Download Key Points

A proposito di… TORSIONE DELLO STOMACO
Il seguente documento potete trovarlo nelle sale d’aspetto di alcune delle più grosse cliniche
presenti negli Stati Uniti ed ha lo scopo di informare la clientela sul tanto dibattuto fenomeno
della torsione gastrica. Di facile lettura anche per chi non conosce benissimo la lingua inglese,
merita attenzione soprattutto nell’ultimo paragrafo dedicato alla chirurgia preventiva che, a
mio avviso, è consigliabile per tutti i cani di taglia grande (oltre 35 Kg), magari abbinabile ad
altri interventi routinari quali le sterilizzazioni, così da ridurre sia i costi che i rischi
dell’anestesia.
Dr. Marco Cozza
Key Points
Stomach bloat is a serious and potentially fatal disease, if early treatment is not instituted
Emergency decompression of the stomach and surgical tacking of the stomach to the body
wall is necessary
Survival rate following surgery is about 90% of the stomach is not devitalized. If a portion of
the stomach has died off, the survival rate is about 50%, in spite of medical and surgical
treatment
A preventative surgery should be done in breeds that are susceptible to this condition
Introduction





The stomach is located in the front part of the abdomen
and is the first part of the gastrointestinal tract located in
the abdominal cavity. Gastric volvulus and dilatation
(GDV) is a condition that starts off with distention of the
stomach with food, fluid such as water, or air due to
excessive swallowing. The stomach twists in a clockwise
direction as it becomes distended. The inlet to the stomach from the esophagus and the
outlet leading into the duodenum get kinked off and the food, fluids and air cannot pass in
either direction. As a result, unproductive retching occurs.
Due to the twisting and displacement of the stomach, the blood supply may be cut off and a
portion or all of the stomach may die. The longer that the stomach has been twisted before
treatment is provided, the greater the risk that the stomach will die.
Another event that occurs is occlusion of the main vein (vena cava) leading from the back
half of the body to the heart and resultant shock. Shock, a condition in which there is
inadequate perfusion of the body with blood, is fatal if not treated. Signs of shock include
pale gums, rapid heart rate, and weak pulses (low blood pressure). Dogs that develop GDV
generally are quite ill and need immediate aggressive treatment.
Infrequently the nerves to the stomach get damaged from the GDV and the paralysis of the
muscles of the stomach wall occurs. This results in chronic bloating that is usually not
responsive to any therapy.
Left is an illustration of a stomach in normal position (E=esophagus; D=duodenum); right after the stomach twists 270o in a clockwise direction, the duodenum as it exits the stomach,
is moved to the top and behind the stomach, the esophagus is twisted and the stomach is
becomes distended like a balloon.
Treatment of GDV
o
o
o
o
o
Initially intravenous catheters are placed and fluids are administered to help reverse
shock. Next a sedative is given and a tube is passed into the stomach. The stomach is
pumped if needed to remove any air, fluid, or undigested food. If the tube cannot be
passed into the stomach due to the twisting of the esophagus, a large needle is passed
through the side of the abdomen into the distended stomach.
The pet is then taken to surgery. The internal organs are examined for damage. The
stomach is repositioned and it is tacked to the right side of the abdominal cavity to
prevent a future GDV. Sometimes a portion of the stomach is found to be dead and
needs to be removed. If too much of the stomach is dead euthanasia may be
recommended. If the stomach is filled with food or other material that cannot be
removed with a tube, which is passed down the throat, the stomach is opened up and
the ingesta is removed.
Occasionally the spleen is also twisted and the blood clots have developed in its
vessels. In this case the spleen will be removed (splenectomy). Dogs can live normal
lives without a spleen. There is about a 40% chance that the heart will develop an
abnormal rhythm if a dog has also developed a problem with the spleen that
mandates splenectomy. The abnormal heartbeat may require treatment to prevent
death.
While the pet is in the intensive care unit, careful monitoring is done in order to
ensure that the internal organs are functioning properly. Fluid therapy, medications,
and transfusions (plasma and/or packed red cells) may be needed after surgery.
Figure 1 below - side view of a dog's abdomen: take note of the stomach is
moderately distended with gas in a dog with GDV. The stomach has a reverse "C"
shape which indicates that it is twisted
After care and convalescence
o
o
After surgery has been completed intensive care must be provided for the best
chance for a successful outcome. Intravenous fluids and antibiotics are administered
for at least 24 hours. If the blood protein level is low, artificial plasma (Hetastarch) is
