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SA DX & TX II > Exam 1 - GDV > Flashcards

Exam 1 - GDV Flashcards

1
Q

what is simple gastric dilatation?

A

enlargement of the stomach beyond its normal limits (with air/froth) WITHOUT malpositioning

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2
Q

what is gastric dilatation & volvulus?

A

enlargement of the stomach associated with rotation of the stomach on its mesenteric axis

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3
Q

what is the general at risk population for GDV?

A

middle aged to older ‘deep chested’ large/giant breed dogs

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4
Q

what dog breeds are associated with having the highest risk of developing GDV?

A

great dane - 42% lifetime risk

gordon setter, irish setter, weimaraner, saint bernard, standard poodle, bassett hound, & GSD

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5
Q

what are some extrinsic risk factors associated with GDV?

A

eating rapidly, raised food bowls, small food particles, single food type, large volume of food per feeding, & history of kenneling/travel

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6
Q

what are some intrinsic risk factors associated with GDV?

A

increased age, first degree relative with history of GDV, males, increased thoracic depth:width, fearful/anxious animal, gastric foreign bodies, & potentially prior splenectomy

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7
Q

what are the steps in which a GDV occurs?

A

stomach dilates - either from esophageal obstruction (animal can’t eructate or vomit) or pyloric obstruction (cannot pass ingesta to small intestine)

stomach rotates in a clockwise direction (~180-270)

pylorus & duodenum move VENTRALLY & to the LEFT of midline (clockwise)

spleen is displaced to the RIGHT

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8
Q

what is the pathophysiology of GDV?

A

massive increase in intra-gastric pressure & volume - 20 mmHg will cause caval compression, with GDV, upwards of 60 mmHg

pressure on the diaphragm causes decreased tidal volume & impaired ventilation

caudal vena cava & portal system are compressed leading to obstructive shock, decreased CO, SV, MAP, & portal hypertension

distributive shock occurs with splanchnic pooling of blood

myocardial ischemia causes decreased venous return to the heart leading to circulatory shock

arrhythmias in 40-70% of cases (due to myocardial ischemia, splenic disease, & pancreatic ischemia - myocardial depression factor)

capillaries collapse causing mucosal necrosis - breakdown of gi mucosa & impaired portal system leading to bacterial translocation & endotoxemia

mixed acid base derangements

coagulopathy - multifactorial & DIC is possible

reperfusion injury from reactive oxygen species & pro-inflammatory mediators released systemically

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9
Q

why can a GDV dog present as anemic?

A

the tearing of the short gastric vessels during the volvulus leads to blood loss

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10
Q

why do we see mucosal necrosis in the stomach in an animal with GDV?

A

the mucosa is very metabolically active & receives >50% of blood flow & is >50% of the weight of the stomach - massive injury

full thickness ischemia & necrosis +/- perforation is possible

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11
Q

what is the most common region of the stomach to necrosis with GDV?

A

greater curvature/fundus

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12
Q

what clinical signs does a GDV patient typically present with?

A

gastric distension, non-productive retching, hypersalivation, restlessness, pain/praying position

progression to depression & lateral recumbency

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13
Q

why is a saphenous catheter for iv fluids useless in a patient with GDV?

A

the venous return from the abdomen is impaired

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14
Q

what is the first step that should be taken for treating a GDV patient?

A

stabilize - large bore catheters in both cephalics or jugular with shock doses of crystalloids +/- colloids

also consider - analgesia, anti-emetics, flow-by oxygen

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15
Q

while fluids are going for a GDV patient, what other tests/information should you pursue?

A

PE, TPR, BP

continuous ecg & treat as indicated

blood gas

PCV, lactate, BUN/crea, electrolytes, & coagulation panel

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16
Q

why should you do an ecg on a GDV patient?

A

many of them have arrhythmias - typically ventricular

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17
Q

what arrhythmia is seen here? how do you know? how do you treat it?

A

v-tach

sustained VPCs, rate >160 bpm, R on T waves, multiform VPCs

lidocaine

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18
Q

why take a right lateral of a GDV patient?

A

pylorus is seen cranial to the body of the stomach - double bubble or reverse C shape

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19
Q

what could cause a pneumoperitoneum in a GDV dog?

A

gastric rupture - very unlikely

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20
Q

what is seen on rads that is supportive of a GDV?

A

pylorus is seen cranial to the body of the stomach - double bubble or reverse C shape

may see decreased serosal detail - rule out blood vs. gastric rupture

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21
Q

T/F: if you confirm a GDV on a right lateral view, you still need a left lateral & VD view

A

false - stop after confirmed!!! avoid VD - can do DV if needed

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22
Q

where is the pylorus seen on a DV view of a GDV dog?

