Gastric Dilatation and Volvulus
Also known as: GDV
Introduction
Gastric Dilatation and Volvulus (GDV) is an acute, life-threatening emergency affecting large and giant breed dogs. The condition is characterised by accumulation of gas in the stomach, malpositioning of the stomach, increased intragastric pressure and shock. Successful management relies on prompt diagnosis and appropriate emergency treatment as the disease will rapidly progress to death if untreated.
Commonly affected breeds include German Shepherds, Great Danes, Irish Wolfhounds, St Bernards and Doberman Pinschers. GDV has also been reported to occur in cats, primates and rarely small breed dogs such as Dachshunds and Miniature Poodles.
Risk Factors
The exact aetiology of the condition is unknown but a number of risk factors have been identified. Studies have shown that dogs with a reduced thoracic width to depth ratio are at an increased risk of developing GDV. Female dogs are also more likely to develop GDV than males and stressed, anxious dogs are more likely to develop GDV than calm dogs. Other risk factors include obesity, feeding a dry food diet and exercise after feeding.
Pathogenesis
An obstruction to gastric emptying due to fluid or gas leads to gastric distention and a rapid increase in intra-gastric pressure. As the stomach dilates, the pylorus shifts through an angle of between 180 and 360oC from its normal position to a dorsal, cranial and leftward location. More than 90% of all gastric volvuli rotate in a clockwise direction when viewed from the surgeon's perspective with the dog in dorsal recumbency.
The most immediate effect is impairment of the gastric blood supply, leading to severe congestion of the gastric wall and infarction and ulceration of the gastric mucosa. Venous return to heart is reduced due to mechanical compression of the caudal vena cava by the distended stomach, leading to decreased cardiac output and hypovolaemic shock. Gastric distension also causes a mechanical impediment to movement of the diaphragm resulting in reduced tidal volume, hypoxia and hypercapnia.
In addition to the above systemic effects, displacement of the stomach may lead to avulsion of the short gastric branches of the splenic artery and of the left epiploic artery along the greater curvature of the stomach. Significant haemorrhage may occur as a result and this may lead to the development of ischaemia-induced gastric necrosis.
History and Clinical Signs
The clinical signs of GDV are usually acute in onset and may follow a period of exercise and/or feeding of a large meal. Affected dogs typically display non-productive vomiting and abdominal distension. Acute onset restlessness, abdominal pain, hypersalivation and abdominal tympany are other common features of GDV. On physical examination, the dog may be collapsed or reluctant to stand. Signs of cardiovascular shock may be present including tachycardia, pale mucous membranes, prolonged capillary refill time and poor peripheral pulses. An irregular heart rate combined with pulse deficits indicates the presence of.
Diagnosis and Management
Diagnosis is usually based on the patient's signalment and a history of unproductive vomiting and abdominal distension.
Fluid Therapy
Initial emergency treatment should be aimed at managing the dog's hypovolaemic shock. It may be beneficial to provide oxygen supplementation whilst the dog is being stabilised. Large bore (16 or 18 gauge) catheters should be placed into the cephalic or jugular veins and a proportion of the shock dose of Compound Sodium Lactate (90ml/kg/h) should be administered intravenously based on the severity of the dog's clinical signs. Hypertonic saline or colloid fluids may be indicated in very large dogs or those who have not responded to a bolus dose of crystalloid fluids.
Gastric Decompression
Following a period of aggressive fluid therapy, gastric decompression should be performed. A lubricated large-bore stomach tube is premeasured (from nostril to last rib) and marked. A roll of 2 inch adhesive tape should be inserted behind the canine teeth and the dog's mouth should be held closed around the bandage. The stomach tube can then be introduced through the bandage into the oesophagus. It is important to minimise stress when this procedure is carried out. Sedation is not usually required but suitable drugs for this include Butorphanol, Fentanyl or Diazepam. If the animal is resistant to orogastric intubation or becomes stressed, trocharization of the most tympanic area caudal to the ribs with a 14 to 16 gauge catheter may be performed. This may allow subsequent completion of orogastric intubation for further decompression. Temporary gastrostomy may also be considered.
Radiography
Abdominal radiography may be beneficial in confirming a diagnosis of GDV and distinguishing between GDV and gastric dilatation. Radiography should not be carried out until gastric decompression has been performed and intravenous fluids have been started. A radiograph performed in right lateral recumbency shows a dorso-cranially positioned pylorus to the left of the midline. The stomach will appear compartmentalised (the classic 'double bubble' pattern) with a soft tissue strip separating the two compartments. The oesophagus may appear dilated with air or fluid. Evidence of air in the abdomen indicates that perforation has occurred and requires an exploratory surgical procedure. Loss of contrast in the abdomen may indicate peritonitis or haemoabdomen.
