Gastric Dilatation Volvulus (GDV)

In this episode of Current Vet, Dr. Lottie talks about gastric dilatation volvulus, why the condition is an EMERGENCY, the key clinical signs to recognise and how to treat these cases when they present.

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Timeline:
00:00 Intro
00:34 Case
01:55 Aetiology & Pathogenesis
05:49 Clinical Signs
06:37 Diagnosis
08:08 Treatment
12:51 Prevention
13:43 Key Points
14:56 Outro

References

• Mazzaferro, E.M. and Monnet, E. (2023) ‘Gastric Dilatation Volvulus’, Small Animal Soft Tissue Surgery. John Wiley & Sons, Ltd, pp. 53–74. Available at: https://doi.org/10.1002/9781119693741.ch7.
• Williams, J.M. (2016) ‘Gastric dilatation-volvulus’, Companion Animal, 21(3), pp. 178–185. Available at: https://doi.org/10.12968/coan.2016.21.3.178.
• Zacher, L.A. et al. (2010) ‘Association between outcome and changes in plasma lactate concentration during presurgical treatment in dogs with gastric dilatation-volvulus: 64 cases (2002–2008)’, Journal of the American Veterinary Medical Association, 236(8), pp. 892–897. Available at: https://doi.org/10.2460/javma.236.8.892.
• Ullmann, B. et al. (2016) ‘Gastric dilatation volvulus: a retrospective study of 203 dogs with ventral midline gastropexy’, Journal of Small Animal Practice, 57(1), pp. 18–22. Available at: https://doi.org/10.1111/jsap.12406.
• Mackenzie, G. et al. (2010) ‘A Retrospective Study of Factors Influencing Survival Following Surgery for Gastric Dilatation-Volvulus Syndrome in 306 Dogs’, Journal of the American Animal Hospital Association, 46(2), pp. 97–102. Available at: https://doi.org/10.5326/0460097.
• Lhuillery, E. et al. (2022) ‘Outcomes of dogs undergoing surgery for gastric dilatation volvulus after rapid versus prolonged medical stabilization’, Veterinary Surgery, 51(5), pp. 843–852. Available at: https://doi.org/10.1111/vsu.13763.
• Bruchim, Y. and Kelmer, E. (2014) ‘Postoperative Management of Dogs With Gastric Dilatation and Volvulus’, Topics in Companion Animal Medicine, 29(3), pp. 81–85. Available at: https://doi.org/10.1053/j.tcam.2014.09.003.

Current Vet is an educational podcast intended for veterinary students, veterinary professionals, and individuals with an interest in veterinary medicine.

All content provided in this podcast and its associated materials is for educational and informational purposes only. It is not intended as, and must not be considered a substitute for, professional veterinary advice, diagnosis, or treatment.

Any clinical cases discussed in this podcast are fictional, and are designed to reflect typical or likely clinical scenarios for educational purposes. They do not represent specific real-life cases, clients, or animals.

While every effort is made to ensure accuracy and alignment with current evidence at the time of publication, veterinary medicine is a rapidly evolving field, and recommendations may change over time.

Creators and Guests

Host

Dr. Lottie Wilkinson

Creator and host of the Current Vet podcast

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Intro

Hello, hello, and welcome back to a brand new episode of Current Vets, the podcast that makes veterinary medicine simple. I'm your host, Dr. Lottie, and today's episode is all about an emergency condition in small animal practice, and it is gastric dilatation-volvulus, or just GDV. So GDV progresses really rapidly, and any delays in treatment can have a big impact on the outcome, so recognizing it and knowing how to treat it is really important.

Let's start with our case

Case

It's 7:00 PM on Friday evening, and you're the vet on duty for emergency consults. Your nurse rushes into the prep room and says that there's a Great Dane in triage who's very anxious, stressed, and retching constantly. The dog is Thor, an eight-year-old male neutered Great Dane.

His owner says that he was completely normal earlier in the day, but about two hours after dinner, he suddenly became restless. He kept pacing around the house, drooling and looking like he was gonna vomit, but nothing ever actually happened After a quick clinical exam, your findings are as follows. Thor is restless and distressed.

He's repeatedly retching with no production of vomit. His abdomen looks visibly distended. His heart rate is 180 beats per minute. His pulses feel a bit weak. His mucus membranes are pale with a prolonged - capillary refill time. And when you gently palpate , his abdomen, it feels quite tense. So at this point, alarm bells should be ringing.