A

pylorus seen on the left

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23
Q

when may you do thoracic rads in a GDV patient?

A

if the patient is stable enough & an older - some may have aspiration pneumonia

older patients - need to rule out neoplasia

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24
Q

before doing gastric compression, what should you do?

A

give the patient an opioid - hydromorphone/methadone/fentanyl - for pain relief & mild sedation

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25
Q

what are the 2 methods used for gastric decompression?

A

orogastric tube

trocharization/percutaneous decompression

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26
Q

how do you use an orogastric tube for gastric decompression?

A

choose a large, stiff tube with a smooth tip & measure from the tip of the nose to the last rib & mark the tube

consider elevating the front half of the body to decrease pressure at the cardia

place a roll of tape in the dog’s mouth to prevent them from biting the tube or use a tape muzzle

pass the tube through the center of the roll of tape & pass down esophagus - if you feel resistance near the cardia, DO NOT FORCE THE TUBE

once the tube is in the stomach - material should flow (have bucket ready)

can lavage after with 5-10ml/kg of warm water

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27
Q

how is percutaneous gastric decompression performed in a GDV patient?

A

determine the area of greatest tympany - often on the left side just behind the last rib - can use ultrasound to confirm the spleen is not between the body wall & stomach

clip/aseptic prep/lidocaine block of the region

use a 14 or 16 G over the needle catheter & insert into stomach - remove the stylet & consider attaching to extension set

apply gentle pressure on the abdomen to decompress

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28
Q

what are the benefits of using an orogastric tube for gastric decompression?

A

can achieve more rapid & complete decompression

can lavage the stomach

29
Q

what are the benefits of using trocharization for gastric decompression?

A

typically no sedation required

may be better tolerated

rapid

30
Q

what are the disadvantages of using an orogastric tube for gastric decompression?

A

some patients may not tolerate the tube without further sedation

may not be able to pass tube beyond the volvulus/cardia

may perforate the stomach if overly aggressive

31
Q

what are the disadvantages of using trocharization for gastric decompression?

A

less complete decompression especially if large amounts of food or thick froth is present

may lacerate the spleen - usual minimal consequence

32
Q

what are the goals of surgery in a GDV patient?

A

decompression, derotation, damage control, & permenant gastropexy

33
Q

what are the anesthetic considerations for surgery for a GDV patient?

A

continue to stabilize the patient & close monitoring

minimize time in dorsal recumbency - clip & initial prep in lateral

minimize anesthetic time

MAC sparing anesthesia protocol

34
Q

what is the first step in GDV surgery?

A

decompression of the stomach - make a LARGE ventral midline incision from xiphoid to pubis

must decompress the stomach before derotating (may be able to palpate cardia & guide OG tube in or can use a catheter/needle & attach to suction)

35
Q

how is derotation done in GDV surgery?

A

standing on the dog’s RIGHT side

use your right hand to pull the pylorus TOWARDS you (ventrally/up - from left to right)

use your left hand to push the body of the stomach dorsally & to the left (away from you/down)

confirm the return to the normal anatomic position with the pylorus & duodenum on RIGHT - should be able to easily pass OG tube

36
Q

after decompression & derotation is complete, what is done next in a GDV surgery?

A

damage control - complete abdominal explore

concurrent gi obstruction is possible (fb, neoplasia, intussusception)

confirm hemostasis

37
Q

why may you see a hemoperitoneum in a GDV surgery?

A

short gastric arteries may tear causing a hemoperitoneum - confirm no continued hemorrhage & ligate as needed

38
Q

what happens if during your abdominal explore in a GDV surgery, you see that the spleen has necrosed?

A

splenectomy - while rare, it can happen

look for lack of pulses & black in color

39
Q

during your abdominal explore of a GDV surgery, you see that the spleen is dark purple - what do you do?

A

nothing - spleen will appear congested & will improve with time

40
Q

what are some signs of gastric necrosis?

A

serosa of the stomach is gray/green/black

thin with lack of normal ‘slip’

lack of bleeding when incised

lack of peristalsis?

41
Q

if in doubt about the viability of the stomach after decompression/derotation, what can you do?

A

complete abdominal explore & go back & re-evaluate

42
Q

T/F: if necrosis or perforation is present in the stomach, resection is indicated

A

true - 60% of the stomach can be removed

greater curvature or fundus resected easily

43
Q

what happens if there is necrosis on the cardia of the stomach?

A

resection isn’t always possible - may be grounds for humane euthanasia

if resection is possible - animal may have reflux esophagitis

44
Q

how is resection performed on necrosed areas of the stomach in a GDV surgery?

