GDV-By; Dr. Dhiren B. Bhoi

GDV and PYLORIC STENOSIS : 

GDV and PYLORIC STENOSIS PRESENTED BY DR. DHIREN B. BHOI M. V. Sc. VETERINARY GYNAECOLOGY AND OBSTETRICS COLLEGE OF VETERINARY SCI. & ANIMAL HUSBANDRY ANAND

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Gastric Dilatation and Volvulus (GDV)

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Introduction: commonly known as ‘bloat’ Stomach dilates and twists into an abnormal position Dilatation — Distension with air but located in normal position Volvulus — Distension associated with twisting of stomach on longitudinal axis

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GDV

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Etiology and Risk Factors: Cause is multi-factorial Non-dietary R.F – Large and deep chested breeds of dogs Stress & hyperactive personality Lean body condition in Giant breeds Breed predisposition - * Great Dane * Labrador * Boxer * Dobermann * St.Bernard * Weinmariner * GSD * Irish setter Small breeds – Dachshund, Pekingese

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II. Dietary R.F – Fast eating Aerophagia Single large meal daily Vigorous post-prandial exercise Eating from raised bowl Drinking large amount of water immediately after eating

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Symptoms: Distended / bloated abdomen Non-productive retching Excess salivation Abdominal pain Anorexia Hyperpnoea Increased heart rate and respiratory rate Pulse deficit due to cardiac arrhythmia Enlarged spleen is often palpable

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Pathophysiology of GDV: Dogs often present in shock with – Pale mucus membrane Prolonged CRT Rapid, weak and thready pulse Gastric Accumulation of Gas, Fluid or Both -functional or mechanical outflow obstruction Rotation of the stomach (usually clockwise)

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Thoracic and Diaphramatic Impingement Decreased Tidal Volume Decreased Blood Flow to Caudal Vena Cava and Portal Vein Decreased Venous Return Decreased Hepatic Endotoxin Clearance Gastric Ischemia Gastric Necrosis Gastritis Cardiac arrhythmia – ventricular, MDF Disseminated Intravascular Coagulation (DIC)

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Diagnosis: Based on signalment and History Physical examination Plain Radiography Right Lateral View – Distended stomach in abnormal position Pylorus seen dorsally as a separate gas filled structure Contrast Radiography – Barium meal ECG – to detect cardiac arrhythmia Blood Gas Analysis – to evaluate respiratory compromise

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7. Lab findings – CBC, Serum chemistry, urinalysis – to assess metabolic status High plasma lactate level – predicture of gastric necrosis at surgery Hemoconcentration Hypokalemia is often seen

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Double-bubble appearance of stomach

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Abdomen – VD view Abdomen - Lateral view

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Differential Diagnosis: Gastric Dilatation without torsion (by radiograph) Intestinal volvulus Mesentric torsion Splenic torsion Abdominal effusion / haemorrhage Foreign body Neoplasia Hernia

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Treatment: Goals Correction of Gastric Malpositioning Assessment and Treatment of Gastric and Splenic Ischemic Injury Prevention of Recurrence Pre Surgical treatment - Stabilising the patient with I/V fluids and Oxygen therapy Gastric decompression – to reverse CV deficits - by orogastric intubation - placing 16 or 18 g needle at the point of distension in right flank region

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Corticosteroids – for hypovolemic shock - to stabilise lysosomal membrane - Dexamethasone @ 4mg/kg Deferoxamine – to prevent reperfusion injury Antibiotics II. Surgical treatment: Emergency temporary gastrostomy for initial decompression Gastropexy

Gastropexy Techniques : 

Gastropexy Techniques

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Prophylactic Gastropexy Incorporating Gastropexy Tube Gastrotomy Circumcostal Gastropexy Belt-Loop Gastropexy Permanent Incisional Gastropexy Laproscopic Incisional Gastropexy

Gastropexy- Goal : 

Gastropexy- Goal To permanently adhere the stomach to the body wall. Gastric muscle must be in contact with the muscle of the body wall.

Incorporating Gastropexy : 

Incorporating Gastropexy

Incorporating Gastropexy : 

Incorporating Gastropexy Surgical Technique Pyloric antrum is grasped and sutured into linea alba along with routine abdominal closure.

Incorporating Gastropexy : 

Incorporating Gastropexy Pros Extremely Quick Useful in emergency situations Cons Liability in Future Abdominal Surgeries Not for routine use

Tube Gastrostomy : 

Tube Gastrostomy

Tube Gastrostomy : 

Tube Gastrostomy Surgical Technique A Foley catheter is placed through stab incision in abdominal wall. A Purse-string suture placed in pyloric antrum and a stab incision is made into the gastric lumen. Catheter is placed through gastric stab incision. The balloon is inflated and the purse-string suture is tied. The pyloric antrum is sutured to abdominal wall with pre-placed simple interrupted sutures.

