gvd

Gastric Volvulus and Dilatation

Dr. Daniel A. Degner, Board-certified Veterinary Surgeon (DACVS)

Key Points
Stomach bloat is a serious and potentially fatal disease, if early treatment is not instituted. Emergency decompression of the stomach and surgical tacking of the stomach to the body wall is necessary Survival rate following surgery is about 90% of the stomach is not devitalized. If a portion of the stomach has died off, the survival rate is about 50%, in spite of medical and surgical treatment A laparoscopic preventative surgery should be done in breeds that are susceptible to this condition

Introduction
The stomach is located in the front part of the abdomen and is the first part of the gastrointestinal tract located in the abdominal cavity. Gastric volvulus and dilatation (GDV) is a condition that starts off with distention of the stomach with food, fluid such as water, or air due to excessive swallowing. The stomach twists in a clockwise direction as it becomes distended. The inlet to the stomach from the esophagus and the outlet leading into the duodenum get kinked off and the food, fluids and air cannot pass in either direction. As a result, unproductive retching occurs.

Due to the twisting and displacement of the stomach, the blood supply may be cut off and a portion or all of the stomach may die. The longer that the stomach has been twisted before treatment is provided, the greater the risk that the stomach will die.

Another event that occurs is occlusion of the main vein (vena cava) leading from the back half of the body to the heart and resultant shock. Shock, a condition in which there is inadequate perfusion of the body with blood, is fatal if not treated. Signs of shock include pale gums, rapid heart rate, and weak pulses (low blood pressure). Dogs that develop GDV generally are quite ill and need immediate aggressive treatment.
Infrequently the nerves to the stomach get damaged from the GDV and the paralysis of the muscles of the stomach wall occurs. This results in chronic bloating that is usually not responsive to any therapy.
Left is an illustration of a stomach in normal position (E=esophagus; D=duodenum); right - after the stomach gvd1

twists 270o in a clockwise direction, the duodenum as it exits the stomach, is moved to the top and behind the stomach, the esophagus is twisted and the stomach is becomes distended like a balloon.

Treatment of GDV
Initially intravenous catheters are placed and fluids are administered to help reverse shock. Next a sedative is given and a tube is passed into the stomach. The stomach is pumped if needed to remove any air, fluid, or undigested food. If the tube cannot be passed into the stomach due to the twisting of the esophagus, a large needle is passed through the side of the abdomen into the distended stomach.

The pet is then taken to surgery. The internal organs are examined for damage. The stomach is repositioned and it is tacked to the right side of the abdominal cavity to prevent a future GDV. Sometimes a portion of the stomach is found to be dead and needs to be removed. If too much of the stomach is dead euthanasia may be recommended. If the stomach is filled with food or other material that cannot be removed with a tube, which is passed down the throat, the stomach is opened up and the ingesta is removed.

Occasionally the spleen is also twisted and the blood clots have developed in its vessels. In this case the spleen will be removed (splenectomy). Dogs can live normal lives without a spleen. There is about a 40% chance that the heart will develop an abnormal rhythm if a dog has also developed a problem with the spleen that mandates splenectomy. The abnormal heartbeat may require treatment to prevent death.

While the pet is in the intensive care unit, careful monitoring is done in order to ensure that the internal organs are functioning properly. Fluid therapy, medications, and transfusions (plasma and/or packed red cells) may be needed after surgery.

side view of a dog's abdomen: take note of the stomach is moderately distended with gas in a dog with GDV. The stomach has a reverse "C" shape which indicates that it is twisted

the belt loop gastropexy involves creating a belt or tongue of tissue on the stomach.

a belt loop is created in the muscle wall of the abdomen on the right side.

the belt or tongue of tissue created on the stomach has been pulled through the beltloop of the abdominal wall and the belt is sutured onto the stomach, completing a beltloop gastropexy.

After care and convalescence
After surgery has been completed intensive care must be provided for the best chance for a successful outcome. Intravenous fluids and antibiotics are administered for at least 24 hours. If the blood protein level is low, artificial plasma (Hetastarch) is administered. Blood pressure is carefully monitored and maintained.
Electrocardiograms are monitored after surgery, as abnormal heartbeats called arrhythmias are common. Usually the arrhythmias will show up within the first 24 hours. Sometimes these need to be treated with medication, as they can be fatal, however, is not common.

