Medical and Surgical Considerations Regarding Bloat
Gastric Dilatation Volvulus Syndrome in the Bloodhound
Dr. John Hamil
Definition: this is an acute life-threatening condition which initiates complex cardiovascular and metabolic changes that result in high mortality following dilatation and rotation of the stomach on its long axis.
CONCERN: Early recognition of the signs of GDV and immediate veterinary attention will greatly improve survival rate. Only if veterinary care is not accessible should the owner attempt to tube or trocarize the dog, although this may be life saving if you must travel a great distance.
CAUSE: Unkown. Probably multifactorial. No age or sex predilection. The bloodhound's size, deep chest, frequent ingestion of foreign material, and genetic predisposition make them common victims of this condition. GDV syndrome is seen primarily in large deep chested breeds and, although heritability has not been proven, does seem to be more prevalent in certain lines. This syndrome is often associated with ingestion of large meals and drinking water, post feeding exercise, following general anesthesia, stress (boarding, traveling, showing, breeding, trailing, etc. ) ingestion of foreign bodies, and gastroenteritis with vomition.
SIGNS: The observant owner may notice the early vague signs of restlessness, pacing, lethargy, dull, vacant or painful expression, and/or shallow respiration. Repeated measurements around the abdomen at the level of the last rib with a cloth measuring tape will demonstrate early increases in abdominal size if you are in doubt. Every owner should be able to recognize the more sever signs of unresponsiveness, unproductive retching, salivation, arched back, anterior abdominal pain, abdominal distention, abdominal tenseness, pale mucus membranes (eyes and mouth), weak pulse, blue-gray mucus membranes, weakness, inability to stand, moribund appearance, and, with endotoxic shock, red injected mucus membranes and rapid capillary refill time.
RULE OUTS: Small intestinal volvulus, splenic torsion, gastric or intestinal foreign body, intussesception, peritonitis, cardiomyopathy, or pleural effusion. Bloodhounds are predisposed to both dilated and hypertrophic cardiomyopathy. They are very likely to ingest foreign objects and seem to be susceptible to intussusception.
DIAGNOSIS: Signalment, history, clinical signs, xray in right lateral recumbency if not in shock or after decompression, this position may show the pylorus and duodenum dorsal to the cardia.
THERAPY: If in shock, decompress immediately by gastric tube, or if necessary, by trocharization with multiple 16-18 gauge needles at the point of greatest distention or perform temporary gastrostomy in right paracostal area, if necessary. If possible have assistants establish IV and initiate treatment for shock simultaneously. If assistant is not available, decompress first, then follow remainder of protocol.
If not in shock try to pass lubricated stomach tube marked at distance from nose to last rib. If unable to pass stomach tube, stand dog on rear legs and "bounce" up and down. if still unable to pass tube in sitting position, trocarize, if still unsuccessful take to surgery immediately after establishing IV and administering medication.
If not in shock or after decompression, take blood, urine, and xrays.
place IV catheter (multiple if needed for severe shock)
start IV LRS (50 cc/lb rapid IV infusion for first hour)
give corticosteroids (500 mg Soludelta cortef IV) for endotoxic shock
flunixin meglumine (one time 0.5 mg/lb IV) for endotoxic shock
gentamycin (1 mg/lb) or cephalothin sodium (10 mg/lb) in initial fluids
sodium bicarbonate (2 meq/lb in initial fluids) if suspect metabolic acidosis
metoclopramide (10 mg SQ) improves gastric emptying and antiemetic
ranitidine (1 mg/lb IV every 8 hours)
start ECG and cardiac medications (60 mg lidocaine in initial fluids) for expected arrhythmias, give additional lidocaine as needed (1 mg/lb IV bolus)
pass stomach tube and lavage stomach removing all content, give coative with simethicone. Take to surgery as soon as possible, particularly if digested blood or mucosal shreds are found in stomach content.
Monitor intensively for cardiac complications until surgery, usually within 4-6 hours, some surgeons prefer to wait until the next day. When stable, hopefully with cardiac signs normal, perform permanent abdominal wall gastropexy. Although patient is not as critical at this time, all precautions must be taken:
Add 60 mg of lidocaine to initial fluids
Induce anesthesia with Propofol, Numorphan, Ket/Val, etc. (no barbiturates or nitrous oxide)
Intubate and inflate cuff
Maintain on isoflurane or halothane 1-2 %
Lead 2 EKG monitoring
Careful on incising linea due to presence of distended stomach or spleen
If markedly distended, decompress stomach with 16-18 gauge needle and suction before trying to derotate.
Remember stomach usually rotates from right to left with pylorus passing ventrally to rest dorsally on left side above the cardia. Always determine position prior to derotation and be gentle, as stomach wall may be friable particularly on greater curvature near cardia. Standing on the right side of the patient in dorsal recumbency, reach across the stomach and elevate the pylorus while pushing the body of the stomach down and away from you, thereby reducing the usual clockwise rotation. If devitalized, excise and close with a 2-layer inverting pattern with 2-0 PDS. Try not to open stomach if it can be avoided.
have assistant pass stomach tube, empty and lavage stomach.
Inspect spleen for infraction or thrombosed vessels. Splenectomy if necessary. Always ligate close to spleen.
Permanent abdominal wall gastropexy (Circumcostal, belt loop, or muscle flap).
Inspect abdomen. Look for torsed intestinal mesenteries. Resect if necessary.
Standard abdominal closure.
Continue cardiac monitoring post operatively until fully recovered from anesthesia.
If lidocaine drip fails to control VPC's:
Give 3-10 mg/lb quinidine deep IM
Give 375 mg oral pronestyl every 6 hours
May need 500 mg oral Procan-S-R every 8 hours
If patient experiences tachycardia with rate over 200 bpm
Give 1/2 mg Inderal IV and monitor return to normal rate. Can repeat as needed up to 3 mg total dose.
NPO for 12 hours
Tepid water and warm ID gruel tid for 4-5 days, should eat within 24 hours, if not suspect ileus, possibly due to intussesception.
Canned ID or dry ID soaked in warm water
500 mg oral Keflex bid for 7 days
10 mg oral cisapride bid for 3 days (same effects as metoclopramide except not antiemetic plus stimulates motility in small and large intestine)
Antiarrhythmic drugs as needed tapered in 7-10 days
Recheck, including EKG in 7 days
Sutures out at 10-14 days
Feed 2-4 times daily
Soak dry kibble in hot water for 5-10 minutes prior to feeding
Limit exercise and water consumption for one hour after eating
Prophylactic gastropexy if relatives have been affected (disadvantage in trying to evaluate breeding potential)
Add simethicone to food
Current Techniques in Small Animal Surgery, 3rd ed.
Bograb, M. JosephLea and Febiger 1990
Dimensions in Surgery
Lippincott, Larry and Schulman,
Alan Surgical Case Report: Protocol for the Gastric Dilatation Volvulus Syndrome Pulse, Journal of the Southern California Veterinary Medical Association
Handbook of Small Animal Practice
Morgan, Rhea V.Churchill Livingstone 1988
New Yorkpp. 385-393
Pathophysiology in Small Animal Surgery
Bojrab, M. JosephLea & Febiger 1981
Small Animal Gastroenterology, 2nd ed.
Stombeck, Donald R. And Guilford, W.
GrantStonegate Publishing 1990 Davis Capp. 224-241
Textbook of Small Animal Surgery, Vol. 1
Slatter, Douglas H.W.B Saunders Co. 1985