Gastric Dilatation and volvulus

• What is GDV?

  • Gastric= stomach
  • Dilatation= stomach becoming larger due to gas distension
  • Volvulus= turning of stomach into an abnormal position
• What is GDV?

  • Just because you have dilatation does NOT mean you will have volvulus as well
  • However this is always a concern
• What is GDV?

  • This is an emergency situation that can be fatal without treatment!
  • Mortality rate of ~30%
• Who is Most at Risk?

  • Most common in large or extra-large breeds
  • ANY dog with a deep, narrow chest is at risk of this condition
• Who is Most at Risk?

  • Most common breeds
  • Great Danes, Saint Bernards, Weimaraners, Irish Setters, Gordon Setters, Standard Poodles, BassetHounds, Doberman Pinschers, Labrador Retrievers,and Old English Sheepdogs
• Other risk factors

  • Males are 2x more likely than females
  • Dogs fed only once daily are 2x as likely to bloat
  • Fast eaters are 5x more likely to bloat
  • Family history of GDV
  • Stressed and/or hyperactive dogs
• How Does GDV Happen?

  • We in the veterinary community don’t have a definitive answer to this
  • Believe it is more common after the patient has eaten
• How Does GDV Happen?

  • Process of condition development
  • Air begins to accumulate in the stomach but is unable to escape
  • As it fills, the stomach begins to flip on itself
  • Cuts off lower esophageal sphincter and pyloric sphincter from being able to empty stomach
• How Does GDV Happen?

  • Spleen and stomach share many blood vessels→ spleen goes along with stomach in flip
  • Cuts off blood supply not only to stomach but to spleen, and in severe cases, pancreas
• How Does GDV Happen?

  • If not corrected, stomach and spleen necrosis is likely
  • Rupture of stomach is also a possibility
• Clinical signs

  • Severely lethargic
  • Unproductive retching
  • Significant and sudden bloating/ bouncy abdomen
  • Abdominal pain
• Clinical signs

  • Restlessness
  • Inability to stand
  • Excessive drooling (hypersalivation)
  • Pale gums
  • Tachycardia and tachypnea
• History/ physical exam

  • Depressed/obtunded mentation
  • In some cases, patient has collapsed and unable to get up
  • Painful on abdominal palpation
• History/ physical exam

  • tachycardia/tachypnea
  • Sometimes will have a “ping” when abdomen is tapped on
  • Patient may be whining and actively retching in the exam room
• History/ physical exam

  • Dog will be clinically fine and then over the span of 30 min to several hours, will become restless, start retching, and will bloat
• What do we do after diagnosis? (1)

  • Get immediate approval from the owner to get rads, fluid therapy, and to give pain medication
  • Due to blood vessel constriction, hypovolemia is likely
  • Need to correct this with fluids at 90mL/kg/hr to avoid shock (which can be fatal!)
  • A rate of 5mL/kg over 5min may be necessary to stabilize patient fas
• What do we do after diagnosis? (2)

  • Get immediate approval from the owner to get rads, fluid therapy, and to give pain medication
  • Opioid butorphanol is often used as pain medication because it is the most cardiac friendly, but fentanyl or oxymorphone are also used if sedation is needed
  • At least right lateral rad needs to be performed for confirmation
• What do we do after diagnosis? (3)

  • Once confirmed, CBC/PCV/Chemistry should be ran to evaluate organ function and severity of hypovolemia
• What do we do after diagnosis? (4)

  • Stomach also needs to be decompressed ASAP
  • Can either do a trocarization method or use sedation to place an orogastric tube
  • OG tube may be very difficult to place depending on severity of vovulus
• Decompression methods

  • Trocarization
  • Orogastric tube
• Trocarization

  • On left side of abdomen, find the most tympanic location
  • Clip and clean area for an aseptic technique
  • Using either a 14, 16, or 18 gauge IV catheter (remember, the smaller the number the larger the needle), stab into area until can feel air escaping through catheter
  • Pull needle out of catheter but keep the other part in patient
  • Unlikely to hit other major organs if don’t go too high or too cranial
  • May have to do multiple times depending on stability of patien
• Orogastric tube

  • Patient is sedated with meds previously stated and diazepam (Valium)
  • Measure an equine nasogastric tube from nose to cranial edge of last rib, mark it with a marker or tape
  • Lubricate tube and gently push it down LEFT side of throat (esophagus is on left in mammals)
  • DO NOT go past mark previously made
  • If you feel air in time with breathing, you’re in the trachea, not the esophagus
  • If struggling, keep dog in sternal position and rotate tube counterclockwise
  • If doesn’t work, will have to trocarize first to alleviate some of the pressure
• Diagnostics