Your pet will be monitored for disseminated intravascular coagulation (DIC). In this situation the clotting system becomes hyperactive and small blood clots develop in the internal organs and multiple organ failure occurs. Generally DIC is fatal when it occurs, therefore early treatment is the only potential safeguard.
In general, about 90% of the dogs having GDV, if treated early will survive. By 10 to 14 days after surgery most patients are felling very well. If a portion of the stomach is dead and needs to be removed, the survival rate is about 50%.

Restricted activity should be instituted so that the tacking of the stomach does not break down. The pet should be kept on a leash when taken outside, and no running, jumping, or horseplay is permitted. By 3 to 4 weeks out for surgery the healing is complete for the most part.

After a pet has had GDV, the daily ration of food should be divided into 2 to 3 meals and exercise should be restricted for 2 hours after eating to prevent rebloating (the stomach will not twist because of the gastropexy); rebloating is not common problem in dogs following surgery.

Potential complications
As with any surgery, complications may arise. Even though relatively uncommon, anesthetic death can occur. With the use of modern anesthetic protocols and extensive monitoring devices (blood pressure, EKG, pulse oxymetry, inspiratory and expiratory carbon dioxide levels, and respiration rate), the risk of problems with anesthesia is minimal.

Infection is also an unusual complication as strict sterile technique is used during the surgery and antibiotics are administered in the perioperative period.

Abnormal heartbeats called arrhythmias
Disseminated intravascular coagulation results in dysfunction of multiple internal organs, bleeding disorder, and commonly death.

Breakdown of the stomach tack (gastropexy) occurs less than 5% of the time. Recurrent GDV can occur.
Chronic recurrent bloat. Recurrent bloat generally occurs infrequently, but usually is due to very poor function of the muscle of the stomach. Medication may be administered to improve the stomach motility, but this will work in only about 50% of the patients. The presentation of this is very similar to a GDV, but the stomach does not twist. A gastropexy (stomach tack) can also breakdown and result in recurrent bloat and twisting of the stomach, but this is unusual (less than 5% chance). Surgery is done to correct this problem.

Because of the high variability of the status of patients that have GDV, it is also very difficult to predict whether your pet is going to have postoperative complications. In general, dogs having necrosis of a portion of the stomach do not fair as well as those having minimal trauma to the stomach.

Prognosis
If treated early, about 90% of the dogs having surgery will survive. If at the time of surgery, a portion of the stomach was found to be dead, the dog has a 50% chance to survive.

Prophylactic surgery
A preventative surgery can be performed to minimize the risk of GDV in high risk patients such as Great Danes, German Shepherds, Blood Hounds, Irish Setters, Irish Wolfhounds, Standard Poodles, and other susceptible breeds. Great Danes are at very high risk and research has shown that one in four Danes will bloat in their lifetime. This surgery is done laparoscopically via two small incisions with the aid of a camera. The surgery can be done as early as 6 months of age (at the time of neutering). This procedure has minimal morbidity, less anesthesia and surgery time, short hospital stay (done as an outpatient surgery), and is less expensive than treating GDV.

Frequently Asked Questions After Surgery

When should my dog have the first bowel movement after surgery?
Many dogs will not have a bowel movement for the first 4 to 5 days after surgery.

Reasons that a dog will not have regular bowel movements after surgery include:

The dog has been fasted prior to surgery

Dogs do not eat well during the hospital stay

They frequently do not eat well when they go home

They are fed highly digestible food that produces little stool

Pain medication that contain narcotics (such as tylenol with codeine, tylenol 3, tylenol 4, morphine, fentanyl patches, tramadol) can be constipating

If a pet does not have a bowel movement on the 5th day of being home, a stool softener such as metamucil can be fed

Dose of metamucil is 1 tsp per 25 Kg mixed in with each meal (canned dog food); feed immediately after mixing, as the metamucil will gel the food and may make it less palatable

My pet had surgery and will not eat. What can be done?

