For Dog Owners: Ice cubes or ice water do NOT cause GDV (bloat) in dogs

Gastric dilatation volvulus (GDV) is a disorder of dogs characterized by extreme dilation and mal-position of the stomach. It is primarily seen in large breed dogs and is due to a number of predisposing factors. There is no scientific evidence supporting the claim that ingestion of ice cubes or ice water has any relationship to GDV in dogs, and I have never seen a case in which there was a correlation between the two.

On hot days if a large breed dog becomes overheated they will pant heavily in attempt to cool themselves down. This can lead to aerophagia (swallowing air) that can cause excessive gas in the stomach and lead to GDV if other contributing factors are present. Keep your dog cool by avoiding exercise during the hottest part of the day, avoid leaving them in a hot car in the sun in a parking lot, and give them access to plenty of cool, fresh water and a shady place to rest. Also, do not let your dog drink massive amounts of water all at once. After drinking a reasonable amount, take the bowl away and offer more after 15 to 30 minutes. A cool bath can also be helpful if you think your dog has become mildly overheated. Severe hyperthermia is an emergency situation requiring immediate care by a veterinarian.

For more information on GDV in dogs, search this blog for GDV, or contact your local veterinarian.

What Was The Outcome On Frank, The Golden Retriever With GDV?

This is not Frank but he's a handsome old guy, isn't he?

For those just tuning in, this is a follow up to the blog about Frank, a 9-year-old neutered male dog who presented with a GDV. The blog was posted 1/19/14.

I decided not to do a partial gastrectomy on Frank. We performed an incisional gastropexy from the pyloric antrum to the interior right abdominal wall, and closed the abdominal incision routinely. Postoperatively, besides routine supportive care with intravenous fluids and analgesics, Frank was placed on antibiotics for pyoderma and omeprazole and sucralfate for his gastritis.

Frank did well in the hospital and was discharged 2 days postoperatively. He was sent home on antibiotics for the pyoderma, Tramadol for pain (5 day course), and omeprazole and sucralfate for 1 week.  The owners were advised to feed Frank small meals several times a day and to monitor his stool for evidence of melena.

Frank was seen at our clinic 9 days postoperatively and was doing reasonably well but the owner felt he was a bit lethargic. He was eating well but only canned food.  His stools were normal. A brief abdominal ultrasound exam revealed no peritoneal fluid. The owner was advised to keep Frank on his gastric medications for another week.

Frank was again examined at our clinic 14 days postoperatively. He was more active, eating both canned and dry food, and had normal stools. His abdominal incision had healed and staples were removed. His owner was happy with his progress.

On the poll where I asked what you would do with Frank's stomach, 32 people voted and 56% choose to not do a gastrectomy. Although his stomach was severely bruised, it did not fit the most important criteria for gastric necrosis. There was not a sharp demarcation between the normal and abnormal color of the gastric serosa, but rather a gradual change from the pink to the bruised area. Also, the tissue on palpation was thick, not paper-thin which is more typical of a necrotic stomach. In addition, although I did not mention this in the original blog on Frank, the color of the affected area slightly improved after the stomach was placed into its normal position.

Please do not hesitate to post any questions you have about Frank, or GDV in general.

Surgical Decision Needed on Frank: What should we do with his stomach?

Fig. 1: A stomach tube has been placed on Frank.

Signalment and History

Frank  is a 9-year-old castrated male golden retriever who recently presented to our clinic with a history of attempting to vomit for several hours. (Fig. 1) The owner observed that he was uncomfortable and his abdomen was distended.

Physical Examination

Physical examination revealed that Frank was ambulatory but weak and in distress. His mucous membranes were pale pink, capillary refill was > 2 seconds, and he was tachycardic. His abdomen was severely distended and tympanic on percussion.

Imaging and Emergency Treatment

Radiographs revealed a grossly distended and malpositioned stomach consistent with a gastric dilatation volvulus.(Fig. 2) 

Fig. 2: Right lateral abdominal radiograph on Frank showing classic
appearance of a GDV.

Attempts to pass a stomach tube were unsuccessful. (Fig. 1)  A gastrocentesis was performed with a 14 gauge over-the-needle catheter and gas removed. A second attempt at stomach tube passage was then successful and a copious amount of brownish fluid was obtained. Intravenous fluids were administered and Frank was prepared for emergency surgery.

