1
Q
What is GDV?
A
Syndrome characterized by accumulation of gas in stomach &
subsequent rotation of stomach causing obstruction of eructation and pyloric outflow
2
Q
What are the 3 presentations of GDV?
A
- Gastric Dilation w/o rotation
- Gastric Dilation Volvulus
- Chronic
3
Q
Which presentation is the worst in the long run for the animal?
A
- Chronic is the most dangerous presentation
- pt tries to vomit after eating a lot, exercising and drinking a lot of water.
- The twisted stomach returns to normal position but is debilitated and doesn’t regain full strength
4
Q
GDV is a medical emergency!!
What is the mortality rate?
A
15-28%
5
Q
Where should you place a catheter in a GVD patient?
A
Jugular→ best
cephalic and IO→ okay
Never saphenous!
6
Q
What is the eitiology of GDV?
A
Unclear but maybe due to delayed gastric emptying, laxity of ligaments, or commercial diets
7
Q
What are the risk factors for GDV?
A
- Breed predilection:
- (Large/Giant) Danes, GSD, Dobie, St.Bernard
- Deep, narrow chest (dachshund, cat)
- Single meal
- Rapid ingestion (airophagia)
- Exercise after meal
8
Q
What are the C/S of GDV?
A
- Cranial Abdominal Distention
- Tachypnea
- Tympanic Abdomen
- Pale MM
- Splenomegaly
- Altered Cardiac and RR parameters
9
Q
What happens to the stomach in gastric dilation?
A
- Stomach distension by air→ fluid & frothy mucoid substance
- Frothy mucoid seals opening
- Dilated stomach pushes against diaphram → imparing respiration & decreased blood return
10
Q
What happens to the stomach with gastric torsion?
A
- Stomache abruptly twists along long axis
- Rotation is < 180 degrees so no complete obstruction
- can be overlooked
- Can lead rapidly to volvulus
11
Q
What happens to the stomach in gastric volvulus?
A
- Twisting of stomach along LONG axis
- Rotation of gastro-esophgeal junction is > 180 degrees →COMPLETE esophageal and pyloric obstruction
12
Q
2 requirements of GDV?
A
- Failure of normal eructation
- Acute pyloric outflow obstruction
13
Q
In GDV w/ clockwise rotation, to what degree is the stomach rotated
and what confirms diagnosis?
A
- Rotation: Between 180°-270°
- Confirmation: Omentum seen wrapped around stomach
14
Q
In GDV w/ counter clockwise rotation, to what degree is the stomach rotated?
A
90 degrees
15
Q
Which is more common in GDV clockwise or counterclockwise rotation?
A
Clockwise
(99% of the time)
16
Q
Time of day for GDV presentation most common to least?
A
- Night → 68.7%
- Afternoon → 22%
- Morning →9.3%
17
Q
What are the most common decompression methods used on GDV patients?
A
- Orogastric intubation (sedate to avoid stressing p)
- Gastrocetesis (use a long catheter)
- Gastrostomy (rarely done, requires LA)
18
Q
Why is a Gastrostomy a bad choice for a GDV p?
A
Prolongs SX b/c have to decompress stomach, suture the stomach, close the abdomen,
THEN perform GDV sx (endangers the patient)
19
Q
C/S of a GDV Patient at risk of Shock?
A
- Dyspnea + abdominal component
- Debilitated (unresponsive)
- Decreased HR & Conscience
- Increased RR, followed by decreased RR
- Back hair coat erect → p is trying to die
20
Q
Should you be overly concerned with X-rays in an unstable GDV patient?
A
NO - Rads AREN’T therapeutic
21
Q
When should you take rads of a GDV patient?
What are you looking for?
A
- Once the patient is stable and more relaxed
- Popeye flex or Smurf head
- Compartmentalization → “Double Bubble” → ensures torsion has occurred
22
Q
Why are Rads used in a GDV patient?
A
To distinguish a gastric dilation(GD) from GDV
23
Q
What are the 3 main objectives of GDV SX Management?
A
- Reposition the stomach
- Assess severity of Ischemic injury
- Perform a gastropexy to prevent recurrence
24
Q
How do you know if the stomach has be repositioned properly in a GDV patient?
Why are we concerned?
A
- Pylorus is back on the R & the gastroesophageal jxn is NOT twisted
- Stomach doesn’t always return to proper position after decompression
25
What standard criteria are used to assess the severity of ischemic injury in a GDV case?
Check color of gastric wall, for presence of pulsating vessels, peristalsis
& bleeding from cut surface
26
How is a "pinch test" helpful when assessing the integrity of the stomach of a GDV patient?
Devitalized areas will feel THINNER than adjacent viable tissue
(helps assess ischemia)
27
How much of the stomach can be removed & the stomach still be viable?
50-60%
28
**What must you ALWAYS do when performing a GDV SX?**
**EXPLORATORY CELIOTOMY!!!!!!!!!!!**
29
What are we often worried about in GDV patient suffering from ischemia?
