PAPER

Journal of Small Animal Practice Vol 54 February 2013 2013 British Small Animal Veterinary Association 75

Journal of Small Animal Practice (2013) 54, 7579
DOI: 10.1111/jsap.12019
Accepted: 26 November 2012
Assessment of two methods
of gastric decompression
for the initial management
of gastric dilatation-volvulus
Z. J. Goodrich, L. L. Powell and K. J. Hulting
College of Veterinary Medicine, University of Minnesota, St. Paul, MN 55801, USA
Dr. Z. J.Goodrichs current address is Texas A&M University, College of Veterinary Medicine, College Station, TX 77843, USA
OBJECTIVE: To assess gastric trocarization and orogastric tubing as a means of gastric decompression
for the initial management of gastric dilatation-volvulus.
METHODS: Retrospective review of 116 gastric dilatation-volvulus cases from June 2001 to October
2009.
RESULTS: Decompression was performed via orogastric tubing in 31 dogs, gastric trocarization in 39
dogs and a combination of both in 46 dogs. Tubing was successful in 59 (755%) dogs and unsuccess-
ful in 18 (234%) dogs. Trocarization was successful in 73 (86%) dogs and unsuccessful in 12 (14%)
dogs. No evidence of gastric perforation was noted at surgery in dogs undergoing either technique.
One dog that underwent trocarization had a splenic laceration identified at surgery that did not require
treatment. Oesophageal rupture or aspiration pneumonia was not identified in any dog during hospital-
ization. No statistical difference was found between the method of gastric decompression and gastric
compromise requiring surgical intervention or survival to discharge.
CLINICAL SIGNIFICANCE: Orogastric tubing and gastric trocarization are associated with low complication
and high success rates. Either technique is an acceptable method for gastric decompression in dogs
with gastric dilatation-volvulus.
INTRODUCTION
Gastric dilatation-volvulus (GDV) is a condition most commonly
seen in large, deep-chested dogs. Mortality rates range from 6 to
16% (Beck et al. 2006, Mackenzie et al. 2010). Typical clinical
signs in dogs presenting with GDV include non-productive vom-
iting, abdominal distension and/or collapse (Rasmussen 2003).
After a presumptive diagnosis of GDV, management is initially
aimed at intravenous fluid resuscitation and gastric decompres-
sion. Gastric distension leads to increased intra-abdominal pres-
sure, which results in compression of the caudal vena cava, portal
vein and splanchnic vasculature. This gives rise to poor venous
return and splanchnic pooling, which causes a reduction in
preload and ultimately a decrease in cardiac output and systemic
blood pressure (Rasmussen 2003, Baltzer et al. 2006). Aggressive
intravenous fluid therapy using both crystalloids and colloids is
utilized to stabilize systemic blood pressure and improve tissue
perfusion and oxygenation.
Once vascular access has been established and fluid resusci-
tation initiated, gastric decompression is performed. Described
techniques of gastric decompression include orogastric tubing
and gastric trocarization (Hedlund & Fossum 2007). Once gas-
tric distension is relieved and intra-abdominal pressure decreas-
es, venous return to the heart improves and cardiac output is
expected to improve.
There are advantages and disadvantages of the two main types
of gastric decompression procedures. Gastric trocarization is
faster to perform than orogastric tubing and, because sedation is
not required for this procedure, it may be a better choice for the
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Z. J. Goodrich et al.
76 Journal of Small Animal Practice Vol 54 February 2013 2013 British Small Animal Veterinary Association

tube and the gavage was allowed to drain. To safely perform this
procedure in the alert animal, sedation (typically a combination
of a benzodiazepine and opioid) was administered intramuscu-
larly or intravenously to facilitate passage of the orogastric tube.
The decision on which method of gastric decompression to
perform first was based on clinician preference, and was not stan-
dardized between cases.
Statistical analysis was performed using chi-squared analysis
(JMP version 8.0.2). Comparisons were made to determine if
statistically significant associations existed between the method
of gastric decompression and gastric compromise treated with
surgical intervention and overall survival. A P-value of less than
005 was considered statistically significant.
RESULTS
The 116 dogs included in this study consisted of 18 German
shepherds (155%); 14 great Danes (121%); 11 standard poodles
(95%); 10 Labrador retrievers (86%); 9 Saint Bernards (78%);
6 golden retrievers (52%); 5 Rottweilers (43%); 4 each of aki-
tas, Bernese mountain dogs, Dobermann and Samoyeds (34%
each); 3 mixed breeds (26%); 2 each of boxers, Chesapeake
Bay retrievers, greyhounds, malamutes, Newfoundlands and
Weimaraners (17% each); and 1 each of basset hound, borzoi,
collie, Dogue de Bordeaux, English setter, English springer span-
iel, Gordon setter, mastiff, old English sheepdog, otterhound,
Hungarian vizsla, and German wirehaired pointer (086% each).
