First, the Basics

The lungs are the focus of this topic. The diaphragm and rib muscles extend and contract to draw breath into the lungs and expel it again. In many ways, the lungs are like sponges filled with air. Life depends on the ability of their small chambers to expand with new air and contract to expel used air.  There is not a lot of extra room inside the chest cavity, so when something (such as fluid) starts taking up space in the chest, the lungs do not have room to inflate to their natural capacity. Breathing becomes hard work, and the patient’s focus becomes expanding the lung against limited space, sort of like trying to blow up a balloon that is too stiff. The fluid inside the chest cavity is called “pleural effusion.”  This fluid is not actually inside the lungs and generally does not lead to coughing or sputtering; it instead surrounds the lungs, making lung expansion difficult, leading to shallow rapid breaths and recruitment of the abdominal muscles to lend strength to the act of breathing.

Types of Fluids

There are many types of fluids that can accumulate in the chest cavity. When the fluid is blood, the problem is called hemothorax. When the fluid is pus, the problem is called pyothorax. When the fluid is actually air, the problem is pneumothorax. When the fluid is lymph, the problem is called chylothorax. With chylothorax, the fluid is milky when it is drained from the chest, and its whiteness is from fat. Chylothorax represents a specific problem and requires specific therapy.

Initial Tests

The effort the patient is making to breathe will probably be the first sign of trouble, and upon seeing this, your veterinarian is likely to recommend radiographs. On those, fluid in the chest will be obvious. From there, the chest will need to be tapped with a needle and the fluid drained. This will create some relief for the patient as the lung will once again be able to expand. The fluid will most likely need to be sent to the lab for testing to determine the type. If the patient is too distressed for radiographs, the chest may be immediately tapped to see if there is fluid pressure that can be relieved. After the fluid has been removed from the chest, new radiographs are often taken to see if there are any structures (such as masses or heart chamber enlargements) that have become visible now that the overlying fluid is gone. 

What is Lymph?

Part of the circulatory path of lymphatic fluid involves certain lymph vessels of the GI tract called lacteals, which are involved in the absorption of dietary fat. Because of this influx of fat, lymphatic fluid is milky white. Lymphatic fluid/chyle contains fat, water, and lymphocytes (cells of the immune system). We all know what blood is. We all know that blood circulates in veins and arteries and is moved by the pumping action of the heart. In fact, there is another circulatory system in the body: the lymphatic system. Lymphatic fluid, also called “lymph” or “chyle,” represents extra fluid draining between the cells of the body, gradually channeling into lymph vessels. The fluid is moved in these vessels by the natural movement of the body’s muscles, and on its way, it picks up assorted cellular debris and carries it along its route like driftwood. Lymph fluid (and its cellular driftwood) circulates through the lymph nodes, where cells of the immune system are exposed to the driftwood. In this way, the immune system sees the remnants of infection, tumor cells, foreign organisms, etc., and can react appropriately. Some immune cells circulate in the lymphatic fluid, facilitating the immune reaction and participating in the body’s defense.

When something goes wrong with the circulation of the lymph fluid and back pressure is created, lymph fluid can leak out and accumulate in the chest.

When the Diagnosis is Chylothorax

If there is a reason for the chyle build-up, it is important to find that reason. Often (especially in cats), the reason is heart disease. Heart disease generally interferes with lymphatic drainage, and poor drainage leads to chyle build up, but there can be other reasons for chyle buildup besides heart disease. Any sort of mass or growth in the chest could also be responsible. If a cause can be found, then it should be addressed if possible. If no cause can be found, then the condition is termed idiopathic and is simply managed either medically or surgically. An echocardiogram/ultrasound of the chest is almost always needed to rule out chest masses and assess the patient for heart disease. Most cases of chylothorax are idiopathic.

Breeds that seem predisposed include Siamese and Himalayan cats, and Afghan hound and Shiba Inu dogs.

Cats are diagnosed with chylothorax approximately four times as often as dogs.

When the Diagnosis is Idiopathic Chylothorax

There are several options for treatment, though they have pros and cons. The most conservative method is medical management. This means that whenever the patient seems to be having some distress, the chest fluid is drained (see video of a fluid drain). How often this is necessary is highly individual, but every few weeks is a common interval. In time, after many taps, scarring can build up to cause the fluid to loculate, which means that small pockets of fluid form rather than one drainable area. This makes tapping more difficult over time. Other problems with periodic tapping are the potential to introduce an infection with the needle stick and the fact that chyle is an inflammatory fluid that can, over a long time, create some problematic scarring between the chest wall and the lung. This is called restrictive or fibrosing pleuritis and is definitely something to avoid (see below).