administered. Blood pressure is carefully monitored and maintained.
Electrocardiograms are monitored after surgery, as abnormal heartbeats called
arrhythmias are common. Usually the arrhythmias will show up within the first 24
hours. Sometimes these need to be treated with medication, as they can be fatal,
however, is not common.
o
o
o
o
Your pet will be monitored for disseminated intravascular coagulation (DIC). In this
situation the clotting system becomes hyperactive and small blood clots develop in
the internal organs and multiple organ failure occurs. Generally DIC is fatal when it
occurs, therefore early treatment is the only potential safeguard.
In general, about 90% of the dogs having GDV, if treated early will survive. By 10
to 14 days after surgery most patients are felling very well. If a portion of the
stomach is dead and needs to be removed, the survival rate is about 50%.
Restricted activity should be instituted so that the tacking of the stomach does not
break down. The pet should be kept on a leash when taken outside, and no running,
jumping, or horseplay is permitted. By 3 to 4 weeks out for surgery the healing is
complete for the most part.
After a pet has had GDV, the daily ration of food should be divided into 2 to 3 meals
and exercise should be restricted for 2 hours after eating to prevent rebloating (the
stomach will not twist because of the gastropexy); rebloating is not common
problem in dogs following surgery.
Potential complications
o
o
o
o
o
o
o
As with any surgery, complications may arise. Even though relatively uncommon,
anesthetic death can occur. With the use of modern anesthetic protocols and
extensive monitoring devices (blood pressure, EKG, pulse oxymetry, inspiratory and
expiratory carbon dioxide levels, and respiration rate), the risk of problems with
anesthesia is minimal.
Infection is also an unusual complication as strict sterile technique is used during the
surgery and antibiotics are administered in the perioperative period.
Abnormal heartbeats called arrhythmias
Disseminated intravascular coagulation results in dysfunction of multiple internal
organs, bleeding disorder, and commonly death.
Breakdown of the stomach tack (gastropexy) occurs less than 5% of the time.
Recurrent GDV can occur.
Chronic recurrent bloat. Recurrent bloat generally occurs infrequently, but usually is
due to very poor function of the muscle of the stomach. Medication may be
administered to improve the stomach motility, but this will work in only about 50%
of the patients. The presentation of this is very similar to a GDV, but the stomach
does not twist. A gastropexy (stomach tack) can also breakdown and result in
recurrent bloat and twisting of the stomach, but this is unusual (less than 5% chance).
Surgery is done to correct this problem.
Because of the high variability of the status of patients that have GDV, it is also very
difficult to predict whether your pet is going to have postoperative complications. In
general, dogs having necrosis of a portion of the stomach do not fair as well as those
having minimal trauma to the stomach.
Prognosis
o
o
If treated early, about 90% of the dogs having surgery will survive
If at the time of surgery, a portion of the stomach was found to be dead, the dog has
a 50% chance to survive
Prophylactic surgery
A preventative surgery can be performed to minimize the risk of GDV in high risk patients such as
Great Danes, German Shepherds, Blood Hounds, Irish Setters, Irish Wolfhounds, Standard Poodles,
and other susceptible breeds. Great Danes are at very high risk and research has shown that one in
four Danes will bloat in their lifetime. This surgery is done laparoscopically via two small incisions
with the aid of a camera. The surgery can be done as early as 6 months of age (at the time of
neutering). This procedure has minimal morbidity, less anesthesia and surgery time, short hospital
stay (done as an outpatient surgery), and is less expensive than treating GDV.
Frequently Asked Questions After Surgery
When should my dog have the first bowel movement after surgery?



Many dogs will not have a bowel movement for the first 4 to 5 days after surgery
Reasons that a dog will not have regular bowel movements after surgery include:
o The dog has been fasted prior to surgery
o Dogs do not eat well during the hospital stay
o They frequently do not eat well when they go home
o They are fed highly digestible food that produces little stool
o Pain medication that contain narcotics (such as tylenol with codeine, tylenol 3,
tylenol 4, morphine, fentanyl patches, tramadol) can be constipating
If a pet does not have a bowel movement on the 5th day of being home, a stool softener such
as metamucil can be fed
o Dose of metamucil is 1 tsp per 25 Kg mixed in with each meal (canned dog food);
feed immediately after mixing, as the metamucil will gel the food and may make it
less palatable
My pet had surgery and will not eat. What can be done?

