal matter but is due to liquid or malformed cecotropes which mat 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 cecotrophes. 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 cecotrophes – something not easily observed by the caregiver. Signs to watch for include those listed above for obviously soft cecotrophes 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 Cecotrophes
Treatment for a cecal motility disorder that manifests as abnormally formed cecotrophes is based on the appropriate diet for a rabbit. This involves feeding unlimited high quality hay, fresh grass, an appropriate serving of greens, stopping all carbohydrate high foods and reducing the portion of pellets down to a safe amount. If the rabbit has overly soft cecotrophes and the problem is diet-related, the prognosis for recovery is excellent as long as dietary guidelines are followed. A gradual change in pellet amount or kind (alfalfa-based to grass-hay-based for example) may have to be done gradually to prevent hepatic lipidosis.

NZ specific information about pellets can be found in the Pellets section.

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. Successfully returning the rabbit to health hinges on stimulating the gut to work again. After initial treatment in the clinic the rabbit may be well enough to continue treatment at home where it will be less stressed. Current research indicates that return to health hinges on fluids and fibre and treatment is similar to that for Ileus - fluids, feeding (vi syringe if necessary) a high fibre, easily digested food such as Critical Care, pain relief & motility drugs. Giving the recovering rabbit gentle tummy massages and encouraging the rabbit to be active helps too.

Because cecal impaction is a serious threat, if the rabbit does not respond to treatment within twenty-four hours, if there is no improvement or if the rabbit’s temperature drops, it’s vital to  go back to the vet. If the rabbit’s digestive system is responsive, a recheck with the vet within the week should be done to make sure the cecum is emptying. If it empties and the flora balance is restored, the prognosis for the rabbit is very good.

Treatment and Prognosis for Recovery: Cecal Impaction
If a rabbit is not treated early, the caregiver will suddenly notice changes in the rabbit’s behaviour 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. 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 is essential.

An analgesic for pain will also be required. When there is dehydration and shutdown, buprenorphine (an injectable morphine derivative aka Temgesic) may be more appropriate. Meloxicam works well in well-hydrated rabbits.

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

If the rabbit recovers, it may be 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.

Sometimes the cecum will not empty with the above treatment so a decision on whether to go to surgery must be made. 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. there are also serious concerns 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.

Home Care: The Rabbit with Abnormally Soft Cecotropes
When a bunny has soft, poorly formed cecotrophes, 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 cecotrophes grazes freely on hay throughout the day reducing other foods such as veges/greens back to an almost primarily hay & long fibrous grass intake can help to re establish a healthy Cecum. Hay drives the gastrointestinal tract. Soft mushy cecotrophes can often be cured with a temporary all-grass-hay diet, then reintroduction of limited leafy greens and a small portion of pellets.

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. 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 cecotrophes 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. Consumption of long fibre hay is the ultimate goal and offering a variety of grass hay like Meadow and Timothy, may create interest and is healthiest for most adult rabbits. Good quality hay should be fed in long-fibre form (i.e., not chopped up) whenever possible. However Chaff may also help entice a reluctant hay eater to consume more hay. If you have a rabbit who refuses hay, query rabbit-savvy people about their successes in getting a rabbit to eat it. Overfeeding pellets and other treats (including fruits and high-sugar vegetables such as carrots) generally results in poor hay consumption.

If it is suspected that leafy vegetables may be the cause of abnormal cecotrophes, the rabbit 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 - long fibrous grass and grass hays.

After the rabbit stops producing the pudding-like cecotrophes and green leafy vegetables are reintroduced, high-fibre greens especially those such as Plantain, Raspberry leaves & Blackberry leaves can be tried. Fibrous weeds and herbs are beneficial due to their vitamin, mineral and fibre content - they are much more fibrous than store-purchased greens such as romaine lettuce. Cooking herbs such as parsley and mint add variety. Freshly pulled long grass (not clippings) also has 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, reduce the quantity of greens. Grass hay is most important for the health of the rabbit.

Home Care: The Rabbit with Cecal Hypomotility
The home-care program for a rabbit suffering from early-stage cecal hypomotility includes fluids and a diet high in fibre. The rabbit must be monitored very closely  and regularly weighed. 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.

The faster the rabbit returns to eating grass hay, the better. If a nutritional cause is suspected, 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 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 you 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).

Original material, with edits made to suit NZ conditions, sourced from:
Disorders of the Cecum - House Rabbit Society

Butt Baths
Baths and Cleaning - Disabled Rabbits

Bathing a Rabbit's Messy Bottom - Dana Kremples