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Understanding Bloat and Torsion

Line Rainbow

Few afflictions kill an otherwise healthy dog as quickly as bloat and torsion. Anyone who's had the misfortune of witnessing bloat can attest to the horrifying and devastating nature of the experience. Although much had been said and written about Gastric Dilation (bloat) with Volvulus (torsion), or GDV, we have yet to find any easy-to-understand guide to early recognition, proper emergency treatment, and after-care of this terrifying killer. This article is a compilation of what we found out through our research over the past 20 years (both from published sources and from discussions with experienced people--owners as well as veterinarians.) It is not meant to be a scientific article--it simply represents our understanding and interpretations of the problem and of how to deal with it.

  1. The Condition and Its Causes
  2. Symptoms
  3. Emergency Treatment of Suspected GDV
  4. Physiological Changes Caused by GDV
  5. Surgery for GDV
  6. Post-Surgery Care and Common Complications
  7. Prevention
  8. Emergency First Aid for Bloat
  9. The Emergency Kit
References

 

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The Condition and Its Causes

Simply put, bloat describes a stomach which has become abnormally enlarged or distended. The stomach is filled with gas, food, liquid, or a combination thereof. Torsion is the abnormal positioning of the stomach which is caused by the stomach's rotation about its axis, i.e. twisting of the stomach. Bloat usually leads to torsion, although torsion can occur without bloat. Chronic gastric volvulus (ongoing mild torsion) may not cause typical signs of GDV, but should be suspected in dogs with intermittent vomiting, weight loss, mild bloating, rumbling sounds in the bowel (borborygmi) and/or belching. Depending on how quickly the problem is dealt with, GDV may result in a stomach that is rotated by anywhere from 90° to 360°. Severe torsion usually means the displacement of both the stomach and the spleen (they exchange positions). The speed at which the stomach empties itself, as well as the stomach's digestive contraction pace, are thought to play a role in the development of GDV. Certain food types (such as peas, onions, beans, beet pulp, etc.) are also implicated. Research analyses of gastric gas from live dogs with GDV suggest that it predominantly results from swallowing air rather than from gastric fermentation (digestive disorder). Some people suggest a genetic predisposition to bloat, while others refute the suggestion. None of these theories has been scientifically proven, and all appear to be only partially true. Based on his extensive clinical experience with GDV cases, Dr. John Lammerding (a Board Certified Veterinary Surgeon) tends to think that GDV in young dogs may suggest a genetic predisposition. However, he believes that GDV in old dogs are typically caused by excessive hyperventilation (sucking too much air) due to the fact that some old dogs, like old people, develop breathing difficulties due to the aging process. In the latter case, GDV could theoretically be prevented by keeping the old dog calm and preventing him/her from hyperventilating. Regardless of the cause of GDV, the end result is a distended and twisted stomach. GDV results in physiological changes that create a medical and surgical emergency. GDV most commonly occurs in large, deep-chested breeds, but has also been reported in Bassets, Dachshunds and cats. Reported fatality rates range from 15% to 60%. There is also a high recurrence rate when surgery (Gastropexy) is not performed to permanently attach the stomach to an anatomically acceptable part of the body, such as a rib. Bloat surgery is a very painful, major operation, and is potentially life threatening especially in cases involving old dogs You should discuss the treatment of bloat and torsion with your veterinarian the next time you see him/her. Not all veterinarians are familiar with the proper emergency treatment of GDV and fewer yet are familiar with proper surgical technique and post-surgery care and monitoring. It is imperative that you make sure that your veterinarian is familiarized with the proper procedures before his/her skills are needed. If your veterinarian is not receptive to or is offended by your queries, then it may perhaps be time for you to find a more responsive veterinarian.

 

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Symptoms

Early signs of bloat may include restlessness, excessive drooling, abdominal pain, retching, and/or non-productive attempts to vomit. The dog may vomit foamy mucous, or a mucousy foam may be evident around the lips. A more advanced sign of bloat is characterized by abdominal distension (enlarged abdomen). Other signs may include pale mucous membrane (evident by pale gum color), and prolonged capillary refill time (detected by pressing the gum with your fingertip and judging the speed at which gum color returns to pink after you stop pressing.) Some people have reported early detection by observing abnormal behavior, such as not wanting to move around; or laying down in a curled up position, etc. when the dog would normally run around and play. During this early phase, stomach enlargement may not be visually evident yet. Bloat can usually be detected when you make the dog stand up and gently feel his/her abdomen. The abdomen should feel soft and tapered inward when the dog is relaxed. If the abdomen feels hard, or sounds hollow (like a drum) when you tap it gently with your hand, then your dog is probably bloating or even torsioning. If you're not sure, get the dog in to the veterinarian (or at least call) right away just in case--it's better to be safe than sorry.

