Exam 1: Lecture 1 & 2: GDV 1 & 2 Flashcards
What is GDV?
-Gastric Dilation-Volvulus
-Enlargement of the stomach associated with rotation on its mesenteric axis
What is GDV also called?
-Bloat or Gastric torsion
What is bloat really?
-Simple dilation
-Stomach is engorged w/ air or froth, but not malpositioned (no rotation)
What kind of condition is GDV syndrome?
-Acute condition
What is the mortality rate of GDV syndrome in treated animals?
-20% - 45%
What happens with GDV syndrome?
-Dilation thought to be from functional or mechanical gastric outflow obstruction which prevents normal emptying (eructation, vomiting, pyloric emptying)
What is ESSENTIAL for survival of GDV syndrome?
-Early recognition & intervention
What is the main cause of gastric outflow obstruction in GDV syndrome?
-Cause of gastric outflow obstruction is unknown, but there are many potential predisposing factors
What are predisposing factors of GDV? (know all of them)
-Male gender
-Increasing age
-Being underweight
-Large volume feeding
-Eating once a day
-Eating rapidly
-Aerophagia
-Raised feeding bowl
-Fearful temperment
-Anatomic predisposition (breed, conformation - having deeper & narrower thorax)
-Stress
-Ileus
-Trauma
-Vomiting
What are some more specific predisposing factors for GDV syndrome?
-First degree relative w/ GDV (may recommend not use for breeding)
-Feeding a dry dog food in which one of the 1st four ingredients is an oil or a fat
-Primary gastric motility disorders
-Atmospheric influence in military working dogs
What are some contributing factors of GDV syndrome that are unsupported by data?
-Exercise before/after large meals or water
-Soy-based or cereal-based dry dog food
-Gastric instability following splenectomy
What are the recommendations for clients to avoid increasing the risk of GDV syndrome?
-Feed several meals a day
-Avoid stress during feeding
-Restrict exercise before & after meals (> 1 hour)
-Do not use elevated feeding bowls
-Do not breed dogs w/ first-degree relative w/ H/O GDV
-Consider prophylactic gastropexy in high-risk dogs
-Seek veterinary care at 1st sign of GDV
What does the stomach do in a GDV?
-Stomach rotates in a clockwise direction when viewed from the surgeon’s perspective
What do the other organs (besides stomach) do during a GDV?
-Duodenum & pylorus move ventrally & to the left of midline, between the esophagus and stomach
-Spleen usually displaced to the right ventral abdomen (varies)
What happens physiology wise during a GDV?
-Caudal vena cava & portal vein compression reduces venous return & cardiac output, causing myocardial ischemia
-Reduction of: central venous pressure, stroke volume, mean arterial pressure, cardiac output
Obstructive shock and inadequate tissue perfusion from GDV can affect
-Kidneys
-Heart
-Pancreas
-Stomach
-Small intestine
-Cardiac arrhythmias (especially if gastric necrosis)
What has been implicated as causing much of the tissue damage that ultimately results in death after correction of GDV?
-Reperfusion injury
What dogs are more predisposed to GDV?
Large deep-chested breeds
-Great Dane, Weimaraner, Saint Bernard, GSD, Irish & Gordon Setters & Doberman Pinscher
-Shar Peis may be increased risk for medium breed
-Basset Hound may be increased risk despitte size
-Middle-age to older dogs (can occur at any age)
There’s a high correlation between ______ and GDV
-Thoracic depth to width & GDV (Lateral compression)
What are the classic things in a history that make your #1 differential GDV?
-Progressively distending & tympanic abdomen
-Painful (arched back, restless, grunting, panting)
-“Dog sitting”
-Hypresalivation
-Nonproductive (or minimally productive) retching
-Dyspnea
-Restlessness
What radiographs should be taken when worried about GDV?
-Take right lateral & dorsoventral radiographs
What does free abdominal air on a radiograph when you suspect GDV suggest?
-Suggests gastric rupture
Air within the wall of the stomach on radiographs indicates
-Necrosis
Why do we need to use caution when handling a suspect GDV patient for radiographs?
-May cause vomiting
-May create unstable patient
What is the bloodwork finding on a patient with GDV?
-CBC is seldom informative
-Potassium may be normal or elevated, but hypokalemia is more common
-Plasma lactate is prognostic -> higher values are associated w/ gastric necrosis & poor prognosis
What are the differential diagnosis when suspecting possible GDV?
