Cats

GDV
by

GDV

Ava

Gastric Dilatation and Volvulus (GDV)

Gastric dilatation and volvulus is commonly called GDV and even more commonly referred to as bloat. The term bloat is somewhat of a misnomer because that really only describes half of the issue. This condition occurs when the stomach both dilates (fills with gas and/or fluid) and rotates on its axis. Unfortunately, we never know which happens first the rotation or the dilation. Regardless, surgery is necessary in order to correct the issue and prevent recurrence, we will describe the procedure below.

This condition most commonly occurs in the large/giant breed dogs and deep chested breeds. It is rarely seen in small and medium size breed dogs. The most common breeds are the Great Dane, Mastiff, etc – you get the picture. Surprisingly, in addition to the larger breed dogs, we also see it in Standard Poodles more frequently. There are a lot of theories out there as to why this may occurs. Some common thoughts range from frequency and size of meals, exercising after meals, elevation and height of bowls, etc. We also see an increase in GDV incidence in dogs that have other types of gastrointestinal disease, such as inflammatory bowel disease.  Stressful environments such as pets being hospitalized, boarding, storms, etc. can increase the risk of this issue too. As a practicing surgeon, I can’t tell you how many times, dogs that present with a GDV are coming from a referring veterinary hospital, boarding facility, the pet-sitter, etc; so it is a real problem. A lot is done to avoid some of these situations to try to prevent this from occurring, the most definitive way to avoid this is to have a prophylactic gastropexy performed either by your veterinary or veterinary surgeon. I will address these techniques later on in the series, and we will spend some time on it, because this can be performed very easily by minimally invasive techniques.

Clinical Signs

Some of the most common signs an owner will see include the attempt to vomit, which is termed non-productive retching. This occurs due to the junction of the lower esophagus and stomach being rotated >180 degrees in effect kinking this area. Other signs are signs of discomfort such as listlessness and the inability to get comfortable. Also, many times you will notice enlargement of the abdomen. In cases that have been going on for some time (even a few hours) you can see dogs that are unable to get up and/or not responsive to stimuli.

As described above, this condition can progress rapidly and be fatal, so immediate veterinary care is a must. This condition not only directly affects the stomach and gastrointestinal system, but also affects the cardiovascular system (compression of the vena cava and return flow to the heart) which places these patients in shock and can propagate various inflammation and coagulation cascades that can also cause death. The spleen can also become affected due to its close proximity ad shared blood supply from the stomach. As the stomach rotates these splenic vessels can become torn.

Diagnosis

An experienced veterinarian will be able to quickly diagnose this condition, based on signalment (breed), clinical signs, and physical examination. Radiographs (X-rays) generally leave little doubt, as there are “tell-tale” signs seen on x-rays. Blood work will also be performed to assess values such as red blood cell concentration, electrolyte abnormalities, lactate, etc all factors that will be used to guide initial stabilization and treatment prior to surgery. Once diagnosed, surgery is required. If surgery is not feasible (patient is not able to be stabilized, owner unable to move forward with surgery, etc), humane euthanasia will be likely recommended.

This is a right lateral abdominal x-ray. Note the large, dilated stomach and evidence of the duodenum (intestine) just above the stomach and below the spinal column.

This is a right lateral abdominal x-ray. Note the large, dilated stomach and evidence of the duodenum (intestine) just above the stomach and below the spinal column.

Treatment

As one may assume anesthesia is more risky in a sick animal, but is needed for this problem. Unfortunately, there is no conservative/ non-surgical approach that has been shown to work. After immediate stabilization of the patient, surgery is indicated.

The surgical goals are to decompress the stomach, place the stomach in the correct position, and attach the stomach to the body wall – to drastically decrease the chance of this happening again. The last part of the procedure is called a gastropexy, dogs that do not have this performed, are at high risk for this to happen in the future.

Other things that need to be evaluated while in the abdomen are the stomach – there are times where necrotic (dying) segments of the stomach must be removed. Unfortunately, there are times where gastric (stomach) necrosis is so profound or is affecting a non-resectable location of the stomach when humane euthanasia may be recommended. Thorough evaluation of the spleen is necessary and a splenectomy may need to be performed. After these organs are evaluated, the rest of the abdomen is evaluated.

