Bloat: The Mother of all Emergencies

Bloat: The Mother of all Emergencies

by PETS Referral Center on December 8, 2011

There is no quicker way to jump to the front of the ER line than if you walk into the hospital with a distended dog. Bloat is a life-threatening condition that I treat frequently, and a good outcome is time-dependent.First, some vocabulary: Bloat is a condition when the stomach fills with air and/or fluid (dilatation). This can progress to a twisting of the stomach upon itself, called GDV (gastric dilatation volvulus). Bloat is often used to describe GDV, but there is a vast medical difference. We’ll get to the details of GDV in a moment, but let’s start with the most important take-home message:

If you even remotely suspect bloat or GDV, take your dog to a veterinary hospital IMMEDIATELY!

What NOT to do:

• Do not give anything by mouth.


• Do not attempt to relieve gas from the stomach with medications or by other means.

A note about the use of Gas X: I hear a lot of comments about “giving Gas X” to help or even “fix” the problem. This medication may help to reduce the amount of stomach gas in the case of “simple” bloat, but it will do nothing to help your pet in the case of GDV. The problem with GDV is not the gas, but the actual twisting of the stomach (think of a balloon being twisted in half, like when a clown makes an animal figure). It is the twist that kills, and a medication will not undo the deadly rotation of the stomach. Please do not waste valuable life-saving moments waiting to see if medication helps! Taking an x-ray of your pet’s abdomen is the only way to tell the difference between bloat and GDV, allowing for appropriate and rapid intervention.

What is GDV and why is it so serious?

The twisted and bloated stomach presses on the major blood vessels that carry blood back to the heart, stopping normal circulation and sending the dog into shock. Making matters worse, the stomach tissue is literally dying because it is stretched tightly and blood cannot circulate through it. Intense pain is associated with this disease, causing the heart to race at such a high rate that heart failure will result.

There can be no recovery until the stomach is surgically untwisted and the gas is released. A dog with GDV will die in a matter of hours unless surgery is performed. For each hour that goes by, there is a greater risk for complications during surgery as well as during the recovery period.

What are the signs of GDV or bloat?

• The biggest clue is the vomiting: A dog with GDV appears highly nauseated and retches but little comes up.


• Drooling.


• There is usually an obviously distended stomach, especially near the ribs, but this is not always evident depending on body configuration.


• Anxiousness, agitation, restlessness and pacing.


• Depressed attitude.


• You can watch this educational video of an Akita experiencing GDV to help you recognize the signs of bloat (don’t worry, he survived!)

What dogs are at risk?

Classically, this condition affects deep-chested breeds, and dogs with deep chests that weigh more than 99 pounds have a 20 percent risk of bloat. Although a rare occurrence, I have also treated three small-breed dogs for this condition in my ten-year career.

There are many theories regarding what triggers GDV, but truly, no one really knows—it remains a veterinary medical mystery. Risk factors, lifestyle and personality profiles that may increase a dog’s potential for developing GDV have been identified over the years and include:

• Feeding only one meal a day.


• Having closely related family members with a history of GDV.


• Eating rapidly.


• Being thin or underweight.


• Moistening dry foods (particularly if citric acid is listed as a preservative in the dry food).


• Feeding from an elevated bowl.


• Restricting water before and after meals.


• Feeding a dry diet with animal fat listed in the first four ingredients. (Contrary to popular belief, cereal ingredients such as soy, wheat or corn, in the first four ingredients do not increase the risk.)


• Fearful or anxious temperament.


• History of aggression toward people or other dogs.


• Male dogs are more likely to bloat than females.


• Older dogs (7–12 years) are the highest risk group.

On the flip side, the following factors may decrease the risk of GDV:

• Inclusion of canned dog food in the diet.


• Inclusion of table scraps in the diet.


• Happy or easygoing temperament.


• Feeding a dry food containing a calcium-rich meat meal listed in the first four ingredients.


• Eating two or more meals per day as well as feeding a smaller kibble size.


• Not breeding animals with a history of GDV in their lineage.

What else can I do?

For breeds with a high risk of bloat, a preventive surgery called prophylactic gastropexy can be performed at the time of spay or neuter. Gastropexy involves surgically “tacking down” the stomach to the inside of the abdomen to prevent rotation. If your dog has already been spayed or neutered, the same procedure can be done laparoscopically, and is minimally invasive. I had this procedure performed on my own Dobie, Bauer. I saw him bloat (and thankfully not twist!) one day at the park, and treated him at work. The next day, I scheduled the laparoscopic procedure.

