Emergency surgery for gastric dilatation volvulus

Photo: Henk Vrieselaar/Adobe Stock

A lateral x-ray of a large dog with a gastric dilatation and torsion is shown.

Andrea Pace, CVT, VTS (ECC), training mentor for the emergency department at Mount Laurel Animal Hospital, discussed the initial stages of managing patients in a variety of emergency cases, during her presentation of, “Emergency Surgeries: What a Vet Tech Needs to Know from the ER to the OR,” at the 2024 Fetch dvm360 Conference in Atlantic City, New Jersey. Gastric dilatation volvulus (GDV) is commonly known as bloat, and it was among the emergency surgery cases covered during the lecture, and it can be life-threatening.

“What happens is, a dog’s stomach, or occasionally a cat’s stomach… fills with air, either [because] they swallow a lot of air, or sometimes because of fermentation in their stomach of their food product, and [the stomach] swells up and twists on itself,” Pace explained in an exclusive dvm360 interview. “When it twists, it closes off the entrance and exit, and can continue expanding, especially if there’s a fermentation component. When it does this, it pushes on the diaphragm, and it pushes on the vena cava.”

In her session, Pace explained that that emergency cases of GDV often occur in deep-chested dogs. She warns, however, that this can be tricky, giving the example that Basset hounds are technically deep-chested dogs, despite their shorter legs and general perception. Dogs with GDV will usually present panting, uncomfortable, and oftentimes with swollen abdomens.

With that said, Pace shared that she has seen cases of dogs presenting with seemingly normal abdomens, and swelling wasn’t recognizable until she felt underneath the ribcage. Although this is the textbook presentation, Pace admits that there are outlier cases. “Sometimes, [the patients] will surprise you,” she said in her session. “I’ve seen [GDV] in dachshunds, I’ve seen it in a cat once, so it’s rare, but it [can happen].” For this reason, it should be included on differential lists, and not ruled out simply on account of breed.

Usually, dogs with GDV will be observed being generally restless, in addition to gagging, retching, and engaging in nonproductive vomiting. Pace explained that these dogs will show other normal signs of pain and anxiety, and can engage in seemingly unusual stretching, and other movement movements, as they attempt to relieve the pain themselves.

She encouraged both pet owners and practitioners to be proactive, explaining that it’s better to assume it’s GDV, assess it, and rule it out, rather than assume the gagging is simply a sign of nausea. An x-ray of a dog’s right lateral abdomen can confirm a GDV diagnosis, with Pace explaining that it will be immediately obvious when it’s GDV, as there will be a large pocket of air in the abdomen.

“We usually warn people that if they have any of these signs in a dog, [they should] just bring it in,” Pace said. “Worst case scenario, we can do an x-ray, and 1 x-ray can be a quick diagnostic that will tell us [whether] this is a problem, or if it’s something else that’s bothering them, and maybe it’s not a surgical emergency.”

Treatment

Once a diagnosis is confirmed, it’s advised to begin treatment immediately. Pace recommends a fluid bolus, starting at ¼ shock dose, and indicating that bigger catheters are preferred in these cases to account for the large amount of fluid required. Patients should also be started on pain medication, and Pace recommends pure-mu opioid, because of their reversibility.

For baseline bloodwork, she emphasized the importance of lactate. According to Pace, the clearance of lactate in GDV can inform a prognosis, with high lactate levels being a solid indication that treatment will be effective, as the patient likely has less gastric necrosis, or other secondary issues. Additionally, she advocated for decompression of the stomach pre-surgery, which involves shaving the stomach, and slowly releasing some air.

In surgery, the stomach should be de-rotated immediately upon opening the abdomen. Cuts should be made in the muscle of the body wall and in the muscularis of the stomach, before the stomach is finally securely sewn to the body wall.

After using pure-mu opioid as pre-medication, Pace advocates for lidocaine, midazolam, and then propofol, or alfaxalone during induction. Throughout, she recommends constant rate infusions (CRIs) of fentanyl and lidocaine, and potentially inhalant, if needed. In recovery, she deploys a bupivacaine liposome injectable suspension, general pain control, antiarrhythmics, prokinetics, and behavior medications.

For anesthetics, she recommends the following, depending on additional complications:

• For distributive shock, treat with resuscitation, fluids, and adjust pressors.
• For ventricular arrythmias, treat with lidocaine CRI, and adjust fluid intake.
• For compression of the vena cava, treat with more fluids and adjustment of colloids.
• For gastric necrosis, treat with resection or euthanasia.
• For splenic infarct, treat with a splenectomy.

“Usually, with that twisted off organ, you have enough tissue damage that it will kill a dog within about 12 hours,” Pace explained. “The sooner you treat it, the better. I have seen some [dogs] survive… about 14 to 16 hours, and they have survived surgery, but they have a much harder road for recovery.”

Reference

Page A. Emergency Surgeries: What a Vet Tech Needs to Know from the ER to the OR. Presented at: Fetch dvm360 Conference; October 14-16, 2024; Atlantic City, NJ.