Dogs
Most pets will not eat their regular dog food after surgery, especially if it is kibble.
Offer a cooked diet having a 1:1 ratio of a protein source and carbohydrate source. The protein source can be any meat (example: chicken breast, turkey breast, lean hamburger) that is low in fat and should be cooked (drain off all fat after the meat has been cooked). The carbohydrate can be pasta, potato or white rice.
Try canned dog food; to enhance the flavor sprinkle a very small amount of garlic powder or chicken or beef broth (Chicken-in-a- MugTM or Beef-in-a-MugTM products)

Try Gerber strained meats for babies such as the chicken, beef, turkey, or veal

Try Hill's A/D diet available at most veterinary hospitals

Hand feeding; place a small amount of food in the mouth so that your dog gets the flavor

Warm the food slightly in a microwave, as the food will be more aromatic; stir the food before feeding and test the temperature on the bottom side of your wrist; it should only be luke warm.

Remember that most pets will not eat the first day or two after they get home from surgery

Cats
Offer smelly foods that contain fish such as tuna or smelly cat foods

Try Gerber strained meats for babies such as the chicken, beef, turkey or veal

Hand feeding: with your finger place a small amount of food on the roof of your cat's mouth; use a syringe to get soft food into the mouth

Warm the food slightly in a microwave as the food will be more aromatic; remember to stir the food before feeding and test the temperature with your finger; it should be only luke-warm

Some cats will only eat dry food, try kibble if your cat normally has been fed that food

Petting and stroking your cat frequently will help to stimulate appetite

Remember that most pets will not eat the first day or two after they get home from surgery

Appetite stimulants such as cyproheptadine may be helpful

If your cat refuses to eat anything for 7 days a stomach tube or nasogastric tube should be placed to provide nutrition so that a serious liver problem (hepatic lipidosis) does not develop

My pet is vomiting. What can be done?
The first thing for you to discern is whether your pet is vomiting or regurgitating. Both will result in fluid or food being brought up. Vomiting always will have heaving or retching of the abdomen prior to expulsion of the vomitus. Regurgitation is not associated with heaving and the pet usually just opens the mouth and fluid or food will be expelled. Usually the regurgitant will be clear or brown colored fluid.

Next is to identify the cause of the vomiting or regurgitation.

Causes and treatment of vomiting after surgery
When some pets return home after a stay in the hospital they may drink excessive amounts of water at one time and then vomit; if this appears to be the case, the water should be limited to frequent smaller amounts.
Medications such as antibiotics or tylenol/codeine commonly cause vomiting after surgery. In order to see which medication is causing the problem, the administration of each drug should be separated 2 hours apart. Usually the pet will vomit or appear nauseated (drooling and sick look) within 1 hour of administration of the medication that they are sensitive to. The antibiotic in some cases may be changed to a different one, or may be discontinued. The tylenol/codeine should be discontinued and another type of pain medication tried to help minimize vomiting.

Stomach upset from anesthesia is a potential cause of vomiting and will pass within a couple of days.
An uncommon cause of vomiting after surgery is internal organ failure. Blood testing will confirm this problem. For this reason vomiting should not be ignored if it persists for more than 24 hours.

If your pet had surgery of the bowels or stomach, vomiting is always a concern, as it may indicate that infection of the abdominal cavity, called peritonitis, is present. Do not ignore this sign.

Symptomatic treatment of vomiting involves withholding food for 12 to 24 hours, then introducing small amounts of bland food such as rice and lean cooked hamburger, if your pet does not vomit after that then gradually wean him/her back onto the regular diet after 3 days. In order to decrease the acidity of the stomach, Pepcid AC 0.5 mg/kg can be given by mouth twice daily for 5 days. Metoclopramide and Serenia are good anti-vomiting medications for dogs and cats. You should always consult a veterinary healthcare professional before administering medication.

Causes and treatment of regurgitation after surgery
The most common cause of regurgitation is reflux of acid from the stomach into the esophagus while your pet is under anesthesia. Acidic fluid from the stomach can cause a chemical burn of the esophagus and result in a bad case of heart burn, called esophagitis. This results in poor motility of the esophagus, therefore water and food will accumulate in this structure. In most cases, esphagitis is self-eliminating and will resolve within two or three days.