This is a same-day surgery with a quick and comfortable recovery. In the Bay Area, the cost is generally $ 1,500–$ 2,500, which is far cheaper than emergency surgery, and worth its weight in gold for peace of mind. One of my biggest fears was to have Bauer bloat while I was away for the day, only to return home to find I was too late.

It should be noted that gastropexy does not prevent future bloat, but it does prevent future twisting, which is the deadly component of the condition.

What is the prognosis?

Decades ago, a diagnosis of bloat was almost always a death sentence, and only 25 percent of pets with bloat survived. Today, the survival rate is better than 80 percent! Part of the reason for this is increased owner awareness (go, pet parents!) leading to rapid intervention and treatment. The earlier the veterinarian gets started with treatment, the better chance for survival. Extremely aggressive medical and surgical intervention early in the course of the disease has the most dramatic impact on overall success.

This is a condition I see much too frequently, but I have to say from a purely personal experience, nearly all dogs return home (95 percent or greater) with early and appropriate treatment.

Being the doting mom of two Dobies, this is a subject that hits close to home, and one I have experienced personally. Feel free to ask questions; I am happy to further elaborate on any area. For now, I’m off to hug my boy, Bauer (pictured), being especially thankful that he is with me today.

The mother of all emergencies

That’s the universal nickname for a “bloat”. I don’t know if that’s necessarily true, given some of the emergencies I’ve seen, but let’s not split hairs.

Bloat is actually a misnomer. The correct term for the condition of the stomach filling with gas and rotating on its axis is called a gastric dilatation and volvulus (GDV). A gastric dilatation without volvulus (twisting) is technically a bloat. Dogs food bloat all the time – they get into the bag of cat food and eat all 20 pounds, and then they lie around and groan. That is a bloat. It is rarely life-threatening (although occasionally it can be). Somehow, the term bloat was applied to a GDV many years ago, and it has stuck. Most vets call a GDV a bloat, but at universities, you’ll likely find sticklers who only say GDV.

At any rate, GDV occurs in large breed dogs such as Great Danes, Weimaraners, St Bernards, Doberman Pinschers, German shepherds, Labradors, and the like. No studies have been able to consistently identify a cause of bloating. There are many theories. Some believe that thin, nervous dogs that are fast eaters and gulp down a lot of air while eating are more prone to GDV. There has been no proof that this is the case. Others think it is strictly conformational – big, deep chested dogs. The truth is that no one knows what causes it. Some of the risk factors that have been identified are:

* Feeding only one meal a day
* Having closely related family members with a history of bloat
* Eating rapidly
* Being thin or underweight
* Moistening dry foods (particularly if citric acid is listed as a preservative)
* Feeding from an elevated bowl
* Restricting water before and after meals
* Feeding a dry diet with animal fat listed in the first four ingredients
* Fearful or anxious temperament
* History of aggression towards people or other dogs
* Male dogs are more likely to bloat than females
* Older dogs (7 – 12 years) were the highest risk group

The onset of a GDV is rapid, and a patient’s condition can deteriorate in a matter of an hour. Once the stomach flips itself, gas, food, and fluid can no longer exit. The stomach rapidly dilates, leading to pressure on blood vessels that return blood from the rest of the body to the heart. Furthermore, the blood supply to the stomach is cut off, rapidly resulting in necrosis (death) of the stomach tissue. Shock rapidly sets in.

The signs of GDV are restlessness/pacing and discomfort, retching but not producing anything (or only producing a small amount of white foam), and a distended abdomen that sounds like a drum when you tap on it. These come on rapidly, and if noted, the patient should be taken to the ER immediately! In this case, minutes count!

Once you arrive at the ER, the technicians will likely whisk your pet away to the back immediately. Initial triage is the placement of an IV catheter, rapid infusion of large amounts of IV fluids to combat the shock, pain medications, and initial bloodwork. Once the patient is as stabilized as possible, a lateral xray of the abdomen will be taken. A GDV looks like this:

Surgery is absolutely the BEST treatment for a GDV. And FAST. Some veterinarians will pass a tube and can de-rotate the stomach that way. This method is fraught with problems. First, placing a tube into a twisted stomach is risky. If there is damage/death to the neck of the stomach (cardia), it is easier to accidentally puncture that neck. Further, if surgery is not conducted, it is impossible to tell how much damage has been done to the stomach. Lastly, if a patient does not undergo surgery and have the stomach de-rotated, a GDV is highly likely to happen again. In one study, at least 25% of dogs that did not have surgery were euthanized within 48 hours because of poor response to treatment.