Other Diagnostic Tools
Plasma lactate concentration has been reported to have a strong link with the patient's prognosis due to its association with gastric necrosis and systemic hypovolaemia. A plasma lactate greater than 6 mmol/L is associated with a poor prognosis.
Electrocardiography (ECG) is essential as cardiac arrhythmias may occur in up to 40% of dogs with GDV. Most arrhythmias are ventricular in origin and occur within 36 hours of admission. Ventricular tachycardia is the most common rhythm disturbance displayed but many other arrhythmias may occur.
Treatment
Once the patient has been stabilised, the volvulus should be surgically reduced via a cranioventral midline laparotomy. The aims of surgery include gastric decompression and repositioning, assessment of the abdominal organ viability, removal of necrotic tissue and gastropexy (to prevent recurrence).
Stomach contents should be removed using a large stomach tube or through a gastrotomy incision (taking care not to spill gastric contents into the abdomen) prior to any resection of devitalised tissue. Partial gastrectomy is ideally performed using a stapler as it is easy to use and considerably reduces the operation time.
It is important to evaluate the viability of the stomach carefully (tissue thickness and colour should be assessed and vessels palpated for pulsations - in questionable areas a stab incision should be made and observed for signs of bleeding). If necrotic tissue is not properly identified and then incorporated into the closure wound, this may subsequently breakdown - resulting in peritoneal contamination.
Splenic damage due to avulsion or torsion may require partial or complete splenectomy. If complete torsion has occurred it is important perform a complete splenectomy before derotating the spleen. Failure to do so will result in the release of ischemic toxins and thrombi into the circulation on de-rotation. If avulsion or torsion is incomplete (and no thrombi are present) the organ should be re-positioned and then allowed to settle before assessing for viability. Lack of viability may appear as dark areas indicating ischaemia or infarction. Again splenectomy is easier to perform with stapling equipment. Splenectomy may also be indicated if any masses are present on the spleen or if haemorrhage cannot be controlled.
Many types of gastropexy have been described including the belt-loop, tube and circumcostal techniques. However the most commonly used in GDV surgery is the incisional gastroplexy as it is simple to perform and has low levels of complications. This technique involves making a partial thickness incision in both the pyloric antral region and adjacent right abdominal wall and suturing the two incisions together. The use of tube gastrostomy is associated with a higher morbidity rate due to alteration of gastric motility and development of cellulitis around the tube. The circumcostal technique produces reliable adhesions but is technically difficult to perform and can result in pneumothorax. Midline abdominal closure gastropexy should be avoided as this means that any future abdominal incision may penetrate directly into the stomach if the surgeon is not warned.
The abdomen should be lavaged prior to closure.
Post-operative Complications and Care
The most common complications following GDV surgery include cardiac arrhythmias, shock, hypokalaemia and surgical complications such as dehiscence. Ventricular tachycardia is the most common abnormal rhythm and continuous ECG monitoring is recommended for the 24-48 hours following surgery. Intravenous fluid therapy should be continued and the haemodynamic, acid-base and electrolyte balance should also be closely monitored. If vomiting occurs the patient should be evaluated for possible peritonitis and if gastric rupture.
Prognosis
Simple GDV mortality rates are around 15%. Patients suffering from gastric necrosis or requiring gastric resection or splenectomy have a higher mortality rate at over 30%.
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References
- Gilson, SD (1998) Self-Assessment Colour Review Small Animal Soft Tissue Surgery Manson
- Hall, E.J, Simpson, J.W. and Williams, D.A. (2005) BSAVA Manual of Canine and Feline Gastroenterology (2nd Edition) BSAVA
- King, L. and Hammond, R. (1999) BSAVA Manual of Canine and Feline Emergency and Critical Care BSAVA
- Tilley, L. P., and Tilley, L. P. (2008) Manual of canine and feline cardiology Elsevier Health Sciences
- Tivers, M. and Brockman, D. (2009) Gastric dilation–volvulus syndrome in dogs 1. Pathophysiology, diagnosis and stabilisation 31(2):66 In Practice
- Tivers, M. and Brockman, D. (2009) Gastric dilation–volvulus syndrome in dogs 2. Surgical and postoperative management 31(3):114 In Practice
- Wingfield, W. E. (2001) Veterinary Emergency Medicine Secrets Elsevier Health Sciences
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