Vol. 22, No.
11 November 2000
CE Refereed Peer Review
FOCAL POINT
★ Improved knowledge about
the pathophysiology of acute
gastric dilatation–volvulus (GDV)
and recent advances in critical
care services have led to more
successful treatment of this
condition in dogs.
KEY FACTS
■ Restoration of intravascular
volume deficits, gastric
decompression, and confirmation
of the diagnosis are the goals of
initial emergency GDV therapy.
■ Because a dilated stomach can
remain within the rib cage in
giant-breed dogs, abdominal
distention may not be seen.
■ Sedative and anesthetic protocols
that have minimal deleterious
effects on cardiovascular and
respiratory system functions
should be used in patients with
GDV.
■ Persistent hypotension,
hypovolemia, and hypoxia
secondary to the systemic
inflammatory response
syndrome are the most severe
complications of GDV and often
result in death.
Management Protocol
for Acute Gastric
Dilatation–Volvulus
Syndrome in Dogs
University of Pennsylvania
Daniel J. Brockman, BVSc
David E. Holt, BVSc
ABSTRACT: Canine acute gastric dilatation–volvulus (GDV) is a potentially catastrophic condi-
tion in which emergency medical and surgical therapy and intensive postoperative care are
needed to optimize the chance of a successful outcome. The events that precede an episode of
GDV vary. Clinical features of the disease include restlessness; retching; and abdominal dis-
tention, discomfort, and tympany. Initial patient evaluation and treatment should be aimed at
determining the degree of cardiovascular compromise and restoration of intravascular deficits
by intravenous fluid administration. Dogs with GDV should receive prompt surgical attention
to permit gastric decompression, removal of any devitalized tissue (e.g., stomach, spleen),
and gastropexy. Intensive postoperative care is essential for dogs recovering from surgery for
GDV. The majority of animals will recover without complications. Some animals, however, will
develop potentially life-threatening complications. Although GDV is a challenge to treat, a good
survival rate can be achieved.
G
astric dilation and gastric volvulus can occur independently,1,2 but to-
gether they represent a potentially catastrophic disease that is referred to
as the gastric dilatation–volvulus syndrome (GDV). GDV is most likely
a polygenic disease with strong phenotypic and environmental influences.3,4
Most episodes of GDV result from a single overwhelming factor or several com-
bined risk factors.5 Simultaneous gastric dilation and volvulus result in patho-
physiologic changes that create a medical and surgical emergency.6,7 Dogs with
GDV develop local and systemic consequences that result in hypovolemia, plac-
ing them at risk for gastric and splenic vascular compromise, focal and general-
ized bacterial infections, initiation and propagation of local and systemic inflam-
mation, disseminated intravascular coagulation, shock, and death.6–9
The overall incidence of GDV in dogs is low.5,8 This condition remains an im-
portant syndrome, however, because successful management requires intensive
emergency, surgical, and postoperative care. Despite what some consider optimal
medical management, the mortality rate for this syndrome can be as high as
Small Animal/Exotics
15% to 20%.8,9 Consequently, many treatment regi-
mens have been recommended and management of
GDV remains controversial. This article discusses a
practical and clinically proven protocol8 for the man-
agement of this condition. A companion article will ex-
plore the pathogenesis of GDV, including an examina-
tion of recent scientific and clinical literature.
HISTORY AND CLINICAL FEATURES
Gastric dilatation–volvulus syndrome occurs most
commonly in large or giant, deep-chested breeds3,4 of
dogs but has also been reported in small breeds.10 The
onset of clinical signs is typically peracute or acute. Ini-
tial signs include restlessness, hypersalivation, and
retching. These signs are usually followed by further
discomfort and gradual abdominal distention. Eventu-
ally, pain becomes evident, along with weakness and
abdominal tympany.
Physical examination findings reflect gastric dilation
and circulatory and respiratory compromise. Therefore,
a distended abdomen, tachycardia, poor peripheral
pulse quality, prolonged capillary refill time (CRT),