Post-operative care is also very important, since many cases are not completely straight forward. Close monitoring, aggressive fluid therapy and appropriate management is necessary for a successful outcome. More recent reports show an 80-85% survival rate (with straight forward cases), which is much higher than previously thought. The more damage done (gastric death, spleen involvement, etc), the worse the outlook. Again, a quick response and aggressive management is what is needed.

Prevention

While there are many different views about how to decrease the chance of a GDV occurring, the most successful way is to have a prophylactic gastropexy performed. A gastropexy is a procedure that attaches the pyloric antrum segment of the stomach to the body wall. While this does not prevent dilation of the stomach, it does prevent the deadly rotation of the stomach.

When is the best time to have this performed? I recommend this procedure be performed at 6 months or older. This timing of the procedure coincides with spaying and neutering of your pet, both procedures can be performed at the same sitting. This procedure is especially easy in female dogs that are being spayed, since the abdomen is already open.

Recently, we have the advantage of doing this procedure and the spay procedure via laparoscopy. Laparoscopy is a minimally invasive procedure in which small incisions (0.5-1.0 cm) are made in the abdomen and the organs are visualized on a screen with cameras and surgery is done with small instruments through these incisions. The laparoscopic gastropexy is typically a very fast and effective procedure and is commonly combined with a laparoscopic ovariohysterectomy (spay). Contact your veterinarian for details about this procedure or a referral to a veterinary surgeon who can perform this procedure.

by

Pet Rehabilitation

Check out the new page on http://www.drbenjamino.com

Pet Rehabilitation.

by

Brachycephalic Upper Airway Syndrome (BUAS) – diagnosis

Diagnostic testing:

In addition to direct visualization of structures it is wise to evaluate both the neck and chest. This is most commonly performed with radiographs (X-rays). Structures to evaluate include the oro/nasopharynx, trachea, lungs (for pneumonia, etc), and cardiac disease. If cardiac disease is suspected due to auscultation and radiographs, an echocardiogram is recommended. A complete blood count (CBC), chemistry and urinalysis should be performed prior to anesthesia to assess total body function and if your pet is a good anesthetic and surgical candidate.

A very important part of the diagnostic workup performed just before surgery is the oral examination. One way to evaluate the upper airway is endoscopy of both the larynx and esophagus. This will provide a very thorough evaluation of the soft palate, ventricles and laryngeal function.

Direct visualization is the most common way of diagnosing the associated factors of the brachycephalic dog. The nares are narrower than a normal dog and the airflow is distorted.  For a sedated oral exam, the patient is typically anesthetized (light plane of anesthesia). Evaluating the laryngeal function in these dogs is very important in differentiating laryngeal paralysis from laryngeal collapse.

The mainstay of treatment for BUAS remains surgical, however some medical measures can also be taken. When considering medical management, it is important to focus on factors that can cause worsening of the signs, such as weight loss and allergies. Other factors to consider are housing the patient in a cool environment, avoiding the use of neck leads, decreased activity levels and the use of gastroprotectants for any concurrent vomiting or regurgitation.

 

by

Brachycephalic Upper Airway Syndrome (BUAS) – physical exam

Most commonly the history of patients with BUAS are very similar. Generally, owners notice snoring and gradual progression of inspiratory stridor. Many times this will occur while the patient is a puppy and continue into adulthood. Other signs that are noted are increasing frequency of dyspnea especially during exercise or a hot environment. Another sign to look for in addition to the other is vomiting and/or regurgitation. This can be a compounding problem as it predisposes the pet to aspiration pneumonia.

On physical exam one of the first things that can be directly visualized is the nares being stenotic. The observant examiner will also note an increased upper respiratory noise with inspiratory stridor on auscultation(listening with a stethoscope. Typically the rest of the general physical examination is within normal limits.

Prior to performing a sedated oral exam various differentials should be on the list and should include neoplasia (oral/pharyngeal masses/cancer), tracheal collapse, laryngeal paralysis, lower airway disease and cardiac(heart)disease. Both lower airway diseases and cardiac disease can greatly exacerbate upper airway signs and if the patient is stable, these should be addressed first or at least concurrently.