Dogs
o
o
o
o
o
o
o
o

Most pets will not eat their regular dog food after surgery, especially if it is kibble.
Offer a cooked diet having a 1:1 ratio of a protein source and carbohydrate source.
The protein source can be any meat (example: chicken breast, turkey breast, lean
hamburger) that is low in fat and should be cooked (drain off all fat after the meat
has been cooked). The carbohydrate can be pasta, potato or white rice.
Try canned dog food; to enhance the flavor sprinkle a very small amount of garlic
powder or chicken or beef broth (Chicken-in-a- MugTM or Beef-in-a-MugTM
products)
Try Gerber strained meats for babies such as the chicken, beef, turkey, or veal
Try Hill's A/D diet available at most veterinary hospitals
Hand feeding; place a small amount of food in the mouth so that your dog gets the
flavor
Warm the food slightly in a microwave, as the food will be more aromatic; stir the
food before feeding and test the temperature on the bottom side of your wrist; it
should only be luke warm.
Remember that most pets will not eat the first day or two after they get home from
surgery
Cats
o
Offer smelly foods that contain fish such as tuna or smelly cat foods
o
o
o
o
o
o
o
o
Try Gerber strained meats for babies such as the chicken, beef, turkey or veal
Hand feeding: with your finger place a small amount of food on the roof of your
cat's mouth; use a syringe to get soft food into the mouth
Warm the food slightly in a microwave as the food will be more aromatic; remember
to stir the food before feeding and test the temperature with your finger; it should be
only luke-warm
Some cats will only eat dry food, try kibble if your cat normally has been fed that
food
Petting and stroking your cat frequently will help to stimulate appetite
Remember that most pets will not eat the first day or two after they get home from
surgery
Appetite stimulants such as cyproheptadine may be helpful
If your cat refuses to eat anything for 7 days a stomach tube or nasogastric tube
should be placed to provide nutrition so that a serious liver problem (hepatic
lipidosis) does not develop
My pet is vomiting. What can be done?



The first thing for you to discern is whether your pet is vomiting or regurgitating. Both will
result in fluid or food being brought up. Vomiting always will have heaving or retching of
the abdomen prior to expulsion of the vomitus. Regurgitation is not associated with heaving
and the pet usually just opens the mouth and fluid or food will be expelled. Usually the
regurgitant will be clear or brown colored fluid.
Next is to identify the cause of the vomiting or regurgitation.
Causes and treatment of vomiting after surgery
o When some pets return home after a stay in the hospital they may drink excessive
amounts of water at one time and then vomit; if this appears to be the case, the water
should be limited to frequent smaller amounts.
o Medications such as antibiotics or tylenol/codeine commonly cause vomiting after
surgery. In order to see which medication is causing the problem, the administration
of each drug should be separated 2 hours apart. Usually the pet will vomit or appear
nauseated (drooling and sick look) within 1 hour of administration of the medication
that they are sensitive to. The antibiotic in some cases may be changed to a different
one, or may be discontinued. The tylenol/codeine should be discontinued and
another type of pain medication tried to help minimize vomiting.
o Stomach upset from anesthesia is a potential cause of vomiting and will pass within
a couple of days.
o An uncommon cause of vomiting after surgery is internal organ failure. Blood
testing will confirm this problem. For this reason vomiting should not be ignored if it
persists for more than 24 hours.
o If your pet had surgery of the bowels or stomach, vomiting is always a concern, as it
may indicate that infection of the abdominal cavity, called peritonitis, is present. Do
not ignore this sign.
o Symptomatic treatment of vomiting involves withholding food for 12 to 24 hours,
then introducing small amounts of bland food such as rice and lean cooked
hamburger, if your pet does not vomit after that then gradually wean him/her back
onto the regular diet after 3 days. In order to decrease the acidity of the stomach,
Pepcid AC 0.5 mg/kg can be given by mouth twice daily for 5 days.
Metoclopramide and Serenia are good anti-vomiting medications for dogs and cats.
You should always consult a veterinary healthcare professional before administering
medication.

