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CASE REPORT

Gastric dilatation and volvulus in a brachycephalic dog with hiatal hernia M. E. Aslanian, C. R. Sharp and M. S. Garneau Department of Clinical Sciences, Tufts Cummings School of Veterinary Medicine, North Grafton, MA, USA

A brachycephalic dog was presented with an acute onset of retching and abdominal discomfort. The dog had a chronic history of stertor and exercise intolerance suggestive of brachycephalic airway obstructive syndrome. Radiographs were consistent with a Type II hiatal hernia. The dog was referred and within hours of admission became acutely painful and developed tympanic abdominal distension. A right lateral abdominal radiograph confirmed gastric dilatation and volvulus with herniation of the pylorus through the hiatus. An emergency exploratory coeliotomy was performed, during which the stomach was derotated, and an incisional gastropexy, herniorrhaphy and splenectomy were performed. A staphylectomy was performed immediately following the exploratory coeliotomy. The dog recovered uneventfully. Gastric dilatation and volvulus is a potentially life-threatening complication that can occur in dogs with Type II hiatal hernia and should be considered a surgical emergency. Journal of Small Animal Practice (2014) 55, 535–537 DOI: 10.1111/jsap.12235 Accepted: 14 April 2014; Published online: 28 May 2014

INTRODUCTION Hiatal hernia (HH) is the protrusion of abdominal contents into the thoracic cavity through the oesophageal hiatus (Ellison et al. 1987, Prymak et al. 1989, Lorinson & Bright 1998). Four types of HH are described (Ellison et al. 1987, Prymak et al. 1989, Lorinson & Bright 1998, Sivacolundhu et al. 2002). Type I, or sliding HH, is the most commonly diagnosed form in dogs and cats and consists of cranial displacement of the abdominal oesophagus, oesophagogastric junction and often a portion of the stomach. Clinical signs and radiographic evidence may be intermittent. Type II, or paraoesophageal HH, has been reported sporadically in dogs and consists of appropriate abdominal oesophagus and oesophagogastric junction positioning and cranial displacement of a portion of the stomach adjacent to the thoracic oesophagus. Type III HH is a combination of Types I and II, or mixed hernia. Type IV is a mixed hernia with the additional complication of herniation of abdominal organs such as spleen or small intestine. HH may be congenital or acquired (traumatic) in origin. It may be due to an abnormally wide hiatus that decreases the resistance of entry of the oesophagogastric junction or cardia into the thorax or an increasing gradient between intra-abdominal and intrathoracic pressure leading to the displacement of abdominal contents into the hiatus (Sivacolundhu et al. 2002). In Type II herniation in humans the HH enlarges with time (Ellis 1980). Gastric volvulus has been reported in approximately 20% of humans with Type II HH having gastrocolic and gastrosplenic ligament laxity (Krähenbuhl et al. 1998). Journal of Small Animal Practice



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Gastric dilatation–volvulus (GDV) in dogs is an acute surgical illness seen predominantly in large and giant breed dogs in which the stomach rotates along its longitudinal axis, resulting in gastric ischaemia and obstructive shock (Monnet 2003). The aetiology of GDV is poorly understood, although several risk factors have been described (Hall et al. 1995, Glickman et al. 2000, Monnet 2003). Acute gastric volvulus has been associated with congenital diaphragmatic hernia in humans (Ayala et al. 1998), and GDV has been reported in both dogs and cats with traumatic diaphragmatic hernia (Ellison et al. 1987, Miles et al. 1988, Formaggini et al. 2008). Although HH has been well described in dogs, particularly brachycephalic dogs, GDV has not been previously documented in these dogs. The purpose of this case report is to describe a case of GDV in a dog with HH.

