Aetiology, diagnosis, treatment and outcome of traumatic reticuloperitonitis in cattle

Journal Pre-proof Aetiology, diagnosis, treatment and outcome of traumatic reticuloperitonitis in cattle Ueli Braun, Christian Gerspach, Stefanie Ohlerth, Sonja Warislohner, Karl Nuss

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https://doi.org/10.1016/j.tvjl.2020.105424

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YTVJL 105424

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6 January 2020

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Review

Aetiology, diagnosis, treatment and outcome of traumatic reticuloperitonitis in cattle Ueli Braun a,*, Christian Gerspach a, Stefanie Ohlerth b, Sonja Warislohner a, Karl Nuss a a

Department of Farm Animals, Vetsuisse Faculty, University of Zurich, 8057 Zurich, Switzerland b Clinic of Diagnostic Imaging, Vetsuisse Faculty, University of Zurich, 8057 Zurich, Switzerland

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* Corresponding author. Tel.: +41 52 7 41 50 60. E-mail address: [email protected] (U. Braun).

Highlights

The clinical signs of traumatic reticuloperitonitis are characteristic in acute cases, but

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Graphical abstract

may be vague or absent in chronic cases 

Haematological findings (white blood cell count, fibrinogen, total solids) alone are not diagnostic

Inflammatory changes in the reticulum and adjacent organs can be detected with

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ultrasonography

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Radiography allows metallic foreign bodies to be visualised and treatment efficacy to be monitored

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Treatment can be conservative (magnet and antibiotics) or surgical (foreign body removal) 1

Abstract Traumatic reticuloperitonitis (TRP) in cattle is caused by ingested nails, pieces of wire, and other nonmetallic materials that injure the reticular wall. Clinical signs of acute TRP may include anorexia, fever, drop in milk production, rumen atony and tympany, abdominal pain, an arched back, a tucked up and “guarded” abdomen and spontaneous grunting, but may be obscure or absent in chronic cases. Haematological findings alone are not diagnostic, but

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total and differential white blood cell counts, the concentration of fibrinogen and total protein and the glutaraldehyde coagulation time may indicate inflammation associated with TRP. The clinical examination is aimed at eliciting a grunt in response to foreign body tests such as

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back grip, pole test or pain percussion. Inflammatory changes of the reticulum and adjacent organs and impairment of reticular motility are characteristic features of TRP and can be

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detected via ultrasonography. Radiography is the technique of choice for the visualisation of

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metallic foreign bodies and for monitoring the efficacy of a magnet. Treatment may be conservative or surgical, but in most cases initial treatment is conservative with

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administration of a magnet and antibiotics. If the cow fails to respond to medical treatment, surgical treatment is the next option other than euthanasia and ideally is carried out after imaging of the reticulum. If this is not feasible, a second magnet and continuation of

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antibiotic treatment is recommended.

Keywords: Cattle; Radiography; Traumatic reticuloperitonitis; Treatment; Ultrasonography Introduction

Traumatic reticuloperitonitis (TRP) has maintained its clinical importance despite a decrease in incidence from as high as 80 % decades ago (Maddy, 1954) to 12.1 % (Poulsen, 1976), 10 % (Cramers et al., 2005), 8 % (Waldner et al., 2009) and 2 to 3 % (Starke and Rehage, 2000). The main cause of this disorder is the ingestion of sharp objects such as nails or pieces of wire 2

that penetrate or perforate the wall of the reticulum (Dirksen, 2002; Braun et al., 2009a; Francoz and Guard, 2015; Constable et al., 2017) leading to localised peritonitis. In the last 20 years, the use of radiography and ultrasonography has led to considerable improvements in the diagnosis of TRP. This review describes the present state of knowledge as it relates to the causes, clinical findings, diagnosis and treatment of TRP.

Preparation of the review The databases PubMed, VetMed Resource and Scopus for the years 1975 to 2018

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were searched for the keywords cattle, cow, reticulitis and reticuloperitonitis. In addition, the list of references of the standard texts (Dirksen, 2002; Francoz and Guard, 2015; Constable et

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al., 2017; Walker, 2017) were scrutinised for relevant articles.

Causes

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The main cause of TRP is the ingestion of sharp metallic objects such as nails or

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pieces of wire that penetrate or perforate the wall of the reticulum (Maddy, 1954; Jagos, 1969; Neumann, 1979; Andersen and Gillund, 1980; Roth and King, 1991) (Table 1). Aluminium foreign bodies are rare (Cramers et al., 2005; Braun et al., 2018c). Other foreign bodies that

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may be ingested include wires from cut tires used to weigh down tarps covering silage (Harwood, 2004; Monies, 2004; Cramers et al., 2005) and fragments from the metal components of mixer wagons (Daniel and Smith, 2008). There have been two reports of

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hardware disease as a herd problem in the vicinity of small airports where surrounding hay fields were contaminated with worn wire bristles from brushes used to clean the runways (Ryzhakov and Lazarev, 2008; Braun et al., 2009a). Non-magnetic foreign bodies are uncommon (Jagos, 1969; Neumann, 1979; Warislohner, 2017). Greater than 99 % of foreign bodies injure the reticulum, and although rare, injury to the abomasum (Haaranen, 1977; Murray et al., 1991; Nuss et al., 2004), duodenum (Mullowney and Whitlock, 1978) and jejunum (Egle et al., 2007) has been reported. Pica has also been implicated in the 3

pathogenesis of TRP. Cattle with TRP and signs of pica had significantly lower blood concentrations of zinc, copper and calcium than healthy cattle and it was assumed that these abnormalities led to nutritional disorders (Ocal et al., 2008).

