3. GDV Flashcards
1
Q
What is the definition of Dilatation? What type of treatment can often treat it?
A
Distension of the stomach with fluid, food, and or gas often treated medically
2
Q
Compare and contrast Dilatation and Dilatation-Volvulus
A
- Dilatation (Dilation):
- Distension of the stomach with fluid, food, and or gas (treated medically)
- Dilatation-Volvulus
- Enlargement of the stomach associated with rotation on its mesenteric axis (malposition/twisting) (treated SURGICALLY)
3
Q
What comes first in terms of etiology (GDV versus Volvulus)?
A
4
Q
Patients often has gas accumulation with leads to these 2 things which then leads to gastric dilatation? ****
A
- Abnormal Gastroesophageal Function
- Delayed Gastric empyting
5
Q
What are 2 main factors that increase the risk of GDV?
A
- Dogs with first degree relative with history of GDV
- Increasing age
6
Q
What type of risk factors do Diet contribute to potentially cause GDV? (4) Adding what can decrease the risk (1)?
A
- Increase volume of food fed once daily (deep chested breeds should be fed 2-3 x day)
- Dry kibble
- Fats/oils in 1st four ingredients
- Raised food bowl (up higher so they will eat quicker and take in air)
Decrease risk when you add fish or egg supplements
7
Q
Does exercise cause GDV?
A
Get with the timesssssss thats so old news and was proved not true!!
It has no impact and doesnt contributes to decreased risk either
8
Q
What breed is our posterchild for GDV?
A
Great danes
9
Q
How does conformation increase the risk of GDV?
A
Increased thoracic depth to width ratio (Deep chested dogs)
10
Q
When you see pita smiling what do you think of terms of risk of GDV?
A
“Happy” dogs with decreased risk
BUT INTERESTINGLY there is a Increasing anxiety level, aggression to people, spending 5 hours a day with owner- increased risk (SO QUIT SMOTHERING PITA JENNN)
11
Q
- Case reports state dogs unergoing splenectomy can potentially develop GDV, It’s especially high if this pathology happens to the spleen?
- Dogs undergoing splenectomy vs control dogs had same low risk of developing GDV 6-8% so should we do a gastropexY?
A
- especially high risk with splenic torsion
- Does not support need for gastropexy at time of splenectomy
12
Q
When what vessels and structures are compressed does GDV espepially become an absolute emergency?
A
-
Caudal vena cava Portal vein
- leading to decreased Venous return, decreased CO and BP, and tissue perfusion leading to hypoperfusion (reperfusion)
-
Pushing on the diaphragm
- causing a decrease tidal volume and leads to ventilation perfusion mismatch
13
Q
What is a reperfusion injury?
A
Period when blood flow to tissue is absent followed by return of blood flow
14
Q
Reperfusion injuries leads to an accumulation of this and what happens once perfusion is restored? What do you need todo to help with this
A
- Accumulation of cellular waste products, toxins, and toxic oxygen radicals
- Once perfusion is restored, toxins are release into general circulation
- Important to stabilize prior to untwisting of the stomach or else you could have systemic response
15
Q
Reperfusion Injury
- Increase capillary permeability
- Changes in vascular tone
- ______ aggregation
- _______ ______
- Microvascular occlusions
- ______
- ______ cardiac contractility
- No reflow phenomenum
A
- Neutriphil
- Platelet activation
- Fever
- Decreased cardiac contractility
16
Q
What is the most common displacement with GDV and its 2 presentations in terms of degree rotated?
A
Clockwise rotation Most common
- Torsion: < 180 degrees rotation
- Volvulus: > 180 degrees rotation
17
Q
Is counterclockwise pretty common with GDV, how many degrees is it often displaced when counterclockwise?
A
Rare <5% (<90 degrees)
18
Q
How does the pylorus move with clockwise displacement? What is covered by the stomach?
A
- Pylorus moves along ventral abdominal wall to left side
- Stomach covered by omentum
19
Q
When you are doing a exploratory laparotomy and you see the omentum covering the stomach what does this indicate?
