Case of the Week #1 – GDV, or Bloat

Pet: LaBrie
Age: 6 yrs, 3 mos.
Species: Canine
Breed: Great Pyrenees
Color: White
Sex: Female, spayed

LaBrie presented to Acupet Veterinary Care in January 2013 at 11:00 on a Monday morning. She had been fine the night before and ate her morning meal that day at approximately 8:00am.

At approximately 9:00 she started to exhibit retching signs, which were non-productive. This continued over the course of the next hour, while simultaneously she began to salivate profusely.

Within the next hour she became increasingly depressed and refused to lay down, which was unusual for her. Between her episodes of pacing the floor, she would stand with her head down, salivating, and continuing to vomit unproductively.

Her owner was increasingly concerned that she had eaten something outside that morning, including possibly a poisonous toad, which she knew she had in the backyard. LaBrie was the type of dog who never had gastric issues, and so the owner became worried very rapidly, which probably helped save the pet’s life.

She called the office and we had her bring the dog in immediately. When taking the history from the owner my first thought was to agree with her – that maybe the dog had ingested something very bad outside, and we were looking at a case of acute, severe food poisoning. The history fit, and given the fact that LaBrie usually had an iron gut, that was my initial differential diagnosis when starting the physical exam (PE).

I usually start my PEs from the back of the dog and work my way forward. When I palpated the abdomen it was immediately obvious that this wasn’t food poisoning, and that something was structurally wrong in the abdomen. I felt a large (small pumpkin-sized), very firm swelling in the mid to cranial (forward part) abdomen, and the pet was obviously uncomfortable on palpation.

The chest was normal, and there were no cardiac murmurs or arrhythmias. Their heart rate was 148, with normal for a dog LaBrie’s size being approximately 110-120. Peripheral lymph nodes all palpated normal, and the eyes, ears, nose, and throat were normal, with the exception that the blood refill time in the oral mucosa was slightly slow. Peripheral pulses were slightly reduced in intensity.

My initial thought at this point was bleeding abdominal mass, with what’s called “Acute abdomen.” It’s not unusual at all to have an animal (dogs and cats both) develop a mass in the abdomen and act relatively normal until the mass becomes a big problem all at once. Then the pet often presents extremely ill, and the signs can be severe. I was thinking that was the case with LaBrie.

We took her immediately to x-ray to shoot a series of abdominal films. I also discussed with the owner the possibility of doing an ultrasound on the abdomen for further clues. However, after we shot the first x-ray we immediately went back to the owner and advised immediate abdominal exploratory surgery. That first x-ray is presented here.

All the dark area in the abdomen is gas that’s accumulated in the stomach and small intestines. This film is a 100% confirmation of a condition in dogs called Gastric-Dilatation-Volvulus (GDV), or Bloat for short.

At this point it’s a race against the clock to get the dog to surgery and correct the GDV. The owner was an extremely good owner and listened attentively as I explained the gravity of the situation. She immediately gave us the authorization to take LaBrie to surgery, and we canceled all other appointments as we raced the clock.

We immediately pulled blood for lab values, and then placed an IV catheter. As the bloodwork was running we sedated the dog and started shock volumes of IV fluids. Antibiotics and pain medications as well as medications for shock were all administered IV, and the dog was prepped for surgery. An EKG to monitor for cardiac arrhythmias was run as the dog was prepped. After prepping the pet was moved to surgery and the surgery team assembled. The total time from owner authorization to surgery was 17 minutes.

Surgery went well. After entering the abdomen I decompressed the stomach with a large bore hypodermic needle. Within ten minutes I had the stomach decompressed and de-rotated to its correct position. We then passed an oro-gastric tube (this is a half-inch plastic tube that is passed from the mouth down to the stomach) and removed more gas and stomach contents.

Once the stomach was back in its normal position and decompressed the abdomen was explored for collateral damage. The spleen is always a primary focus of a GDV. When the stomach flips it takes the spleen with it, as they’re closely attached. When that happens it shuts down the blood supply to the spleen, and the spleen gets ischemic.

When this happens it becomes a judgment call as to whether the spleen is still viable upon re-vascularization, or if the damage is permanent, and the spleen is destined to become necrotic. In LaBrie’s case, the spleen was engorged to approximately twice its normal size. This was because of occlusion of the normal venous drainage from the organ. In addition, there were areas of deep purple congestion, indicating areas of severe ischemia. There was a definite possibility that the spleen would survive post-surgically. However, there was also the possibility that at least parts of it would die and become necrotic. Also, when the blood supply to an organ is occluded, free radicals and other organically reactive molecules accumulate in the de-vascularized organ.

When the organ is returned to normal function these free radicals and toxins are released into the general circulation, thus introducing toxic insult to the body. This is a major cause of post-surgical death in many otherwise successful GDV surgeries.

Because of the possibility of this post-surgical toxicosis, I opted to remove LaBrie’s spleen. Once that was accomplished the stomach was decompressed and lavaged one last time, and the abdomen was closed routinely.

Post-surgically LaBrie did well. She never developed the arrhythmias we see so commonly post-GDV surgery, and her pain was controlled successfully with morphine. We kept her at our office for the next two days and transferred her to the emergency room both nights for continuous monitoring, fluid administration, and pain control. She went home late on day 3, and her recovery from there was uneventful. She’s doing well to this day.