Volvulus (GDV), Stomach Bloat and Torsion
Ron Hines DVM PhD
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On occasion, gastric misalignment or volvulus occurs as a chronic, non-emergency condition. When it does, the signs of the problem are much less dramatic or specific. They include weight loss, inactivity, chronic vomiting and abdominal pain. (ref)
In severe and untreated cases, the stomach can actually rupture. All this can occur quickly and to the point where dogs go into shock and die. An unusual finding by veterinary statisticians is that the incidence of bloat appears to have increased many fold over the past 30 years.
Occasional cases of GDV progress more slowly and less typically, resulting in an abnormal position for the stomach and chronic indigestion.
Gastric dilatation/volvulus (GDV) is not the common condition of puppies that simply overeat and end up with a severe tummy ache.
Is One Breed Of Dog More Susceptible To GDV Than Another ?
Large, deep-chested and barrel-chested dogs are most at risk. Breeds we associate with this condition are setters, Weimaraners, Great Danes, Borzoi’s, Afghans, German Shepherds and Greyhounds but it can occur in any breed. Certain bloodlines see more of the problem than others. Males are as susceptible as females.
Guard dogs owned by the US Department of Defense lead an institutionalized life - quite unlike the life of your domestic pooch. For one, they are generally fed once a day, for another, their “pack/family” social interactions are quite limited. Most are Belgian and German Shepherds – deep chested breeds with an increased tendency for GDV. GDV is the fifth leading cause of death in these dogs, occurring in one out of eleven dogs in 927 in the program during the mid 1990s. You can read that study here.
Do Veterinarians Know What Causes Gastric Dilatation/Volvulus ?
But we do know some things most dogs with GDV have in common. First off, they are usually deep-chested large breeds. They also tend to be older dogs. We know that dogs that do not get routine, outdoor exercise seem more prone to develop GDV. We also know that dogs that are feed primarily dry kibble dog food , particularly in one or two large portions during the day, are more susceptible than dogs that munch throughout the day or are fed canned or moist home made diets. We know that dogs are more likely to develop GDV if their parents, siblings or prior litters did. It also appears that feeding diets with a high fat content predispose dogs to this condition.
Rumors about one cause or another have circulated for years. Some breeders believed that exercise just after or before eating brings on GDV and we used to think that dogs developed GDV when they just ate too much. In this theory, dogs that drank after a large meal of dry chow caused the food to rapidly expand. This theory assumed that the enlarged stomach then flipped over during rough exercise. We now know that the actual explanation is not nearly that simple. We also know that GDV is associated with abnormal muscular contractions of the stomach walls. These, plus the kink that forms in the stomach’s openings, prevent the dog from belching out swallowed air. Lack of normal motility and circulation in the stomach when this occurs; cause the body to become too acidic (metabolic acidosis). We also know that dogs who eat from elevated dishes appear more likely to become bloated - their dishes should always be on the floor. A 2000 Purdue Veterinary School study confirmed most of these suspicions. Dogs that ate primarily dry dog chow were almost three times as likely to develop GDV. High fat content, citric acid and premoistening the food also increased risk. High meat-content dog foods tended to decrease risk. Those authors suggested that withholding water for about an hour before and after meals might be helpful. You can read that study here.
In 2012 another important study of GDV in 1,114 dogs was published. In that study, the feeding of dry dog chow was again an important risk factor. Dogs fed one large meal a day rather than more frequent small meals were at greater risk of GDV. In this study, moderate exercise after meals and throughout the day appeared to lessen the likelihood of GDV. Large and giant breed deep-chested dogs were, again, most at risk. History of the problem in the genetic line (pedigree) made the problem much more likely. Pre-moistening the dry food with water and keeping the bowel high were not helpful - the opposite was true. You can read the study results here.
Many owners of GDV dogs describe them as greedy eaters.
What Are The Signs of GDV I Might See In My Dog ?
dilatation and volvulus often occurs shortly after your dog consumes
a large meal.
Is This An Emergency ?
Time is of the essence in getting to your veterinarian. All pet owners need to think ahead. Find out where the nearest 24 hours emergency animal hospitals are in your areas before you need them. Look into their reputations, then tape their phone number on your refrigerator and enter it in your cell phone. Sudden weakness and discomfort in your pet - with no logical explanation - is always an emergency. The most important factor in the survival of dogs with GDV is the speed with which the problem is addressed.