A
Displacement! (clockwise)
20
Q
How does the pylorus move with counterclockwise displacement? Is the stomach covered by omentum in this displacement too?
A
- Pylorus moves dorsally to lie adjacent to esophagus
- Stomach NOT covered by omentum
21
Q
When GDV suspected animals present with a hosotry of chronic GI signs this is indicative of an _______ displacement often?
A
Counterclockwise
22
Q
With counterclockwise displacement the _____ _______ lies along midline
A
greater curvature
23
Q
What types of CS are often see with GDV? (7) Which one is classic GDV signs
A
- Acute
- Restlessness
- Hypersalivation
- “Praying” posture
- Vomiting
- Nonproductive retching (CLASSIC)***
- Weakness
- Collapse
24
Q
when dogs are exhibiting the “Praying” posture what are they doing?
A
Trying to take the weight off the peritoneum
25
What does abdomen often feel like?
Distended, painful, tympanic abdomen
26
Upon physical exam dogs can often exhibit active retching, \_\_\_\_, and varying degrees of _____ (compensatory and decompensatory\_
* Collapse
* Shock
27
What do you need todo to initially stabilize our GDV case?
Aggressive fluid therapy- Large bore cephalic or jugular catheters
(shock dose is 90 ml/kg bc that us replensihing blood volume, give 1/4 of a bolus at a time and monitor)
28
When offering aggressive fluid therapy to stabilize our GDV cases using Large bore cephalic or jugular catheters, why do we not use Intravenous catheters in the legs?
Bc the stomach is compressing the caudal vena cava and the blood isnt going to be getting back to the heart as well as we need it to in that location
29
For initial stabiliation along with fluids we should be monitoring ______ and \_\_\_\_\_\_
* BP
* EKG
30
CBC and chiochem can often be vague indicators fo GDV but what is prettygood for indicating prognsis compared to what it indicated in 1999 comapred to 2011?
* 1999: Lactate levels \< 6.0 shows an increased survival
* 2011
* Absolute values NOT AS VALUABLE
* **CHANGES IN LACTATE LEVELS in response to fluid resuscitation is a better indicator**
31
What is the goal for treatment initially with GDV?
* Goal is to stabilize cardiovascular, respiratory and renal systems initially
* Fluids
* Decompression
* Pain management (can potentiate shock)
* Then use of antimicrobial, free radical scavengers which **occurs after decompression**
* THEN SURGERY and post op tx
32
What does gastric decompression improve?
Improves CV and respiratory function
33
What is the first gastric decompression instrument of choice?
**Stomach tube** (can be difficult ot get past esophageal sphinctor so you may need to trocharize 1st)
34
When performing an orogastric intubation its important to use a roll of vet wrap to prevent this?
Bite block (could swallow bitten off tube)
35
What should we do in terms of sedation for orogastic intubation?
It is better for them to be awake with milkd sedation so can protect their airway with gag reflex or you can fully anesthezie and intubate if you have to
36
Before choosing a tube for orogastirc intubation where should I measure on my patient?
Measure and mark the tube lenth and use the xiphoid as a good landmark located near the last rib
37
With Orogastric intubation why do we advacne the tube slowly and not force the tube?
Can cause Perforation!!!
38
What do you do for gastric decompression once we advance the tube into the stomach? (3)
* Empty contents
* Check effluent
* Gastric lavage
* 5-10 mL/kg warm water
* Gavage pump
39
So if you can't pass the tube to decompress the stomach what is your next step and on what side is it often performed on, also state the potential complications?
**Trocharization**
* Large bore needle/catheter
* **Most tympanic site (LEFT SIDE**, can hear the "ping" but if sounds really dull the spleen could be over the stomach so don't stick the needle in that
* Complications
* Spleen
* Leakage
40
What are the differences in survival for orogastric tubing versus trocharization?
NO DIFFERENCE (shit get that through yo head!)