 

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Emergency Treatment of Suspected GDV

The first thing to remember in any emergency situation is to remain calm, your dog's life will depend on your clear thinking and quick actions.
  1. Whenever possible, call the hospital and warn them that you'll be bringing in a bloat case so that they can save precious time by making the necessary preparations while you're on your way. Be sure to indicate your approximate arrival time because some clinics close at set hours regardless of your situation.
  2. If you're not close to the hospital (or if someone else can drive), and your dog's stomach is distended, you may want to initiate emergency first aid by gently passing a well-lubricated tube to decompress the stomach (see EMERGENCY FIRST AID FOR BLOAT section). If you do not have a tube readily available, some people have reported success with the use of a garden hose (with the ends cut off), lubricated with water. Always pass a tube down slowly and gently--push it down an inch or so at a time, and only after the dog has swallowed, without gagging, the section you have already pushed in. NEVER force a tube down--you can do severe damage to the internal organs! If tube passage is unsuccessful due to internal obstruction, then it means the stomach has probably twisted. Get to the hospital as quickly as possible.
  3. It is important that the veterinarian first treat the dog for shock with intravenous fluid and drug therapy. The veterinarian may also start a continuous electrocardiogram (EKG) to monitor cardiac functions.
  4. Generally, the initial goals of emergency veterinary treatment of GDV are to decompress the stomach and to restore and support the dog's blood circulation. If the stomach is twisted, the veterinarian may have to determine the location of the stomach and cut an opening into the stomach through the side of the body to release the gas.
  5. The second step is to determine (by X-rays either before or after decompression) whether simple dilation (bloat) or GDV (bloat with torsion) has occurred. This is very important because simple dilation can often be managed without emergency surgery, but if the stomach has twisted, emergency surgery may be required to reposition the stomach.

 

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Physiological Changes Caused by GDV

GDV results in physiological changes that create a medical and surgical emergency. Changes are both localized (limited to the organs involved, i.e. the stomach and the spleen) and systemic (affecting other vital organs in the body). Increased pressure inside the stomach causes blood flow there to slow and eventually stop. Severe torsion can tear the short branches of the artery between the spleen and the stomach, thus increasing the potential for necrosis (death of cells) of the stomach wall. Displacement of the spleen can cause blood clots in the blood vessels there or even torsion of the spleen. Obstruction of blood flow from these abdominal organs to the heart causes systemic changes. The rapid and often massive reduction of blood returning to the heart reduces cardiac output and therefore deprives tissues of sufficient nutrients and oxygen. Furthermore, the abdominal organs become engorged with blood, which makes the intestines more permeable to the bacteria and bacterial products within them, thus releasing bacteria and their toxic substances (endotoxin) into the bloodstream. The reduced blood flow to the heart, coupled with the circulation of substances released from the pancreas, spleen and other organs severely impair cardiac functions, and cause cardiac arrhythmia (irregular heartbeats). Blood flow to the kidneys falls which increases the risk of acute kidney damage. A condition called Disseminated Intravascular Coagulation (DIC, a life threatening bleeding disorder of the blood clotting mechanism) may occur. Finally, the stomach and/or intestines may perforate, resulting in the contamination of the abdominal cavity with stomach contents and bacteria. A combination of septic, endotoxic and hypovolemic (abnormally low blood circulation) shocks; septic peritonitis (acute and painful inflammation of the membranes lining the abdominal and organ walls); and DIC (bleeding disorder) with multiple organ failures; results in death within hours of the initial signs of bloat.