A large, deep-chested dog with acute abdominal distension, non-productive retching, and signs of shock. Your top differential is, of course, gonna be GDV. So before we talk about what to do with Thor, let's break down what GDV actually is

Aetiology / Pathogenesis

So gastric dilatation volvulus is two key processes. The first is gastric dilatation, and this is where the stomach rapidly fills with gas, fluid, or food, causing severe distension. The second process is volvulus, which means that the stomach rotates around its axis. This rotation usually occurs clockwise if you're viewing the dog in dorsal recumbency as if for surgery, and the stomach commonly rotates about 180 to 270 degrees.

But this varies. So when this happens, the pylorus, which normally sits on the right side of the abdomen, becomes displaced dorsally and to the left of the abdomen. As the stomach twists, both the esophagus and the pylorus become obstructed, so the stomach becomes essentially a sealed, distending, like, balloon that gas and fluid can't escape from.

And as it continues to expand, the stomach begins to compress surrounding organs. One of the most important structures in this area is the caudal vena cava, obviously, this is the biggest vein that carries blood back to the heart, so when it becomes compressed by this distending stomach, the venous return to the heart drops.

When venous return drops, cardiac output then drops as well, and this is why GDV patients often present in circulatory shock. At the same time, the rotation of the stomach is going to compress gastric blood supply, especially the venous drainage out of the gastric wall. This is gonna cause venous congestion, tissue hypoxia, ischemia, and then potentially necrosis if it lasts long enough The spleen is also commonly displaced during GDV because of its attachment to the stomach via the gastrosplenic ligament, and this can cause splenic congestion As the condition progresses, multiple systemic effects are going to develop. So we're gonna see metabolic acidosis from poor perfusion, release of inflammatory mediators, endotoxemia as that gastric wall becomes compromised and toxins can move into the circulation, and then potentially ventricular arrhythmias as well.

Okay, let's just talk about a couple of risk factors of why some dogs develop GDV and others don't. So the truth is we don't know the exact cause, but there are a couple of risk factors that increase the likelihood of - GDV occurring. The biggest one is gonna be a deep chest conformation. So that deep narrow chest in dogs means they have a much higher risk of GDV because the stomach has more space to move and to rotate. So breeds with the highest risk are gonna be those deep chested breeds like Great Danes, Dobermans, German Shepherd dogs, Irish Setters, and then Standard Poodles as well Age is also a bit of a risk factor, so it's more common in middle-aged to older dogs because those gastric ligaments and connective tissues become looser and weaker with age.

Some other risk factors include eating large one-off daily meals instead of smaller, more frequent meals; eating really, really quickly; ingesting air as you eat, that's just known as aerophagia; exercising immediately after eating; and then also just increased stress or anxiety. There does also appear to be a genetic component because dogs with relatives who have had GDV seem to have a higher risk as well.
So in Thor's case, an older Great Dane who ate dinner shortly before this episode began, he is already fitting a couple of those classic risk factors

Clinical Signs

The clinical signs of GDV often develop really quickly. So the classic early signs are gonna be that non-productive retching, abdominal distension, restlessness, and hypersalivation.
These signs are caused by that distended stomach and obstruction of gastric outflow. As the condition progresses, signs of shock start to develop, so we can see tachycardia, weak pulses, pale mucus membranes, a prolonged capillary refill time, and then collapse - in advanced cases. Respiratory distress can also occur because that distended stomach is gonna start pushing against the diaphragm, which reduces lung expansion and can cause dyspnea

Diagnosis

Once Thor is stable enough, we're first going to do radiographs. So we do right lateral abdominal radiographs, and this is the standard view used to diagnose GDV. Classic findings on the radiograph are gonna be a compartmentalized stomach, often described as a double bubble or Popeye sign, and this occurs because that twisted stomach forms two gas-filled compartments.

Blood work is often also done, and common findings include - high lactate, metabolic acidosis, and electrolyte abnormalities, especially hypokalemia, because potassium becomes sequestered within the dilated and obstructed stomach, so then levels in serum start to fall. Lactate is a particularly useful measurement because it reflects hypoperfusion and ongoing , tissue ischemia.

Very high lactate values can indicate gastric necrosis, so monitoring the trends over time in lactate is gonna be much more informative than just looking at single measurements. If they're continuing to go up, that indicates that there is ongoing ischemia and potentially necrosis that hasn't been addressed.
If they start to drop, that -- generally indicates that the animal is starting to recover. ECG monitoring is also recommended because ventricular arrhythmias are very common in GDV patients

Treatment

Okay, now we have confirmed that Thor has GDV. Treatment should begin immediately. There are two key phases of management. So first is gonna be stabilization, and then the second is surgical correction. So for stabilization, we need fluid therapy. The first priority is always aggressive IV fluids. So we do our bolus of isotonic crystalloids given over 15 minutes to treat shock and restore perfusion. We're using large bore IV catheters in the cephalic veins, and we can do two catheters one in each of the front limbs to increase that fluid rate and make sure that we can get as much fluid in as possible, as quickly as possible. We need to remember though that the venous return in the caudal body is going to be compromised, so we shouldn't be placing catheters in the saphenous veins in the hind limbs.

