Gastric Dilation and Volvulus Syndrome (GDV)

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Gastric Dilation and Volvulus Syndrome (GDV)

• Shanna Jack
• Margaret Hollis

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There is not a single cause found for GDV

• Multiple Factors
• Dilated stomach
• Gastric volvulus
• Dietary factors
• Increased stress
• Gastric ligament laxity
• Conformation- deep chested dogs

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Breeds

• Great Dane
• German Shepard
• Standard Poodles
• Weimeraners
• Saint Bernards
• Gordon / Irish Setters
• Large Mixed Breeds
• Smaller Breeds Bassett Hound

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The Observable Phases of GDV

• Phase I
• Pacing, restlessness, salivation panting
• Ineffective Vomiting Attempts (10-20 minute
  intervals)
• Abdomen increased in size may appear full

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GDV Observable Phases

• Abdomen further increased
• Deep red gums
• NEEDS VETERINARY ATTENTION ASAP!!

• Phase II
• Increased Restlessness
• Whining
• Increased salivation, panting
• Ineffective vomiting attempts every 2-3 minutes
• Increased heart rate (100 bpm)

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GDV Observable Phases

• Phase III
• Gums pale or cyanotic
• Dog appears shaky when standing, or cannot
  stand
• Abdomen very large
• Tachycardia more severe (100 bpm)
• Pulse is weak
• Death may be near

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GDV.RADIOGRAPHS!!!

• Radiographs are
• Necessary in cases of GDV
• Needed before surgery
• Right lateral is best ventrodorsal usually is
  not necessary as this view can add stress

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Radiographic Signs of GDV
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• GDV Pathophysiology
• Gastric Distention ? Gastroesophaeal Angle Change
  ? Eructation Impairment
• Rotation Stomach?? Ultimate Duodenum Compression
  Prevention of Gastric Emptying

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GDV Pathophysiology Complications

• Distention of stomach ? Decreased venous return
  of blood to heart ? Lowered systemic tissue
  perfusion shock
• Diaphragm compression ? Decreased ventilation ?
  Increase in respiratory rate decrease in tidal
  volume

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GDV PathophysiologyComplications

• Cardiac arrhythmias
• Obstruction of venous outflow increased
  intragastric pressure ? gastric wall edema,
  anoxia ? damage to stomach
• Often see hemorrhage, necrosis, mucosal
  ulcerations wall of stomach may get necrotic

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GDV- Preoperative Care
AGGRESSIVE THERAPY!!!

• Treat immediately a dog showing signs of GDV
• Initially want to treat shock and decrease
  gastric compression
• Stabilizing the patient is the first priority

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GDV- Preoperative CareReperfusion injury may
play a role in GDV

• Production of oxygen radicals
• These radicals lead to lipid
• peroxidation and cellular death

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GDV- Gastric DecompressionTwo Main Ways

• 1) Orogastric intubation- Stomach Tube
• 2) Needle trocarization

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GDV Gastric Decompression

• Orogastric intubation
• A lubricated stomach tube is passed to the
  stomach to relieve gastric compression
• Be sure to advance the tube carefully at the
  gastroesophageal junction. If resistance is
  found, rotate tube and then advance.

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GDV Gastric Decompression

• Passage of the stomach tube into stomach lumen
  does not mean that there is no gastric rotation!!
  
• Likewise, inability to pass the tube
• does not confirm rotation of the stomach

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GDV Gastric Decompression

• Needle Trocarization
• An 18 gauge (large bore needle) is used
• The stomach wall is against the body wall so
  other viscera is misplaced, low risk of injury to
  other tissues

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GDV Treatment of Shock

• Intravenous Fluids!!!
• Balanced isotonic electrolyte solution given at
  shock rate (90 ml/kg/hour)
• Colloids, hypertonic solution may be indicated
• Urinary catheter placed to monitor urine
  production as an indicator of tissue perfusion
  (at least 2.0 ml/kg/hour)

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GDV Treatment of Shock

• Antibiotics / Glucocorticoids??
• Monitor cardiac arrhythmias with an ECG
• It may be helpful to give some patients oxygen

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Surgical Correction of Volvulus

• Timing depends on patient stabilization
• Surgeons experience and judgement are important
• If gastric necrosis is present, prognosis worsens
  as time elapses
• Usually, surgery occurs within 4-6 hours after
  presentation

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Anesthesia

• Neuroleptoanalgesics or narcotics preferred for
  induction
• Maintained with isoflurane or sevoflurane
• Nitrous oxide is contraindicated

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Surgery

• The dog is placed in dorsal recumbency
• A standard midline abdominal incision is made
  from the xiphoid to caudal to the umbilicus