 

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Surgery for GDV

The immediate aim of surgery is to return the stomach to its normal position and to evaluate it and the spleen for signs of irreversible damage (such as tissue necrosis--cell death). Long-standing or severe twisting may occasionally cause necrosis in portions of the esophagus (the food canal down the throat)--if so, chances for survival is poor. If gastric perforation at any site (perforation of the organ wall) has occurred, then the chances for survival is extremely poor, and euthanasia should be seriously contemplated. Barring any sign of irreversible damage, the veterinarian should perform gastropexy (attaching a flap of stomach wall to an acceptable part of the abdomen in order to help keep the stomach from twisting in the future.) There are a number of techniques of gastropexy, and debate continues as to which method is more effective. The fact that there is still heated debate in the techniques indicates that none is currently totally satisfactory. Again, you may want to discuss it with your veterinarian before there is an emergency. We will briefly describe a few of the more popular techniques :Tube gastropexy - A large balloon catheter is used to secure the stomach to the right abdominal wall. The catheter creates strong adhesions (fibrous scar tissues formed by the body that join normally unconnected parts). The tube must remain in place for 7 to 10 days following surgery. The presence of the tube allows access to decompress the stomach if bloat recurs during the first 10 days. It also permits tube feeding if the dog refuses to eat for more than a couple of days after surgery. Tube gastropexy is the easiest and faster gastropexy technique, and is often used in extremely weak dogs who may not survive an extended period of being anesthetized. The main argument against this technique is that it may not help keep the stomach in place as well as some other gastropexy techniques. The most common complications of tube gastropexy are premature tube loosening and inflammation of the skin where the tube exits the abdomen. Skin inflammation is usually caused by leakage of gastric contents around the tube. Occasionally, the balloon of the catheter becomes eroded by the acidic gastric fluid, causing the tube to dislodge early. This usually happens after 5 to 7 days as the dog becomes more active. Typically, no further treatment is required. However, if the tube dislodges during the first 48 hours, it may be necessary to replace the tube to prevent the risk of contamination of the abdomen with gastric juice. Belt-loop gastropexy - A flap of the stomach wall is used to attach the stomach to the right abdominal wall by braiding the stomach flap to strands of the abdominal wall. This technique takes longer than the tube technique, but may create a stronger bond. However, argument against it is similar to that of the tube's--it may not help keep the stomach in place as well as some other gastropexy techniques. Circumcostal gastropexy - A flap of the stomach wall is used to attach the stomach to the last rib on the right side. The argument in favor of this technique is that the rib is a more rigid and stable part of the anatomy, and will likely keep the stomach in place better than the abdominal wall will. There is a 5% chance of recurrence following gastropexy. Most of the recurrences are simple dilation (bloat without torsion), and respond well to decompression (passing of stomach tube). However, a full blown recurrence of GDV may cause or follow the breakdown of the gastropexy. Therefore, medical and dietary management after GDV is important to help prevent recurrence. In addition to gastropexy, some veterinarians perform pyloroplasty to help prevent recurrence of GDV. pyloroplasty is an operation in which the pylorus (the outlet from the stomach) is widened to ensure the free passage of food into the intestine. In clinical studies, researchers reported a much higher number of complications, during the first week after surgery, in dogs that underwent this procedure as compared to dogs that underwent gastropexy alone.

 

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Post-Surgery Care and Common Complications

Some dogs may continue to have poor circulation and therefore shock despite receiving large amounts of intra-venous fluids. Some dogs may become anemic or hypoproteinemic (abnormally low protein in the blood), and may require blood transfusion or plasma administration. These dogs should be reevaluated frequently by the veterinarian. Cardiac arrhythmia (irregular heartbeat) is common following an acute episode of GDV. The veterinarian should perform frequent EKGs to monitor the heartbeat during the first week. In fact, continuous EKG monitoring for 48 to 72 hours is required in acute cases. Anti-arrhythmic drugs may be necessary to treat this condition. Gastric necrosis (cell death) and perforation can occur up to a week after surgery, especially if resection (surgical removal of part or all of a diseased organ) was performed. The veterinarian must monitor the stomach fluids closely both during surgery and during the first 5 days after surgery :
  1. A pale green to gray fluid indicates arterial (blood vessel) damage caused by ischemic (insufficient blood supply to an organ) or necrotic (dead cells) regions which will require resectioning (surgical removal of part of the organ).
  2. A black or blue/black fluid suggest venous occlusion (blockage in the veins that carry blood back to the heart) and intramural hemorrhage (internal bleeding within the organ). Some of these lesions are not reversible.
  3. Areas with compromised blood supply but do not require resection are dark red.
  4. Researchers also recommend that color be reevaluated 10 to 15 minutes after repositioning and decompression of the stomach, before completing the surgery.

