Aceh Journal of Animal Science (2021) 6 (1): 13-18

Aceh Journal of Animal Science

Journal homepage: www.jurnal.unsyiah.ac.id/AJAS

Gastric dilatation and volvulus (bloat)- A case report and mini-review of

literature
Kalaiselvan Elangovan1, Shivaraju Shivaramu1*, Swapan Kumar Maiti1, Sunil Kumar Shirangala Padmanabha2,
Divya Mohan3
1Division of Surgery, ICAR-Indian Veterinary Research Institute, Izatnagar-243122, India.
2Division of Extension Education, ICAR-Indian Veterinary Research Institute, Izatnagar-243122, India.
3 Veterinary Surgeon, Kerala, India.

ARTIC E L INF O ABSTRAC T

Keywords: Gastric dilatation and volvulus (GDV) is a progressing bloat condition in dogs characterized as dilatation followed by rotation of
Bloat
stomach. A sevenyear old 18 kg black colour female non-descriptive dog presented, with history of difficulty in respiration within half
Dog
Gastropexy an hour after feeding of curd meals. With the history and general clinical examination the case tentatively diagnosed as gastric
Lidocaine
dilatation. After unsuccessful advancement of oro-gastric tube, needle gastric paracentesis was performed on left side of the abdomen
Emergency
caudal to the last rib for decompression. Mid-ventral celiotomy and gastrotomy were performed after stabilization of heart rate and
respiratory rate. After evacuating the whitish frothy content from the stomach, derotation and incisional gastropexy was performed.
Received: 9 January 2021
Accepted: 25January2021 On 14th postoperative day telecommunication confirmed the milk based meal induced GDV canine patient recovered uneventfully.
Available online: 28January 2021
Electrocardiogram monitoring done for first 24 hours period and ventricular arrhythmia was managed by using lidocaine
DOI: (loading@2mg/ kg bw followed by 25mcg/kg/min for 30 min). It is concluded that on 14th postoperative day telecommunication
10.13170/ajas.5.2.19384 confirmed the milk based meal induced GDV canine patient recovered uneventfully.

Introduction disturbances, gastric necrosis, splenic hemorrhage,

Gastric dilatation and volvulus (GDV) is a reperfusion injury and bacterial translocation
progressing bloat condition in dogs characterized as (Broome and Walsh, 2003; Paravicini et al., 2020).
dilatation followed by rotation of stomach. There are Surgical intervention is a choice of therapy in these
multiple factors predisposed and exact cause clearly cases with stabilization. In this case report we are
not understood (Goshall et al., 1999; Maki et al., addressing a successful management of gastric
2017). This is a life threatening syndrome commonly dilation and volvulus affected dog and short review.
affecting deep and narrow chested breed of dogs
(Grauer et al., 1978; Raul et al., 2018; Da Silva et al., Case History, Presentation and Diagnosis
2012). In comparison of human literature, rotation of A seven year old 18 kg black color female non-
stomach less than or more than 180 degree often descriptive dog presented on January 1 2018 to
referred as gastric torsion or volvulus, respectively. Teaching Veterinary Clinical Complex & Referral
But in veterinary literature torsion and volvulus are Veterinary Polyclinic, with history of difficulty in
used synonymously. This syndrome displays high respiration within half an hour after feeding of curd
fatality rate by the causing hypovolemia, cardiac meals. The ailments described by the owner are

* Corresponding author.
Email address: [email protected]