-Simple Gastric Dilation (especially in puppies)
-Small intestinal volvulus
-Primary splenic torsion
-Diaphragmatic Herniation
-Ascites
What is seen in this radiograph?
-“Reversev C” or “Double bubble” indicative of GDV
What do we see in this dorsoventral radiograph of a dog with GDV?
-Pylorus appears as a gas-filled structure to the left of the midline (black arrows)
-Notice duodenum coursing from pylorus toward the right abdomen (white arrows)
What is the initial objective in the medical management of GDV?
-To stabilize the patient
How would you initially stabilize the patient in the medical management of GDV?
-One or more large-bore IV catheters
-Fluids (isotonic or hypertonic)
-CBC & biochemical profile
-Broad spectrum abx (cefazolin, ampicillin + enrofloxacin)
-Oxygen therapy
-Gastric decompression while treating for shock
How do we medically manage gastric decompression while treating for shock?
-Needle decompression
-Trocar (right paralumbar)
-Stomach tube (measure it!)
What is this?
-GDV decompression apparatus
When should you perform surgery on a GDV patient?
-Surgery should be performed as soon as the patient is stable
Does surgery need to be performed on a GDV if the stomach is decompressed?
-Yes!
-Rotation of an undistended stomach still interferes with gastric blood flow & may potentiate gastric necrosis
What do we do for preoperative management of GDV?
-IV fluids
-Antibiotics
-Oxygen
-Correct significant electrolyte & acid-base abnormalities
-Gastric decompression as needed
-ECG to monitor for cardiac arrhythmias
What is important to note about anesthesia and GDV cases?
-GDV cases can present unique challenges for anesthesia
What instrument/equipment is used for GDV surgery?
-Foal nasogastric tube & stomach pump
-Suction machine & sterile tubing
-Poole suction tip
-Laparotomy pads
-Balfour retractor
-“Spay pack”
-TA stapler
What is the surgical technique for a GDV?
-Patient placed in dorsal recumbency
-Ventral midline incision is made from xyphoid to pubis to facilitate a full exploratory celiotomy
-Prep big! (Include mid-thorax to pubis)
-Always count sponges before incision & before closing (no kick buckets)
What OR personal is needed for a GDV?
-Surgeon
-Scrubbed assistant
-Anesthetist/unscrubbed assistant
What are the goals of a GDV surgery?
-
Assess viability
-Inspect stomach * spleen to identify & remove damaged or necrotic tissue -
Decompression/Derotation
-Decompress the stomach & correct malpositioning -
Gastropexy - DO IT
-Reported rate of recurrence of 80% w/out gastropexy
What is usually the first thing you see when you enter the abdomen?
-Omentum
What is the surgical procedure for a GDV?
-Initial assessment of gastric viability
-Gastric decompression
-Gastric derotation
-Abdominal exploratory
-Secondary assessment of gastric viability
-Check for torsion of gastrosplenic ligament
-Palpate intra-abdominal esophagus to ensure stomach is de-rotated
-Gastropexy
Why do we do an abdominal exploratory when doing a GDV surgery?
-Assess vascular supply to the spleen (splenectomy if indicated)
-Palpate the stomach wall & pylorus
-“Run” the bowel & assess other viscera
Why do we do a secondary assessment of gastric viability in a GDV surgery?
-Partial gastrectomy or invagination if gastric wall necrosis is noted
What are the gastric and gastroepiploic arteries derived from and what do they supply?
-Gastric = lesser curvature of stomach
-Gastroepiploic = greater curvature of stomach
-Both arteries are derived from the celiac artery & supply the stomach
What are the short gastric arteries derived from and what do they supply?
-Derived from splenic artery & supply the greater curvature
Rupture of what arteries is common during a GDV surgery and what can it result in
-Rupture of the short gastric arteries
-May result in blood loss or gastric infarction/necrosis
____ % of arterial blood flow is to the mucosa
80%
____ % of arterial blood flow is to the muscularis and serosa
20%
What is NOT a reliable indicator of gastric wall viability?
-Observation of muscosal color is NOT a reliable indicator of gastric wall viability
What are some helpful hints for a GDV surgery?
-Decompress the stomach before repositioning (14 or 16-gauge needle attached to suction, orogastric stomach tube)
-Intraoperative manipulation of the cardia facilitates an assistant passing the Orogastric tube
-A small gastrotomy incision can be performed to empty the stomach (less preferred)
If the color of the seromuscular layer of the stomach is red to purple, what does that mean?
-Consider it viable
If the color of the seromuscular layer is green to black, what does that mean?
-Probably nonviable
What should be palpated in order to determine gastric viability?
