Gastric dilatation volvulus (GDV), also known as twisted stomach, is a serious medical condition that occurs when the distended and rotated stomach presses on large blood vessels and disrupts normal circulation. It is a life-threatening condition that requires immediate medical attention. GDV is most commonly seen in deep-chested breeds of dogs and has a mortality rate of up to 60% without surgery.
Causes
Gastric dilatation volvulus, more commonly referred to as bloat or twisted stomach, is a life-threatening condition that requires immediate treatment. It occurs when the distended stomach rotates on itself causing a blockage of blood flow to the stomach. The resulting shock and multi-organ dysfunction causes death in animals that do not receive veterinary care on time. GDV is most common in deep-chested large breed dogs, but can affect any dog, regardless of their size or weight.
The disease begins with a full stomach (dilatation) that then twists on itself to form a closed compartment in which gas is trapped. The progressively distending and air-filled stomach also compresses major abdominal vessels that transfer blood back to the heart, causing a reduction in oxygen supply to the body. This decrease in oxygen delivery to the organs, accompanied by reduced blood flow to the stomach and compression of the diaphragm, leads to multi-organ failure and shock.
Signs of a twisted stomach include extreme abdominal pain, difficulty breathing, retching without throwing up any gastric material, drooling, pale gums and lips, rapid pulse and labored breathing. The abdomen is visibly enlarged and hard to the touch, usually with a protruding spleen and/or intestines.
The diagnosis is made based on a physical exam and X-rays, with a CT scan identifying the abnormal anatomic location of the stomach. Surgical intervention is performed after your pet has been stabilized with fluid therapy and blood products, and the tacked stomach is sewed to the internal wall of the abdomen in order to prevent another episode of dilation-volvulus. In some cases, the spleen may be needed to be removed, especially if it shows signs of necrosis; this procedure is called splenectomy. It is important to realize that, even after surgery, there is still a high risk for the development of a new episode of gastric dilatation-volvulus. This is why it is critical to take your pet to the veterinarian as soon as you notice symptoms of a twisted stomach.
Symptoms
The stomach becomes distended with air or fluid (dilation) and then twists on itself (volvulus). This prevents normal gastric emptying, trapping the gas within the twisted stomach compartment. The dilated stomach also compresses major abdominal vessels, restricting blood flow and causing systemic shock and multi-organ dysfunction. In addition, the spleen often twists with the stomach, resulting in internal bleeding and death of tissue in the spleen (necrosis) and bacterial translocation throughout the body (endotoxemia). Diminished oxygen delivery to tissues results in hypoxia, which may cause multiple organ failure and cardiac arrhythmias. The condition is frequently fatal, especially in deep-chested breeds.
Diagnosis
The first step is to critically evaluate the abdomen. The stomach needs to be repositioned, and the surgeon must confirm the correct position via palpation of the gastroesophageal junction. There is often free peritoneal blood from the avulsed short gastric arteries and veins, which need to be ligated. The spleen is usually malpositioned, and the surgeon must determine the cause of this (normal variation, inflammation, metabolic disorder, scarring, neoplasia, or foreign body).
Acute volume resuscitation with shock rate fluids is the next step. The patient is then given a general anesthetic, and the surgeon begins performing surgery to untwist the stomach. A right-sided gastropexy is performed to prevent the stomach from twisting in the future. The surgeon can also perform a partial gastric resection or splenectomy to remove necrotic tissue, if necessary. Antibiotic administration is continued postoperatively based on the high risk of bacterial translocation to other organs. Acute mortality rates can still be high, even with surgical intervention.
Treatment
The first step is to stabilize the patient with rapid volume therapy (isotonic crystalloids bolus, titrated to perfusion) and gastric decompression. Flow-by oxygen is usually given, as are antiemetics and prokinetics. The patient should be monitored closely for signs of shock, e.g., tachycardia and a decrease in the capillary refill time of the legs (hypovolemic shock).
The symptomatic stomach should be palpated to confirm the diagnosis. It is often hard to the touch with a feeling of fullness. If the symptoms progress to volvulus, the abdomen becomes distended and the abdominal muscles will tighten when lightly tapped. There is a hollow percussion sound and the blood vessels in the abdomen are typically pale to cyanotic. The blood supply to the stomach is compromised, causing a decrease in the gastric secretions of acid and bicarbonate and resulting in vomiting.
Once the patient is stabilized, surgery is performed to correct the torso rotation and to ensure the viability of the stomach wall and spleen. The spleen may also be removed to prevent further ischemia if necessary. The stomach is then permanently anchored to the chest wall with a surgical procedure called gastropexy, which decreases the risk of the disease recurrence.
The most common cause of gastroparesis is aging, but it can occur in people with diabetes or nerve damage, and is more prevalent in women. It causes the stomach to empty more slowly, leading to nausea and pain. Non-narcotic pain medicines can reduce the pain, and dietary changes can help. If these measures do not improve the symptoms, a gastroenterologist can recommend medications that inhibit long-term gastric emptying. Another surgical option is a gastric electrical stimulation (GES), which uses surgically placed electrodes to send electric impulses to the stomach nerves and helps decrease nausea and vomiting in some patients. For more information about gastroparesis, visit NIDDK’s website. This site is an excellent source of information on many digestive disorders and conditions, including GERD and gastroesophageal reflux disease.