Surgery

Abdominal exploratory revealed a gastric dilatation volvulus. A small amount of blood was present in the peritoneal cavity. The stomach was de-rotated and placed into normal position and the gastric tissues examined. The gastric fundus was inflamed and a portion severely bruised. (Fig. 3-4)

Fig. 3: The gastric body and part of the fundus on Frank.

Fig. 4: The gastric fundus on Frank.

The bruised area was along the greater curvature and extended to the level of the cardia. On palpation of the gastric wall the tissue was moderately thickened. No areas of perforation were seen.

Question

Should this area of stomach be resected? Or should the abnormal area be invaginated? Can this area be left alone and the dog treated postoperatively with supportive care including famotidine and sucralfate?

Select your answer on the poll on the upper right hand column of the blog website. Remember that you must view the blog in “web version” to see the poll. (It does not automatically show up on your mobile phone version.) In a few days I will let you know what I decided to do and how things turned out on Frank.

Gastric Invagination for GDV Induced Necrosis: Safe and effective, or risky and ill advised?

 

Gastric necrosis along the fundus and body of an Irish Setter with GDV.
Note the abnormal color and sharp demarcation between normal and devitalized tissue.

The gastric invagination technique was first described in a series of experimental dogs in 1986.¹ The necrotic area of stomach, instead of being removed by partial gastrectomy, was pushed into the stomach lumen and over sewn with inverting suture patterns. The devitalized tissue was left to be digested by the stomach enzymes allowing the healthy tissue to heal. Some of the dogs in the study had melena for several days and healing of the gastric wall took more than 2 weeks.

The technique seems to fly in the face of conventional surgical wisdom. Necrotic tissue is supposed to be removed.  Allowing the dead tissue to remain and then slough out in the stomach lumen would potentially result in a serious gastric ulcer and possible delayed healing of the stomach wall. In fact, a case report described that very scenario.² A German Shepherd, 3 weeks after surgical treatment for GDV and gastric invagination, presented with a bleeding ulcer that required partial gastrectomy. The dog had also developed a splenic torsion.

Although anecdotal, many surgeons have reported performing gastric invagination on dogs with good success and minimal complications. Dr. John Williams, a respected and experienced surgeon in the United Kingdom, wrote in a book chapter: “Gastric invagination is a quick, safe, and effective technique.”³ Personally, I have performed the technique on only a few dogs over the years but they have done well and did not develop bleeding ulcers.

As with most controversial issues common sense probably lies somewhere in the middle ground. The accepted technique for treating necrotic stomach is partial gastrectomy. Stay sutures are placed around the necrotic area, the tissue removed and the stomach closed with a double layer inverting suture pattern (Cushing followed by Lembert patterns).

However, invagination could be considered in these situations:

• The surgeon’s skills and facilities do not allow for a properly performed partial gastrectomy,
• The dog is not stable under anesthesia and the surgery needs to progress quickly,
• The necrotic area is relatively small and well demarcated,
• PDS or similar suture is available for the closure,
• Appropriate postoperative monitoring and care can be administered.

The invagination is begun by placing a continuous inverting suture
(Cushing pattern) with 2-0 PDS grabbing healthy tissue at the dotted lines.

This is the same dog as above after completing the invagination
with a second layer of inverting suture (Lembert pattern)

Here are a few other considerations. If invagination is performed, monitor the dog postoperatively for evidence of bleeding ulcer or other issues such as peritonitis. Also, treat the dog with gastric protectants like Sucralfate and antacids such as famotidine. These drugs should be continued for at least 1 month postoperatively.

Additional observations: If the the short gastric vessels have been ruptured or thrombosed as a result of the GDV, the spleen may also be infarcted and may have to be removed. Also, I have not had good success with stomach stapling for partial gastrectomy. Problems with delayed healing and leakage have been my experience and that of others.  The stomach tissue tends to be quite thick and I think the staples may not always properly engage and appose the tissues, particularly in dogs with GDV.

1. MacCoy DM, Kneller SK, Sundberg JP, Harari J. Partial invagination of the canine stomach for treatment of infarction of the gastric wall. Vet Surg 1986, 15:3, 237-245.

2. Parton AT, Volk SW, Weisse C. Gastric ulceration subsequent to partial invagination of the stomach in a dog with gastric dilatation-volvulus. J Am Vet Med Assoc. 2006 Jun 15;228(12):1895-900.

3. Williams JM. Gastric dilatation and volvulus. In: Williams and Niles, editors BSAVA Manual of Canine and Feline Abdominal Surgery. British Small Animal Veterinary Association, 2005, pg. 80.

Incisional Gastropexy: Detailed description and video!