Clinical findings The clinical signs of TRP have been described in detail in relevant textbooks (Dirksen, 2002; Francoz and Guard, 2015; Constable et al., 2017) and are the topic of numerous reports that also deal with secondary diseases typical of TRP (Leonard, 2004; Braun et al., 2007b;

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Orpin, 2007; Gerspach et al., 2011; Watts and Tulley, 2013). However, the majority of information is largely based on empirical evidence, and systematic evaluation of the clinical findings in cattle with a definitive diagnosis of TRP has not yet been done. Therefore, the

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clinical findings of 503 cattle with TRP were described in detail (Braun et al., 2018a). The most common clinical findings were, in decreasing order of frequency, abnormal general demeanour

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(87 %), reduced or absent rumen motility (72 %), a minimum of one positive foreign body test

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(58 %), poorly digested faeces (57 %), decreased or absent intestinal ruminal motility (50 %), reduced rumen fill (49 %), fever (43 %) and spontaneous signs of pain (39 %), such as arching of the back in 18 %, bruxism in 20 % and grunting in 2 % (Fig. 1) (Braun et al., 2018a). Arching

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of the back is a sign of parietal pain, bruxism is a sign of pain associated with many diseases and spontaneous grunting is a response to pain caused by reticular contractions. In addition, 30 % cattle had watery to loose faeces, 21 % cattle had bradypnoea, 14 % had a fuller than normal

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rumen, 14 % had abnormally thick faeces and 10 % had ruminal tympany. Rectal examination showed distension of the rumen in 19 %. Eating and rumination were decreased (Braun et al., 2017). In 12 cattle with localised fibrinopurulent to apostematous traumatic reticuloperitonitis the median daily eating time was 168 minutes (reference interval in healthy cows 211 to 319 min), rumination time was 233 minutes (370 to 511 min) and the number of chewing cycles per cud was 40 (45 to 65) (Braun et al., 2017). In rare cases, the sternum is involved in the inflammatory process and affected cattle rest in lateral recumbency to avoid pressure on the 4

painful sternal region (Braun et al., 2009b). Comparison of the observed clinical findings and those described in the literature showed several differences. An arched back, ruminal tympany and spontaneous grunting, which are considered characteristic findings, were relatively rare (arched back 18 %, rumen tympany 10 %, spontaneous grunting 2 %), whereas bruxism, which has not been mentioned in the textbooks as a sign of TRP, occurred in 20 %. A possible reason for this discrepancy is that in clinical practice, acute cases with characteristic clinical signs are predominantly seen, whereas at a referral clinic, chronic cases that have not responded to treatment and are accompanied by vague clinical signs are more common. The literature does

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not mention bruxism as a sign of pain in cows with TRP, but this is a very subtle indicator of pain and requires careful observation; it may be muffled by common barn sounds and therefore

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missed during physical examination in a barn.

The most important complications of TRP are traumatic pericarditis (Braun et al.,

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2009a), hepatic inflammation or abscesses (Braun et al., 1995; Dirksen, 2002), splenic

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inflammation or abscesses (Nuss et al., 2009; Dirksen, 2002), pleuropneumonia (Dirksen, 2002), vagal indigestion (Rebhun et al., 1988; Rehage et al., 1995) and generalised peritonitis (Dirksen, 2002). There also have been reports of cardiac tamponade following foreign body-

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induced perforation of a coronary artery (Awadhiya et al., 1974), fatal reticular haemorrhage after puncture of the reticular vein by a foreign body (Constable et al., 2017), thrombosis of the cranial vena cava (Gerspach et al., 2011) and aortic thromboembolism (Du Preez et al.,

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1995).

Clinical diagnosis A thorough clinical examination is a must in all cattle with abnormal general demeanour, and particular attention must be given to signs of pain including spontaneous grunting and bruxism in cattle suspected of having TRP. One goal of the clinical diagnostic procedure is to elicit a grunt or groan by carrying out foreign body tests, but it is important to 5

remember that other painful conditions of the abdomen and thorax can induce the same reaction (Henninger and Mullowney, 1984; Ward and Ducharme, 1994; Dirksen, 1990). Eliciting a grunt is easier in acute than in chronic TRP (Dirksen, 1990) because the pain often subsides in chronic stages of the disorder resulting in a faint grunt or no sound at all. The audibility of a grunt can be enhanced by placing a stethoscope over the larynx (Dirksen, 2002) or trachea (Radostits, 2000), or vibrations associated with the grunt may be felt by placing the palm of one hand over the laryngeal area (Stöber, 1961).

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There are a variety of tests to diagnose traumatic reticuloperitonitis. The most important foreign body tests are the back grip, the pain percussion over of the reticulum with a mallet and the pole test (Andres, 1952; Williams, 1974; Dirksen, 1990) (Figs. 2-4). Other

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tests include the zone test developed by Kalchschmidt (Andres, 1952), which involves testing of the sensitivity of the withers region by touching, displacing or pulling the skin, or gentle

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pulling of the hairs (Dirksen, 1990), leading the cow up and down an incline, and ferroscopy,

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which involves scanning the thoracic and abdominal walls with a metal detector (Dirksen, 1990). It is recommended, that at least the back grip, the pole test and pain percussion are carried out if a foreign body is suspected (Dirksen, 1979). Ideally, the tests are done after a

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plastic rectal sleeve has been placed over the mouth and nose to temporarely prevent the animal from breathing (Dirksen, 1979); the brief period of apnoea results in strong diaphragmatic contractions, which increases the sensitivity of the tests (Dirksen, 1990). In a

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retrospective study of 503 cattle with TRP it was recommended to carry out each test 4 times and to interpret each test separately (Braun et al., 2018a). In that study, a test was considered positive when it elicited a short grunt three out of four times. Only a few studies have scrutinised the results of foreign body tests (Hjerpe, 1961; Braun et al., 1993a; Braun et al., 2018a). A grunt was elicited by the back grip in 41 % and by deep palpation with a fist caudal to the sternum in 45 % cattle suspect for TRP (Hjerpe, 1961) and in another study, 16 (61 %) of 26 cattle with radiographically confirmed TRP had at least one positive foreign body test 6

(Braun et al., 1993a). In a recent study of 503 cattle with TRP, 58 % had at least one positive foreign body test (i.e., at least one of the tests had a positive reaction in 3 of 4 attempts to elicit a grunt (Braun et al., 2018a). The pole test was positive in 43 %, the back grip in 39 % and pain percussion in 24 % (Braun et al., 2018a). Even though the presence of a foreign body was confirmed radiographically in all the cattle, 42 % had negative foreign body tests. The grunt test may be positive, negative or equivocal in cattle with chronic localised peritonitis (Constable et al., 2017).