Reperfusion injuries
30
**What type of Gastropexy reduces GDV recurrence by 92%?**
**RIGHT sided Gastropexy**
31
What should you do after performing a *_Right_* sided Gastropexy in a GDV patient?
Document it in patient's medical record!!!!!!!
(has implications for future SXs)
32
List the 4 different Gastropexy Techniques used for GDV correction.
* Circumcostal Gastropexy
* Belt Loop Gastropexy
* Incisional Gastropexy
* Grid Approach Gastropexy
33
How is a Circumcostal Gastropexy performed?
* Flap is created from the pyloric antrum & passed through the rib musculature
* Flap is sutured back to the stomach
34
What are the dimensions of the flap created in a Circumcostal Gastropexy?
Height of flap should be 1 1/2 times the width of the flap
35
How is the flap created in a Circumcostal Gastropexy?
from **LESSER** curvature of the stomach → lift up seromuscularis of pyloric antrum →
bring antrum as close as possible to the last rib
36
What happens if you hear a "hissing" sound while performing a Circumcostal Gastropexy?
Need a Thoracostomy tube!!!!
37
Where does the flap come from in a Belt Loop Gastropexy?
@ the level of the antrum from the the **GREATER** curvature of the stomach
38
Why is a Belt Loop Gastropexy preferred to a Circumcostal one?
* Easier to do & safer
* Can save time using skin staples
39
Describe a Belt Loop Gastropexy
* Flap made from greater curvature
* 2 PARALLEL incisions over Transversus abdominus mm CAUDAL to the last rib
* Pass "belt" through the transversus mm & suture back to the antrum
40
Describe an Incisional Gastropexy
* Secures pyloric antrum to abdominal wall
* 2 incisions
* **Suture the *seromuscularis* layer of the *pyloric antrum* to the _muscle wall_ of the _abdomen_**
* Just as strong as the Circumcostal method
41
When can you perform a Gastropexy via Grid Approach?
* As a LAST RESORT, only if decompression was successful and owner can't do SX
* prophylatic gastropexy
42
How do you perform a Gastropexy via Grid Approach?
* Bypass the esophagus and place a peg tube
* Go all the way through to mucosa & submucosa
* Attach peg tube to abdominal wall
43
Advantages of Gastrostomy Tube?
* Easy access for food & medications
* decompresses the stomach
44
How do you pace a Gastrostomy Tube?
What should you avoid?
* Wide incision lateral to the nipple line
* Place tube @ level of pyloric antrum & inflate balloon @ the tube's end w/ saline
* Secure tube to stomach with Purse String suture pattern \*Pull stomach against abdominal wall to secure
* Use a Chinese Finger Trap to secure the tube externally \*
* Remove in 5-7 d.
* Don't obstruct the pylorus
45
What technique is performed to remove dark tissue (dead) from the stomach?
Gastrectomy
46
What percentage of patients requiring a partial Gastrectomy die?
35% or 1/3
47
What should you avoid when performing a Gastrectomy?
Why?
Leaving unhealthy tissue behind → Increases risks of rupture & subsequent peritonitis
48
At what level should you scrape the surface of the stomach to check for stomach health?
Boundary between live & dead tissue
49
What technique can be used for prophylactic gastropexy during on OHE?
Laparoscopy
50
How do you perform an Invagination (Gastrorrhaphy)?
* Determine amt of tissue that must be removed
* **INVERT tissue & suture it **
* Avoid harming the Greater Curvature vessels
* Tissue will slough off & be digested
51
Post-Op care for GDV SX?
\*Intensive monitoring \*Fasting/Enteral nutrition/Bland diet/low residue \*ABX \*SX control \*Cardiac control \*Pain control
52
What should be monitored during Post-Op GDV recovery?
* SX site →E-collar
* Urinary catheter → 1-2 mL/Kg/hr of urine
* **Continually check BUN & Creatinine (TQ)**
53
What is the ABX regime for GDV SX?
* ABX post op
* Repeat ABX if SX is \> 90 min.
54
**What should you always watch out for in Post-Op GDV patients?**
**(think \<3)**
**Premature Ventricular Contractions**→ can kill!
(always have an ECG on them)
55
**What are some important points when educating clients about GDV?**
* **Several meals a day (min of 2)**
* High protein (\>30%, raw meat is good)
* Low fat diets
* Only feed small volumes each meal
* Need adequate amt of fiber
* **No strong exercise after eating**
* **Control water intake post meal**
* **Don't perform a gastropexy → 75.8% of dogs will develop GDV again**
56
List factors that increase the risk of bloat (GDV) in large breed dogs.
* Raising the food dish→doubles the risk
* Very fast eaters→ 38% increased risk
* Age →risk increases 20% w/ each additional yr of age
* Family HX →immediate relative w/ GDV increases patient's risk by 63%
57
**When is the risk of post-op mortality the most high for GDV patients?**
**First 4 d. post-op**
58
What often is the **PRIMARY** cause of post-op mortality in GDV patients?
(3)
* Gastric necrosis
* Gastric rupture
* Peritonitis
59
What is often the **SECONDARY** cause of post-op mortality in GDV patients?
Cardiac arrhythmias (50.6%)