  • As mentioned before, will need to do rads and bloodwork to assess stability of the patient
  • If stomach has flipped, will be a “popeye arm” in location of stomach
  • Need at least right lateral but beneficial to have VD as well
  • May only see 2 gas bubbles and not the full extent of stomach
• Diagnostics

  • Bloodwork abnormalities (1)
  • HCT/PCV may be low due to circulation being cut off (hypovolemia)
  • Creatine kinase (CK) can be elevated due to striated muscle damage
• Diagnostics

  • Bloodwork abnormalities (2)
  • Potassium can be elevated due to cell damage
  • Prerenal azotemia is often found due to secondary hypotension
  • Serum ALT and AST levels may increase secondary to hypoxic damage.
• Diagnostics

  • Bloodwork abnormalities (3)
  • Increased lactate is a common finding and is secondary to systemic hypotension and inflammation.
  • Hyperlactatemia (>6 mmol/L) is associated with an increased likelihood of gastric necrosis and the need for partial gastric resection
• After diagnostics?

  • Once confirmed, need to present treatment options to owner
  • Surgery is the only treatment option
• Surgery is the only treatment option

  • If rads are inconclusive, owners on the fence may want to wait and see if patient improves with supportive care
  • However, the longer you wait, the more likely there will be tissue damage and the prognosis drops dramatically
  • A GD can change to a GDV without warning
• Euthanasia IS a valid option in GDV cases

  • Surgery for this condition is expensive: $3,000-$10,000 depending on length of hospitalization that may be needed and location of clinic (city vs. rural)
  • It has a high mortality rate and no guarantee surgery will be successful
• (side note: discussion on food bowl height is highly debated and research cannot conclusively determine if it plays a role in GDV)
• Surgical Procedure

  • Surgical preparation for this procedure and initial incision are identical to a foreign body surgery
  • However, be mindful of meds that may have already been given and that there may be delayed side effects due to hypovolemia and hypotension
• Surgical Procedure

  • After the surgeon has entered the abdomen, the stomach is isolated
  • Surgeon will find landmarks on the stomach to better understand how the stomach has twisted
  • Sometimes they will have flipped themselves back by the time you entered the abdomen BUT sometimes they will also rotate 360°
• Surgical procedure

  • Technician, with an orogastric tube, will be at the head of the dog with a bucket
  • They will place the tube in the esophagus and gently advance it as the surgeon flips the stomach back to normal orientation
  • Contents of stomach will then drain from stomach into bucket so can fully decompress stomach, then flush with water until runs clear
  • Make sure your endotracheal (ET) tube is put in correctly or can get aspiration
• Surgical procedure

  • Surgeon will evaluate stomach and spleen to see if there is any considerable damage/necrosis
  • Will have to remove if tissue does not appear to be viable
  • Surgeon will then perform a gastropexy to try to prevent a recurrence of GDV
• Surgical procedure

  • Rest of abdomen is examined for any other damage/abnormalities, and then the abdominal incision is closed
• Gastropexy

  • The stomach is basically tacked to the side of the abdominal wall
  • 3 main techniques (there are more but generally not used during emergency surgery)
  • Circumcostal, belt-loop, incisional
• Gastropexy

  • Circumcostal
  • relies on a gastric seromuscular tissue flap which is passed through a tunnel created behind the last full rib and sutured back to the stomach.
  • Results in a very strong connection.
  • Gastric dilatation can still occur after performed, but risk reduced to ~4%
• Gastropexy

  • Belt-loop
  • Seromuscular flap is passed through a soft tissue tunnel in the abdominal wall instead of aroundthe last rib.
  • It is just as strong as circumcostal technique
  • No reports of recurrence in several studies up to 33 months
• Gastropexy

  • Incisional
  • relies on the healing and fusion of the edges of a gastric seromuscular incision to the edges of a vertical transverse abdominal muscle incision.
  • Mechanically slightly weaker adhesion
  • Still results in a dramatically decreased GDV recurrence (0–4%).
  • B/c this technique is faster and has fewer complications it is considered the technique of choice
• Gastropexy

  • Must be mindful where cutting on abdominal wall!
  • Do not want to accidentally cut the diaphragm