What Is Happening Within My Dog To Make It So ill ?
The stomach of a dog has a great capacity to enlarge, and as it does so, it presses on the organs around it and prevents the normal circulation of blood. When blood circulation within the stomach wall cannot occur normally, toxic products are quickly liberated into the pet's blood stream. At that point it is no longer a gastric problem, the pet’s entire body is affected. Gums often become pale and dry, the pulse weak, rapid and thready. Gums remain blanched (whitish, decreased capillary refil time -CRT) when pressed with the finger, the pet’s abdomen enlarged and often becomes drum-like.
Normal exit of blood circulation from the dog’s spleen is often prevented (splenic congestion) by the presence of a greatly enlarged stomach causing the spleen to become greatly enlarged.
As the problem progresses, respiration difficulties due to the enlarged stomach and a loss of adequate blood flow through the heart (decreased cardiac function due to pressure on the large vena cava and hepatic veins that returns blood to the heart) result in hypoxia (inadequate oxygen) , shock and collapse. Other organs, the kidneys, liver, and intestinal lining that require considerable oxygen begin to disintegrate (see the tests) and shut down – releasing more toxins and liberating intestinal bacteria into the bloodstream (sepsis and peritonitis). Blood pressure often drops and heartbeats become abnormal (arrhythmic) and weak.
Insults to your dog’s body of this magnitude often result in a life threatening condition in which blood both fails to clot and clots where it shouldn't called disseminated intravascular coagulation or DIC.
How Do Veterinarians Diagnose This Problem ?
Many problems can cause abdominal enlargement, but few, other than GDV, come on so suddenly. It is often the dog’s lower left side (abdomen) that is most enlarged and firm.
When these dogs are radiographed (x-rayed) the gas-filled, enlarged stomach is usually quite apparent. From the position of the gas bubble(s) within it, the vet can get a good idea if the stomach has flipped over into an abnormal position (volvulus) or if it is just distended (bloat or dilatation).
Laboratory examination of the blood confirms the metabolic acidosis as the problem progresses. It is also common for blood potassium to be low. Low blood potassium affects heart rhythm and causes muscle weakness. Blood plasma lactate levels are often increased and the degree of elevation appears to parallel the severity of the case. (ref)
Your veterinarian will probably take a blood sample from your pet and run some standard tests. These include a complete blood cell count (CBC /WBC) and blood chemistry values. You can see what those values ought to be here. Your vet may also check your pet’s urine (urinalysis). In severe cases, when heart irregularities (arrhythmias) are suspected, you vet may run an ECG.
There are other diseases that sometimes have similar symptoms and that your veterinarian would want to consider. One is under-performing adrenal glands (Addison’s disease). Various tumors, splenic and intestinal torsions, obstructions, hemorrhage, and diaphragmatic hernias might also need to be ruled out.
The First Step – Stabilizing Your Pet
The first job of your veterinarian is to stabilize your pet’s circulation (circulatory system). If that can be done, the actual surgery to correct the problem is quite likely to succeed. When it cannot be done, corrective surgery will be of no help.
Veterinarians rely on intravenous fluids to bring your pet’s cardiovascular system and circulation back under control. So they will place catheters in your dog’s forelegs (cephalic veins) or neck (jugular veins) to administer those fluids. Along with those fluids, most veterinarians administer antibiotics and shock-alleviating corticosteroid medications. If your dog was taken to a facility specializing in emergencies , blood will be drawn periodically to be sure that its electrolyte (salts and ions) gas (CO2 and Oxygen) constituents and acidity (pH) are maintained within normal limits. Your dog will remain under close observation because these fluids must not be administered faster than the dog’s body can properly distribute them. Its urine flow and body weight will be monitored. Fluids given too fast can lead to fluid accumulation in the lungs (pulmonary edema).