If gastric necrosis and perforation occurs, euthanasia should be seriously considered. Food and water is typically withheld for the first 48 to 72 hours after gastropexy (bloat surgery), then multiple small meals are fed. Once the dog returns home, he/she should be fed smaller-than-usual portions of bland food frequently (3 times daily), and should not be exercised within 2 hours after meals. Veterinary attention should be sought immediately if there are signs of recurrence.

 

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Prevention

There are no sure-fire ways to prevent or predict GDV. Here is a list of suggestions :
  1. Feed 2 or 3 smaller meals daily (as opposed to 1 large meal).
  2. Any changes in the diet should be made gradually, over a period of a week.
  3. Vigorous exercise, excitement and stress should be avoided from 1 hour before to 2 hours after meals.
  4. Excessive drinking should also be avoided.
  5. Avoid feeding food that are known to cause flatulence (gas), e.g. soy, beans, peas, onions, beet pulp, etc.
  6. Some veterinarians advocate the feeding of large pieces of fresh/raw fruits and vegetables (e.g. apples, oranges, carrots) 3 to 4 times a week. The reason is that commercial dog food lacks the appropriate amount of roughage that a dog needs in order for the stomach to function properly.
  7. Some people give their dogs over-the-counter anti-flatulent (Simethecone products, such as Gas X®), just before or after they put their dogs through stressful situations. It may also be handy when the dog appears to have a lot of gas. Simethecone works by breaking down the surface tensions of the small air bubbles in the stomach, thus causing bigger bubbles to form, which theoretically, are easier for the stomach to pass.
  8. On dogs known to be highly susceptible to GDV (e.g. ones that have already bloated before) discuss the use of medicinal prevention (such as Metoclopramide Hydrochloride, or Reglan®) with your veterinarian. The medicine is widely used in human after abdominal surgery to combat painful intestinal flatulence. It chemically decompresses the stomach and intestines, thus forcing the gas out. Like all drugs, there are side effects, so the benefits and problems of long term use should be carefully weighed and discussed with your veterinarian.

 

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REFERENCES

  • __________, "Gastric Dilation-Volvulus in Dogs", Morris Animal Foundation, pp 11-12, 1987.
  • Brockman D.J., BVSc, CVR, CSAO, MRCVS, "Gastric Dilation-Volvulus Syndrome in the Dog", Pedigree Breeder Forum, Vol 3 # 3, 19-23, 1994.
  • Greenfield C.L. et al., Small Animal Clin Sci, Michigan State Univ. "Significance of the Heineke-Mikulicz Pyloroplasty in the Treatment of Gastric Dilation-Volvulus", Vet Surgery 18:22-26, 1989.
  • Hall J.A., College of Veterinary Medicine, Colorado State University, "Gastric Dilation-Volvulus is Associated With Altered Gastric Electro-Electromechanical Activity", Proc Ann ACVIM Forum, 1990.
  • Lieb M.S. et al., College Vet Med, Virginia Tech, "Suspected Chronic Gastric Volvulus in A Dog With Normal Gastric Emptying of Liquids", 191:699-700, 1987.
  • Matthiesen D.T., Anim Med Center, New York, "Partial Gastrectomy as Treatment of Gastric Volvulus: Results in 30 Dogs", Vet Surg 14:185-193, 1985.
  • Whitney W.O. et al., Westbury Animal Hospital, "Belt-Loop Gastropexy: Technique and Surgical Results in 20 Dogs", JAAHA 25:75-83, 1989
  • Woolfson J.M. and Kostolich M., Sch Vet Med, Tufts Univ, "Circumcostal Gastropexy: Clinical Use of the Technique in Dogs With Gastric Dilation-Volvulus", JAAHA 22:825-830.

Picture of A Bloating 5-Year Old Male Standard Poodle

Source: D.J. Brockman, BVSc, CVR, CSAO, MRCVS

"Gastric Dilation-Volvulus Syndrome in the Dog",
Pedigree Breeder Forum, Vol. 3 # 3, 19-23, 1994.

In case you should wonder what a bloating dog looks like, the picture shows a bloating 5-year old Standard Poodle. Notice:
  • The dog looks like he is pregnant.
  • He has already been started on IV fluids.
  • Other than panting, the dog does not appear distressed.
This is a point you should remember -- dogs are stoic and have very high pain tolerance. Sometimes they don't show distress until they're in critical conditions. Therefore as a watchful owner, you must rely on subtle indicators such as changes in behavioral patterns to alert you to potential problems with your dog.
Line Rainbow

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