Median age of all dogs at the time of presentation was 75
years (range, 06-156 years). There were 70 (603%) males and
46 (397%) females. Of the 70 males, 61 (871%) were neutered
and 9 (129%) were intact. Of the 46 females, 39 (848%) were
spayed and 7 (152%) were intact. Median weight was 39 kg
(range, 195-80 kg). Median length of hospitalization was 1 day
(range, 1-6 days). One hundred eleven dogs (957%) survived to
discharge, while 5 (43%) dogs did not.
Of the 75 dogs in which the degree of volvulus at the time
of surgery was recorded, three dogs (4%) had a 90 volvulus, 46
(613%) had a 180 volvulus, 16 (213%) had a 270 volvulus, 3
(4%) had a 360 volvulus, 1 (13%) had a 540 volvulus and in
6 (8%) dogs no volvulus was noted at the time of surgery. The
degree of volvulus in the remaining 41 dogs was not noted in the
medical record.
Of 116 dogs, orogastric tubing was performed in 31 (27%),
gastric trocarization in 39 (34%) and a combination of both
techniques in 46 (40%). For those dogs undergoing both proce-
dures, the decision of which procedure to perform first was not
standardized and was based on clinician preference.
General anaesthesia was not needed in any dog in order to
pass an orogastric tube. Sedation was used in 47 of 77 dogs to
facilitate passage of the orogastric tube. Orogastric tubing was
successful in 59 (766%) dogs and unsuccessful in 18 (234%)
dogs. Success was defined as passage of the tube into the stomach
with visualization of gastric contents in the tube. Of the 18 cases
in which tubing was unsuccessful, 2 cases were diagnosed with
a severe volvulus, 9 with a moderate volvulus and in 7 cases the
haemodynamically unstable patient. However, gastric trocariza-
tion does not allow the evacuation of stomach contents (fluid,
food and other particles) or gastric lavage, as can be carried out
with orogastric tubing.
To the authors knowledge, there is no study assessing these
two methods of gastric decompression for initial management of
GDV. The objectives of this study were to report the effective-
ness of orogastric tubing and gastric trocarization, to report their
complications, and to investigate any differences in complication
rate between the two methods.
MATERIALS AND METHODS
Records of 116 confirmed cases of GDV were retrospectively
reviewed. The electronic medical record database (University
Veterinary Information System, Version 4.0) at the University
of Minnesota Veterinary Medical Center (UMN-VMC) was
searched for all dogs diagnosed with GDV from June 2001 to
October 2009. Cases were included if GDV was diagnosed via
a right lateral abdominal radiograph, the method of preopera-
tive gastric decompression was noted, and definitive surgical cor-
rection was performed at the UMN-VMC. Cases were excluded
from analysis if the method of preoperative gastric decompres-
sion was not noted in the medical record.
The medical records were evaluated for the following crite-
ria: signalment, method of preoperative gastric decompression,
degree of volvulus noted in surgery, splenic laceration, splenec-
tomy, gastric compromise treated with surgical intervention,
presence of gastric perforation, aspiration pneumonia, oesopha-
geal rupture, length of hospitalization and survival to discharge.
Gastric compromise was defined as the status of the gastric wall
noted at time of surgery and surgical intervention included either
partial gastrectomy or gastric invagination. Degree of volvulus
was divided into the following categories: none (volvulus not
observed at the time of surgery), moderate (90, 180 or 270
of volvulus) or severe (360 or 540 of volvulus). The degree of
volvulus was determined intra-operatively via direct visualization
and was based on the amount of de-rotation needed to return the
stomach to a normal anatomical position. Aspiration pneumonia
was defined as those dogs with a radiographic diagnosis of the
disease.
Gastric trocarization or orogastric tubing was performed as
previously described (Rasmussen 2003). Briefly, gastric trocariza-
tion was performed using a 14 gauge, over-the-needle intravenous
catheter (BD Angiocath). The catheter was inserted through the
aseptically prepared skin, at the area of greatest abdominal disten-
sion, and into the stomach. Lateral pressure was applied to the
abdomen to facilitate evacuation of gas from the stomach.
Orogastric tubing was performed using a large-bore, silicone,
orogastric tube. A roll of 75 cm white medical tape (3M) was
used as a mouth gag in all dogs before passing the tube. Tube
length was measured from the tip of the nose to the last rib; the
tube was lubricated with a water-soluble lubricant (Surgilube;
Fougera Pharmaceuticals) and passed through the roll of tape
and into the stomach. In all dogs, water was instilled through the
Journal of Small Animal Practice Vol 54 February 2013 2013 British Small Animal Veterinary Association 77
Gastric decompression for GDV

tubing and gastric trocarization in two dogs (Table 1). All these
dogs were diagnosed with disseminated intravascular coagulation
(DIC) before death.