When electrolyte imbalances are found in the dog’s bloodwork, they are corrected. Some dogs are given corticosteroids (methylprednisolone, dexamethasone ,etc.) to counteract shock. Oxygen therapy may even be necessary. It is important that pressure within the pets stomach be quickly removed. Most dogs are so shocky that they need little or no tranquilizers or anesthetics. Vets first try to pass a stomach tube through the dog’s mouth and into the stomach to remove the air. Then a back and forth flush of water through the tube helps to remove food (gastric lavage) . Adding simethicone to the lavage can help decrease froth and pockets of air. But in many cases, the "kink" in the stomach does not allow the tube to pass. When this is the case, a large bore needle called a trochar can be inserted through the side of the dog and into the stomach or a surgical cut-down on the abdominal wall and the stomach with temporarily suturing of the openings together, removes the trapped pressure. Vets often administer large amounts of antibiotics to these dogs because impaired circulation can allow bacteria to enter the pet's circulation from their intestines and because the vet must move so rapidly that surgical sterility is compromised.
Once the size of the stomach has been reduced and your pet’s general condition stabilized, the vet can get on to surgery to permanently correct the problem. That surgery, called a gastropexy, permanently anchors the stomach in its correct position. You can read more about how that surgery is performed in the next section.
How Do Veterinarians Continue To Treat The Problem ?
Once your dog has been stabilized, the problem will almost always require surgical correction if it is not to happen again. The surgery is called a gastropexy. The object of the surgery is to anchor (sew) the pet’s stomach in its proper position so it cannot shift and become obstructed again. There are several ways to do this and each surgeon has his/her preference. You can read about the techniques used in some of them here.
In advanced cases, stomach wall tissue that is no longer alive (vital) must be removed. In others, the vets feel that removing the pet’s spleen is advisable.
Will My Dog Survive ?
Early in my career, only about half the dogs I saw with GDV survived. But since then, veterinarians have learned that very aggressive treatment to stabilize these dog's cardiovascular system before attempting surgery greatly improve the chances of recover. In 2012, perhaps 80% of the dogs brought to U.S. clinics with GDV go on to recover with treatment. Of course the survival of individual dogs will depend on how soon treatment is begun, concurrent health problems the dog may have and the severity of the GDV. Dogs experiencing heart irregularities (arrhythmias) , those whose stomachs have already suffered irreversible damage and those who could not get to the vets soon enough are at much greater risk of death. Your vet can detect some of these prognostic (prediction) factors prior to surgery - but not all of them. Gas infiltrating the stomach wall or escaped free into the abdomen means the stomach wall has degenerated – a bad sign as are high lactic acid blood levels. But the outcome of severely ill individual dogs during surgery and just after surgery cannot be predicted well. Be there during recovery to encourage and caress your dog (and, perhaps, offer a prayer on its behalf).
What Kind Of Postoperative Care Will My Dog Need ?
Your dog will be hospitalized and not be allowed to eat for several days. It will receive the nutrients it needs intravenously (parenterally). Its heart rate blood pressure, kidney function and degree of oxygenation (pulse oxymetry) will be monitored if it is at a large veterinary center. It will receive medications to control pain and it may receive medications that encourage gastrointestinal motility (metoclopramide, cisapride).
After the pet is discharged, it will probably be sent home with a bland prescription diet and instructions to feed it small amounts frequently throughout the day.
The dog’s incision line needs to be protected from chewing and frequently checked to see that all of the sutures are holding.
Your dog may drink more than it normally does when it returns home. That is good, it needs all it desires - but given in frequent small amounts. Check its rectal temperature as frequently as your veterinarian suggests – post surgical infections occasionally occur and need antibiotic cover.
Is Preventive Surgery Worthwhile ?
Many board-certified veterinary surgeons suggest preventative (prophylactic) gastropexy before GDV occurs. If your dog comes from a specific blood line within a breed that commonly develops GDV or if its parents or littermates developed GDV, that might be a good option. When the surgery is performed before a GDV crisis, it can often be done through a very small incision (laparoscopically) or through other, minimally invasive methods. Some vets even offered the surgery at the same time the dog is neutered or spayed. The procedure is not 100% effective in preventing future GDV.
I would never perform this preventive procedure on breeding stock dogs or purchase a puppy of a mother who experienced preventative or emergency gastropexy.
If your dog does not fit into this former high risk group, if it is just from a breed known to have a relatively high incidence of GDV, I would prefer you just establish a regular exercise plan for it, feed it smaller amounts of higher protein food frequently during the day and avoid the dry dog foods that seem to make GDV more likely to occur. You might even put another pot on the stove. (ref)