A

partial gastrectomy - pack off the abdomen & place several stay sutures

cut out necrotic tissues

close in 2 layers (mucosa/submucosa SC & muscularis/serosa inverting with 2-0 PDS)

45
Q

what is invagination in terms of techniques used in GDV surgery?

A

area of necrosis on the stomach is folded inward (invaginated) with a cushing/lembert pattern placed through the healthy tissue around it

may be faster than resection

46
Q

what are some possible complications of invagination of necrotic tissues of the stomach?

A

ulceration - common

hemorrhage

gi obstruction from tissue

47
Q

which is preferred for addressing necrotic tissue on the stomach in a GDV surgery, resection or invagination?

A

resection

48
Q

why is a gastropexy necessary for a GDV surgery?

A

80% recurrence rate without a pexy - need to do a right sided gastropexy to prevent the same problem from happening

incisional gastropexy preferred

49
Q

T/F: after a GDV surgery, the patient can be considered out of the woods

A

false

50
Q

what is included in post-operative management of GDV surgery patients?

A

continuous ECG for at least 24 hours, blood pressure, PCV/TS, lactate, +/- periodic brief abdominal ultrasound

+/- cbc/chem every few days

51
Q

if the arrow is pointing out the caudal most extent of the diaphragm, what does the line next to it represent?

A

location of where you should do the gastropexy

52
Q

what are some common post-operative complications of GDV?

A

arrhythmias, hypotension, ileus (vomiting/regurgitation), anorexia, & aspiration pneumonia

less common - DIC & sepsis/peritonitis (gastric necrosis not identified & treated intra-op or dehiscence)

53
Q

what is the ball structure seen in the center? what is to the right of it?

A

omentum

spleen

54
Q

when should you use antibiotics post-op in a GDV patient?

A

indicated if there was perforation/septic peritonitis or evidence of septicemia

55
Q

T/F: you should avoid NSAIDs in post-op GDV patient

A

true

opioids instead - methadone has less gi effects

56
Q

what kind of gi support should be offered to post-op GDV patients?

A

antiemetics, prokinetics as needed, & antacid meds

may need an ng tube to periodically empty the stomach if there is severe ileus

57
Q

how is nutrition handled post op in a GDV patient?

A

begin feeding within 12-24 hours

if anorexic for >24 hours - consider NG tube

58
Q

what are some poor prognostic indicators in GDV patients?

A

lactate that doesn’t improve, pre-op arrhythmias, >6hr of clinical signs, hypotension at any time, need for splenectomy/partial gastrectomy, peritonitis/sepsis, & DIC

59
Q

T/F: there is 10-28% mortality reported in GDV patients

A

true

60
Q

T/F: lactate increases in GDV patients due to hypoxia secondary to anaerobic metabolism

A

true

61
Q

T/F: there is a general shift towards response to resuscitation rather than a cut off value in predicting prognosis when it comes to watching lactate values

A

true - there are many papers evaluating the prognostic value of lactate & they all have conflicting results

62
Q

T/F: you should recommend a prophylactic gastropexy to at risk breeds & any dog that develops dilatation as it will prevent volvulus, bloat, & dilatation

A

false - while you should recommend the surgery, it only prevents volvulus not bloat/dilation

63
Q

what are some ways owners can prevent the risk of their pet developing GDV?

A

avoid raised bowls

minimize stress/anxiety especially during feedings

feed multiple smaller meals rather than one large meal a day

64
Q

______ ________ is a possible sequela to GDV & can require resection of the stomach

A

gastric necrosis

65
Q

T/F: stabilization in a GDV patient before surgery is extremely important

A

true - fluids & gastric decompression

66
Q

how is an incisional gastropexy performed?

A

4-6cm incision is made through the peritoneum & transversus abdominis on the right body wall 1cm behind the last rib & parallel to the linea

make a similar 4-6cm incision through the seromuscular layer of the pyloric antrum

use 0 or 2-0 PDS in a simple continuous pattern, suture the dorsal aspect of each incision together followed by the ventral aspect

67
Q

how is a belt loop gastropexy performed?

A

seromuscular flap created around a vessel along the greater curvature of the pyloric antrum

make 2 5 cm incisions along the right body wall through the peritoneum/transversus abdominis m. for flap to be passed through

68
Q

how is a circumcostal gastropexy performed?

A

make a double or single-hinged flap of the seromuscular layer over the pyloric antrum passed cranial to caudal around the 11th or 12th rib

rare complications include - pneumothorax (particularly if using the mid to proximal portion of rib) & rib fractures

69
Q

what are some common post-operative complications of GDV?

A

arrhythmias, hypotension, ileus (vomiting/regurgitation), anorexia, & aspiration pneumonia

less common - DIC & sepsis/peritonitis (gastric necrosis not identified & treated intra-op or dehiscence)

SA DX & TX II (62 decks)

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