41
* Tubing is successful \_\_\_\_% of the time
* Trocharization is sucessful \_\_\_\_% of the time
* Is there evidence of gastric perfortion with either
* Tubing is successful **_75.5_** % of the time
* Trocharization is sucessful **_86_** % of the time
* No evidence of gastric perforation
42
What is wrong with this radiograph
Pylorus shouldn't be up there!
43
When performing rads what view should be avoided and why? Which is ok?
* Right lateral and DV OKAY
* **VD can predispose to reflux or aspiration :-(**
44
What does oxygen therapy do to help aid with GDV
Helps offset poor ventilation
45
When choosing paincontrol which should we consider and whY?
* **Drugs with minimal CV effects**
* **Oxymorphone, fentanyl, buprenorphine**
46
What are some free radical scavanegers for reperfusion injury?
* Acetylcysteine
* Vitamin C, vitamin E, Selenium
* **Desferoxamine**
* Iron chelator
* **Lidocaine**
* Scavenger of reactive oxygen species (ROS)
47
Surgery should be performed as soon as our patients are stabilized, what are the 2 main benefits of doing surgery early?
* Gastric repositioning improves bloodflow
* Surgery may be completed before onset of arrhythmias
48
What things do we need to look at with surgical management (5)?
* Gastric repositioning
* Assessment of gastric viability
* Evaluate pylorus
* Evaluate spleen
* Gastropexy
49
We do gastric repositioning to decompress the stomach if still distended, what are the steps and how do you perform it?
* Push down on fundus with right hand
* Grasp pyloric antrum with left hand and rotate stomach counterclockwise
* Confirm proper reduction by examining gastroesophageal junction
50
HOW DO WE ASSESS GASTRIC VIABILITY?
* “Standard” Criteria
* Color
* Pulsation of blood vessels
* Bleeding from cut surface
* Peristalsis
* Palpation of wall thickness
* Surface oximetry
51
Where does gastric necrosis often take place?
Greater curvature near short gastric arteries
52
Do hand sutures or stapling devices have a higher association with mortality?
Hand sutures assoc. with higher mortality
53
Evalution of the spleen?
* Venous congestion
* resolution?
* Vessel thrombosis
* resolution?
* Splenic torsion
* resolution?
* Venous congestion
* resolution? **Self limiting**
* Vessel thrombosis
* resolution? **Splenectomy**
* Splenic torsion
* resolution? **Splenectomy**
54
True or False:
Gastropext does prevent dilatation and volvulus?
False!!!!
**Does NOT prevent dilatation**
55
Gastropexy recurrance \_\_\_\_% without pexy, and there's a recurrence of \_\_\_\_\_% with pexy
Gastropexy recurrance **50** % without pexy, and there's a recurrence of **4**% with pexy
56
Most gastropexy techniques perform similarly and the success rate is \_\_\_\_\_%
95
57
An incisional gastropexy is you incise the ________ layer in the gastric antrum and ______ abdominal wall. You suture the edge of abdominal wall to the gastric incision with a ______ \_\_\_\_\_\_ pattern
* Seromuscular
* right abdominal wall
* simple continuous
58
What is the minimum length for a long incision in the transversus abdominus for an incisional gastropexy?
3 cm
59
What are you trying to prevent when creating incisions for an incisional gastropexy?
## Footnote
Make incisions so that pyloric outflow tract and proximal duodenum are not twisted or kinked
60
What is the strongest gastropexy technique? and what type of flap and where is it placed? What are the 2 risks
**_Circumcostal Gastropexy_**
* Seromuscular flap placed around 13th rib
* Risks:
* Rib fractures
* Pneomothorax
61
What are the 3 advantages of doing endoscopic asssited GDV surgery?
* Equipment more widely available
* Pyloric antrum accurately visualized
* Gastropexy performed with standard surgical instruments
62
What are the 2 limitations to endoscopic assited GDV surgery?
* Expertise in gastroscopy required
* Potential organ trauma
63
What is the likelyhood of recurrence of GDV of GD after gastropexy?
40 dogs with 2yr follow up
* No dog had recurrence of GDV
* 2 dogs (5%) had GD
64
What indications should we consider for prophylactic gastropexy?