Oxygen therapy and some sedation may also be needed if the dog is particularly distressed. And then we also need analgesia. So these patients are often in quite a lot of pain, so opioids like methadone, fentanyl are commonly used. NSAIDs are generally avoided because renal perfusion is often already compromised, which is gonna increase the risk of acute kidney injury.

We also don't want to cause further GI damage, which is another side effect of NSAIDs, so opioids are gonna be the preferred analgesic Next, we need to relieve some of that pressure inside the stomach. So this can be done with an orogastric tube. However, if the stomach has rotated severely, passing a tube may not be possible.

So in those cases, percutaneous trocarization can be performed, which is when a large bore needle or catheter is inserted into the stomach through the body wall at that point of maximal distension to release the gas buildup in the stomach While this is a temporary relief and decompression doesn't fix the underlying cause, it can dramatically improve venous return, respiration, and then patient comfort in the short term before we're able to get into surgery

Okay, once the patient is stabilized, surgery is required to definitively correct the displacement. So the goals of surgery are gonna be, one, to derotate the stomach; two, assess tissue viability; three, remove any necrotic tissue if it's present; and then four, perform a gastropexy to prevent this recurring in the future.
We typically use a ventral midline laparotomy, and the stomach is then gently rotated back into its normal position. And then the surgeon can assess the gastric wall. Healthy tissue is gonna be pink, well-perfused, and then bleed when it's incised, and non-viable tissue can appear quite dark or gray or greenish colored, and it may not bleed.

If necrosis is present, a partial gastrectomy may be required to remove that tissue, and then the spleen should also be examined because it can be congested or twisted by this process, and a splenectomy may be needed if the spleen is also non-viable The final step of surgery is gonna be performing a gastropexy, and this involves surgically attaching the stomach wall to the abdominal wall.

The most common technique is an incisional gastropexy, where basically an incision is made into the stomach wall, only a partial thickness, it's not going straight into the stomach, and then a small incision into the body wall, and then those incisions are sutured together to create a permanent adhesion that is gonna prevent that stomach from rotating again

After surgery, quite intense monitoring is needed because those complications like arrhythmias, ventricular arrhythmias, hypotension, gastric necrosis, peritonitis, and disseminated intravascular coagulation can develop. So continuous ECG monitoring is recommended for at least 24 hours. If ventricular arrhythmias do occur, Lidocaine is typically the first-line treatment, and then fluid therapy, analgesia, and electrolyte monitoring should also be continued.

Once the patient is stable, we can start some early enteral feeding with small, easily digestible, quite palatable meals, and this is gonna help speed up healing of the gastric mucosa

Prevention

Because GDV can be so catastrophic, prevention is so, so important to discuss with owners of these high-risk breeds. So management strategies are gonna include feeding multiple small meals per day instead of that one really big meal. Avoiding really rapid eating, so we could use a slow feeder for this.
Avoiding vigorous exercise immediately after meals, making sure that owners aren't taking their dogs out for a walk after a big meal. But the most effective preventive measure is a prophylactic gastropexy, and this is often performed electively in high-risk breeds, particularly ones like Great Danes, and the procedure can be done often during spaying in females or as a laparoscopic surgery as well

Key Points

Before we wrap up, here are the key points to know about GDV. So GDV is a life-threatening emergency that involves gastric dilatation and then rotation, volvulus of the stomach

It most often occurs in large, deep-chested breeds, particularly Great Danes. Classic signs include non-productive retching, abdominal distension, restlessness, and signs of shock. Diagnosis is confirmed with a right lateral abdominal radiograph showing gastric compartmentalization and dilatation.

Treatment requires rapid stabilization, gastric decompression, and then emergency surgery to derotate the stomach, and a gastropexy should be performed to prevent recurrence. And then for prevention, prophylactic gastropexies should be considered in high-risk breeds, and then also those management changes, so, , feeding them multiple small meals, avoiding really fast eating, and making sure that we're not exercising our dogs straight after a meal.

Outro

And that is gastric dilatation-volvulus, thank you so much for listening to this episode. If you found it helpful, make sure to follow or subscribe wherever you get your podcasts, so you get our next episode downloaded straight away.

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