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Haematological findings The bulk of information is largely based on empirical evidence, and systematic

evaluation of the haematological findings in cattle with a definitive diagnosis of TRP has not

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been done. Therefore, the haematological findings of 503 cattle with TRP were described in

detail (Braun et al., 2018a). The principal findings were a decreased haematocrit in 45 % and

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leukocytosis in 42 %. The main biochemical abnormalities were hyperfibrinogenaemia in 69

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% and hyperproteinaemia in 64 %. Total and differential leukocyte counts, fibrinogen and total protein concentrations and the glutaraldehyde coagulation test (Metzner et al., 2007) have some clinical significance, but it should be remembered that other inflammatory

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conditions induce the same haematological changes and the absence of haematological changes does not rule out TRP (Francoz and Guard, 2015). A differential leukocyte count is a better diagnostic indicator for acute peritonitis than the total leukocyte count (Constable et al.,

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2017). Neutrophilia (Tharwat et al., 2012; Reddy et al., 2014), commonly with a left shift (Francoz and Guard, 2015; Constable et al., 2017) is characteristic of acute localised peritonitis but only in the first three days of the illness, after which time normalisation of the findings occurs in uncomplicated cases (Constable et al., 2017). In chronic cases, complete normalisation may not occur for extended periods and affected cattle have persistent moderate leukocytosis, neutrophilia and monocytosis (Constable et al., 2017) although normal total and differential leukocyte counts have been reported in chronic cases (Francoz and Guard, 2015). 7

Acute diffuse peritonitis may be associated with leukopenia with a degenerative left shift attributable to migration of circulating neutrophils to the site of inflammation combined with reduced bone marrow response (Tornquist and Rigas, 2010). This finding is associated with a poor prognosis because of inability of the bone marrow to respond to the inflammatory process (Jain, 1986).

Hyperfibrinogenaemia and hyperproteinaemia have previously been documented in TRP (Dubensky and White, 1983; Jafarzadeh et al., 2004; Nazifi et al., 2009) and are better

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indicators of this disorder than leukocyte counts. Fibrinogen may be increased as early as 2 to 3 days after the onset of TRP (Hirvonen and Pyörälä, 1998; Jafarzadeh et al., 2004; Nazifi et al., 2009). In cattle with chronic TRP, the total protein concentration is also increased because

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of an increase in the globulin concentration (Hirvonen and Pyörälä, 1998; Jafarzadeh et al., 2004). The glutaraldehyde coagulation test is a simple and rapid point-of-care method for

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semiquantitative determination of γ-globulin and fibrinogen concentrations (Sandholm, 1974; Liberg et al., 1975; Liberg, 1978). There is a significant positive correlation between the time

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to gel formation and the γ-globulin and fibrinogen concentrations (Doll et al., 1985). The diagnostic sensitivity of the test is high at 97.8 % for a coagulation time of 3 minutes and 87.9

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% for 6 minutes (Doll et al., 1985). The relationship between coagulation time and gamma globulin plus fibrinogen is best described by an exponential curve (Metzner et al., 2007). The maximum value for the sum of sensitivity and specificity was found at 7 and 8 min. Of 498

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glutaraldehyde tests in cattle with TRP, 75 % coagulated within 6 minutes with a median time of 3.5 minutes (Braun et al., 2018a). Chronic TRP may be accompanied by erythropenia, thrombocytopenia and abnormal blood coagulation parameters including prolonged activated partial thromboplastin, prothrombin and thrombin times (Gokce et al., 2007). A recent report identified serum iron concentrations as an indicator of acute inflammation in cattle; iron concentrations were significantly reduced in cattle with TRP and acute mastitis (Baydar and Dabak, 2014). In addition to fibrinogen, cattle with TRP have increased concentrations of 8

other acute-phase proteins including serum amyloid A (Nazifi et al., 2009) and haptoglobin (Hirvonen and Pyörälä, 1998; Nazifi et al., 2009; Kirbas et al., 2015). Furthermore, cattle with TRP have increased serum nitric oxide concentrations and decreased total antioxidant capacity, which are believed to reflect the diverse bacterial population associated with peritonitis (Atakisi et al., 2010). Some cattle with TRP-associated myocardial cell damage have increased blood concentrations of cardiac troponin-I (cTn-I) and cardiac troponin-T (cTn-T) (Gunes et al., 2008).

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Rumen fluid Results of rumen fluid analysis are not pathognomonic for TRP.

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Ferroscopy

Scanning of the ventral and lateral thoracic and abdominal wall with a metal detector

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can provide information about the presence of ferromagnetic foreign bodies (Leuenberger et al.,

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1978a; Dirksen, 1990; Sawandkar et al., 2009). It should be noted that foreign bodies that penetrate the dorsal aspect of the reticulum and non-magnetic foreign bodies (copper or aluminium) may have false-negative results and non-perforating ferromagnetic foreign bodies

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such as bolt nuts and magnets have false-positive results. A compass can be used to identify magnets that had been given previously by the producer or veterinarian.

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Abdominocentesis

A teat cannula or a hypodermic needle can be used for abdominocentesis. The authors

of this review prefer a spinal needle with stylet for the procedure, which is ideally conducted under ultrasonic guidance at a site where ultrasonographic changes are seen (Braun, 2016). When the fluid appears heterogeneous, the sample should include the echogenic sediment to increase the likelihood of collecting bacteria and inflammatory cells. The amount, colour, transparency, odour and consistency of the sample are assessed and the presence of other 9

material is noted (Braun, 2016). A refractometer is used to determine specific gravity and total solids. Samples with alterations should undergo cytological and bacteriological examination. An exudate is defined as a cloudy, watery to viscous and foul-smelling fluid that may clot quickly after collection. It commonly contains flecks of fibrin, has a specific gravity of greater than 1.015 and a protein content greater than 30 g/l. It is important to remember that when assessing aspirated peritoneal fluid (Hirsch and Townsend, 1982; Wilson et al., 1985; Kopcha and Schultze 1991a, b; Fecteau, 2005) differentiation of abdominal transudate and exudate based on standard textbook definitions does not always apply to sick cattle