As a sidenote, I recently saw a Great Dane that had a GDV. He presented to us, collapsed in the lobby, and proceeded to die. We were able to successfully resuscitate him, but after all that, his owners elected euthanasia. Afterwards, they casually mentioned to me that the dog had bloated before! but had not had surgery to correct it. The vet had passed a stomach tube and that was that. Had this dog had surgery, it is likely that I would never have seen him, and he would still be alive.

Surgery consists of de-rotating the stomach, passing a stomach tube and emptying out the contents, and then tacking the stomach to the body wall (gastropexy). If the stomach has suffered irreversible damage, then some of it might have to be removed.

Many people have the mistaken impression that a GDV cannot be fixed. This is not so! While it is a life-threatening emergency, rapid intervention and surgical repair can fix it. Rapid identification of the problem and surgery are absolutely imperative. Waiting 6 hours before deciding that a vet should be consulted is not a good idea.

Hospitalization after GDV repair can last for as little as 24 hours to as much as a week. My last 2 have spent about 36 hours hospitalized, then went home to live normal, happy lives. Complications can arise post-operatively, necessitating longer stays in the hospital. The whole process is also very expensive. Most dogs that we treat for GDV are 90 pounds or heavier. As a result, everything is more expensive. For surgery and post-operative care (in our hospital), a GDV will not run less than $ 1800-2500. As a result, we see many financial euthanasias. It’s always sad, because a GDV is such a fixable problem.

*A special note about Great Danes. Some research indicates that as many as 1 in 4 Danes will bloat at some time in life. I highly recommend that all Great Danes undergo gastropexy (stomach tacking) as puppies. Especially females! It can be done while they are under anesthesia for a spay. It is important to remember that even though your dog has a pexy, it is possible that a GDV could still occur. Occasionally, these pexies break down! If a dog is pexied and exhibits signs of a GDV, it should be seen ASAP.