CASE SUMMARY A four-year-old castrated male Boston terrier weighing 9·3 kg was presented to a local emergency clinic with an acute onset of retching, abdominal discomfort, restlessness and anxiety. In the preceding 2 days the owners reported transient retching immediately following meals. The dog also had a history of exercise intolerance and stertorous breathing, particularly while sleeping. The dog did not have a history of trauma or gastrointestinal symptoms. Abdominal radiographs were performed and revealed herniation of part of the stomach into the thorax. It was unclear whether it was the gastric fundus or the pylorus that was herniated on these radiographs. A diagnosis of HH was made.

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Initial treatment included 0·01 mg/kg buprenorphine (Buprenex; Reckitt Benckiser) intravenously (iv) for analgesia, and 100 mL lactated Ringer’s solution (Lactated Ringer’s injection, USP; Hospira, Inc.) subcutaneously. At this time the dog was referred for further evaluation. On presentation the dog had normal vital signs. Abdominal palpation revealed mild cranial abdominal discomfort, with no evidence of gastric distention, or organomegaly. Point-ofcare laboratory testing revealed a packed cell volume (PCV) of 48% (reference interval, 37 to 55%), total plasma solids of 70 g/L (54 to 75 g/L), mild hyperglycaemia [10·21 mmol/L (4·55 to 6·49 mmol/L)] and hyperlactataemia [4 mmol/L (0·3 to 1·0 mmol/L)]. Treatment was initiated with approximately 60 mL/kg/day isotonic crystalloid (Lactated Ringer’s injection, USP; Hospira, Inc.), 1 mg/kg famotidine (Baxter) iv every 24 hours, 0·8 mg/kg dolasetron (Anzemet; Sanofi-Aventis) iv every 24 hours and supplemental oxygen in an oxygen cage (FiO2 40%). A decision was made to continue supportive care overnight and re-evaluate the patient the following day. Approximately 5 hours after presentation the dog became tachycardic, began vocalising and was extremely anxious. On physical examination his abdomen was distended and tympanic. The spleen could be palpated in the left flank and was firm and enlarged. The dog was given 0·1 mg/kg hydromorphone (Hospira) iv for analgesia and a cranial abdominal radiograph was taken (Fig 1). Imaging was suggestive of paraoesophageal herniation of the gastric pylorus with GDV. Emergent exploratory coeliotomy was performed; 22 mg/kg cefazolin (Hospira) iv was administered. The dog was premedicated with 0·2 mg/kg midazolam (Hospira) iv and anaesthesia was induced with iv propofol (Propoflo; Hospira) titrated to allow endotracheal intubation. Examination of the upper airway identified an elongated soft palate resulting in partial obstruction of the rima glottidis. The dog was intubated and anaesthesia was maintained with inhaled isoflurane (IsoFlo; Abbott) in oxygen, in addition to continuous rate infusions of 50 µg/kg/min lidocaine (Lidocaine HCl; Hospira) and 0·6 mg/ kg/hour ketamine (Ketaset; Fort Dodge Animal Health). Anaesthetic monitoring included continuous electrocardiography, pulse oximetry, capnography and oscillometric measurement of