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because the protein and fibrinogen concentrations in the peritoneal fluid of healthy and sick animals can overlap (Wilson et al., 1985). In addition, animals with liver cirrhosis or cardiac failure can have unexpectedly high protein concentrations in the peritoneal fluid and cattle

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with severe infections may have unexpectedly low concentrations (Wittek et al., 2010a). The number of cells may be reduced because of cytolysis. To improve the diagnostic usefulness of

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peritoneal fluid analysis, other variables including glucose and D-dimer concentrations were

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measured in peritoneal fluid and serum; the peritoneal fluid-to-blood ratios of these variables were also calculated (Wittek et al., 2010a). The glucose concentrations of blood and peritoneal fluid usually are similar in healthy cattle. When bacteria are present in the

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peritoneal fluid the glucose is metabolized by the bacteria and therefore its concentration is low. For this reason, the glucose concentration is considered a very specific criterion (specificity = 90.2 %, sensitivity = 47.1 %) for the diagnosis of septic peritonitis (Wittek et

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al., 2010b). D-dimer concentration is another useful parameter for the diagnosis of peritonitis (sensitivity = 96.2%, specificity = 94.1%). It is a fibrin degradation product and plays an important role in the diagnosis of coagulation disorders; healthy cattle have a D-dimer concentration of less than 0.60 mg/l (Wittek et al., 2010a). Peritonitis in cattle is associated with massive synthesis of fibrin immediately accompanied by fibrinolysis, generating Ddimer. Therefore, D-dimer concentration is considered the best criterion for the diagnosis of peritonitis (Wittek et al., 2010b), since both, the sensitivity and the specificity, are high. 10

Laparoscopy Laparoscopy of the bovine abdomen has been dealt with in several publications (Wilson and Ferguson, 1984; Anderson et al., 1993; Schiller and Staufenbiel, 1999; Steiner and Zulauf, 1999) and was shown to be useful for the detection of inflammatory changes in the anterior abdomen (Wilson and Ferguson, 1984). However, massive adhesions often restrict the visibility of the reticulum, and the detection of penetrating or perforating foreign

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bodies via laparoscopy has not been reported.

Endoscopy of the reticulum

There have been no studies on the endoscopic examination of the reticulum and

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attempts to do so at our clinic (unpublished) were unsuccessful.

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Ultrasonographic findings

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Ultrasonography has been used for the diagnosis of TRP (Kurosawa et al., 1991; Kaske et al., 1994; Ramprabhu et al., 2004; Flöck, 2006; Tharwat et al., 2012; Kurt and Cihan, 2013; Rizzo et al., 2013; El-Esawy et al., 2015; Khalphallah et al., 2015; Braun et al.,

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2018b). The reticulum is examined ultrasonographically using a 3.5 to 5.0 MHz linear or convex transducer applied to the ventral aspect of the thorax on both sides of the sternum and to both sides of the lateral thorax up to the level of the elbow. For assessment of reticular

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motility, the transducer is placed at the left ventral thoracic region and the reticulum is located and observed for three minutes without moving the transducer. The position and contour of the reticulum, the frequency and amplitude of reticular contractions, type and scale of visible changes and the involvement of neighbouring organs are recorded. In cattle with suspected TRP, the contour and motility of the reticulum are examined first (Braun and Götz, 1994; Braun and Rauch, 2008; Braun, 2009b) and when abnormalities are detected, the examination area is extended to determine the extent of the lesions. Depending on the severity of the 11

inflammatory changes, the rumen (Braun et al., 2013; Braun and Schweizer, 2015), omasum (Braun and Blessing, 2006; Braun et al., 2007a), abomasum (Braun, 2009b), spleen (Braun and Sicher, 2006), liver (Braun, 2009c) or the entire abdomen is scanned (Braun, 2009b). When there are signs suggesting pericarditis or pleuropneumonia, the examination should include the heart (Braun, 2009a) and lungs (Braun et al., 1996).

Inflammatory changes of the reticulum and surrounding organs are common in cattle with TRP (Braun et al., 1993b; Braun, 2009b) and occurred in 83 % of 503 cattle with TRP

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(Braun et al., 2018b). Previous studies have confirmed that echogenic deposits, with or without hypo- or anechoic fluid pockets, and structures of various shapes and echogenicities with central echogenic fluid collections, reflect foreign body-related inflammatory changes of

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the peritoneum that include fibrinous deposits and abscesses (Braun et al., 1993b; Braun, 2009b; Braun et al., 2018b). Therefore these sonographic findings were interpreted and

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referred to as inflammatory changes of the peritoneum. Fibrinous-apostematous reticular

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lesions usually are echogenic and heterogeneous and interspersed with hypoechoic or anechoic fluid (Braun et al., 1993b; Braun, 2009b; Braun et al., 2018b) (Figs. 5, 6). Abnormalities were limited to the reticulum in 57 % and extended to the umbilical or flank

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region in 10 and 13 % cases (Braun et al., 2018b). Diagnostic rule-outs include omental bursitis, which occurs with type 5 abomasal ulcers (abomasal perforation into the omental bursa associated with localised omental bursitis) (Constable et al., 2017) when inflammatory

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lesions are seen predominantly on the left side, and generalised peritonitis when inflammatory lesions are seen predominantly on the right (Braun, 2016). In 28 % of 484 cattle with TRP, the inflammatory lesions involved neighbouring organs, most commonly the spleen (Fig. 7), the liver and the rumen (Braun et al., 2018b). Of note, inflammatory lesions of the reticulum or other abdominal organs may regress partly or completely within 6 months of successful treatment (Herzog et al., 2004), which means that distinct reticular changes usually are less

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than 6 months old and justify a presumptive diagnosis of TRP in cattle with typical clinical signs.