Bloat, the Mother of All Emergencies

Bloat, the Mother of All Emergencies

What you need to know about this life-threatening condition

Shea Cox, DVM | November 30, 2011


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There is no quicker way to jump to the front of the ER line than if you walk into the hospital with a distended dog. Bloat is a life-threatening condition that I treat frequently, and a good outcome is time-dependent. Last week, JoAnna Lou wrote about recognizing the signs of bloat and included an educational video of an Akita experiencing GDV (don’t worry, he survived!). This topic elicited excellent comments and questions, prompting me to want to expand upon it further. I hope to answer some of the questions put forth by readers as well as dispel misconceptions that could potentially harm your pet. First, some vocabulary: Bloat is a condition when the stomach fills with air and/or fluid (dilatation). This can progress to a twisting of the stomach upon itself, called GDV (gastric dilatation volvulus). Bloat is often used to describe GDV, but there is a vast medical difference. We’ll get to the details of GDV in a moment, but let’s start with the most important take-home message: If you even remotely suspect bloat or GDV, take your dog to a veterinary hospital IMMEDIATELY! What NOT to do:             Do not give anything by mouth.        Do not attempt to relieve gas            from the stomach with medications or by other means. A note about the use of Gas X: This medication may help to reduce the amount of stomach gas in the case of “simple” bloat, but it will do nothing to help your pet in the case of GDV. The problem with GDV is not the gas, but the actual twisting of the stomach (think of a balloon being twisted in half, like when a clown makes an animal figure). It is the twist that kills, and a medication will not undo the deadly rotation of the stomach. Please do not waste valuable life-saving moments waiting to see if the medication helps! Taking an x-ray of your pet’s abdomen is the only way to tell the difference between bloat and GDV, allowing for appropriate intervention. What is GDV and why is it so serious? The twisted and bloated stomach presses on the major blood vessels that carry blood back to the heart, stopping normal circulation and sending the dog into shock. Making matters worse, the stomach tissue is literally dying because it is stretched tightly and blood cannot circulate through it. Intense pain is associated with this disease, causing the heart to race at such a high rate that heart failure will result. There can be no recovery until the stomach is surgically untwisted and the gas is released. A dog with GDV will die in a matter of hours unless surgery is performed. For each hour that goes by, there is a greater risk for complications during surgery as well as during the recovery period. What are the signs of GDV or bloat? The biggest clue is the vomiting: A dog with GDV appears highly nauseated and retches but little comes up.
 Drooling. There is usually an obviously distended stomach, especially near the ribs, but this is not always evident depending on body configuration. Anxiousness, agitation, restlessness and pacing. Depressed attitude. View some of these symptoms in the video we posted last week. What dogs are at risk? Classically, this condition affects deep-chested breeds, and dogs with deep chests that weigh more than 99 pounds have a 20 percent risk of bloat. Although a rare occurrence, I have also treated three small-breed dogs for this condition in my ten-year career. There are many theories regarding what triggers GDV, but truly, no one really knows—it remains a veterinary medical mystery. Risk factors, lifestyle and personality profiles that may increase a dog’s potential for developing GDV have been identified over the years and include:         Feeding only one meal a day. Having closely related family members with a history of GDV. Eating rapidly. Being thin or underweight. Moistening dry foods (particularly if citric acid is listed as a preservative in the dry food). Feeding from an elevated bowl. Restricting water before and after meals. Feeding a dry diet with animal fat listed in the first four ingredients. (Contrary to popular belief, cereal ingredients such as soy, wheat or corn, in the first four ingredients do not increase the risk.) Fearful or anxious temperament. History of aggression toward people or other dogs. Male dogs are more likely to bloat than females. Older dogs (7–12 years) are the highest risk group. On the flip side, the following factors may decreasethe risk of GDV:          Inclusion of canned dog food              in the diet. Inclusion of table scraps in the diet. Happy or easygoing temperament. Feeding a dry food containing a calcium-rich meat meal listed in the first four ingredients. Eating two or more meals per day as well as feeding a smaller kibble size. Not breeding animals with a history of GDV in their lineage. What else can I do? For breeds with a high risk of bloat, a preventive surgery called prophylactic gastropexy can be performed at the time of spay or neuter. Gastropexy involves surgically “tacking down” the stomach to the inside of the abdomen to prevent rotation. If your dog has already been spayed or neutered, the same procedure can be done laparoscopically, and is minimally invasive. I had this procedure performed on my own Dobie, Bauer. I saw him bloat (and thankfully not twist!) one day at the park, and treated him at work. The next day, I scheduled the laparoscopic procedure. This is a same-day surgery with a quick and comfortable recovery. In the Bay Area, the cost is generally $ 1,500–$ 2,000, which is far cheaper than emergency surgery, and worth its weight in gold for peace of mind. One of my biggest fears was to have Bauer bloat while I was away for the day, only to return home to find I was too late. It should be noted that gastropexy does not prevent future bloat, but it does prevent future twisting, which is the deadly component of the condition. What is the prognosis? Decades ago, a diagnosis of bloat was almost always a death sentence, and only 25 percent of pets with bloat survived. Today, the survival rate is better than 80 percent! Part of the reason for this is increased owner awareness (go, pet parents!) leading to rapid intervention and treatment. The earlier the veterinarian gets started with treatment, the better chance for survival. Extremely aggressive medical and surgical intervention early in the course of the disease has the most dramatic impact on overall success. This is a condition I see much too frequently, but I have to say from personal experience, nearly all dogs return home (95 percent or greater) with early and appropriate treatment. Being the doting mom of two Dobies, this is a subject that hits close to home, and one I have experienced personally. Thank you to JoAnna for helping raise awareness of this all-too-common condition in our large-breed babies. Feel free to ask questions; I am happy to further elaborate on any area. For now, I’m off to hug my boy, being especially thankful that he is with me today.

Article courtesy of BARK magazine and Dr. Shea Cox
http://thebark.com/content/bloat-mother-all-emergencies

The Mother of All Emergencies or Dr. Rogers Saves the Day

Classic X-Ray of a GDV, see the Smurf hat?

You will have to bear with me, I started this new exercise program and I may die while typing this blog.  If I die it will be from sheer lactic acid buildup. Otherwise, I could possibly get hit by a car because I physically can’t get out of the way of a speeding car or projectile because I am so stiff and sore I can’t move that fast. 

My first class was on Friday.  Saturday I had to work, walking around like an old person.  I felt like I could barely hold up the little 1/4 ounce  bottle of microscope oil. 

