The arrows show the size of the stomach. The stomach can also twist onto itself, cutting off blood supply to the stomach and other major organs. It also blocks the exit of air and stomach contents. Less obvious signs of GDV include pacing, salivating, restlessness, inability to lie down, a distressed attitude, rapid breathing, and pale gums. There are many risk factors. Some are questionable if not plain ridiculous. Here are a few scientifically proven causes of GDV.
Bernards are all at risk but it also occurs in smaller breeds like Boxers, Basset Hounds and Standard Poodles. Because duration of clinical signs is one of the risk factors of GDV-associated death, it is imperative to recognize and correct this condition immediately. Correction of hypovolemia is the first treatment priority and is achieved by rapid fluid replacement with one or more large-bore to gauge IV catheters placed in cranial jugular, cephalic veins.
Flow-by oxygen should be provided during stabilization. Electrolyte and acid-base disturbances are usually corrected by adequate fluid therapy and gastric decompression. Gastric decompression occurs concurrently with fluid resuscitation. Agents that cause vasodilation eg, phenothiazines should be avoided. A stomach tube is measured from the incisors to the last rib and marked. The tube must not be placed beyond this marking. The lubricated tube is introduced into the mouth often held open with a roll of tape or bandage material while the dog is in a sitting position.
Some resistance is typically encountered at the esophageal-gastric sphincter. Gentle manipulation and counterclockwise movement of the tube may be necessary to allow passage of the tube into the stomach, but caution must be exercised because it is possible to perforate the esophagus with the tube. Once the tube enters the stomach, gastric gas rapidly escapes.
Successful passage of a stomach tube does not exclude the presence of volvulus. After gas and stomach contents are released from the stomach via the tube, the stomach should be lavaged with warm water to decrease the rate of redilation with gas.
If an orogastric tube cannot be readily passed, percutaneous gastrocentesis may be performed to release excess gastric gas. Percussion of the area should reveal tympany; this helps avoid accidental puncture of an overlying spleen. If a tympanic structure is not appreciated, the left paracostal region should be assessed.
A large-bore needle or over-the-needle catheter is introduced through the skin and body wall into the stomach at the site of greatest tympany. Decompression usually allows for subsequent passage of an orogastric tube and lavage of the stomach. Surgical correction of GDV rapidly follows the initial stabilization. Aseptic preparation of the abdomen is performed before surgery, and a cranioventral midline approach is performed.
Before correcting the gastric torsion, the stomach should be decompressed with the help of an assistant placing an orogastric tube or via gastrocentesis intraoperatively. The stomach is then returned to its normal position, and the stomach and spleen are evaluated for ischemia. Any areas of ischemic gastric wall are removed, and a splenectomy is performed if necessary. Extensive gastric necrosis and necrosis of the gastric cardia are considered poor prognostic indicators.
The stomach is emptied of contents, and a gastropexy is performed to decrease risk of recurrence. Several gastropexy techniques have been described and include a simple incisional pexy, a circumcostal belt-loop pexy, and a tube gastrotomy and pexy. Pre-, intra-, and postoperative monitoring should include continuous ECG, intermittent blood pressure measurement, and frequent assessment of vital parameters, PCV, total solids, electrolytes, blood glucose, and serum lactate.
Postoperative medical management includes IV fluid therapy and analgesia. In most cases, the stomach has rotated to degrees. To derotate the stomach, it may be necessary to first decompress it, which can be performed either by having an assistant pass an orogastric tube or by trocharizing the stomach with a needle intraoperatively. Then use your right hand to reach the pylorus, which is usually located dorsal to the esophagus on the patient's left side. With your left hand, form a fist and push the distended fundus malpositioned on the dog's right side dorsally while you pull the pylorus ventrally and to the right.
The spleen will usually derotate with the stomach. After derotation, perform complete exploration of the abdomen. Residual hemorrhage from the short gastric arteries may need to be controlled with ligatures. Palpate the stomach carefully for a gastric foreign body-gastrotomy is required in this case. Assess the color of the spleen-splenic engorgement is expected and the spleen should return to a dark purple color following derotation. If the spleen is black in color or thrombosis of the splenic artery has occurred or both , a splenectomy is indicated.
Next, assess the gastric wall. This is a subjective assessment; accuracy improves with surgeon experience. Be sure to evaluate the stomach all the way to the lower esophageal sphincter. Gastrectomy can be performed by either a cut-and-sew technique with an inverting suture pattern, the use of surgical stapling equipment, or invagination of the ischemic gastric wall.
The procedure is well described elsewhere. If you have performed a gastrectomy, lavage the abdomen with warm sterile saline and suction it, then exchange gloves and instruments for a sterile set. The next step is gastropexy. The pexy site on the stomach is located 2 to 3 cm oral to the pylorus, on the ventral surface, between the greater and lesser curvatures.
The pexy site on the body wall is located in the right transverse abdominis, caudal to the last rib, parallel to the skin incision and approximately one-third of the distance from ventral to dorsal. In some larger dogs it may be necessary to place the pexy slightly more cranial, over the last ribs, but take care not to pass the insertion of the diaphragm on rib 11 to avoid an inadvertent thoracotomy!
It is helpful to have an assistant stand on the patient's right side, grasp the right abdominal wall along the linea alba with towel clamps and elevate it toward the ceiling for better visualization. A description of one way to perform the procedure is below:.
Patients will require hour care postoperatively, so transfer to a referral facility may be necessary. Continue fluid resuscitation and address electrolyte imbalances.
Continue analgesia with pure mu agonists until the patient is able to tolerate oral analgesia. NSAIDs are contraindicated. You can continue to provide a lidocaine CRI to provide analgesia as well as to treat cardiac arrhythmias. Continuous ECG is helpful to screen for ventricular arrhythmias, which may persist for 48 to 72 hours postoperatively.
Discontinue antibiotics within 24 hours of surgery unless gastric necrosis was present. Patients can be fed within 12 to 24 hours of surgery, either via nasogastric NG feeding tube or orally. Small meals of a bland or gastrointestinal diet are ideal. Prokinetic therapy e. H2 antagonists e. Gastropexy can be performed at the time of spay or neuter and is recommended once dogs are close to adult size.
Minimally invasive approaches result in less postoperative pain and a faster return to normal activity than open approaches and are equally as effective. GDV is a true medical and surgical emergency, but most patients can do well with aggressive early stabilization and prompt surgical care.
Taking the time to stabilize your patient prior to surgery will greatly improve postoperative outcomes, whether you plan to perform surgery yourself or transfer the patient to a referral facility. Palpating as many normal stomachs as possible and performing gastropexy in a prophylactic setting first will improve your technical expertise and confidence if and when you are required to perform surgery on a clinical GDV case.
Saturdays by appointment a. Davis Animal Hospital Phone Emergency Pet Hospital Animal Specialty Hospital This is a life-threatening emergency that requires surgery to correct.
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