Splenic laceration, gastric perforation or aspiration pneumo-
nia did not occur in any of the dogs that underwent orogastric
tubing. One dog that underwent gastric trocarization was diag-
nosed with a splenic laceration. Otherwise no dogs that under-
went gastric trocarization were diagnosed with gastric perforation
or aspiration pneumonia.
No significant difference was found between the method of
gastric decompression and gastric compromise requiring surgical
intervention (
2
=08, P=068) or survival to discharge (
2
=038,
P=083).
DISCUSSION
There are no published veterinary studies investigating the risks
of gastric trocarization. In theory, gastric trocarization could
cause splenic laceration and/or gastric perforation leading to
leakage of gastric contents. Of the eight dogs in this study in
which a splenectomy was performed, none had evidence of
splenic laceration. All splenectomies were performed because of
the presence of vascular thrombi and resulting splenic ischaemia
that was noted during surgery. In the one case in which a splenic
laceration was noted at the time of surgery, splenectomy was
not performed. In that case, gastric trocarization was performed
bilaterally. It is unknown whether the splenic laceration occurred
when gastric trocarization was performed on the left side, and the
spleen was positioned normally, or when gastric trocarization was
performed on the right side and the spleen was malpositioned.
If gastric trocarization is performed, it may be advisable to use
ultrasound guidance to identify the location of the spleen before
the procedure. While gastric perforation causing leakage of gas-
tric contents was not noted in our study, the possibility of this
complication remains.
Gastric trocarization was successful in the majority of cases but
was unsuccessful in a few. The possible reasons for an unsuccess-
ful outcome after gastric trocarization in this study include too
small a catheter (in length or gauge), the absence of a significant
amount of gas in the stomach or a failure to place the catheter
into the stomach. Given the retrospective nature of this study,
it is not possible to definitively state why gastric trocarization
was unsuccessful in some cases. A prospective study investigating
these possibilities is needed to determine the exact cause of failure
of gastric trocarization.
Orogastric tubing in humans can be associated with aspira-
tion pneumonia, oesophageal necrosis, oesophageal perforation
and/or gastric perforation (Hafner et al. 1961). In theory, these
risks also exist in veterinary patients. In the dogs undergoing oro-
gastric tubing in this study, no instances of oesophageal or gastric
perforation were noted at the time of surgery. In four of these
cases, gastric necrosis was noted at the time of surgery. A diagno-
sis of necrosis was made based on abnormal serosal surface colour
and palpation. In areas of necrosis, where the gastric wall is more
friable, it is possible that perforation could occur with contact of
degree of volvulus was not listed in the medical record. Other
than inability to pass the tube, no complications during orogas-
tric tubing were encountered during tube passage or subsequent
gavage. No dogs that underwent orogastric tubing were diag-
nosed with or developed clinical signs of aspiration pneumonia
or oesophageal perforation while hospitalized.
No sedation was required for dogs undergoing gastric troc-
arization only. Trocarization was successful in 73 (86%) dogs and
unsuccessful in 12 (14%) dogs. Success was defined as the passage
of gas through the catheter. Gastric trocarization was performed
on the left side in 13 dogs, on the right side in 4 dogs, bilaterally
in 5 dogs and in 61 dogs the side of gastric trocarization was not
listed in the medical record. No evidence of gastric leakage into
the abdomen was noted at surgery in any dog undergoing gastric
trocarization. Splenic laceration occurred in 1 of 85 (12%) dogs
in which gastric trocarization was performed; however, the dog
did not require subsequent splenectomy. In that case, gastric tro-
carization was performed bilaterally.
Splenectomy was performed in 8 of 116 (69%) dogs. Sple-
nectomy was performed if vascular thrombi in the splenic ves-
sels were noted, or if the spleen had obvious signs of ischaemia
that did not resolve after gastric de-rotation and decompression.
Of those dogs requiring splenectomy, orogastric tubing was per-
formed in one, gastric trocarization in three and a combination
of orogastric tubing and gastric trocarization in four dogs. Of the
seven dogs undergoing gastric trocarization, the side of gastric
trocarization was not listed in the medical record.
Gastric perforation was not noted in any dog undergoing oro-
gastric tubing or gastric trocarization. Gastric compromise that
required surgical intervention was seen in 13 of 116 dogs. Gas-
tric necrosis was noted in four of these dogs, while severe gastric
hyperaemia was noted in the other nine dogs. Of those 13 dogs
with gastric compromise, orogastric tubing was performed in 4,
gastric trocarization in 3, and a combination of orogastric tubing
and gastric trocarization in 6 dogs (Table 1). Gastric resection or
invagination was performed if gastric necrosis was present, or if
severe gastric hyperaemia was present and the surgeon deemed it
likely that the area of hyperaemia may progress to necrosis.