pale and dry mucous membranes, tachypnea, and dys-
pnea may occur depending on the duration and severi-
ty of the episode. Because a dilated stomach can remain
within the rib cage in giant-breed dogs, classical ab-
dominal distention may not be seen in these breeds.
MANAGEMENT OF GASTRIC
DILATATION–VOLVULUS
The therapeutic goals in cases of suspected acute
GDV are to restore and support the circulation, de-
compress the stomach, establish whether GDV or sim-
ple dilation is present, perform rapid surgical correction
if volvulus has occurred, and determine environmental
influences that may have triggered the condition.
Emergency Care
Management of hypovolemia—to prevent or treat
shock—is the primary goal of emergency treatment of
GDV. Two large-bore catheters (ideally 16 or 18 gauge)
should be placed in the cephalic or jugular veins. If a
facility for rapid results is available, a blood sample
should be taken for packed cell volume (PCV), serum
total protein (TP) estimation, and serum electrolyte
levels. Sufficient blood should also be drawn for subse-
quent performance of full serum chemistry, hematolog-
ic evaluation, and evaluation of coagulation parameters.
Fluid therapy should be started at a rate of 90 ml/kg/
hour using a balanced electrolyte solution. In giant-
breed dogs, a hypertonic saline–dextran combination
(7% sodium chloride in 6% dextran-70) administered
at 5 ml/kg over 5 minutes may provide more rapid ini-
HYPOVOLEMIA ■ FLUID THERAPY ■ DECOMPRESSION ■ OROGASTRIC INTUBATION
Compendium November 2000
tial circulatory resuscitation.11 Both the high-volume
crystalloid and low-volume hypertonic saline–dextran
fluid resuscitation protocols should be followed by
high-volume crystalloid administration (20 ml/kg/
hour) for maintenance of resuscitation. The decision to
introduce blood products or a synthetic colloid to pro-
vide further circulatory support and help improve oxy-
gen delivery to the tissue should be influenced by sub-
sequent PCV, TP, and circulatory stability estimations.
If available, a continuous electrocardiogram (ECG)
should be started or a baseline recording made.
Gastric decompression should only be attempted af-
ter correction of the intravascular volume deficit is well
under way. Close patient monitoring is essential. Fur-
ther delay of decompression could influence gastric
wall integrity and the amount of inflammatory media-
tors that are released from the splanchnic circulation.
Gastric decompression can usually be achieved by
orogastric intubation of the conscious or sedated ani-
mal. For sedation, a combination of fentanyl (2 to 4
µg/kg intravenously [IV]) or oxymorphone (0.1 mg/kg
IV) followed by diazepam (0.25 to 0.5 mg/kg IV) can
be used. A selection of smooth-surfaced equine naso-
gastric tubes with large end and side holes can be used.
The tube selected should be measured from the exter-
nal nares to the caudal edge of the last rib and marked.
The tube should not be inserted beyond this mark. A
bandage roll placed between the dog’s teeth can aid pas-
sage of the lubricated tube. If tube passage is not possi-
ble, the dog should be placed in a sitting position and
the tube gently rotated in a counterclockwise direction.
If orogastric intubation is still impossible, gastrocente-
sis—using a large-bore needle in the right or left para-
costal space at the site of greatest tympany—will usual-
ly facilitate orogastric intubation and avoid inadvertent
splenic damage. Routine aseptic technique should be
used.
The patient should be assessed frequently by collec-
tion and analysis of subjective and objective clinical data
(i.e., peripheral pulse pressure and quality, heart rate,
mucous membrane color, CRT, PCV and TP concen-
tration, degree of abdominal distention, ECG). To opti-
mize tissue perfusion and oxygen delivery, IV fluid type
and composition should be tailored to the patient’s
needs.
Radiography
Radiography is not necessary to diagnose gastric dila-
tion but is an invaluable aid in diagnosing volvulus.12,13
When considering the need for radiography, it is impor-
tant to remember that the easy passage of an orogastric
tube does not rule out volvulus. A lateral view of the cra-
nial abdomen taken with the animal in right lateral re-
Compendium November 2000 Small Animal/Exotics

