Gastric Dilatation – Volvulus (GDV)

Gastric Dilatation –
Volvulus (GDV)
Takanori Sugiyama MS, MVDr, MANZCVS
2nd year resident
How many of these
will develop GDV?
Overview
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Incidence
Risk factors
Pathophysiology
Surgery
Outcome
Prognostic factors
Incidence
• Glickman et al JAVMA 2000a
– 2-4% in large breed
– 2.7% in giant breed
– Life time risk: 21-24% for large and giant
breed dogs
– Risk increased by 20% with each year of
age
Aetiology
• Unknown
• Considerable risk factors:
• Increasing age (Evans and Adams 2010,
Glickman 1994, 2000)
• Breed/Chest conformation (Glickman 1994,
Brockman 1995)
• Inheritance (Glickman 2000b)
• Diet related: (Raghavan 2004)
• Lean body (Glickman 1997, Raghavan 2004)
• Personality (Glickman 2000b)
• Previous splenectomy (Grange 2012)
• Pre-existing GI problems (Gazzola 2014, de
Battisti 2012, Braun 1996)
Risk factors - age
• Glickman et al JAVMA1994
– 1934 GDV and 3868 control multi-centre
study
• Glickman et al JAAHA1998
– trend of dying with increasing age, but
statistically not significant
• Glickman et al JAVMA 2000b
– Risk increased by 20% with each year of
age
Risk factors - breed
• Glickman et al JAVMA1994
– Great Dane, Weimaraner, St Bernard, Gordon Setter, Irish
Setter, Standard Poodle
• Brockman 1995
– German Shepherd, Great Dane
• Glickman 2000a,b
– Likelihood of large/giant breed developing GDV
during its life time is 21-24%
– Risk of developing GDV in Great Dane in life time
is 42.4%, dying from GDV is 12.6%
• Evans and Adams JSAP 2010
– Otterhound, Irish setter, Weimaraner in the UK – GSD was
excluded
Risk factors – body conformation
• Deep chested breeds – abdominal height and
width ratio
• Lean body (Glickman 1997, Raghavan 2004)
• Large body size and deep chested structure –
large abdominal cavity for a stomach heavily
filled with food to stretch the hepatogastric
ligament (Hall 1995)
• Separation of gastrosplenic ligament during
splenectomy should result in GDV – no
significant difference (Grange 2012)
Risk factors - inheritance
• First-degree relative with a hx of GDV
(Glickman 1997, 2000a,b, Raghavan
2004)
Risk factors - feeding
• Risk increased by 30% with increase in
speed of eating (Glickman 2000b)
• Raised food bowl increased by 3054%(Glickman 2000b)
• Larger volume of food per meal regardless of
the number of meals per day significantly
increased 2 fold (Raghavan 2004)
• Large volume of food once daily significantly
increased 3 fold (Raghavan 2004)
Risk factors – aerophagia vs fermentation
• Van Kruiningen (2013)
– Stomach gas analysis of dogs with GDV
showed that the gas was from fermentation
and not atmospheric gas
Risk factors - personality
• Fearful dogs are more risk (Glickman
2000b)
• Nervous, stressed dogs (Glickman
1994)
Risk factors – previous splenectomy
• Goldhammer (2010)
– Only one of 37 dogs had GDV after splenectomy,
and GDV did not develop in controlled dogs
– Not significant
• Grange (2012)
– Splenectomy 8% GDV vs control (enterotomy)
6.4% GDV
– Not significant
• Sartor et al (2013)
– 5 times higher incidence of GDV in previous
splenectomied patients
Risk factors – pre-existing GI diseases
• Gastric motility (Gazzola and Nelson
2014)
– Abnormal motility and delayed gastric
emptying are suspected as the cause
• Foreign body (de Battisti et al 2012)
– Gastric FB was 4.9 times higher risk of
developing GDV
• IBD (Braun et al 1996)
– Intestinal biopsy in GDV patients
– 60% had IBD
Pathophysiology
• Clockwise vs anticlockwise rotation of
the stomach
• Involvement of the
spleen
• Stomach wall necrosis
Pathophysiology
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Obstructive shock
Distributive shock
Hypovolemic shock
Haemorrhagic shock (minor role)
Septic shock (minor role)
Cardiogenic shock
Pathophysiology
Anatomy – arterial supply
From Tobias and Johnston: Small
Animal Surgery textbook pp 1487
Surgical procedures
• Decompression
– Stomach tube vs trocarization in 116 dogs with
GDV (Goodrich 2013)
• Orogastric tube successful in 77% - 23% was
inability to pass the tube, sedation was required
in 38%
• Trocharization successful in 86% - high
success rate, no sedation
• Derotation of the stomach
• +/- partial gastrectomy
• +/- splenectomy
• Gastropexy
Partial gastrectomy
• Invagination vs gastrectomy
• Evaluation and judgement
– Colour
– Consistency
– Haemorrhage
• Staplers vs hand sawing (Clark and
Pavletic1991)
Gastropexy
• Allen and Paul 2014 – review paper
– Open
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Incisional
Belt-loop
Circumcostal
tube
– Less invasive approach (for prophylactic
gastropexy)
Gastropexy effective?
