Well, that's a first

I was recently presented with a bloated Great Dane. Gastric-dilatation volvulus (GDV/"bloat") is extremely common in this breed. It requires immediate surgical intervention if the patient is to live (see sidebar for more information). The first step beyond physical exam in diagnosing the GDV is a lateral xray of the abdomen. When I took the lateral xray on this patient, it wasn't the typical xray we always see (called the "double bubble"). It was definitely a torsion, but it just looked wrong for some reason. I filed that away for later consideration and went to talk to the owners about surgery. They agreed to proceed.

Now, I do GDV surgery fairly often. In fact, I did one on my last week of work. It went swimmingly - textbook, "caught it early" GDV. This one...far from textbook.

The first clue came when I opened the abdomen. In a typical GDV, the omentum is on the top, as the stomach is torsed 180 degrees, pulling that tissue up and over itself. So it **should** be the first thing you see. Instead, I was staring at a massively engorged spleen. Hemorrhage came pouring out of my incision. My heart did a little skip as my brain computed. What the heck was going on?

I lifted the spleen up as gently as I could, and as soon as I did, blood started to pour out of it. It was then that I realized I was looking at a 360 degree GDV. This is a much less common manifestation of GDV in which the stomach twists completely around. The complete torsion pulls the spleen up and over, so it is the first thing you see when exploring the abdomen. In doing so, the spleen is often torn off of its blood supply, leading to massive hemorrhage.

I'll tell you guys, that was the fastest I have EVER done a splenectomy in my life. That spleen was out in about 4 minutes. Afterwards, the surgery proceeded fairly routinely, as we passed a tube and deflated the stomach.

Our patient recovered mostly uneventfully and will hopefully go on to live a normal and long life. And now I have an explanation for the weird xray. Hopefully should I see one again, I'll be ready for it!