Causes and treatment of regurgitation after surgery
o The most common cause of regurgitation is reflux of acid from the stomach into the
esophagus while your pet is under anesthesia. Acidic fluid from the stomach can
cause a chemical burn of the esophagus and result in a bad case of heart burn, called
esophagitis. This results in poor motility of the esophagus, therefore water and food
will accumulate in this structure. In most cases, esphagitis is self-eliminating and
will resolve within two or three days.
o If the esophagitis is severe the esophagus may develop one or more strictures. A
stricture is a narrowing or stenosis of the esophagus and does not allow passage of
food down the esophagus, in regurgitation that lasts longer than one week. This
problem should be brought to the attention of your pet's doctor within the first two
weeks so that it can be treated by ballooning the stricture (minimally invasive
procedure, as it is done with the aide of an endoscope). If an esophageal stricture is
chronic surgery is needed.
o Symptomatic treatment of regurgitation caused by esophagitis includes feeding bland
food, and administering a coating agent (sucralfate) and an acid blocker (omeprazole
or other). Consult a veterinary health care professional if the regurgitation continues
for more than a couple of days.
How do I know that my dog is in pain following surgery?

Signs of pain include
o crying
o biting if you get near the surgical site
o grimacing (lips are pulled back and the the dog looks anxious)
o tragic facial expression
o panting
o restlessness and unable to sleep; pacing
o if abdominal surgery was done the pet will not lie down on the incision, or will
continually sit up in spite of appearing very tired
o the worst pain will be for the first 2 to 3 days after surgery
What can I do to control my dog's pain?


Pain medication such as tylenol with codeine, butorphanol, Duragesic (fentanyl patch) antiinflammatories such as Deramaxx, Rimadyl, Previcox, or Etogesic; in some cases a sedative
such as acepromazine will augment the effect of pain medication and allow your pet to sleep
If an orthopedic surgery has been done cold packing the surgical site may be helpful
o A cold pack may be a pack of frozen peas, crushed ice in a Ziploc bag, or a cold gel
pack; place a thin barrier between the skin and the cold pack. An alternative to a
cold pack is to freeze water in a styrofoam cup; after frozen cut the bottom of the
styrofoam cup out. Cool the surgical site around the incision by rubbing the exposed
ice directly on the skin in a circular pattern. Cooling the surgical site helps to numb
the area.
How do I know that my cat is in pain following surgery?


Pain is more difficult to assess in cats versus dogs, as signs can be more subtle and they
usually do not vocalize when in pain
Signs of pain in a cat include the following:
o biting if you get near the surgical site
o
o
o
growling or deep cry
not wanting to eat
hiding and not wanting to be near owner (remember that this could also be caused by
the cat just being upset about leaving home and coming back)
What can be done for pain at home for my cat?



Pain medication such as buprenorphine or a Duragesic (fentanyl) patch
Tylenol will kill a cat as they lack abundant glutathione enzyme in the liver
Anti-inflammatories can be used, but the dose is much less than dogs
Is it okay for my pet to lick the incision?






If a dog licks the incision, the healing process may be delayed.
Licking can remove stitches and cause the incision to open
Licking can become a severe habit that is difficult to break
Licking can cause infection as the mouth has many bacteria
Dogs will frequently lick the incision when the owner is not watching such as at night time;
if the skin looks red or excoriated the most common cause is from licking.
To stop your pet from licking the following can be tried:
o Elizabethan collar can be placed on the neck; this will not help stop your pet from
scratching at the region
o Cervical collar (bite not collar) is a less awkward device and can be effective at
stopping a pet from licking the surgical site
o A tee shirt can be used to cover an incision on the chest or front part of the abdomen;
gather the waist of the shirt up over the dog's back and wrap an elastic band around
this part of the shirt.
o A bandage or sock can be used to cover an incision on a limb; fasten the top of the
sock to the dog's limb with tape.
o Bitter apple can be applied around the incision; many dogs will continue to lick after
application of this topical
o Bitter Apple and Liquid HeetTM (obtain this from a drugstore...it is used for sore
muscles) mixed in a 2:1 ratio can be applied around the skin incision
Antipsychotic medication in some cases is needed
Preventative Surgery


A preventative surgery is available for dogs that are in the suspect breed group. This is in
essence a form of "insurance" as it has been shown to prevent the problem before it happens.
Calculate your dog’s risk to develop GDV to see if you should have the preventative surgery
performed: http://www.vet.purdue.edu/epi/clbr.htm
Our surgeons perform a prophylactic gastropexy, which results in less pain for the patient than
traditional open surgery, and allows that patient to go home the same day.