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Surgical Anatomy and Rotation

• Clockwise rotation of stomach is most common
• Most rotations are between 180 and 270 degrees
• Occasionally, counterclockwise of 90 degrees is
  seen
• Stomach is rotated about the distal esophagus and
  tilted cranially

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Increased malposition of the stomach with
increasing rotation

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Repositioning of the Stomach

• Manipulate the omentum
• Surgeons hand enters between the stomach and
  liver and the stomach is withdrawn caudally
• Stomach is grasped to elevate the pylorus and
  depress the fundus
• Stomach gently twisted back into normal position

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• Complete derotation is determined by palpating
  and visualizing the cardia and intra-abdominal
  esophagus
• Stomach tube passage can serve as a reference
• Easy passage of the tube and lack of tissue folds
  at the gastroesophageal junction indicate
  complete derotation

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Determining Stomach Viability

• Approximately 10 of GDV patients have gastric
  necrosis
• After repositioning the stomach, gastric
  viability is assessed and devitalized areas are
  excised by partial gastrectomy

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Criteria for Gastric Necrosis

• Serosal Color - gray or green
• Thickness of stomach wall - thin is bad
• Vascular patency

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Considerations

• Once stomach is repositioned thus relieving
  venous outflow obstructions, the appearance of
  the serosa can greatly improve in 5-10 minutes
• Small incisions can be made in questionable areas
  and the appearance of arterial blood indicates
  probable survival

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• If any question exists about the viability of an
  area, that area should be excised

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Gastropexy

• A technique with the goal of creating a permanent
  adhesion between the stomach and body wall
• Greatly decreases the rate of GDV recurrence
• The pyloric antral region is fixed to the
  adjacent right abdominal wall

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Common Procedures of Gastropexy

• Right sided Tube Gastrostomy (tube gastropexy)
• Incisional Gastropexy
• Circumcostal Gastropexy
• Belt Loop Gastropexy

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Tube Gastropexy

• Advantages
• - Provides rapid, easy access to the gastric
  lumen
• - Relieves post-op gastric distention
• - Recommended for patients with necrotic gastric
  tissue
• Disadvantages
• - Potential leakage of gastric contents

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Tube Gastropexy
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Tube Gastropexy

• Sutures between the stomach and the body wall
  maintain the apposition
• Omentum develops a water-tight fibrin seal within
  4-6 hrs. when it is wrapped around
  intra-abdominal drains

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Incisional Gastropexy

• Can be used as a prophylactic procedure in high
  risk patients
• Does not require the aftercare that is involved
  with tube gastropexy

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1. Initial pyloric antrum incision
2. Matching incision on body wall
3. Suturing of body wall and pyloric antrum

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Circumcostal Gastropexy

• Popular because it forms a stronger adhesion than
  two previous methods
• Includes a viable muscle flap adhesion and a more
  proper anatomic placement of the stomach
• Disadvantage Possible rib fracture or creation
  of pneumothorax

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• Two 1X4 cm partial thickness gastric flaps are
  created and are wrapped around either the 11th or
  12th costal cartilage

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Belt Loop Gastropexy

• Modification of circumcostal method
• Seromuscular flap is created in the shape of a
  belt instead of an I to eliminate corners and
  simplify flap passage and suturing
• The seromuscular stomach flap is passed around a
  belt loop of transverse abdominus muscle

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Belt Loop Gastropexy
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GDV- Postoperative Considerations

• Closely watch cardiovascular function and
  electrolyte acid-base status
• Do not feed orally for 2-3 days
• Give a balanced electrolyte solution IV at 60-120
  ml/kg/day

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GDV- Postoperative Considerations

• Antiarrhythmic medication may be indicated
• Lidocaine/ procainamide are most common
• Postoperative pain relief with systemic
  administration of opioid analgesics such as
  morphine, or oxymorphone

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Thank-you!!

• Any Questions?

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References

• Aronson, L.R., Brockman, D.J. and D.C. Brown
  Gastrointestinal Emergencies. The Veterinary
  Clinics of North America- Small Animal Practice
  303, 2000.
• Bojrab, Joseph M. Current Techniques in Small
  Animal Surgery. 4th ed. Williams Wilkins,
  Philadelphia. 223-242, 1998
• Glickman LT, Glickman NW, Schellenberg DB, et al.
  Incidence of and breed-related factors for
  gastric dilation-volvulus in dogs. JAVMA 21640,
  2000.
• Matthiesen, David T Gastric Dilation-Volvulus
  Syndrome in Textbook of Small Animal Surgery. 2nd
  ed. W.B. Saunders Co., Philadelphia. 580-591,
  1993.