Fig. 1: The letters and arrow indicate where the gastric incision
is made for incisional gastropexy

A critical part of the operative treatment for GDV is to perform a gastropexy. Creating a permanent adhesion between the pyloric antrum and the right side of the abdominal cavity prevents recurrence of rotation of the stomach. Many options for gastropexy are available, including tube gastrostomy, circumcostal gastropexy, belt loop gastropexy, or incisional gastropexy. Because of its simplicity, incisional gastropexy has gained popularity among surgeons in recent years. Creating a seromuscular incision in the pyloric antrum and a similar incision in the interior abdominal wall starts the incisional gastropexy. These two incisions are sutured to each other to create the permanent adhesion. Incisional gastropexy is a straightforward technique and studies have shown it to be very effective at preventing gastric volvulus in dogs.

            
In addition to performing the procedure for dogs that have already developed GDV prophylactic gastropexy is also indicated in dogs that may develop GDV sometime in their life. (see previous blog on risk factors for GDV)

Towel clamps are placed on the edge of the right body wall and held by an assistant to increase exposure. A simple interrupted suture of 2-0 PDS (taper needle) is placed at the lesser curvature of the pyloric antrum ("a" in Fig. 1) and sutured to the interior of the abdominal wall just caudal to the last rib. A second suture is placed at the greater curvature of the antrum ("b" in Fig. 1) and then sutured to the interior of the abdominal wall at a point approximately 4-6 cm caudal to the first suture depending on the size of the animal. (Fig. 2) The needles are left on these initial sutures since they will be used to suture the stomach to the abdominal muscle after incisions are made.

Fig. 2 The pyloric antrum has been tacked to the interior of the
body wall on the right side.
(R: right, L: left, Cr: cranial, Ca: caudal)         

A seromuscular incision is made in the pyloric antrum being careful not to enter the stomach lumen. The incision is perpendicular to the long axis of the stomach. (arrow in Fig. 1) To start this incision, the stomach wall can be pinched between the thumb and first finger. Allow the gastric mucosal layer to slip through the fingers and thus not be included in the incision. Metzenbaum scissors or scalpel are used to incise the tissue being held by the fingers which amounts to a seromuscular incision. This incision is then lengthened by using the Metzenbaum scissors to undermine the seromuscular layer and separate it from the mucosal layer. The scissors are then used to incise the seromuscular tissue to complete the stomach incision. A corresponding incision is then made in the interior abdominal musculature the exact same length as the stomach incision. (Fig. 3)

Fig. 3 Incisions have been made in both the stomach and body wall.

Use the previously placed PDS sutures to appose the stomach incision to the abdominal incision. Suture the lateral aspect of the stomach incision to the dorsal aspect of the abdominal incision with one suture line. (Fig. 4) 

Fig. 4 The lateral aspect of the stomach incision has been sutured
to the dorsal aspect of the body wall incision.

Then suture the medial aspect of the stomach incision to the ventral aspect of the abdominal incision with the other suture line. (Fig. 5)

Fig. 5 the medial aspect of the stomach incision has been sutured
to the ventral aspect of the body wall incision.

Video:

Acknowledgement: Thank you to my good friend and colleague Dr. Gary Ellison for his help in developing this incisional gastropexy technique.

Decompression of the massively distended GDV stomach: Needle or stomach tube?

The dog presents in distress, pale mucous membranes, shock, and a has huge gas distended stomach. The owner says he has been trying to vomit for several hours but has only brought up some foamy fluid. Radiographs reveal a very large stomach filled with air and a Smurf hat appearance on the lateral view (see previous blog on diagnosis). The distended stomach is compressing the vena cava causing hypovolemia and inhibition of normal respiration by putting pressure on the diaphragm.

First step?

From: www.studyblue.com

The two most importance initial actions in GDV are to begin intravenous fluid therapy at shock doses (90ml/kg/hr), and to decompress the stomach. Decompression can be via gastrocentesis with a needle or over-the-needle catheter or with a stomach tube. I have used both, but in a severely affected dog my first step would be to do a quick clip and prep of the lateral abdomen over the area of greatest distention and insert a large bore over the needle catheter percutaneously into the stomach to evacuate the air. In a large dog a 14 gauge, 6 inch catheter (horse jugular vein catheter) works very well.

Large bore over the needle catheter is being placed into the stomach percutaneously

Massage the abdomen to allow additional air to escape. This is a quick and effective way to initially empty the stomach and allow improvement of venous return and cardiac output.