Our next segment will be an overview of the surgical treatment and then we can wrap up this topic.

by

Happy Holidays

I want to take a moment to thank everyone for their continued interest and support of this blog. Your continued support has meant a lot to me and allowed me to continue to post various topics. I want to wish everyone Happy Holidays during this joyous time of the year! I wish you all the best in the New Year too! Keep your pets safe throughout this time, but definitely spoil them (we want them to ring in the New Years without any ailments)! Please continue to follow this blog!

Seasons Greetings!!

Kevin

by

Brachycephalic Obstructive Airway Syndrome (BOAS)

What makes up BOAS? The most common components of this disease are both stenotic nares(nostril) and an elongated soft palate. These two features are commonly seen. Other components are everted saccules, hypoplastic trachea, and secondary laryngeal collapse. In dogs that have stenotic nares the cartilage that makes up the nares is generally thicker and more condensed and oftentimes more medially displaced which causes an obstruction. Also, the conchae(cartilage in the nasal passageway) can be altered and displaced causing further airway turbulence and obstruction.

Anatomically the soft palate is just caudal(behind) to the hard palate and further divides the nasopharynx from the oropharynx (nasal passage from the mouth or oral cavity). In the normal patient the soft palate will typically extend caudally to just touch (slightly overlap) the epiglottis. In patients with an active obstruction this can be seen to extend 1-2 cm (or more) past the epiglottis. Due to this extension past the epiglottis, this tissue can actively obstruct airflow into the larynx and also become edematous(swollen) and undergo inflammation. Inflammation from this airway obstruction can extend to the tissue surround the pharyngeal region.

Generally considered to be a secondary side effect of the aforementioned conditions, everted saccules can develop due to the presence of increased air pressure of a prolonged period of time. Laryngeal saccules are normal out-pouchings noted adjacent to the vocal folds. Normally they extend outward away from the airway. After being under constant negative pressure these out-pouchings will evert and extend into the caudal laryngeal lumen causing an obstruction. Another secondary effect noted due to the constant high pressure is laryngeal collapse. This generally occurs in later stages of the disease process and will progress in severity. There is a grading scale that is used to assess the condition. Grade I laryngeal collapse is present when the laryngeal lumen is narrowed by everted saccules. Grade II collapse is characterized by both everted saccules and the cuneiform processes begin to collapse inward and fail to abduct during inspiration. Grade III collapse is characterized by the addition of the corniculate processes inwardly folding during inspiration, which signifies complete collapse.

The next posting will go over some of the physical exam findings and what we can do to help these patients out for the long run.

Note the narrow nostrils.

Note the narrow nostrils.

by

Upper Respiratory Issues – Brachycephalic Upper Airway Syndrome (BUAS)

Overview:

A very common airway problem seen in small dogs and some bigger dogs is a syndrome termed Brachycephalic Upper Airway Syndrome (BUAS). This disease process affects brachycephalic dogs due to the development of their skull structure. These dogs can be thought of having the same anatomy as a longer nose dog, just in a much smaller area. As one could image, this can cause difficulty in the passage of air as it traverses through the nasal passage and into the naso- and oropharynx causing an increased pressure.

Common breeds that are affected and grouped into the breed type(brachycephalic) range from the Bulldog to the Cavalier King Charles Spaniels. Dogs that are affected by BUAS can present with many different symptoms that all involve the passage of air and include snoring, stridor, exercise intolerance, apnea and even gastrointestinal side effects such as vomiting and regurgitation. There are factors that can worsen the signs such as weight gain, allergies, environment conditions etc. Factors that can be controlled should be addressed.

In the next segment we will look at the physical features of dogs that have brachycephalic upper airway syndrome. Feel free to ask questions.

Pug and stenotic nares - after surgery

Pug and stenotic nares – after surgery

by

Treatment for an Intestinal Obstruction

Sorry about the nearly one month lapse in writing. I think it would be good to finish the topic on intestinal obstructions. The biggest question to be asked is, once the diagnosis is made – how do we correct the issue. The answer is one of three: 1. endoscopic removal of gastric foreign material, 2. surgical removal by an abdominal exploratory (or laparoscopy – only if a focal obstruction), and 3. hospitalization and fluids, if and only if , the foreign material is diagnosed as being in the large intestine/colon.