Printed ISSN 2502-9568; Electronic ISSN 2622-8734

This is an open access article under the CC - BY 4.0 license (https://creativecommons.org/licenses/by/4.0/)
Kalaiselvan et al. Aceh Journal of Animal Science (2021) 6 (1): 13-18

progressive engorgement of abdomen, respiratory of the stomach. Gastrotomy incision was closed in
distress and frothiness on mouth. General clinical two layers Connell pattern reinforced with Lembert
examination revealed sudden bloat with pattern using polyglaction-910. Before derotation, to
progressively diminishing patient condition. The combat reperfusion injury a single dose
patient was presented with symptoms like dexamethasone @ 0.5 mg per kg body weight was
aerophagia, siallorhea, dyspnea, tachycardia administered.
(innumerable via auscultation), and weak femoral Derotation was done as follows: pyloris hooked
pulse, prolonged capillary refill time (CRT), pale and by right index finger with compression of fundus of
dry mucous membranes and asynchrony of heart rate stomach, then the stomach reverted to normal
and pulse rate. With the history and general clinical anatomic location. Spleen follows stomach rotation.
examination the case tentatively diagnosed as gastric Unwrapped mesentery of stomach and normal
dilatation. The weak pulse and easy palpation of anatomic location of spleen and pylorus ensures
spleen preclude for GDV. complete derotation. Splenic examination revealed
mild red infarct on the surface. The discussion with
Medical Therapy owner about splenectomy was unsuccessful, so
Immediately we administered aggressive fluid procedure was not performed. Incisional gastropexy
therapy (90 ml per kg body weight) on both the was performed on right abdominal wall using 2-0
cephalic vein. After Unsuccessful advancement of polyglactin 910 sutures. Mid-ventral celiotomy
oro-gastric tube made us to perform needle gastric incision was closed in three layer patterns as follows:
paracentesis on left side of the abdomen caudal to the linea alba with interrupted suture pattern,
last rib for decompression. Surgical intervention was subcutaneous tissues closed with simple continuous
considered after stabilization of heart rate and suture pattern and skin was closed with cross
respiratory rate. mattress pattern using polyamide suture.
Surgical treatment
The dog was premedicated with atropine sulphate
@ 0.04mg/kg, [email protected]/kg and
Butorphanol @ 0.2mg/kg body weight. The animal
was restrained on dorsal recumbency and mid ventral
celiotomy site (from xiphoid to brim of pelvis)
prepared aseptically and pre-oxygenated. Anesthesia
was induced with propofol@4mg per kg “till effect”
and maintained with isoflurane. Vital parameters
were monitored till recovery of patient. Real-time
ECG showed occasional ventricular premature
complex.
Mid-ventral celiotomy skin incision was
performed from xiphoid to pubis. On subsequent
dissection of linea alba a layer mesentery covered Figure 1. Dilated and rotated stomach was observed
distended stomach was found (Figure 1). This immediately after entering into abdominal cavity.
confirms the gastric torsion. Because in normal
anatomical stomach mesentry won’t wrap around the
stomach and in mid-ventral celiotomy also we can’t
find mesentery covered over stomach. Pulling aside
of mesentery showed small pin point congestion over
the stomach and displaced spleen. Gastrotomy was
performed on near greater curvature where fewer
blood vessels noticed. About 3.5 liter foamy sour
odorous gastric contents were evacuated (Figure 2).
Warm water lavage and suction was done 2 times till
clear warm water sucked out by medical suction
device. Gastric mucosa was assessed grossly to rule
out necrosis. We have noticed small area of
discoloration and gross necrotic changes in and out Figure 2. White foamy sour odorous gastric contents were
evacuated from dilated stomach.
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Kalaiselvan et al. Aceh Journal of Animal Science (2021) 6 (1): 13-18

Figure 3. Pathophysiological events during gastric dilatation with volvulus (Systemic effects).