blood pressure. A ventral midline coeliotomy was performed. On entering the abdomen the gas-distended stomach was seen, consistent with clockwise rotation of the stomach with dilatation. The spleen was enlarged, deep purple to black in colour, and the splenic capsule was ruptured at the tail of the spleen resulting in haemorrhage. A splenectomy was performed using a vessel-sealing device (LigaSure; Covidien). Paraoesophageal herniation of the pylorus was noted confirming a Type II HH. An orogastric tube was passed to decompress the stomach. The pylorus was returned to the abdominal cavity and the volvulus was corrected. The paraoesophageal hernia was 4 cm in length and was repaired using 0 monofilament polypropylene (Surgipro; US Surgical Corp) in a simple interrupted pattern. A routine incisional gastropexy was performed using 2-0 poliglecaprone (Monocryl; Ethicon) in a simple continuous pattern. The abdomen was copiously lavaged with warm sterile saline and closed routinely. Subsequently staphylectomy was performed using a carbon dioxide laser (NovaPulse CO2 laser; Lumenis). Intraoperatively the dog was tachycardic (heart rate between 160 and 180 bpm) and hyperlactataemic [7 mmol/L (0·3 to 1·0 mmol/L)], with mean arterial blood pressure of 80 to 100 mmHg. The PCV dropped to 25% with a total plasma solids of 34 g/L. A total of 30 mL/kg isotonic crystalloid (Lactated Ringer’s injection, USP; Hospira, Inc.) and 5 mL/kg synthetic colloid (Vetstarch 6% hydroxyethyl starch 130/0·4; Abbott Laboratories) were administered as iv boluses, resolving the tachycardia. Repeat PCV, total plasma solids and lactate during anaesthesia recovery were 23%, 32 g/L and 1 mmol/L, respectively. Treatment with isotonic crystalloid, famotidine and dolasetron was continued for 72 hours postoperatively. Analgesia was provided with a continuous rate infusion of 3 µg/kg/hour fentanyl (Fentanyl citrate injection; Hospira) iv for the first 24 hours, after which the dog was transitioned to 0.01 mg/ kg buprenorphine iv for every 8 hours. Postoperatively the dog ate well with no signs of retching, nausea, vomiting or abdominal distention. The dog was discharged from the hospital after 3 days and was prescribed 2·6 mg/kg maropitant (Cerenia; Pfizer) orally every 24 hours and 2·7 mg/kg tramadol (Tramadol HCl; Amneal) orally every 8 hours for use at home.

DISCUSSION

FIG 1. Right lateral cranial abdominal radiograph confirming hiatal hernia and associated gastric dilatation and volvulus

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It was hypothesised that the dog in this case report had a preexisting Type II HH and subsequently developed GDV. Although Boston terriers are not reported to be predisposed to HH, chronic negative intrathoracic and intraoesophageal pressure observed in brachycephalic dogs with upper airway obstruction has been suggested to contribute to HH by pulling the stomach into the thorax (Sivacolundhu et al. 2002, Poncet et al. 2005, 2006). Given that this dog had clinical signs and anatomical abnormalities consistent with brachycephalic upper airway obstruction it is suspected that this conformational disorder may have predisposed him to Type II HH. In addition, paraoesophageal herniation of

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the gastric fundus in Type II HH in humans has been reported to increase traction on the greater curvature of the stomach and increase the laxity of the gastrosplenic ligament resulting in gastric volvulus (Krähenbuhl et al. 1998, Sivacolundhu et al. 2002). It is believed that this mechanism could explain the development of GDV in this dog that would have otherwise been considered at low risk for GDV. This case demonstrates a rare but potentially fatal complication of Type II HH in a dog. Type II HH is a surgical disease in dogs (Bright et al. 1990, Sivacolundhu et al. 2002). Surgical repair of Type II HH should close the hernia opening to prevent reherniation of the stomach or other abdominal organs. In Types I, III and IV HH, additional surgical techniques are also indicated to restore normal function of the lower oesophageal sphincter. These include a combination of hiatal closure, gastropexy, oesophagopexy, antireflux procedures and feeding tubes (Ellison et al. 1987, Miles et al. 1988, Prymak et al. 1989, Lorinson & Bright 1998, Sivacolundhu et al. 2002). The outcome of the dog reported here was good; however, in retrospect different management decisions could have been made that may have reduced morbidity. Firstly, the dog had adequate indications to be taken to surgery shortly after admission, given the acute and severe nature of his clinical signs. Additionally, although the heart rate was normal at presentation, the presence of mild hyperlactataemia was suggestive of tissue hypoxia and may have been due to early obstructive shock in this dog. Consequently, the dog may have benefited from more aggressive iv fluid administration when the mild hyperlactataemia was noted, and this may have reduced the likelihood of cardiovascular instability intraoperatively. This case report documents GDV resulting in acute abdomen and cardiovascular instability in a dog with Type II HH. GDV should be considered in dogs with HH and acute abdominal pain and distension. As in the case of GDV in isolation, GDV in dogs with HH is a surgical emergency.