Generally, surgical explore of the abdomen and removal via a gastrotomy, enterotomy, or intestinal resection and anastomosis is recommended. Rather than go into the technical aspects of the surgeries, it would be better to put the emphasis of the importance of early detection and treatment of an intestinal obstruction, especially a complete obstruction. The biggest worry is both where in the gastrointestinal tract and to what extent did the material cause damage to the intestine. This can range from irritation and inflammation to perforation and necrosis (death) of the affected intestine. Early intervention is key in trying to reduce the risk of extensive damage. The more aggressive the procedure required increases post-operative risk to the patient.

Most patients will do well with surgery and recover uneventfully. Standard enterotomies and resection/anastomosis have a 10-15% complication rate when performed according to the literature. The most concerning complication is termed dehiscence (leaking of the intestinal suture line) and require another surgery to repair the area. Unfortunately, with more surgery required, the complication rate increases.

The best word of advice would be to attempt to identify possible foreign bodies and remove them them your pets reach. Some examples would be torn pieces of toys, squeakers from toys that have been removed, string/fishing line from cats, etc. However, if you do find your pets have the common signs – seek veterinary help right away.

An x-ray of a foreign body both in the stomach and within the intestines.

by

Common Signs with Intestinal Obstructions

Welcome back. This shouldn’t take too long, but let’s review some of the more common signs seen with intestinal obstructions. The most common sign would be vomiting and generally not a one time occurrence. This will usually be profuse vomiting (but can vary with every patient). Other signs to look for is anorexia (not wanting to eat), lethargy, and abdominal pain. As with any type of foreign body the gastrointestinal tract can become perforated and significantly worse signs can become evident. Whenever an intestinal foreign body is suspected immediate veterinary care (whether your primary veterinarian or an emergency clinic) is highly recommended. Generally these signs will occur very acutely (all of a sudden) once the object begins to obstruct the intestine. We don’t always know what our dogs get into, especially if they are left unattended or go outside in the back and unsupervised. It seems like many owner don’t know what there pet got into and swallowed.

During the initial evaluation, your veterinarian may recommend some diagnostic tests to help support the diagnosis of an intestinal foreign body and justify surgery. Most of the time the physical exam will show, dehydration (high heart rate, dry mucus membranes, etc), evidence of vomiting, pain on abdominal palpation, fever (if perforated intestines) and other various signs. Some dogs when presented early show few signs and are very stable, other dogs show very severe signs and may be very unstable and require aggressive supportive care including aggressive fluid management and other treatments.

The standard diagnostics after initial triage (physical exam, blood pressure, etc) typically include abdominal radiographs (x-rays), complete blood work, possible chest radiographs (if aspiration suspect or in the geriatric dog) and possible abdominal ultrasound if the radiographs are non-diagnostic. Some may also recommend contrast radiographs with barium contrast in an attempt to highlight the foreign body.

Once a presumptive diagnosis is made and the patient is deemed stable surgery generally is the next step. If the foreign body is only in the stomach, endoscopy may be performed succesfully to remove the object.

by

Intestinal Obstructions

Hello all!!! I hope everyone is well!!! It has been a busy past few weeks. I recently was in Mexico lecturing, which was very exciting, my first international lecture series. Everyone was great in Mexico, very hospitable, I hope to be invited in the future. The next few weeks will prove to be busy as well – we will see how things go – stay tuned for updates.

I was trying to think of topics to share that might be beneficial for both owner and professional, and thought I would share a little about gastrointestinal obstructions – namely foreign bodies/materials. As a general surgeon, intestinal foreign bodies and obstructions are a common reason to go to surgery. Countless times per week we are faced with the decision of surgery in intestinal obstructions. While eating a foreign body is a major way of causing an obstruction, there can be other reasons as well such as cancer, etc. We will stick to foreign body obstructions in this blog.

Defining the terms: Foreign body refers to any material (ingested, in this case) that is foreign to the body. We are referring to objects swallowed by an animal and can range from fabric, stick, coins, tennis balls, rocks, etc. When an animal ingests an object there are three possible outcomes: 1. passing the object and excreting it in the feces, 2. becoming partially lodges in the stomach or intestines and partially blocking the normal flow of contents, and 3. becoming lodged in the stomach (pylorus) and/or intestines and causing a complete obstruction, not allowing any gastrointestinal contents to pass. These can also occur in the esophagus too.

Now that we got that out of the way, we will start talking about common signs you may see with your pet when they swallow a foreign object. Stay tuned!!!