Peritoneal effusion characterised by fluid accumulation that does not have an echogenic border and is usually limited to the reticular region is common in cattle with TRP. Depending on the amount of fibrin and cellular material, the fluid appears anechoic to hypoechoic. The surrounding fluid may contain strands of fibrin and accentuates the ultrasonographic appearance of fibrin deposits. There may be a large amount of fluid that

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extends to the caudal abdomen. The fluid may be contained by the omentum in the omental bursa or located outside the bursa, causing generalised peritonitis. With extensive peritoneal effusions, the greater omentum appears as an echogenic and sometimes thickened structure

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surrounded by fluid (Fig. 8) that may contain echogenic fibrin septa (Fig. 9). About 20 %

cattle with TRP have reticular abscesses characterised by an echogenic capsule of varying

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thickness and a cavity with hypoechoic to moderately echogenic, homogeneous or

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heterogeneous content (Fig. 10). Most abscesses are located caudoventrally but some are cranial or lateral, between the reticulum and spleen, liver, omasum or abomasum or between the rumen and abdominal wall (Braun, 2009b). Perforating foreign bodies may cause

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abscesses of the spleen or liver. The examiner should attempt to determine the exact location of the abscess via ultrasonography to determine whether the abscess shifts during reticular contractions. Shifting indicates that the abscess likely involves the reticulum. If the abscess

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does not move synchronously with reticular contractions this may indicate that it is adherent to the abdominal wall or another organ. This distinction is essential for the surgical drainage of an abscess (see section on treatment). Magnets in the reticulum and foreign bodies in and outside of the reticulum are rarely seen on ultrasonograms.

The amplitude, frequency and velocity of reticular contractions are affected in almost all cattle with TRP; most often the amplitude was reduced (74 % of the cattle), or there was 13

complete reticular atony (Kurosawa et al., 1991; Braun et al., 1993b, 2018b; Braun, 2009b; Kaske et al., 1994). The velocity of reticular contractions is often decreased and contractions become conspicuously slow. The reduction in reticular contractility is usually due to mechanical factors associated with adhesions to adjacent organs and only rarely is caused by inhibition of the vagal nerve from the gastric centre (Constable et al., 1990) because cattle with only mild inflammatory changes generally have normal reticular contractions. A reduction in the frequency of reticular contractions is rare and was observed in only 49 % cattle (Braun et al., 2018b); the normal frequency of 3 to 4 per 3 minutes may be reduced to 2

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or 1 or there may be complete reticular atony. The pattern of reticular motility usually is not diagnostic. In cattle with TRP, contractions are normally biphasic (except in cases with

reticular atony) but may be triphasic during rumination. The biphasic or triphasic contraction

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pattern is maintained regardless of the degree of amplitude reduction.

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Radiographic findings

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Radiographs are best taken in standing cattle (Fubini et al., 1990; Partington and Biller, 1991). Radiography is the imaging method of choice to visualise metallic foreign bodies in the reticulum (Braun et al., 1994). A linear foreign body that is at least 1 cm long is

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considered clinically relevant (Partington and Biller, 1991). The sensitivity and specificity of radiography for the diagnosis of TRP range from 71 to 83 % and from 82 to 90 %, respectively (Partington and Biller, 1991; Braun et al., 1993a), and foreign bodies detected

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surgically or during postmortem examination were detected radiographically in 93 % (Fubini et al., 1990) to 96 % cases (Braun et al., 2018b). Not only the mere presence of a foreign body but also its position is of great importance; foreign bodies in the reticulum that do not contact the ventral aspect of the reticulum or those at an angle of greater than 30 degrees to the ventral aspect of the reticulum are most likely penetrating (Fig. 11) (Fubini et al., 1990; Partington and Biller, 1991; Braun et al. 1993a, 1994; Farrow, 1999). Foreign bodies that are partly or completely outside of the outer contour of the reticulum have perforated the reticular 14

wall (Fig. 12). Gas shadows (Fig. 12) or gas-fluid interfaces in close proximity to the reticulum strongly suggest a perforating foreign body and infection with gas-producing and pyogenic bacteria. Foreign bodies that lie flat on the ventral aspect of the reticulum and those with varying positions on serial radiographs are considered non-penetrating but they still pose a risk for TRP. Foreign bodies that are completely attached to a magnet also are considered non-penetrating, whereas foreign bodies partially attached to a magnet with one end protruding may be penetrating the wall of the reticulum. Foreign bodies on the ventral aspect of the reticulum but not attached to a magnet in the reticulum may be nonmagnetic (Braun et

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al., 2003c). Similarly, corroded nails may lose their magnetic properties and not be attracted to a magnet. A foreign body may penetrate a dorsal area of the reticulum and therefore be

outside of the magnetic field, or a magnet may have no contact with the foreign body because

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it is located in the anterior dorsal blind sac of the rumen (Fig. 12).

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In a retrospective analysis of radiographs from 484 cattle with TRP, a total of 536

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foreign bodies were identified; 236 (44 %) were in contact with a magnet and 300 (56 %) were not (Braun et al., 2018b). Of the foreign bodies without contact with a magnet, 18 % lay flat on the ventral aspect of the reticulum, 10 % were on the ventral aspect of the reticulum at

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an angle greater than 30 degrees, 14 % had penetrated the reticulum dorsally, 12 % had perforated the reticulum and 1 % had travelled through the wall of the reticulum and were

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completely outside it.

Treatment

Treatment of TRP is conservative or surgical (Dirksen, 2002; Constable et al., 2017).

Conservative treatment involves the oral administration of a regular magnet, or a magnet with a plastic cage, and antibiotics. The advantage of cage magnets is that the foreign body is better contained and penetration of the reticulum by a protruding part of the foreign body is less likely (Poulsen, 1976; Smith et al., 1992). The efficacy of a magnet depends largely on 15

the position of the foreign body in the reticulum; foreign bodies lying on the ventral aspect of the reticulum or in an upright position are more likely to become attached to a magnet than foreign bodies that have no contact with the ventral aspect of the reticulum or have perforated the reticulum (Braun et al., 2003b, 2018c). Efficacy rates in terms of clinical improvement of up to 97 % have been reported (Federer, 1965; Wittwer, 1966; Spadiut, 1972; Kalmar, 1984) and the treatment effect of magnets has also been confirmed radiographically (Dorresteijn, 1973). However, the efficacy of magnet treatment at a referral clinic was considerably lower (Braun et al., 2003b, 2018c); in 100 cattle with TRP, the efficacy was 54 % (Braun et al.,

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2003b) and in another 177 cattle it was 53 % (Braun et al., 2018c). A possible reason for this discrepancy is that field studies commonly involve uncomplicated and acute cases, whereas

referral clinics deal primarily with cattle that failed to respond to treatment in the field. In one