If the esophagitis is severe the esophagus may develop one or more strictures. A stricture is a narrowing or stenosis of the esophagus and does not allow passage of food down the esophagus, in regurgitation that lasts longer than one week. This problem should be brought to the attention of your pet's doctor within the first two weeks so that it can be treated by ballooning the stricture (minimally invasive procedure, as it is done with the aide of an endoscope). If an esophageal stricture is chronic surgery is needed.

Symptomatic treatment of regurgitation caused by esophagitis includes feeding bland food, and administering a coating agent (sucralfate) and an acid blocker (omeprazole or other). Consult a veterinary health care professional if the regurgitation continues for more than a couple of days.

How do I know that my dog is in pain following surgery?

Signs of pain include
crying

biting if you get near the surgical site

grimacing (lips are pulled back and the the dog looks anxious)

tragic facial expression

panting

restlessness and unable to sleep; pacing

if abdominal surgery was done the pet will not lie down on the incision, or will continually sit up in spite of appearing very tired

the worst pain will be for the first 2 to 3 days after surgery

What can I do to control my dog's pain?
Pain medication such as tylenol with codeine, butorphanol, Duragesic (fentanyl patch) anti-inflammatories such as Deramaxx, Rimadyl, Previcox, or Etogesic; in some cases a sedative such as acepromazine will augment the effect of pain medication and allow your pet to sleep

If an orthopedic surgery has been done cold packing the surgical site may be helpful

A cold pack may be a pack of frozen peas, crushed ice in a Ziploc bag, or a cold gel pack; place a thin barrier between the skin and the cold pack. An alternative to a cold pack is to freeze water in a styrofoam cup; after frozen cut the bottom of the styrofoam cup out. Cool the surgical site around the incision by rubbing the exposed ice directly on the skin in a circular pattern. Cooling the surgical site helps to numb the area.
How do I know that my cat is in pain following surgery?

Pain is more difficult to assess in cats versus dogs, as signs can be more subtle and they usually do not vocalize when in pain

Signs of pain in a cat include the following:

biting if you get near the surgical site

growling or deep cry

not wanting to eat
hiding and not wanting to be near owner (remember that this could also be caused by the cat just being upset about leaving home and coming back)

What can be done for pain at home for my cat?
Pain medication such as buprenorphine or a Duragesic (fentanyl) patch

Tylenol will kill a cat as they lack abundant glutathione enzyme in the liver

Anti-inflammatories can be used, but the dose is much less than dogs

Is it okay for my pet to lick the incision?
If a dog licks the incision, the healing process may be delayed.

Licking can remove stitches and cause the incision to open

Licking can become a severe habit that is difficult to break

Licking can cause infection as the mouth has many bacteria

Dogs will frequently lick the incision when the owner is not watching such as at night time; if the skin looks red or excoriated the most common cause is from licking.

To stop your pet from licking the following can be tried:
Elizabethan collar can be placed on the neck; this will not help stop your pet from scratching at the region

Cervical collar (bite not collar) is a less awkward device and can be effective at stopping a pet from licking the surgical site

A tee shirt can be used to cover an incision on the chest or front part of the abdomen; gather the waist of the shirt up over the dog's back and wrap an elastic band around this part of the shirt.

A bandage or sock can be used to cover an incision on a limb; fasten the top of the sock to the dog's limb with tape.

Bitter apple can be applied around the incision; many dogs will continue to lick after application of this topical

Bitter Apple and Liquid HeetTM (obtain this from a drugstore...it is used for sore muscles) mixed in a 2:1 ratio can be applied around the skin incision

Antipsychotic medication in some cases is needed

Board-certification by the American College of Veterinary Surgeons
What does it mean? Four years of advanced training in surgery beyond the Doctor of Veterinary Medicine Degree
Experience in the development of new surgical treatments
Rigorous examination by the American College of Veterinary Surgeons to ensure competency in advanced surgical techniques
Assurance that a veterinarian is a surgical specialist
All information on this web site is copyright © 2004 Vet Surgery Central Inc. VCS Inc. will not be held liable for any information on this site that may be used for or against medical litigation.

reprinted with kind permission from Dan Degner
http://www.vetsurgerycentral.com

The above information is simply informational. It's intent is not to replace the advice of a veterinarian nor to assist you in making a diagnosis of your pet. Please consult with your own veterinarian for confirmation of any diagnosis. Your pets life may depend on it.