E2- GDV Flashcards
Definition of dilation/dilatation
“bloat”
distension of the stomach with fluid, food, and or gas (pressure on caudal vena cava if distension is huge)
MEDICAL- induce vomiting, antonausea meds
Definition of dilatation-volvulus
enlargement of the stomach associated with rotation on its mesenteric axis (maalposition/Twisting)
SURGICAL
Risk factors for GDV
***Dogs with first degree relative w/ hx of GDV***
increasing age
Dietary things that increase chances of GDV?
increase volume of food fed once daily
dry kibble
fats/oils in 1st four ingredients
raised food bowl
What dietary thing decreases the risk of GDV?
fish or egg supplements
What is the relationship b/t exercise and GDV?
used to think it was a risk factor, BUT now it is seen that it has no impact
no definitive conclusion
GDV breed dispositions
Great Danes
GSD, Irish setter, Doberman
GDV body conformation risks?
increased thoracic depth to width ratio
deep chested dogs!
Temperment association with GDV
“happy” dogs- decreased risk
increasing anxiety, aggression to ppl, spending 5 hrs a day with O = increased risk bc of stress
Should dogs undergoing a splenectomy get a gastropexy as well due to increased risk?
no supporting evidence
only 6-8% chance of developing GDV
Describe the event causes a reperfusion injury
period when blood flow to tissue is absent followed by return of blood flow
What type of by-product accumulates during a reperfusion injury?
anaerobic metabolism by-products
accumlation of cellular waste products, toxins and toxic oxygen radicals
What happens once reprofusion is restored?
toxins are released into general circulation
Factors of reprofusion injury
Gastric displacement most common direction?
CLOCKWISE rotation
torsion is <180º rotation
volvulus is >180 rotation
Less common directoinal rotation?
counterclockwise rotation
rare <5% of cases
displacement <90º
Clockwise displacement- pylorus moves along the ______
ventral abdominal wall to the left side
Clockwise displacement- what is the stomach covered by?
omentum
Counterclockwise displacement- the plyorus moves where?
pylorus moves dorsally to lie adjacent to esophagus
Counterclockwise displacement- the greater curvature lies where?
along the midline
Counterclockwise displacement- is the stomach covered by omentum?
NO
Many Counterclockwise displacement GDVs are presented with history of ____
chronic GI signs
Clinical signs of GDV
acute
restlessness
hypersalivation
“praying” posture- taking pain away from abdomen
vomiting- nonproductive retching
weakness
collapse
GDV physical exam findings
distended, painful, tympanic abdomen (acute abdomen)
active retching
collapse
varying degrees of shock- compensatory & decompensatory
What do we do for initial stabilization GDV?
Aggressive fluid therapy- large bore cephalic or jugular catheters (avoid hindlegs)
initial fluids: crystalloids, hypertonic saline- colloid
maintenance: crystalloids, colloids
Blood pressure and EKG monitoring- shock 90mls/kg dog (25% right away)
How do we Dx GDV with lab findings?
CBC, Biochem, Lactate levels
lactate levels <6.0 increased survival
The goal of treatment for GDV is to…..
followed by?
stabilize cardiovascular, respiratory and renal systems initially
-fluids, decompression, pain management
then surgery and post surgical treatment
What is the first choice for GDV decompression?
stomach tube decompression is 1st choice!
trocharization, then tube, sedation, gastric lavage
Why is gastric decompression important?
improves CV and respiratory function
When do we perform gastric decompression?
after/during fluid/volume support
What is important to remember with orogastric intubation?
bite block
measure and mark tube length -xiphoid is good landmark
advance tube slowly
DO NOT force tube
T/F: gastric decompression can be performed with either sedation or general anesthesia
true
during gastric decomprssion, what do we do once the stomach tube is in stomach?
empty contents
check effluent
gastric lavage- 5-10mls/kg warm water, gavage pump
(if they are not intubated, dont heavily sedate bc they can aspirate)
If we are initially unable to pass an orogastric tube what should we do?
trocharization- only releases so much, not all
use large bore needle/catheter
most tympanic site- stomach is on LEFT SIDE
complications: spleen, leakage
then repeat orogastric intubation
Assessment of orogastric tubing Vs trocharization
Tubing successsful 75.5%
Trocharization successful 86%
no evidence of gastric perforation
one splenic laceration w/ trocharization
NO DIFFERENCE b/t both methods and survival!
What does the radiograph show?
GDV- after stabilization
Why dont we put GDV dogs on their backs?
VD can predispose to reflux or aspiration
What types of pain control?
drugs with minimal CV effects
Oxymorphone, fentanyl, buprenorphine
What can be used for free radical scavengers for the reperfusion injury?