-Palpate thickness in antrum compared to dorsal fundus - necrotic areas feel “thin”
How does blood help you determine gastric viability?
-Bleeding in response to incision
What are some things to know for a partial gastrectomy?
-Mortality & complications increase
-Can resect fairly large areas
-Remove all nonviable tissues
-Tube gastropexy for post op decompression
-Invagination may be used for small areas
-Stampling devices vs suturing
What is the gastropexy technique?
-Some method of securing the ventral antrum to the right body wall (tube gastropexy, circumcostal, incisional, belt-loop)
-Recommend incisional gastropexy
Which gastropexy is stronger than most techniques but is technically more difficult and why is it more difficult?
-Circumcostal gastropexy
-More difficult b/c increased surgery time, increased complications
What gastropexy is shown in this image?
-Tube gastropexy
What gastropexy is shown in this image?
-Circumcostal gastropexy
What gastropexy is shown in this image?
-Belt loop gastropexy
In an incisional gastropexy, what size incision goes through the seramuscularis?
-3 to 5 cm incision
In an incisional gastropexy the incision should be ______ from the pylorus in an avascular area of the pyloric antrum
8 to 10 cm from the pylorus
In an incisional gastropexy you should make a _____ incision in the right ventrolateral abdominal wall caudal to the last rib
3 to 5 cm incision
What should you check in an incisional gastropexy?
-Always check to see that your gastric incision will reach the selected area of abdominal wall BEFORE making the abdominal wall incision
What is shown by the red lines and red arrow?
-Preferred location of 3-5cm gastropexy incision
What is shown by the black lines and blue arrow?
-Preferred location of gastrotomy incision
What can you do in an incisional gastropexy to miminize the change for accidental needle entry into the lumen of the stomach?
-Driving your needle from the inside edge of your seromuscular incision out
What is the preferred suture material and pattern is preferred for incisional gastropexy & why?
-A continuous closure for your pexy site w/ absorbable monofilament suture is preferred
-B/c reduces the chance of developing a fistulous tract
What are common post-GDV complications?
-Cardial arrhythmias (~45%) (PVCs)
-Shock
-Hypokalemia
-GI motility abnormalities
-Gastric necrosis - Peritonitis
-Recurrent dilation
-Anemia
What are some other post-GDV complications?
-Acid-base disturbance
-Sepsis
-Pancreatitis
-Hepatic or Renal failure
-DIC (~20%)
-Incisional dehiscence
-Intestinal volvulus/intussusception
-Esophagitis - Megaesophagus
How long should fluids be continued post-op after GDV surgery?
-Continuous IV fluids for 24-48 hours
What should be monitored post-op from GDV surgery?
-Monitor K+ and supplement K+ if hypokalemic
When should food and water be offered post op?
-Small amounts of water and soft, low-fat food should be offered at 12 to 24 hours
What should you monitor on your patient post op?
-Pulse quality
-CRT
-MM color
-Hydration
-Urine output
-Body temperature
Why does an EKG need to occur post op?
-75% of arrhythmias occur post-op
When and what antibiotics should be offered post op?
-Antibiotics = broad spectrum through critical period (2-5 days)
-Cefazolin, ampicillin + enrofloxacin, gentamicin + penicillin
Most serious complications occur within the first _____
-within the first 72 hours
What should be monitored for post op?
-Gastric necrosis/peritonitis 2-5 days post-op
-Dehiscence 3-5 days post-op
-Hypoalbuminemia (early)
-Anemia (early)
-Cardiac arrhythmias
What are the indications to treat ventricular arrhythmias?
-Correct hypokalemia first (may correct arrhythmia, hypokalemia may interfere with Lidocaine)
-Decreased cardiac output (poor peripheral pulse)
-Multiform premature ventricular complexes
What strengthens the argument for prophylactic treatment of patients in the setting of acute myocardial infarction?
-inability to always identify the precursors of tachyarrhythmias
Warning: lidocaine toxicity may be enhanced in patients given ____ concurrently
Cimetidine
What are the signs of lidocaine toxicity?
-Muscle tremors
-Vomiting
-Seizures
When is prognosis post GDV surgery poor?
-Poor with gastric necrosis, perforation, or delayed surgery
____ has a higher mortality than ____
GDV has higher mortality than Gastric Dilation
Is the degree of gastric rotation associated with death prognosis?
-NO
What increases the survival in GDV patients?
-Early treatment
-Aggressive fluid therapy
-Gastric decompression (early surgery!!)