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study, ultrasonography or surgical exploration was used to confirm that the strength of the

magnet was insufficient to remove a penetrating foreign body in the face of massive fibrinous

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changes in some cattle (Gansohr, 2001). It is also likely that efficacy rates for treatment with a

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magnet reported in field studies are inflated because of misdiagnoses and inclusion of cattle without TRP (Braun et al., 2003b). A problem is that not all orally administered magnets reach the reticulum directly. There have been many attempts to correct this shortfall such as

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guiding a magnet into the reticulum on a piece of string (Schneider, 1982), directing the course of an orally-administered magnet using a second magnet externally, fasting the cow for one day before magnet application, lowering the position of the forelimbs during application

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(Leuenberger et al., 1978b) and subcutaneous administration of atropine before administration of the magnet (Schneider, 1982; Kalmar, 1984; Kleint, 1987; Taffe, 1993; Gansohr, 2001; Braun et al., 2002, 2003a). According to current opinion, it is not possible to influence placement of a magnet in the reticulum by means of external manipulations or drugs, especially atropine.

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The current recommendation for the treatment of cattle with acute and uncomplicated TRP is to administer a magnet, and antibiotic treatment over several days (Dirksen, 2002; Francoz and Guard, 2015; Constable et al., 2017; Fubini et al., 2018). Penicillin and broadspectrum antibiotics such as ampicillin, ceftiofur and tetracyclines are most commonly used (Fubini et al., 2018). Flunixin meglumine and ketoprofen are used as anti-inflammatory drugs (Braun et al., 2018c). If conservative treatment fails to resolve the problem within 2 to 4 days, surgery to remove the foreign body or euthanasia should be considered (Dirksen, 2002; Fubini et al., 2018). The response to treatment is considered positive when the rectal temperature

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normalises and eating and rumination improve (Braun et al., 2017; Fubini et al., 2018) but can also be confirmed radiographically (foreign body completely attached to the magnet).

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There are two main surgical techniques for rumenotomy (Dirksen, 2002). The first is a laparorumenotomy, in which the rumen is permanently sutured to the peritoneum and

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transverse fascia permitting extraperitoneal access to the rumen as well as extraperitoneal

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healing of the rumenotomy incision. The second technique involves temporary extraabdominal fixation and subsequent repositioning of the sutured rumen to its normal abdominal position. Both techniques have been described in detail (Dirksen, 2002; Ducharme,

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1990; Dehghani and Ghadrdani, 1995; Niehaus, 2008; Walker 2017). There are several methods that use temporary fixation of the rumen including the rumen board technique, Weingarth’s ring rumenotomy, skin suture fixation, stay suture fixation and skin clamp

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fixation (Dehghani and Ghadrdani, 1995). One study evaluated the indications for rumenotomy or rumenostomy and factors related to the outcome and concluded that these procedures can be effective in treating or relieving complications secondary to forestomach disorders in cattle. Cattle undergoing rumen surgery had a favorable prognosis for survival and a fair prognosis for potential return to production (Hartnack et al., 2015). Laparotomy is carried out in the left flank and after assessment of the abdominal organs, the reticulum is carefully examined and palpated. Adhesions should not be broken down (Ducharme, 1983; 17

Ward and Ducharme, 1994). Some perforating foreign bodies and those outside of the reticulum can be removed without rumenotomy (Nuss and Schmid, 2010). When rumenotomy is required, the rumen is partially emptied to allow palpation of the reticular lumen, and foreign bodies are identified and removed (Ducharme, 1983; Ward and Ducharme, 1994; Dirksen, 2002). When a fluctuating mass protrudes into the reticular lumen, its content is aspirated using a needle attached to transparent piece of plastic tubing on the end of a syringe; abscesses that are firmly and broadly attached to the reticulum can be incised and the content drained into the reticulum. The abscess is then carefully examined for foreign bodies

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(Ducharme, 1983; Nuss and Schmid, 2010). In the pre-ultrasound era, liver abscesses and other abscesses not attached to the reticulum were treated via a midline or paramedian approach during a second operation (Ward and Ducharme, 1994), whereas nowadays

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ultrasonography can be used to plan the approach: an abscess that shifts and moves off the

ultrasound screen during a reticular contraction is most likely attached to the reticulum and

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can be treated by means of drainage into the reticulum during rumenotomy. On the other

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hand, an abscess that does not move synchronously with reticular contractions should be approached via laparotomy or transcutaneous drainage. Ultrasound-guided transcutaneous drainage (Braun et al., 1998; Fecteau, 2005) (Figs. 13, 14) is the method of choice for the

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treatment of abscesses adherent to the thoracic or abdominal wall when a penetrating foreign body is not seen on radiographs. Another requirement is sufficient space for the incision between the ribs and the sternum; space is limited in the cranial intercostal spaces because of

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their proximity to the diaphragm and pleural cavity. Splenic abscesses are treated by means of splenectomy in the standing cow using paravertebral anaesthesia and removal of a rib (Nuss et al., 2009) or via a transthoracic approach with the cow under general anaesthesia (Thompson et al., 1992). Of 503 cattle with TRP at a referral clinic (Braun et al., 2018c), 232 were treated conservatively, 206 were operated and 61 were slaughtered or euthanased. Surgery had a better outcome in that not-randomized study than conservative treatment; 186 of 206 (90 %) operated and 191 of 232 (82 %) conservatively-treated cattle were discharged (P < 18

0.05), similar to reported success rates of 84 (Fraser, 1961) and 89 % (Hjerpe, 1961) after conservative treatment and 90 to 95 % after surgery of acute cases (Dirksen, 2002). In summary, the first line of treatment of cattle with suspected TRP is to give a magnet and antibiotics and the outcome is considered successful when eating and rumination times, number of regurgitated cuds and number of chewing cycles per cud normalise within 3 to 5 days (Braun et al., 2017). When conservative treatment fails, a decision to operate or euthanase should be made, ideally after another radiograph has confirmed that the foreign

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body is not attached to the magnet.

