GDV – Double bubble trouble

“Astro” Cooper was one of our recent success stories. His owners caught his illness quickly and he received early treatment, though did experience marked cardiac changes post-operatively. Photo courtesy of Travis Cooper

I am going to start my blog by writing about an emergency situation that brings excitement to my heart and fear to so many. The GDV.

Also known as gastric dilation/dilatation with volvulus, gastric torsion, twisted stomach or just plainly, bloat, this is one of the most life-threatening emergency situations we face in veterinary practice. It commonly occurs in large breed dogs with deep chests and is overrepresented by Great Danes and German Shepherds amongst other breeds. With more space under the rib cage, the stomach may twist on itself, blocking the entrance (to the oesophagus) and exit (to the intestine). Gas forming bacteria continue to form gas which has nowhere to go. So the stomach swells. It rarely occurs in small breeds and certainly would not be the first thing I would consider when presented with a Maltese with a bloated belly!

Signs to watch out for include depression, drooling, retching, collapse and a swollen tense abdomen. The dilated stomach may be difficult to notice in some deep chested dogs where the stomach may be positioned up under the rib cage. Surprisingly, the condition seems to occur more often at night but may also be seen during the day. The few cases that I have seen in practice in the morning have been far advanced, having spent most of the night bloated. However, this is not always the case.

Death may come quickly to dogs with a GDV and is associated with poor cardiac output. The swelling stomach puts pressure on the large vessels in the abdomen returning blood to the heart. Once sufficiently compressed, the heart does not have enough blood flow to provide a normal output to keep the animal alive. Respiratory arrest may also occur as the swelling stomach prevents normal chest excursions for breathing.

This was Astro’s stomach at presentation. The gas bubble in the top left corner is the displaced pylorus which should be positioned below the stomach. Ths stomach is distended with gas, fluid and food, and the small intestine is also markedly dilated. This is a classic presentation for GDV and reflects the “double bubble” image that we look for.

The outcome for a dog with a GDV can be good if caught early and surgery is performed fairly promptly. Diagnosis is usually quick, especially in emergency practices familiar with the presentation.  Xrays can help diagnose a simple bloat from one that involves a twisted stomach.  Early decompression can help to buy some time to allow us to stabilize the dog prior to surgery.  Vets will do this either by passing a stomach tube, which is often unsuccessful if unable to bypass the twist, or by trocharisation, which involves the sterile placement of a large bore cannula through the abdominal wall into the stomach to release some gas and pressure.  This procedure is not without risk but often necessary risk in order to help treat shock and prevent the progression towards death.

Rapid intravenous fluids are administered for shock in the early phase, alongside analgesia, possibly oxygen, and heart monitoring.  Blood tests may also be performed early, some of which may be used to guide prognosis.  Elevations in blood lactate and clotting times may suggest a very poor outcome after surgery.

During surgery, the stomach is carefully rotated back to its normal position and a procedure called a gastropexy is performed to attach the stomach to the internal abdominal wall.  This procedure aims to prevent the stomach from twisting again in the future.  The stomach wall will also be evaluated for viability.  In some of the more advanced presentations, vessels are torn as the stomach twists and bruising and potentially loss of blood supply can occur, exacerbated by the bloating stomach.  If areas of the stomach wall are thought to have lost their blood supply, the surgeon may consider cutting out this area of the stomach to reduce the potential for post-operative wall rupture.  This is a complicated procedure and some surgeons may prefer to close the abdomen and refer the patient to a specialist to perform a second look surgery in order to provide a more optimal outcome for their patient.  The spleen may also be removed at surgery if there has been evidence of significant trauma or pathology.

Post-operatively, there may be other complications encountered depending on how early the condition has been caught and managed.  It is quite common for dogs to experience heart beat irregularities which may or may not present some clinical signs and may require treatment.  Other dogs with more advanced disease may experience blood clotting issues and generalised inflammatory changes which might require days to weeks of intensive care and significant cost for recovery.  However, the majority of dogs who present to the veterinary practice within the first couple of hours and undergo prompt treatment and surgery will have a good outcome, some going home within 2-3 days of surgery.

At the outset of a consultation for a patient with a GDV, one of the first things that needs to be discussed and considered is the cost for treating these patients.  At specialist referral/emergency centres, there are very few of these patients that leave hospital with a bill of less than $5000 after surgery.  And unfortunately, there are only two options for treating this condition -> surgery or euthanasia.  It is a very emotional condition and one that does not allow a lot of thought or reflection before decisions must be made.  Trying to manage these patients without surgery is, in my opinion, unethical and prone to failure.  There is the very, very rare case where the stomach may de-rotate by itself once decompressed enough, without surgery.  However, these cases are either only partially twisted to begin with, or very likely to twist again in the very near future.  So they still require surgery to at least have a gastropexy performed and prevent the need for an emergency surgery or euthanasia.

Why does this condition occur?  Well this is the $50 million dollar question with many different answers rarely proven or agreed upon.  The only proven method to prevent a GDV is to have a gastropexy performed on your dog at a young age.  For female dogs who are not being used for breeding, the recommended time to have this performed is when she is being neutered.  One opening of the abdomen for two procedures which will help provide a long and healthy life (barring other diseases of course!).  Male dogs could also have this done at the time of castration so they only require one anaesthetic, though they will have two wounds to recover from.  This procedure should be considered for any large breed dog, including Labradors and Golden Retrievers.  I highlight those two breeds specifically because they are very prone to simple dilations from over engorgement on food.  The once overstretched stomach does seem to be more prone to being floppy and potentially twisting in the future.

There may be a familial linkage in dogs that experience GDVs, something to consider when questioning breeders if you decide to buy a large breed puppy.  Some studies have found a link also between inflammatory bowel disease in dogs and GDVs, however, the IBD is often only diagnosed at the time of surgery via biopsies of the intestine.  Hard to treat if you are not aware of its presence!

I hope this information can provide pet owners or potential pets owners with some valuable insight so they can be aware of the issues they may come across and be prepared.  If you think your dog may be showing signs of a twisted stomach, you should call and see your local vet urgently.

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