Figure 4. Pathophysiological events during gastric dilatation with volvulus (Local effects).
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Kalaiselvan et al. Aceh Journal of Animal Science (2021) 6 (1): 13-18

Postoperative care surgeons (Song et al., 2020). The pathophysiology of

The suture line was protected by abdominal GDV causes multi-organ dysfunction. Though
bandage. Nothing per os followed for 24 hours. pathological events occur parallel, for the
Electrocardiogram monitoring was done for first 24 understanding purpose it has been divided into local
hours period and ventricular arrhythmia at 14th hour and systemic effects (Tivers and Brockman, 2009a),
of postoperative period was managed using lidocaine which are depicted in figure 3 and 4. Acidosis,
(loading@2mg/kg body weight followed by hyperlactemia, prolonged capillary refilling time,
25mcg/kg/min for 30 minutes). Slow intravenous decreased cardiac output, increased levels of cardiac
potassium given along with fluid therapy for first two troponin I and T along with gastric distension
postoperative days. The animal was discharged on associated clinical signs evidences in GDV affected
second post operative day as per owner wish. dogs.
Postoperative antibiotic (Ceftriaxone@20mg/kg), Acute nature of devastating condition needs
analgesic ([email protected]/kg) and fluid therapy immediate diagnosis and stabilization of patient. The
(Ringers lactate) was advised for 7 days. stabilization procedure includes restoration of
circulation, decompression of the stomach and
Discussion maintaining almost normal vital parameters to
Gastric dilatation and volvulus is a critical proceed for surgical correction of GDV. Shock fluid
emergency case. The critical events progress from therapy using crystalloids, colloids or hypertonic
stomach rotation and eventually cause mortality. saline commonly followed, it’s advised to have blood
There are many predisposing factors well products because large volume resuscitation may
documented but exact cause is unknown for GDV. drops the PCV. In addition empirical shock therapy
Breed, age, body size and conformation, gastric and @ 90 per ml kg no longer recommended due to fluid
pyloric variations in location and activity are intrinsic overload. Hence titration of fluid therapy according
risk factors for GDV. Breeds with less thoracic width to patients is mandatory. Decompression can be
and high thoracic height are most susceptible. Pure carried out in many ways like orogastric,
large breeds like Great Dane, Saint Bernard, and percutaneous or laparoscopy assisted. But failure of
German shepherd are most susceptible. A recent orogastric method of gastric decompression does not
poster report documented that feeding from height, preclude GDV confirmation. Moreover needle or
presence of gut sounds and history of previous percutaneous gastric decompression assists passing
abdominal surgery are influencing factors in the of orogastric tube into stomach and further useful for
development of GDV in grey hounds (Dolbear and luke warm gastric lavage. Eventually in stabilization
Dunning, 2019). Neutered female animals have high part use emergency drugs to maintain stable vital
incidence of GDV (Pipan et al., 2012). High incidence parameters considered. Radiography is not necessary
of GDV is reported in old aged patients. Feeding to diagnose gastric dilation but is an invaluable aid in
program, animal temperament and environmental diagnosing volvulus (Hathcock, 1984; Brockman,
factors are extrinsic risk factors responsible for GDV 2008). It is a necessary tool to differentiate between
(Glickman et al., 1994; Glickman et al., 1997). gastric dilatation (GD) and gastric dilatation and
Interestingly we observed that the day of case volvulus (GDV). In radiographic view double
presentation was humid (Humidity: 79-100%) with bubble/compartmentalization/popeye arm sign,
high barometric (maximum 1022 mbar) pressure displaced spleen and pylorus are characteristic for
than rest of the week days (timeanddate.com, 2018). GDV and just single distended structure of stomach
The onset of clinical signs displayed often after a gastric dilatation (Paravicini et al., 2020). Right lateral
large meal with or without extreme activities. view of abdomen is better choice for GDV patients
Restlessness, gastric distension, lethargy and collapse with prior stabilization and decompression. In
are the common signs of GDV affected dogs. surgical intervention, anesthesia should be
Clinically tachycardia, tachypnea, pale mucus appropriate and do not compromises the cardio-
membrane and gastric tympany associated with respiratory functions. Though minimal anaesthetic