Tube Gastrostomy : 

Tube Gastrostomy Pros Relatively Quick Technically Simple Permanent Adhesion Allows for Post-op Gastric Decompression Cons Premature Tube Dislodgement Balloon rupture Removal by patient Local or generalized peritonitis/cellulitis (leakage around tube) Persistent Stroma Drainage Extended Hospital Stay Recurrence 5-29%

Circumcostal Gastropexy : 

Circumcostal Gastropexy

Circumcostal Gastropexy : 

Circumcostal Gastropexy Surgical Technique Flap is created from muscularis layer of ventral pyloric antrum . Incision is made over the costochondral junction of the most complete caudal rib. Through peritoneum and transversis m. The rib is exposed using blunt dissection Gastric Flap placed beneath exposed rib Flap is re-sutured to its original gastric margins

Circumcostal Gastropexy : 

Circumcostal Gastropexy Pros Lower recurrence rate than tube gastrostomy Stronger pexy than tube or permanent incisional gastropexy. Does not enter gastric lumen (less risk of leakage) No special post-op management Cons Technically more difficult than tube gastrostomy Potential complications rib fracture pneumothorax

Belt-Loop Gastropexy : 

Belt-Loop Gastropexy

Belt-Loop Gastropexy : 

Belt-Loop Gastropexy Surgical Technique Two parallel stab incisions made in the parietal peritoneum and transversus m Flap is made in ventral pyloric antrum Gastric flap is passed through abdominal loop and sutured back to original gastric margins

Belt-Loop Gastropexy : 

Belt-Loop Gastropexy Pros Quick Technically simple (compared to circumcostal method) Cons Some degree of technical difficulty

Permanent Incisional Gastropexy : 

Permanent Incisional Gastropexy

Permanent Incisional Gastropexy : 

Permanent Incisional Gastropexy Surgical Technique Longitudinal incision in the muscularis layer of the ventral pyloric antrum Incision into peritoneum and transverse abdominus m. in the right ventrolateral abdominal wall. Gastric incision is sutured to abdominal wall incision w/simple continuous pattern

Permanent Incisional Gastropexy : 

Permanent Incisional Gastropexy Pros Relatively Simple Quick Avoid complications of tube gastropexy Avoid technical difficulty of circumcostal and belt-loop methods Cons Invasive as a purely prophylactic technique.

Laproscopic Incisional Gastropexy : 

Laproscopic Incisional Gastropexy

Laproscopic Incisional Gastropexy : 

Laproscopic Incisional Gastropexy Surgical Technique Abdominal insufflation with CO2 Midline trocharization for laproscope port Right side trocharization for grasping stomach and gastropexy Gastropexy technique similar to permanent incisional gastropexy

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Laproscopic View - Grasping Stomach with Laproscopic Babcock Forceps

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Laproscopic View of Gastropexy from Inside the Abdomen

Laproscopic Incisional Gastropexy : 

Laproscopic Incisional Gastropexy Pros Minimally Invasive Technically Simple Quick Similar to Permanent Incisional Gastropexy Cons Mainly for prophylactic use. Expense and Maintenance of Laproscopic Equipment

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PYLORIC STENOSIS

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Benign thickening of various layers of muscle and mucosa of pylorus obstruction to flow of food and water thro stomach also known as congenital pyloric muscle hypertrophy CHPG – both mucosa & muscular layer Etiology: common in young animals Hypergastrinemia along with stress, drugs, trauma & electrolyte abnormalities Seen in Boston terriers, Boxers and Siamese cats

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Symptoms: Intermittent vomiting Reflux oesophagitis Abdominal distension Good appetite with weight loss No abdominal pain Lab findings: Metabolic Alkalosis – due to vomiting Hypokalemia Hypochloremia Hemoconcentration

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Diagnosis: By history and physical examination Gastroscopy – biopsy to ensure thickening is benign Survey radiography – only gastric distension seen Contrast radiography – pyloric wall thickening & filling defects seen Ultrasonography - pyloric wall thickening and neoplasia detected

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Surgical treatment: Pyloromyotomy - Fredet-Ramstedt pr. Transverse pyloroplasty – Heineke-Mikulicz pr. Y-U pyloroplasty – for mucosal hypertrophy Pylorectormy with gastroduodenostomy (Billroth-I)

References : 

References Fossum, Theresa W. Small Animal Surgery, 2nd Ed. Mosby, 2002. Slatter, Douglass. Textbook of Small Animal Surgery, 3rd Ed. Saunders, 2003. Rawlings, C.A., Mahaffey, M.B., Bement, S., & Canalis, C. Prospective evaluation of laproscopic-assisted gastropexy in dogs susceptible to gastric dilatation. J Am Vet Med Assoc. 2002 Dec 1;221(11):1576-81.

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