Acetylcysteine
Vitamin C, E & selenium
Desferozamine -iron chelator
Lidocaine- scavenger of reactive oxygen species (ROS), arrhythmias, CRI for pain control
When do we want to do surgery?
as soon as stabilized- the longer the torsion, the increase risk of lack of blood supply
Benefits of early surgery?
better prognosis
gastric repositioning improves bloodflow
surgery may be completes before onset of arrhythmias
What are the 5 factors when doing surgical management for GDV?
gastric repositioning
assessment of gastric viability
evaluate pylorus
evaluate spleen
gastropexy
Discribe surgical gastric repositioning
decompress the stomach if still distended
push down on fundus w/ right hand
grasp antrum w/ left hand and rotate stomach counterclockwise
confirm proper reduction by examinging gastroesophageal junction
(trying to bring pyloris from left side to the right side)
Assessment of gastric viability
“standard” criteria- color pink/red (black=bad), pulsation of blood vessels, bleeding from cut surface, peristalsis (movement is indicator of health)
palpation of wall thickness
surface oximetry
Gastric necrosis location
greater curvature near short gastric arteries
Gastric necrosis- hand suturing vs staples?
hand sutures associated with higher mortality
staples are better?
Areas of necrosis are present in ____% of GDV cases
10%
Gastric perforation occurs when
the stomach wall is very thin
non-viable tissue, remove the necrosis
entire stomach necrotic? euthanize :(
Evaluation of the spleen with GDV sx?
venous congestion- self limiting
vessel thrombosis- splenectomy
splenic torsion- splenectomy
What are the chances of GDV reoccurring without a pexy surgery?
50% -it will happen again!!
What is the chance of recurrence with the pexy surgery for GDV?
4% - VERY LOW
T/F: gastropexy prevents dilation
FALSEE does NOTT
Goal of gastropexy?
permanent adhesion on right lateral body wall (pexy pylorus)
____% success rate for most gastropexy techniques
95%
Incisional gastropexy procedure
incise the seromuscular layer in gastric antrum and right abdominal wall- dont penetrate mucosa
suture edge of abdominal wall to gastric incision w/ simple continuous pattern
3-4cm oral to pylorus in the transverse abdominus
make the incisions so that pyloric outflow tract and proximal duodenum are not twisted or kinked
What type of gastropexy is this?
Belt loop gastropexy
make a loop of stomach tunnel through transversus muscle
What is the strongest gastropexy technique?
circumcostal gastropexy
Describe the circumcostal gastropexy procedure
seromuscular flap placed around 13th rib
technically demanding
Risks: rib fractures (bc you make a flap & go around rib), pneumothorax
Laparoscopic-Assisted gastropexy
dorsal recumbancy
single port-SILS port
Two ports- camera port and instrument port (babcock forceps)
Endoscopic assisted advantages
equipment more widely available
pyloric antrum accurately visualized
gastropexy performed w/ standard surgical instruments
Endoscopic assisted limitations
expertise in gastroscopy required
potential organ trauma
Reasons for doing propylactic gastropexy
breed risk- great danes esp if 1st relative had it
identified risk factors
owner requests it
Postoperative care for GDV
NPO for 12-24hrs
Fluid and electrolyte replacement
Monitor for arrhythmias for 24hrs after sx
Pain control
Blood pressure monitoring -hypotension at any time is risk factor for death
encourage limited exercise- get them up and walking
What is medical postop care for GDV?
anti-emetic: maropitant (cerenia)
H2-receptor antagonists (nausea) -ranitidine, famotidine
Sucralfate (coats stomach/esophagus)- 0.5-1gram PO BID or TID
+/- metoclopramide- promotility
Deaths following GDV postop occur w/in_____
1st 4 days postop
Postop death from shock
hypovolemic
septic- endotoxic
Postop death from gastric necrosis
gastric necrosis leads to peritonitis
- unrecognized areas of necrosis
- perforating ulcers
- reperfusion injury
Electrolyte disturbances postop GDV
Hypokalemia- can induce or potentiate arrhythmias, muscular weakness, lethargy
Hypochloremia- gastric sequestration
____% of P will develop arrhythmia
50%
Cardiac arrhythmias occur _____ after onset of GDV
12-36hrs
(usually less intense in 24-72hrs)
Cardiac arrhythmias are typically what type?
ventricular are most common
Causes of cardiac arrhythmias
myocardial ischemia (decrease CO so myocardium gets irritated)
electrolyte abnormalities
acid-base alternatives
vasoactive substances
imbalance of autonomic nervous system
Types of arrhythmias with GDV?
premature ventricular contractions
paroxysmal ventricular arrhythmias (runs)
idioventricular rhythm (slow v-tach)
ventricular tachycardia >180HR
multifocal PVCs → v fib
When do we treat arrhythmias?
V-tach with high rate (>180-190bpm)
pulse deficits
poor pulse quality
weakness
multifocal PVCs
Lidocaine use for arrhythmias
bolus 1-2mg/kg IV q 5 mins
constant rate infusion (maintenance) 25-80ug/kg/min
What electrolytes should we check for refractory arrhythmias?
potassium, magnesium, calcium
Pain relationship to refractory arrhythmias?
pain → arrhythmias
so we need pain management
Survival rate for uncomplicated cases of GDV?
80-90% -very good