* Breed risk
* Identified risk factors
* Owner request
Risk/cost benefit ratio
Rotties 2.2 fold reduction in mortality
Great Danes 30 fold reduction in mortality
When lifetime risk =/\> 34%, procedure cost effective
65
You could perform a prophylactic gastropexy during a spay or open castration, the unfortunate thing is that regardless of performing the gastropexy there is one thing that it can't prevent it from which is??
Does not prevent dilatation!!!
66
What are 6 post operative care indications after gastropexy?
* NPO for ≈ 12-24 hours
* Fluid and electrolyte replacement
* Monitor for arrhythmias for 24 hours
* Pain control
* Blood pressure monitoring
* Encourage limited exercise
67
Why is it so important to monitor blood pressure after a gastropexy?
Hypotension at any time is risk factor for death
68
What kinds of drugs should we give post after gastropexy or GDV?
**Anti-emetic: Maropitant (Cerenia)**
**H2-Receptor antagonists**
* Ranitidine
* Famotidine
**Sucralfate**
* 0.5 - 1 gm PO BID or TID
**+/-Metoclopramide**
69
Post op deaths following a GDV are at their highest risk within how many days post op?
within the first 4 days!
70
Post op deaths following a GDV are at their highest risk within 1st 4 days post op, what kinds of things cause death?
**Shock**
* hypovolemic
* septic - endotoxic
**Gastric necrosis i.e peritonitis**
* unrecognized areas of necrosis
* perforating ulcers
* reperfusion injury
**Cardiac arrhythmias**
71
What kinds of electrolyte disturbances do we see with GDV? (2 main what do they cause?)
**_Hypokalemia_**
* can induce or potentiate arrhythmias, muscular weakness, lethargy
**_Hypochloremia_**
* gastric sequestration
72
73
\_\_\_\_% of GDV patients will develop arrythmias \_\_\_\_-\_\_\_\_ hours after onset of GDV. They are typically \_\_\_\_\_\_\_(atria or ventricular?) and usually abate \_\_\_\_-\_\_\_\_ hours
**_50_**% of GDV patients will develop arrythmias **_12-36_** hours after onset of GDV. They are typically **_ventricular_** (atria or ventricular?) and usually subsides **_24-72_** hours
74
What are 5 main causes of cardiac arrythmias in GDV patients? Which is most common cause
* **Myocardial ischemia (MOST COMMON)**
* Electrolyte abnormalities
* Acid-base alterations
* Vasoactive substances
* Imbalance of autonomic nervous system
75
What are some causes of ventricular arrythmias (5)?
* Premature ventricular contractions
* Paroxysmal ventricular arrhythmias (runs)
* ldioventricular rhythm (Slow V-tach)
* Ventricular tachycardia
* Multifocal PVCs
76
When do we need to step in and treat the arrythmia?
* **V-tach with high rate (\>180-190bpm)**
* Pulse deficits
* Poor pulse quality
* Weakness
* **Multifocal PVCs**
77
What drug can we give as a bolus or constant rate infusion for ventricular arrythmias?
Lidocaine
78
When we see refractory arrythmias what should we check for in GDV patients?
* **Check electrolytes**
* Potassium
* Magnesium
* Calcium
* **Pain management**
79
**_Prognosis_**
* \_\_\_-\_\_\_% Survival rate for uncomplicated cases
* Preoperative arrhythmias – \_\_\_\_\_% mortality
* Gastric necrosis - \_\_\_\_% mortality
* Partial gastrectomy – \_\_\_\_% mortality
* Splenectomy – \_\_\_\_% mortality
* Partial gastrectomy + splenectomy – \_\_\_\_% mortality
* Overall mortality _____ in recent years
* **80-90%** Survival rate for uncomplicated cases
* Preoperative arrhythmias – **38%** mortality
* Gastric necrosis - **46%** mortality
* Partial gastrectomy – **35%** mortality
* Splenectomy – **32%** mortality
* Partial gastrectomy + splenectomy – **55%** mortality
* Overall mortality **decreased** in recent years