I would then attempt to pass a stomach tube. It is not necessary to use a large stomach tube; a medium or even smaller sized tube is all that is necessary. Measure the tube from the tip of the nose to the 13th rib and place a piece of tape in that spot to serve as orientation and let you know when you are at the cardia of the stomach. Lubricate the end of the tube with KY jelly and gently pass it into the stomach. Do not try to force the tube into the stomach if you feel resistance. The gastric fundus and cardia may be compromised so gently pushing the tube in this area is important. Sometimes a slight twisting motion will help get the tube past the cardia. Try putting the dog in different positions if the tube will not pass initially. A stomach tube is more likely to remove fluid and solid debris from the stomach than gastrocentesis.

If there is an anticipated delay between initial treatment and the surgery to correct the GDV, an option to maintain decompression is to pass a nasogastric tube. Although this will be a small bore tube (a 14 Fr size tube would be ideal) it can be used to remove excessive gas from the stomach and keep the animal stable during the interim period between emergency treatment and surgery.

From: Crisp MS. Critical care techniques in Saunders Manual of Small Animal Practice.  1st edition,  Birchard and Sherding, editors, W.B. Saunders, 1994, pg 22.

Acknowledgement: Thank you to my wife Dr. Becky Ball for her help with this blog.

Next blog: Incisional gastropexy to prevent recurrence of GDV.

Fast eating Fred has to slow down with the muffin tin method.

The Animated GDV Stomach Video!

This video depicts the anatomic changes that occur in the stomach of a dog with a gastric dilatation volvulus. The stomach is shown with the dog laying on its back with head at the top of the frame.

Animation created by Mr. Tim Vojt, Senior Medical Illustrator, College of Veterinary Medicine, The Ohio State University

Gastric Dilatation Volvulus: Which dogs are at high risk?

The short answer is Great Danes! In an article in the Preventative Veterinary Medicine Journal in 2003 the Great Dane was the most common breed of the ones studied, and they had a life time risk of developing GDV of 37%. Other most common breeds in that study were Irish Setter, Rottweiler, Standard Poodle and Weimaraner. Obviously large breed deep chested dogs are most commonly affected, although smaller breeds have been reported to have GDV.


Other factors that have been identified to predispose to GDV are:

• large or giant breeds, deep chested conformation
• parent or sibling that was affected by GDV
• large dogs that are fast eaters and prone to aerophagia
• dogs that have previously developed gastric dilatation without volvulus
• large dogs that are high strung, excitable, and not “happy”
• dogs undergoing splenectomy for splenic masses

GDV dogs also seem to have delayed gastric emptying and laxity of the gastric ligaments, particularly the hepatoduodenal ligament which maintains the position of the pylorus on the right side of the abdominal cavity. The gaseous distention of the stomach is due to aerophagia. Therefore, anything that causes dogs to ingest air, such as panting, will allow air accumulation in the stomach and may set the stage for GDV. Postprandial exercise has also historically been thought to contribute to episodes of GDV, although clinical studies have not proven this to be an important factor.

Feeding dogs from a muffin tin can significantly slow them down.

Critical to successful management of GDV is an appreciation of the anatomic changes that occur in the stomach and associated structures. A key aspect of the stomach rotation is that the pylorus moves from right to left. (See figure below).

It does this by rotating first ventrally, then dorsally and to the left. When viewing the dog from the rear, this is a clockwise rotation of the stomach. The stomach fundus moves to the right side, and the spleen may also move from left to right. Occlusion of the pylorus and cardia results from this malposition of the stomach.     

Understanding the malposition of the stomach makes it clear how a gastropexy between the pyloric antrum and interior of the right body wall can prevent further rotation of the stomach. Watch the following video, produced by VisioCare Consult, that clearly shows the anatomic changes in the stomach during a gastric dilatation volvulus. The stomach is viewed as you would see it during a ventral midline abdominal exploratory. 

Definitive diagnosis of a GDV is with plain film abdominal radiographs. On a right side down lateral projection, the stomach looks like a Smurf hat, with the pylorus and antrum seen cranial to the remainder of the stomach.

Typical appearance of the stomach in a dog with GDV.

In the next post we will continue to look at this disorder, including emergency treatment methods and surgical correction (which is the best part!)

References

Prev Vet Med. 2003 Sep 12;60(4):319-29.
Benefits of prophylactic gastropexy for dogs at risk of gastric dilatation-volvulus.
Ward MP, Patronek GJ, Glickman LT.