An Actual Smurf Hat.

Anyways, as I was hobbling around, the receptionist runs back and announces that there is a new client in the lobby and she says her dog is bloated.  “Yah right” I think, clients always think their dog is bloated, but they never are. 

Bloats only happen at night…. (key the ominous music)

The staff rushes the dog back, its a beautiful Springer Spaniel, it’s flat out on its side, it’s gums are white and it’s stomach is totally distended and tight as a drum. 

Holy crap it IS a bloat! 

I immediately panic (on the inside, I was cool and calm on the outside, because that’s how I roll), and summon Dr. Rogers who has worked at the emergency room and loves this stuff.  Subsequent to that, I quickly absconded into the nearest exam room to deal with the appointment side of things while Rogers swooped in to the rescue. 

Bloat is the mother of all emergencies.  AKA Gastric Dilatation and Volvulus (GDV).  It’s when the dogs stomach twists around itself.  Whatever food material is in the stomach immediately starts to ferment and produce gas and the stomach swells.  The stomach loses blood supply because it’s twisted, often the spleen goes along with it and gets compromised as well.  The rest of the GI tract starts to lose blood supply when the stomach gets so distended. 

All that blood supply loss quickly results in the buildup of toxins and the death of tissue (very often the stomach or spleen). According to the (brand-new version of)  The 5 Minute Veterinary Consult, the overall survival rate from bloat is around 84%.  Dogs with stomach necrosis seem to have around a 66% survival rate. 

The reason I said bloats only happen at night, is because in a total of 20 years in the vet biz (13 of those as a practicing vet), I’ve never actually seen a bloat case.   I’ve only ever worked days.

Even in vet school, when I was on emergency duty I never saw one.  I’m not sure I ever saw any  emergencies, actually, when I was in vet school.  Generally regular people didn’t come to the vet school for run-of-the-mill things, they took that stuff to their regular vets.  We pretty much just stayed up til 10 or whenever our shift was over and answered the phone and ate pizza.  Somehow the real emergencies went to the live-in vet students who did the late night calls.  Rumor has it that Texas A&M has a pretty awesome critical care facility now, so things have changed from the late 90′s when I was there.

Back to the present, the treatment for bloat is to decompress the stomach as quickly as possible by passing a stomach tube while concurrently treating the patient’s shock and circulation issues with aggressive IV fluids.  I know this because I memorized it in vet school, not because I’ve actually done it.  I did pass a stomach tube once my first year out of vet school on a dog that had been poisoned with sleeping pills by an angry neighbor (two of the client’s other dogs had died, but we saved that one). 

Generally dogs that bloat have severe dry-heaves and their bellies swell, then they pass out/go into shock.  Diagnosis is confirmed with a right lateral x-ray where the stomach takes on this characteristic “smurf hat” appearance.  

Dr. Rogers’ patient had all the signs and the tell-tale x-ray.

Back in the ER: there was a moment of panic when Dr. Rogers couldn’t find the stomach tubes (because we never use them!), she had to call Dr. Sharp in Michigan so he could tell her where they are.  She quickly sedated the patient with Propofol (she is a trained professional and is very capable of using this drug without killing her patient, unlike Michael Jackson’s doctor).  It took her two tries to finally get the tube passed, because of the severity of the twist. She let out the air and flushed out as much food and debris from the stomach as she could. 

The next step in this process, once the patient is stable is to take them to surgery to attach the stomach to the body wall so it can’t twist again.  While in there, you have to also check for organ damage secondary to the twist (generally in the stomach and spleen).  This dog ended up going to the emergency clinic for surgery (so she wouldn’t have to be transferred post-op as we would be closed for the weekend, Dr. Rogers is a very capable surgeon, it was just a logistical thing).  They ended up taking out her spleen as it was damaged, and her stomach was heavily bruised but ok. 

The post twist and post op periods for a GDV case are the most critical.  Remember all that tissue that lost blood supply?  Once blood starts flowing back into those areas, all kinds of nasty toxins get released and wreak havoc elsewhere in the body.  The biggest problem is that it cause cardiac arrythmias.  Many dogs die post op because of this complication. 

This dog spent the weekend in the ER, and went home from the hospital on Monday minus her spleen, but doing great. 

Dr. Sharp, the old guy said he’s only seen a handfuls of daytime bloats in his 40+ years in the day-practice biz, so hopefully we won’t see another one for a long time.  One is plenty.