cumbency is the initial exami- monitoring should be done

nation of choice. 12,13 If the during anesthesia. Intraopera-
diagnosis remains uncertain, tive fluids should remain at a
additional radiographs (e.g., high rate (10 to 20 ml/kg/hour)
ventrodorsal, left lateral) should to offset further deterioration
be obtained. The radiographic in hemodynamics during
features of GDV include a surgery. A catheter should be
large, dilated, gas-filled gastric placed in the urinary bladder
shadow, which may be divided and connected to a closed
into two compartments by the urine collection system. PCV
soft tissue of the lesser curva- and TP should be evaluated
ture and the proximal duode- intraoperatively at 30- to 60-
num, which courses caudally minute intervals. Again, IV
from the abnormally posi- fluid type and composition
tioned pylorus in the cran- should be tailored to the pa-
Figure 1—Right lateral radiograph of a dog with gastric dil-
iodorsal quadrant of the ab- tient’s needs in an attempt to
atation–volvulus. The gastric shadow is dilated with gas
domen (Figure 1). If stomach and divided into dorsal (malpositioned pylorus) and ven- ensure adequate tissue perfu-
rotation is not severe, the ab- tral (fundus and corpus) compartments by soft tissue of sion and oxygen delivery by
normal position of the pylorus the folded lesser curvature of the stomach wall. There is maintaining a mean arterial
(dorsal and to the left of the generalized intestinal dilation, suggesting ileus. The metal- blood pressure above 65 mm
fundus) is diagnostically help- dense objects seen on this radiograph are the surgical sta- Hg and a hematocrit at or
ful, although the pylorus may ples that remain in the peritoneal cavity following splenec- above 25% to 30%.
not be visible on left lateral ra- tomy, performed 6 months before this episode.
diographs. Splenic enlarge- Surgical Therapy
ment and malposition may be The immediate aim of sur-
evident. Gas within the gastric wall may indicate gastric gery is to return the stomach to its normal position and
wall compromise; if gastric rupture has occurred, free gas evaluate it and the spleen for signs of irreversible vascu-
will be present in the abdominal cavity. lar compromise. Any necrotic portions of stomach and
spleen should be removed and the stomach emptied com-
Anesthesia pletely. Finally, a gastropexy should be performed in an
In practice situations, the choice of anesthetic agents attempt to prevent recurrence of the volvulus.
may be limited. If the previously mentioned sedative Following routine aseptic preparation, a cranioventral
combination has been used preoperatively, endotracheal midline laparotomy should be performed. The stomach
intubation may be achieved after another IV infusion is usually immediately visible and covered by greater
of the same cocktail. The inclusion of IV lidocaine (2 omentum when a clockwise volvulus of 180˚ to 270˚
mg/kg) into the induction protocol will help desensitize has occurred. At this stage, gastric decompression will
the larynx and facilitate endotracheal intubation as well help subsequent manipulation and relocation of the
as enhance the overall state of anesthesia. In addition, if stomach. This can be achieved intraoperatively by nee-
a different induction agent is to be used, the quantity dle gastrocentesis if the stomach is still tightly distend-
required will be reduced because of residual effects of ed. Alternatively, for a less distended stomach, an assis-
the sedative. Circulatory compromise will influence the tant (with the intraoperative guidance of the surgeon)
speed and efficiency of drug distribution. Because IV can gently place an orogastric tube. After decompres-
access should already be established, small amounts of sion, the pylorus should be identified and grasped gen-
induction agent should be given to effect. Maintenance tly with the hand. If the gastric rotation is in a clock-
should be with halothane or isoflurane and oxygen. Ni- wise direction, downward pressure on the right side of
trous oxide should not be introduced until permanent the visible portion of the stomach along with gentle
gastric decompression is achieved. traction on the pylorus will aid counterclockwise rota-
The placement of additional IV and intraarterial tion. The spleen should follow passively. Systematic
catheters in the pelvic limbs following the induction of evaluation of the abdomen should then be performed.
anesthesia will facilitate intraoperative blood pressure Hemoperitoneum often results from avulsion of the
monitoring and the addition of blood products (e.g., to short gastric branches of the splenic arteries. Active sites
the intraoperative fluid therapy regimen). Continuous of hemorrhage should be identified and ligated. Careful
ECG and continuous or intermittent blood pressure inspection of the stomach and spleen should be per-