cardiac compromise are noticeable derangements of protocols, selection based on deranged physiology of
GDV patients (Pipan et al., 2012). A retrospective GDV affected patients would be fruitful. Use of
study on 736 canine GDV patients found higher nitrous oxide and arrythmogenic agents prohibited in
survival rate during early admission time and surgical these patients. Surgical procedure comprises of
correction within 3 hours of admission by specialist gastric derotation and gastropexy and rarely
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gastrotomy performed prior to gastropexy to remove monitoring of GDV patients due to cardiac
gas and contents of stomach. Midventral incision has arrhythmias which mostly from ventricular origin
supremacy than paracostal or flank incision due to (Homer, 2020). Treatment strategy for arrhythmias,
wide exploration of abdominal organ and easy lidocaine@ 2mg per kg IV followed by 25-50
manipulative maneuver for derotation of stomach. microgram per kg per minute or procainamide@2mg
Mid body incision at 1 to 2 cm dorsal or ventral to per kg per minute if needed 25-50 microgram per kg
the grater curvature of the stomach is a site of choice per minute in refractory lidocaine cases is advised
for gastro-centesis or temporary gastrotomy in GDV rather prophylaxis. Moreover, lidocaine prevents
affected patients, because mid body is an uncommon ischemic reperfusion injury (Bruchim and Kelmer,
site of gastric necrosis (Fox-Alvarez et al., 2019). 2014). These agents are pro-arrhythmic hence use
Gastric deroration often assumed as problematic for with caution when required (Buber et al.,
both experienced and novice surgeons due to 2007missing in list of ref). Diet formulation should
dysbiosis and ischaemic reperfusion injury. be carried for individual patient based on either
Nonetheless many antioxidants are in use, nothing gastrectomy or spleenectomy or any additional
has given fruitful results. Derotation maneuver surgical intervention done.
usually performed after administration of Expected postoperative complications like
antioxidants. hypotension, hypoperfusion, cardiac arrhythmias,
The derotation maneuvers includes emptiness of peritonitis, ileus, systemic inflammatory response
stomach, identification of pylorus and grasping on syndrome and disseminated intravascular coagulation
right hand, supine compression of stomach by left (DIC) should be addressed promptly by fluid
hand, bring back the pylorus from left side to right therapy; oxygen therapy or blood products;
hand side of the animal by gentle traction (Tivers and antiarrythmics; prokinetics; antibiotics
Brockman, 2009b). Assessment of gastric wall, administration and peritoneal lavage are advisable
spleen and other abdominal structures is necessary to (Bruchim and Kelmer, 2014). Systemic inflammatory
improve survivability. Stomach viability usually response syndrome and DIC noticed patients has
assessed by color, wall thickness and presence of poor prognosis. A goal directed therapies would be
pulse in the local vessels of stomach. Bleeding from beneficial in such multiorgan dysfunction syndrome
seromuscular incision would be indication of viable (McGowan and Silverstein, 2015). Close monitoring
stomach wall. Any color change, reduced thickness in early postoperative period about 3 to 4 days may
and reduced blood supply in Doppler warrants partial be recommended to address complications from
gastrectomy. Spleen usually follows paths of stomach severely affected highrisk patients. GDV can happen
and hence rotation of stomach may lead spleen in unusual patients without proper substantial
torsion. Once ensured spleen torsion complete evidences on time, but back tracking and notifying to
splenectomy done prior to correction of splenic veterinarian and owners will improve understanding
torsion to avoid entry of toxins into systemic and to form therapeutic and preventive measures. In
circulation. While spleen inspection any wide area of this report, we found case presented on the high
infarction and palpable thrombi are suggestive for humid weather day after feeding of normal meal and
partial or complete splenectomy. Making permanent managed successfully. Nonetheless full proof of
adhesion between pyloric antrum and right metrological change increased risk of GDV on dogs,
abdominal wall is preventive as well as reoccurrence this has to be considered further for prospective
abolishing surgical procedure in GDV higher risk and controlled investigation on dogs.
affected patients. Rate of reoccurrence is as high as
80% in cases where gastropexy was not performed. References
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