• Glickman 1998 – 85 cases
– 54.5% recurrence rate without gastropexy
– 4.3% recurrence rate with gastropexy
• Meyer-Lindenberg 1993
– 75.8% recurrence without gastropexy
– 6.6% recurrence with gastropexy
• Gastrocolopexy – 20% recurrence (Allen and Paul
2014)
• Gastropexy considered in dogs with splenectomy and
at-risk breeds (Goldhammer 2010)
Prognosis
• Mortality rate - overall
– Up to 60% in 70-80s (Muir 1982)
– 33.3% (Glickman 1994)
– 15% (Brockman 1995)
– 18% (Brourman 1996)
– 24.3% (Glickman 1998)
– 16% (Beck 2006)
– 10% (Mackenzie 2010)
– 17% (Santoro Beer 2013)
Mortality by severity of GDV
• GDV with partial gastrectomy
– 60% (Matthiessen 1985, Clark 1991)
– 31% (Brockman 1995)
– 35-46% (Brourman 1996)
– 26% (Beck 2006)
– 9% (Mackenzie 2010)
• GDV with splenectomy
– 32% (Brourman 1996)
– 15% (Mackenzie 2010)
• GDV with partial gastrectomy+splenectomy
– 54% (Brourman 1996)
– 20% (Mackenzie 2010)
• Sepsis and peritonitis 29-68% (Beck 2006)
Prognostic factors - hypotension
• Beck et al JAVMA 2006
– Age, gastrectomy, DIC were risk factors for
development of hypotension
– Overall prognosis is favourable, but
following affected prognosis:
• Clinical signs >6h
• Hypotension at any time
• Peritonitis, DIC, sepsis
– Early treatment to fight hypotension
Prognostic factors – clinical presentation
• Glickman JAAHA1998
– Recumbent at the presentation: 4.4times
higher risk of dying
– Depressed or comatose patients: 36 times
more likely of dying
– Gastric necrosis: 11 times greater
probability of dying
FDPs
• Millis et al Vet Surg1993
– Tried to correlate prognostic factors and
predictive value
– FDP APTT and ATIII were most useful in
predicting gastric necrosis
• Beck JAVMA 2006
– FDP, APTT, AT III were not significantly
associated with short-term outcome, but
associated with DIC
Plasma lactate concentration
• de Papp et al JAVMA (1999)
– 99% survival with <6.0mmol vs 58%
survival with >6.0mmol
– Preoperative plasma lactate concentration
was good indicator of gastric necrosis and
outcome for GDV
Plasma lactate concentration
• Zacher et al JAVMA (2010)
– 90% survival rate in dogs with initial
concentration <9.0mmol vs 54% survival
rate with >9.0mmol
– 91% survival at absolute concentration
<6.4mmol
– 86% survival at absolute change >4mmol
– 100% survival at percentage change
>42.5%
Plasma lactate concentration
• Green et al JVECC (2011)
– Initial plasma lactate >6mmol is not
predictive of gastric wall necrosis or
survival in dogs with GDV
– A decrease in plasma lactate
concentrations >50% within 12 hours
may be a good indicator for survival
Plasma lactate concentration
• Santoro Beer, et al JAVMA (2013)
– Cut off of 7.4mmol 82% accurate for
predicting gastric necrosis, 88% accurate
for predicting outcome
Arrhythmias
• No statistical correlation between development of
arrhythmias and outcome (Brockman 1995)
• Arrhythmias in 47/120 dogs (Muir 1982)
– 11 death with arrhythmias
– 28 death without arrhythmias
• Preoperative arrhythmias 38% of dogs (Brourman
1996)
• Postoperative arrhythmias in 50.6% (12 pre-op, 43
intra-op, 29 post-op) (Beck 2006)
• Preoperative arrhythmia 11%, postoperative
arrhythmia 77% (Mackenzie 2010)
Complications
• Regurgitation
– Aspiration pneumonia
– Esophagitis
• Abnormal gastric motility
• Further gastric necrosis – perforation,
sepsis
• SIRS and DIC
Conclusion
• Still no known aetiology
• Widely accepted risks and preventative
methods
• Prophylactic gastopexy in high risk breed
• Prognostic factors depending on
metabolic status of the patients = severity
of disease
• Intensive care pre- and postoperatively
• Overall current mortality 10-15%, but…
References
Allen, P. and A. Paul (2014). Top Companion Anim Med 29(3): 77-80.
Beck, J. J., A. J. Staatz, D. H. Pelsue, S. T. Kudnig, C. M. MacPhail, H. B. Seim and E. Monnet (2006). 166 cases (1992-2003)." JAVMA 229(12): 19341939.
Braun, L., S. Lester, A. B. Kuzma and S. C. Hosie (1996). JAAHA 32(4): 287-290.
Brockman, D. J., R. J. Washabau and K. J. Drobatz (1995). JAVMA 207(4): 460-464.
Brourman, J. D., E. R. Schertel, D. A. Allen, S. J. Birchard and W. D. DeHoff (1996). JAVMA 208(11): 1855-1858.
Clark, G. N. and M. M. Pavletic (1991). Vet Surg 20(1): 61-68.
de Papp, E., K. J. Drobatz and D. Hughes (1999). JAVMA 215(1): 49-52.
Gazzola, K. M. and L. L. Nelson (2014). Top Companion Anim Med 29(3): 64-66.
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Glickman, L. T., N. W. Glickman, D. B. Schellenberg, M. Raghavan and T. Lee (2000). JAVMA 217(10): 1492-1499.
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