PROXIMAL DUODENUM ■ SPLEEN ■ GASTROPEXY ■ LAPAROTOMY

Small Animal/Exotics Compendium November 2000

formed. If all organs look The cardia or the abdominal

grossly normal, an assistant esophagus will occasionally
should lavage the stomach us- become necrotic secondary to
ing clean, warm water via the longstanding or severe twist-
orogastric tube. ing; therefore, this area should
The junction between the be examined carefully. Resec-
fundus and body along the tion of the abdominal esopha-
greater curvature of the stom- gus and gastric cardia can be
ach is the most common site technically demanding, and
of gastric necrosis following the outcome following such a
GDV.14 Evaluation of tissue resection, even in healthy ani-
blood flow remains subjec- mals, is unknown. Because
tive; however, gentle palpa- necrosis at this site is usually
Figure 2—Partial gastric resection using stapling equip-
tion for pulsation in the gas- seen in animals that are already
ment. The stomach has undergone spontaneous perfor-
tric and splenic vessels can be ation. The demarcation between viable and nonviable severely compromised, the
helpful. If the serosal surface tissue (blackened area being removed) is clear. Despite prognosis for recovery is poor.
is either torn, gray–green, or successful partial gastric resection, this patient subse- The spleen can sustain vas-
black 10 minutes after ana- quently died of systemic inflammatory disease. cular damage or occlusion
tomic reduction of the stom- following GDV. The spleen
ach, ischemia should be sus- and associated vasculature
pected and subsequent tissue should, therefore, be carefully
necrosis anticipated (Figure evaluated for the presence of
2). In these situations, resec- thrombi and irreversible vas-
tion of the affected portion of cular compromise. Any devi-
the stomach should be per- talized portion of splenic tis-
formed. It may be difficult to sue should be resected either
determine how much of the by hand or using a surgical
stomach to remove. A full- stapling device (Figure 3). If
thickness gastric wall resec- the spleen has undergone tor-
tion is carried out until the sion around its pedicle, sple-
cut edges are actively bleeding nectomy should be performed
to ensure healing without fur- before reducing the twist to
ther necrosis. Figure 3—Partial splenic infarction in a patient with gastric lessen the risk of releasing tox-
Closure of the stomach fol- dilatation–volvulus. The demarcation between viable and ins, myocardial active sub-
lowing partial resection should nonviable splenic tissue is indicated by a color change. The stances, and thromboemboli
be in two or three layers. A vascular pedicle at the ventral extremity of the spleen is into the systemic circulation.
simple continuous suture pat- torn and partially avulsed from the hilus. Partial splenecto- A gastropexy should be per-
tern in the submucosa should my was performed, and the dog recovered. formed.16–20 Tube gastropexy is
be followed by a simple inter- easy to perform, creates strong
rupted pattern in the muscularis and serosa. Oversewing adhesions, and has the additional advantage of provid-
the suture line with a continuous or interrupted invert- ing enteral access.20 A large (24 or 26 gauge) Foley or
ing pattern (e.g., Cushing, Lembert) can reinforce this Pezzer’s urologic catheter is placed through a stab inci-
closure. Polydioxanone, polyglactin 910, polyglycolic sion in the body wall approximately 2 cm lateral to the
acid and polyglyconate are all suitable suture materials. ventral midline and 2 cm caudal to the last rib on the
Alternatively, surgical stapling devices can be used to per- right side. The catheter is then passed through a loop of
form partial gastric resection. The use of a GI anastomo- omentum and into the stomach via a purse-string suture
sis instrument (GIA-50, US Surgical, Norwalk, CT) has through a small incision in the pyloric antrum. The bal-
been described for this purpose15; however, we prefer to loon on the Foley catheter is then inflated but kept away
use a thoracoabdominal stapler (TA-90, US Surgical) from the stomach wall to avoid inadvertent puncture
with a 4.8-mm (green) staple cartridge. Again, this clo- while pexy sutures of polypropylene are preplaced
sure should be reinforced using a continuous or inter- around the abdominal and gastric wall incisions in an
rupted Cushing or Lembert inverting pattern to oversew overlapping mattress pattern. The sutures are then tied
the staple line. and the balloon or mushroom tip drawn up to the