Conclusions

Most clinical signs of TRP are non-specific and can occur with other abdominal,

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thoracic or systemic conditions, or clinical signs may be subtle, particularly in chronic cases. However, a tentative diagnosis is often possible and the cow is treated with a magnet and

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antibiotics. If there is no clear response to medical treatment within 3 to 5 days, further

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diagnostics including ultrasonography and radiography are indicated. If this is not feasible, rumenotomy, euthanasia or in certain cases a second magnet and further antibiotic treatment

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is recommended.

Conflict of interest statement

None of the authors of this paper has a financial or personal relationship with other

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people or organisations that could inappropriately influence or bias the content of the paper.

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Schiller, D., Staufenbiel, R., 1999. Laparoskopie beim rind – untersuchungstechnik, physiologische verhältnisse in der bauchhöhle. Praktischer Tierarzt 80, 426-436. Schmutzer, A., Rosenmayr, E., 1959. Magnetsonde, fremdkörperoperation, konservative therapie. Tierärztliche Umschau 14, 164-168. Schneider, E., 1982. Der verweilmagnet in der therapie der reticulitis traumatica des rindes. Schweizer Archiv für Tierheilkunde 124, 97-105. Siegfried, J. P., 1960. Betrachtungen zur fremdkörper-behandlung mit dem metallevaquator „system eisenhut“. Tierärztliche Umschau 15, 125-128. Smith, D. F., Becht, J. L., Whitlock, R. H., 1992. Traumatic reticuloperitonitis. In: Anderson, N. V. (Ed.), Veterinary Gastroenterology. Lea and Febiger, Philadelphia/London, pp. 715-719. 27

Spadiut, H., 1972. Zur Therapie der reticulitis traumatica mit dem käfigmagneten (Modell Rinderklinik Hannover). Wiener Tierärztliche Monatsschrift 59, 326-328. Starke, A., Rehage, J., 2000. Diagnose und therapie bei abszedierender reticuloperitonitis traumatica. Tierärztliche Praxis 28 (G), 93-95. Steiner, A., Zulauf, M., 1999. diagnostische laparoskopie bei der kuh. Schweizer Archiv für Tierheilkunde 141, 397-406. Stöber, M., 1961. Beitrag zur Diagnose der Reticuloperitonitis traumatica des Rindes: Die betastung der luftröhre als einfaches hilfsmittel zur feststellung des schmerzhaften stöhnens bei den fremdkörperproben. Deutsche Tierärztliche Wochenschrift 68, 497498.

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Warislohner, S., 2017. Reticuloperitonitis traumatica beim Rind – eine Analyse von 503 Krankengeschichten. Dr Med Vet Thesis, University of Zurich, Switzerland. Watts, A. S., Tulley, W. J., 2013. Case report: sequelae of traumatic reticuloperitonitis in a Friesian dairy cow. New Zealand Veterinary Journal 61, 111-114. Williams, F., 1974. Einige diagnostische Hilfen zur Feststellung der traumatischen retikuloperitonitis und perikarditis beim rind. Deutsche Tierärztliche Wochenschrift 81, 558. Wilson, A. D., Ferguson, J. G., 1984. Use of a flexible fiberoptic laparoscope as a diagnostic aid in cattle. Canadian Veterinary Journal 25, 229-234. 28

Wilson, A. D., Hirsch, V. M., Osborne, A. D., 1985. Abdominocentesis in cattle: Technique and criteria for diagnosis of peritonitis. Canadian Veterinary Journal 26, 74-80. Wittek, T., Grosche, A., Locher, L., Alkaassem, A., Fürll, M., 2010a. Biochemical constituents of peritoneal fluid in cows. Veterinary Record 166, 15-19. Wittek, T., Grosche, A., Locher, L. F., Fürll, M., 2010b. Diagnostic accuracy of d-dimer and other peritoneal fluid analysis measurements in dairy cows with peritonitis. Journal of Veterinary Internal Medicine 24, 1211-1217.

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Wittwer, F., 1966. Erfahrungen mit dem Käfigmagneten in der Fremdkörpertherapie. Schweizer Archiv für Tierheilkunde 108, 621-624

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Figure legends

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Fig. 1. Most frequent clinical findings in cattle with traumatic reticuloperitonitis (TRP).

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Fig. 2. Back grip. (A) Preparing for the back grip foreign body test; both hands are placed

over the thoracic spinous processes caudal to the withers. (B) A fold of skin is pulled up with

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both hands, which forces the back to sink.

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Fig. 3. Pain percussion. The examiner gently swings a heavy rubber hammer toward the area of the reticulum (A) for percussion of the region (B).

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Fig. 4. Pole test. Two assistants hold the pole in place (A) and then pull the pole upwards

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against the cow’s abdomen (B).

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Fig. 5. Ultrasonogram showing echogenic deposits on the reticulum and fluid imaged from the sternal region using a 5.0-MHz convex transducer in a cow with traumatic reticuloperitonitis (TRP). (1) Ventral abdominal wall; (2) Reticulum; (3) Echogenic deposits

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with anechoic fluid pocket; Cr, Cranial; Cd, Caudal.

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Fig. 6. Ultrasonogram showing echogenic deposits with a fluid pocket adjacent to the

reticulum and fluid in a cow with traumatic reticuloperitonitis (TRP) imaged from the sternal region using a 5.0-MHz convex transducer. (1) Ventral abdominal wall; (2) Reticulum; (3)

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Echogenic deposits with anechoic fluid pocket; Cr, Cranial; Cd, Caudal.

Fig. 7. Ultrasonogram showing echogenic deposits between the reticulorumen and spleen imaged from the 7th intercostal space on the left side using a 5.0-MHz convex transducer in a cow with traumatic reticuloperitonitis (TRP). (1) Abdominal wall; (2) Spleen; (3) Rumen; (4) Reticulum; (5) Echogenic deposits between the reticulorumen and spleen; Ds, Dorsal; Vt, Ventral.

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Fig. 8. Ultrasonogram showing fluid accumulation (peritonitis) and echogenic changes

imaged from the 12th intercostal space of the left side using a 5.0-MHz convex transducer in

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a cow with traumatic reticuloperitonitis (TRP). (1) Abdominal wall; (2) Fluid; (3) Echogenic

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fibrin; (4) Greater omentum; (5) Rumen; Ds, Dorsal; Vt, Ventral.