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Conflict of interest None of the authors of this article has a financial or personal relationship with other people or organisations that could inappropriately influence or bias the content of the paper. References Ayala, J. A., Naik-Mathuria, B. & Olutoye, O. O. (2008) Delayed presentation of congenital diaphragmatic hernia manifesting as combined-type acute gastric volvulus: a case report and review of the literature. Journal of Pediatric Surgery 43, 35-39 Bright, R. M., Sackman, J. E., DeNovo, C., et al. (1990) Hiatal hernia in the dog and cat: a retrospective study of 16 cases. Journal of Small Animal Practice 31, 244-250 Ellis, F. H. (1980) Controversies regarding the management of hiatus hernia. American Journal of Surgery 139, 782-788 Ellison, G. W., Lewis, D. D., Phillips, L., et al. (1987) Esophageal hiatal hernia in small animals: literature review and a modified surgical technique. Journal of the American Animal Hospital Association 23, 391-399 Formaggini, L., Schmidt, K. & De Lorenzi, D. (2008) Gastric dilatation-volvulus associated with diaphragmatic hernia in three cats: clinical presentation, surgical treatment and presumptive aetiology. Journal of Feline Medicine and Surgery 10, 198-201 Glickman, L. T., Glickman, N. W., Schellenberg, D. B., et al. (2000) Incidence of and breed-related risk factors for gastric dilatation-volvulus in dogs. Journal of the American Veterinary Medical Association 216, 40-45 Hall, J. A., Willer, R. L., Seim, H. B., et al. (1995) Gross and histologic evaluation of hepatogastric ligaments in clinically normal dogs and dogs with gastric dilatation-volvulus. American Journal of Veterinary Research 56, 1611-1614 Krähenbuhl, L., Schäfer, M., Farhadi, J., et al. (1998) Laparoscopic treatment of large paraesophageal hernia with totally intrathoracic stomach. Journal of the American College of Surgeons 187, 231-237 Lorinson, D. & Bright, R. M. (1998) Long-term outcome of medical and surgical treatment of hiatal hernias in dogs and cats: 27 cases (1978-1996). Journal of the American Veterinary Medical Association 213, 381-384 Miles, K. G., Pope, E. R. & Jergens, A. E. (1988) Paraesophageal hiatal hernia and pyloric obstruction in a dog. Journal of the American Veterinary Medical Association 193, 1437-1439 Monnet, E. (2003) Gastric dilatation-volvulus syndrome in dogs. The Veterinary Clinics of North America: Small Animal Practice 33, 987-1005 Poncet, C. M., Dupre, G. P., Freiche, V. G., et al. (2005) Prevalence of gastrointestinal tract lesions in 73 brachycephalic dogs with upper respiratory syndrome. Journal of Small Animal Practice 46, 273-279 Poncet, C. M., Dupre, G. P., Freiche, V. G., et al. (2006) Long-term results of upper respiratory syndrome surgery and gastrointestinal tract medical treatment in 51 brachycephalic dogs. Journal of Small Animal Practice 47, 137-142 Prymak, C., Saunders, H. M., Washabau, R. J. (1989) Hiatal hernia repair by restoration and stabilization of normal anatomy. An evaluation in four dogs and one cat. Veterinary Surgery 18, 386-391 Sivacolundhu, R. K., Read, R. A. & Marchevsky, A. M. (2002) Hiatal hernia controversies – a review of pathophysiology and treatment options. Australian Veterinary Journal 80, 48-53

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Gastric dilatation and volvulus in a brachycephalic dog with hiatal hernia.

A brachycephalic dog was presented with an acute onset of retching and abdominal discomfort. The dog had a chronic history of stertor and exercise int...
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