NECROSIS ■ PARTIAL GASTRIC RESECTION ■ FOLEY CATHETER

Small Animal/Exotics Compendium November 2000

be kept clean and protected by a bandage. After

removal of the tube, the gastrostomy is left to
heal by second intention. Clients should be in-
formed of the signs of recurrence and encour-
aged to seek veterinary attention as soon as pos-
sible if these signs occur.
Figure 4—Electrocardiogram (top) and direct arterial pressure trace (bottom)
from a 5-year-old spayed Great Dane recovering from gastric dilatation– POSTOPERATIVE COMPLICATIONS
volvulus, 1 day after surgery. During the early (rapid) phase of this multi- Persistent hypotension may be suspected if
form ventricular tachycardia, there is disparity between the ventricular de- peripheral pulse quality is poor, tachycardia and
polarization and ejection rates. The pulses formed, however, are strong and poor CRT are evident, and urine output is low.
adequate. This arrhythmia does not require treatment if all other aspects of This hypotension is usually caused by hypo-
patient care are appropriately managed. volemia secondary to inadequate fluid therapy
following surgery. Hypotension may also devel-
stomach wall and the tube is secured with either a Chi- op if the IV crystalloid fluid therapy is failing because of
nese finger trap suture or tape tabs sutured to the skin. inadequate primary surgical hemostasis, subsequent
Alternatively, an incisional gastropexy is simple and whole blood deficits, reduced colloid osmotic pressure,
effective.21 With this technique, a 5-cm seromuscular or abnormal body fluid distribution. Occasionally, hy-
incision is made in the pyloric antrum, and a matching potension in post-GDV surgery patients is caused by
incision is made in the parietal peritoneum and trans- poor cardiac function. If PCV and TP levels reveal
verse abdominal muscle, just caudal to the 13th rib on hemoconcentration, a return to high-volume, rapid
the right body wall. The edges of the gastric wall inci- crystalloid infusion may be necessary for a short time
sion are sutured to the edges of the body wall incision (i.e., 1 hour at 90 ml/kg) followed by a return to 10 to
using either polydioxanone or polypropylene. Care 15 ml/kg/hour. If PCV or TP is low, blood products or
must be taken not to penetrate the gastric lumen. synthetic colloid should be administered to correct the
Closure of the abdominal incision is routine. A ban- deficit(s). The patient should be reevaluated frequently
dage is placed around the abdomen to protect a gas- following any change in fluid therapy.
tropexy tube. Cardiac arrhythmias are common following an acute
episode of GDV.8,9,24 They are usually ventricular in ori-
Postoperative Care gin and range from intermittent ventricular premature
Fluid therapy should be maintained at a rate of 8 to conductions to sustained ventricular tachycardia. Supra-
10 ml/kg/hour using a balanced electrolyte solution for ventricular abnormalities (e.g., atrial fibrillation) are oc-
the first 24 hours. Systemic administration of opioid casionally seen.9,25 Cardiac arrhythmias may need to be
analgesics (e.g., intramuscular morphine at 0.5 mg/kg treated if they are associated with primary heart disease
every 4 to 6 hours) will reduce postoperative discom- (e.g., dilated cardiomyopathy) or if there is evidence of
fort and facilitate recovery. During this period, it is use- poor cardiac performance. If continuous ECG and si-
ful to monitor PCV and TP intermittently; peripheral multaneous blood pressure monitoring are available, a
pulse quality, mucous membrane color, and urine out- decision about cardiac function with regard to arrhyth-
put should also be monitored. Again, continuous ECG mia is relatively easy (Figure 4). An attempt to abolish a
should be used if available or intermittent records cardiac arrhythmia that is associated with hypotension
made. The stomach tube, if present, should be vented using antiarrhythmic drugs is considered only if acid–
as needed. Nothing should be given by mouth. base and electrolyte imbalances have been corrected
If complications do not occur, water can be offered and intravascular volume replenishment is adequate.
the second day after surgery and the IV fluid rate re- The most common complications of tube gastropexy
duced to 4 ml/kg/hour. Patient comfort level should be are local cellulitis caused by leakage of gastric contents
assessed and additional analgesia provided as needed. around the tube or premature tube dislodgment.18 Occa-
Small amounts of food can be offered by the end of the sionally, the balloon of a Foley catheter can be eroded by
second postoperative day. Animals that have undergone the acidic gastric fluid, causing early loosening of the
partial gastrectomy may take longer to regain normal tube. Usually this occurs after 5 to 7 days, as the animal
gastric motility. IV metoclopramide (1 to 2 mg/kg/day) becomes more active, and will spontaneously resolve. If
or low-dose oral erythromycin (0.5 to 1.0 mg/kg every it occurs in the first 48 hours, the risk of peritonitis sec-
8 hours oral) might be beneficial.22,23 The gastropexy ondary to leakage of gastric contents mandates tube re-
tube should remain in place for 7 to 10 days. It should placement with the patient under general anesthesia.