Median length of hospitalization of dogs undergoing orogas-
tric tubing, gastric trocarization, or a combination of orogastric
tubing and gastric trocarization was 1 day (range, 1-6 days), 2
days (range, 1-5 days) and 1 day (range, 1-6 days), respectively.
Five dogs (43%) did not survive to discharge from the hos-
pital. Of those dogs, orogastric tubing was performed in two,
gastric trocarization in one and a combination of orogastric
Table 1. Association between the method of gastric
decompression and resulting gastric compromise and
survival to discharge
Method of gastric
decompression
Gastric compromise Survived to discharge
Yes No Yes No
Orogastric tubing 4 27 29 2
Gastric trocarization 3 36 38 1
Both 6 40 44 2
There was no significant difference between any groups (P > 005)
Z. J. Goodrich et al.
78 Journal of Small Animal Practice Vol 54 February 2013 2013 British Small Animal Veterinary Association

available, most notably the degree of gastric volvulus and the
location of gastric trocarization. Follow-up of the cases was not
performed, and therefore the medical records were only reviewed
for information gathered until survival to or death before hospi-
tal discharge.
A further limitation is that the method of gastric decompres-
sion and the order in which they were performed was not stan-
dardized and instead based on clinician preference. Without a
standardized protocol for gastric decompression, there is the pos-
sibility of bias in selecting cases to perform one method over the
other. In this study, approximately 40% of the cases underwent
both gastric trocarization and orogastric tubing. Because both
techniques were utilized in these cases, it reduces the number of
cases available for direct comparison between the two techniques
and decreases the overall power of the study.
The final limitation is that survival to discharge is influenced
by other factors not evaluated in this study. One such factor is
haemodynamic stability and the response to intravenous fluid
resuscitation. Two recent studies have shown that a decrease in
plasma lactate concentration in response to intravenous fluid
therapy can be predictive of survival in dogs with GDV (Zacher
et al. 2010, Green et al. 2011). Because of the retrospective nature
of this study and that the manner of fluid resuscitation was not
standardized between cases, it was not possible to investigate the
effect the method of gastric decompression had on the haemody-
namic status of the patient. Also, given that these patients present
in varying degrees of hypovolaemic shock, it would be difficult
to draw conclusions as to whether it was the method of gastric
decompression that improved the haemodynamic status of the
patient or if the improvement was simply a response to intrave-
nous fluid therapy.
In conclusion, this study found minimal complication rates
and high success rates of two methods of gastric decompression
in this population of dogs presenting with GDV. Gastric troc-
arization, however, did not require sedation when compared to
orogastric tubing, which may make it a better option for gas-
tric decompression, especially in the haemodynamically unstable
patient. Further prospective studies are required to determine if
the method of gastric decompression affects short- and long-term
mortality rates or the haemodynamic status of the patient.
Conflict of interest
None of the authors of this article has a financial or personal
relationship with other people or organisations that could inap-
propriately influence or bias the content of the paper.
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gastric necrosis was present underwent orogastric tubing during
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was able to partially de-rotate. This theory is supported by the cur-
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of surgery. All these dogs were diagnosed with a GDV via radiogra-
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to pass the orogastric tube in the seven cases in which the degree of
volvulus was not listed in the medical record.
In this study, gastric trocarization and orogastric tubing were
associated with low complication rates and high success rates.
While neither procedure required general anaesthesia, over half
of the dogs undergoing orogastric tubing required sedation before
the procedure, while none required sedation before gastric troc-
arization. In instances of the haemodynamically unstable patient,
sedation may not always be safe, and a procedure that can be
done without sedation may be preferred. Furthermore, while not
seen in this study, the risk of aspiration pneumonia secondary
to orogastric tubing is still theoretically possible. Whether sedat-
ed or not, those patients undergoing orogastric tubing are not
intubated, and thus their airway is not protected. If any gastric
contents leak from the orogastric tube or are expelled from the
stomach around the tube, it is possible aspiration would occur.
It could be argued that the risk of splenic laceration is a reason
to avoid gastric trocarization. Even if splenic laceration occurs
it may not cause a clinically significant problem to the patient
(as evidenced by the dog in this study in which a splenic lac-
eration occurred but splenectomy was not required) or if it does
(i.e. persistent haemorrhage from the spleen) that the patient will
be undergoing immediate surgery for correction of the GDV, at
which time the haemorrhage can be stopped.
It is acknowledged that there are limitations to this study,
including its retrospective nature. Cases were included if GDV
was confirmed with radiography and the method of gastric
decompression was noted. In some cases, the medical records
were incomplete and further required information was not
Journal of Small Animal Practice Vol 54 February 2013 2013 British Small Animal Veterinary Association 79
Gastric decompression for GDV

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