Fig. 9. Ultrasonogram of the reticular region imaged from the 9th intercostal space of the left abdominal wall using a 5.0-MHz convex transducer in a cow with traumatic reticuloperitonitis (TRP). There are fibrin septa interspersed with anechoic fluid. (1) Abdominal wall; (2) Fluid accumulation and fibrin septa; (3) Rumen; Ds, Dorsal; Vt ,Ventral.

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Fig. 10. Ultrasonogram showing an abscess between the reticulum and the spleen imaged

from the 8th intercostal space of the left side using a 5.0-MHz convex transducer in a cow

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with traumatic reticuloperitonitis (TRP). (1) Abdominal wall; (2) Spleen; (3) Abscess; (4)

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Reticulum; Ds Dorsal; Vt Ventral.

Fig. 11. Lateral radiographic view of the reticulum of a cow with a perforating reticular foreign body. There is one magnet at the ventral aspect of the reticulum and another in the anterior dorsal blind sac of the rumen. (1) Elbow; (2) Sternum; (3) Rib; (4) Reticulum; (5) Anterior dorsal blind sac of rumen; (6) Wire; (7) Magnet in reticulum; (8) Magnet in anterior dorsal blind sac of rumen; Cr, Cranial; Cd, Caudal. An x-ray machine with a maximum capacity of 150 kVp and 1250 mAs was used. The focus-to-film distance was 115 cm. A 34

parallel grid with a 6:1 ratio and 40 lines/cm intensifying screens and films of 35 x 43 cm

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were used.

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Fig. 12. Lateral radiographic view of the reticulum of a cow with a perforating foreign body (nail) in the caudal reticular wall. Gaseous inclusions dorsal and ventral to the foreign body

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suggest infection with gas-producing bacteria. A magnet is seen in the anterior dorsal blind sac of the rumen. (1) Reticulum; (2) Sediment; (3) Perforating nail; (4) Gaseous inclusions;

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(5) Magnet in anterior dorsal blind sac of rumen; Cr, Cranial; Cd, Caudal. Technical notes see

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Fig. 11.

Fig. 13. A stream of pus is seen after ultrasound-guided transcutaneous incision of a reticular abscess in a 2.5-year-old Fleckvieh cow. 35

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Fig. 14. Aspiration of pus from an abscess between the reticulum and the liver after

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ultrasonographic localisation of the abscess in a 5-year-old Braunvieh cow.

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Table 1. Causes of traumatic reticuloperitonitis (TRP) in cattle Finding

Maddy (1954)

Lesions of TRP were seen in 79.6 % of 42,892 slaughtered cattle; 75 % of these were caused by baling wire, 20 % by nails and 5 % by

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Jagos (1969)

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foreign bodies composed of other materials.

A total of 2,140 foreign bodies were found in 600 cattle with TRP (3.5 foreign bodies per animal). 51.6 % were wire, 30.6 % were nails, 9.9 % were metallic fragments, 5.5 % were strips of tin and 1.7 % were other objects. Sharp foreign bodies were found in the reticulum of 13.4 % of 2,337 slaughtered cattle. 430 (18.4 %) of cattle had metallic foreign

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bodies, most of which were magnetic; 210 were fixed and 212 were loose. Nails and pieces of wire made up 69 % of magnetic foreign

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bodies. 2.2 % of all cattle had a cage magnet in the reticulum, and of 41 cattle with a sharp foreign body in the cage magnet. Andersen and

Inspection of 507 bovine stomachs at an abattoir showed 41.2 % with one or more sharp foreign bodies and/or lesions as a result of

Gillund (1980)

injury; 120 cows (23.7 %) had lesions associated with lodged or dislodged foreign bodies. About 36 % of all cattle had lesions caused by sharp objects.

Sixty fatal cases of traumatic reticulitis in cattle were reviewed. Fifty-nine cases were caused by fragments of wire, and a nail perforated

(1991)

the reticulum of the remaining animal.

Braun et al.

Four cows with TRP caused by copper wires were described. The magnets did not neutralise the wires and radiographs showed no

(2003c)

contact between the magnets and the wires.

Harwood (2004)

Seven cows of a herd of 200 became ill after ingestion of tire wires. The wires originated from cut tires that were used to weigh down

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Roth and King

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tarps covering silage.

Monies (2004)

In a Cornish dairy herd, 11 cows became ill after ingesting tire wires.

Cramers et al.

A total of 286 foreign bodies were retrieved from 1,491 slaughtered cows. 11 % were tire wires, 14 % fencing wires, 5 % screws, 9 %

(2005)

nails, 37 % mixed pieces of metals, 2 % copper and 22 % remnants of boluses containing antiparasitic drugs.

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Nine cattle from a 270-cow dairy herd became ill after ingesting fragments from metal components of a mixer wagon.

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Daniel and Smith (2008)

Thirty-two cows that were pastured in the vicinity of an airport suffered TRP and four suffered traumatic pericarditis after ingesting

Lazarev (2008)

pieces of wire bristles from a brush attachment used to clean the runways. The bristles had detached from the brush and subsequently

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Ryzhakov and

contaminated the adjacent pastures.

All cows from a herd of 31 had to be slaughtered or euthanased because of TRP. Investigation showed that the cattle had eaten forage

(2009a)

harvested from a field immediately adjacent to an airport. The snow had been cleared from the airport runways with a machine that had

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a wire-bristle brush attachment. Mechanical wear resulted in numerous wire bristles breaking and these were blown with the snow onto the adjacent fields. The wire pieces became incorporated into the hay and grass silage at harvest the next summer and were

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subsequently ingested by the cattle. Braun et al.

Of 299 foreign bodies retrieved from 271 cattle with TRP, there were 141 pieces of fencing wire, 121 nails, 13 screws, 8 flat pieces of

(2018c)

metal, five pieces of barbed wire, four arms from eye glasses, two staples, one hair clip, one piece of aluminium, one fence insulator, one belt buckle and one set of nail clippers. The foreign bodies ranged from 1.5 to 18 cm in length (median, 6 cm), and 273 were

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ferromagnetic.

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