HYPOTENSION ■ CRYSTALLOID INFUSION ■ CARDIAC ARRHYTHMIAS

Compendium November 2000 Small Animal/Exotics

Your comprehensive
Preoperative retching and vomiting, and postopera-
tive esophagitis and regurgitation put these animals at guide to diagnostic
risk for aspiration pneumonia.8 Alterations in breathing
rate and pattern coupled with crackles and wheezes on ultrasonography
thoracic auscultation are suggestive of pneumonia.
Thoracic radiography, arterial blood gas evaluation, and Nautrup and Tobias
tracheal/bronchoalveolar wash fluid cytology and cul-
ture will help confirm this diagnosis. Treatment with
the appropriate antibiotic(s), local fluid therapy (nebu-
lization), thoracic coupage, supplemental oxygen, and
frequent short periods of exercise should aid recovery.
Gastric necrosis and perforation can occur up to 5
days after surgery, especially if resection was performed
and despite careful intraoperative assessment of gastric
wall viability.14,15 Although this complication may be
difficult to confirm without surgical exploration of the
abdomen, it may be suspected on the basis of clinical
progression of disease, radiographic and ultrasono-
graphic findings, and cytologic evaluation of peritoneal
fluid. Treatment is by debridement and repair of the
gastric wall defect followed by continued intensive sup- New
portive care. If gastric necrosis and perforation occur,
the prognosis is grave.
Persistent ongoing hypotension, despite appropriate
fluid therapy, is a serious concern. Serum electrolyte
concentrations (i.e., sodium, potassium, chloride, mag-
nesium, calcium) should be measured, coagulation pa-
rameters assessed, acid–base status evaluated, and blood
$
149
Robert E. Cartee, Editor
gas levels determined before further altering therapy.
Electrolyte abnormalities should be corrected. An ab-
400 pages, hard cover
normal hemostatic profile or a clinical bleeding tenden- 1597 illustrations
cy should be interpreted as evidence of disseminated in-
travascular coagulation. Replacement of consumed ■ Sonographic diagnosis in dogs and cats,
coagulation factors using fresh-frozen plasma should be including ultrasound, M-mode, pulsed
considered in addition to continued therapy for the un-
and color Doppler echography
derlying cause of shock.
Hypoxemia may occur secondary to pneumonia or ■ Echocardiography, abdominal and pelvic
pulmonary edema. Pulmonary edema may develop sec- sonography, and fetal ultrasonography
ondary to overzealous IV fluid administration, primary
cardiac dysfunction, or reduced colloid osmotic pres- ■ Case illustrations using conventional
sure or following acute lung injury as a component of radiography, computed microfocal
the systemic inflammatory response syndrome. In turn,
tomography, specimen photography,
the systemic inflammatory response syndrome can be
triggered by several factors, including endotoxemia, and line drawings
organ reperfusion injury, and local inflammatory con- ■ Recognition of the disease process and
ditions (e.g., peritonitis, pneumonia, pancreatitis).
Thoracic and abdominal radiography, cardiac and ab- courses of treatment
dominal ultrasonography, abdominocentesis, tracheal/
bronchoalveolar wash sample cytology and culture, and
further hematologic and serum chemistry evaluation CALL OR FAX TODAY TO ORDER
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THORACIC RADIOGRAPHY ■ GASTRIC WALL

Small Animal/Exotics
plications in which systemic inflammation is suspected
are poor prognostic signs. Therapy for such patients
may include oxygen supplementation and ventilator-as-
sisted breathing as well as continued intensive circula-
tory support. The prognosis for animals with these
complications is poor.
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Compendium November 2000
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About the Authors
When this article was submitted for publication, Drs.
Brockman and Holt were affiliated with the Department of
Clinical Sciences and the Center for Veterinary Critical
Care, School of Veterinary Medicine, University of Penn-
sylvania, Philadelphia. Dr. Brockman is now affiliated with
the Department of Small Animal Medicine and Surgery,
The Royal Veterinary College, University of London. Both
are Diplomates of the American College of Veterinary
Surgeons. Dr. Brockman is also a Diplomate of the Euro-
pean College of Veterinary Surgeons.