A supplement called rutin may help. Rutin is available in vitamin stores and acts to stimulate cells called macrophages to carry away some of the fat in the chyle. In some individuals, this supplement is helpful in reducing the amount of chyle build-up.

Another treatment involves somatostatin, a chemical normally produced in the brain to regulate intestinal hormone and enzyme secretion. One of its effects is to reduce chyle flow through the thoracic duct. A commercial product can be used in pets, but its use should be considered somewhat experimental.

A low-fat diet (approximately 6 percent fat on a dry matter basis) is generally also used in conjunction with the above. Medical management such as this is often recommended before surgery, as some cases of chylothorax will spontaneously resolve.

Treatment

In many cases, the cause of chylothorax cannot be defined. In this situation, chylothorax is said to be idiopathic, and it must be treated without the benefit of treating its underlying cause. There are several options for treatment, though they have pros and cons. The most conservative method is medical management. This means that whenever the patient seems to be having some distress, the chest fluid is drained.  How often this is necessary is highly individual, but every few weeks is a common interval. In time, after many taps, scarring can build up to cause the fluid to loculate, which means that small pockets of fluid form rather than one drainable area. This makes tapping more difficult over time.

A supplement that may help is called rutin. Rutin is available in vitamin stores and acts to stimulate cells called macrophages to carry away some of the fat in the chyle. In some individuals, this supplement is helpful in reducing the amount of chyle build-up.

A low-fat diet (approximately 6% fat on a dry matter basis) is generally also used in conjunction with the above.  Medical management such as this is often recommended before surgery, as some cases of chylothorax will spontaneously resolve.

More permanent solutions require surgery. 

Thoracic Duct Ligation and Pericardiectomy

The thoracic duct is the largest lymph vessel in the body, and it runs alongside the aorta (the largest artery in the body) through the chest. Lymph fluid flows through it on the way to the subclavian artery, where it dumps into the bloodstream. When the thoracic duct is tied off, lymph fluid must find other channels for circulation, and the flow of lymph through the chest is greatly reduced. Ligation (tying off) of the thoracic duct resolves the chylothorax in approximately 50% of dogs and less than 40% of cats. See a video of thoracic duct ligation in a cat.

Success is hugely increased by stripping the pericardium from around the heart.

The pericardium is the fibrous sac containing the heart. When it is bathed in chyle, it becomes thickened and may slightly constrict the low-pressure right side of the heart. This causes increased pressure on the right side of the heart, which in turn causes increased pressure in the lymphatics. Stripping the pericardium relieves this pressure, and when thoracic duct ligation is combined with pericardiectomy, chylothorax resolved in 100% (10 out of 10) dogs studied and in 80% of cats studied. This is now the surgery of choice for chylothorax in cats and dogs.

Cisterna Chyle Ablation

The cisterna chyle is a structure where lymph collects just before it flows into the thoracic duct. The removal or destruction of the cisterna chyle further diverts lymph flow away from the chest. This procedure is generally reserved for patients who did not find success with thoracic duct ligation/pericardiectomy.

Complications

It can take up to 50 days to realize the benefits of surgery for chylothorax. Some animals simply will not achieve adequate resolution, and some (as many as 30% of dogs) will resolve their chylothorax only to develop some other type of chest fluid. The simple use of prednisone as an anti-inflammatory measure can resolve such fluid in as many as 60% of dogs, though it takes four to six weeks. If this is ineffective or a more rapid solution is needed, a port can be surgically placed under the skin to allow for easy fluid drainage, or a pump can similarly be placed to allow the owner to pump fluid from the chest into the abdomen.

Beware of Fibrosing Pleuritis

Chyle in the chest is irritating to the local tissue; the lungs can develop scarring from being in contact with chyle. Scarring prevents the lungs from expanding normally even after the chyle is removed. The only treatment is to surgically remove the scar tissue using a procedure called decortication, a process fraught with complications if the lungs are diffusely affected. If both lungs must be decorticated, it is common for life-threatening pulmonary edema to occur as the lungs try to re-expand. Sometimes, air leaks out of the lungs and fills the chest with air (pneumothorax). Before opting for any surgical treatment of idiopathic chylothorax, this potential complicating factor should be discussed with the surgeon.

Surgical treatment of chylothorax is something that not all veterinarians are comfortable performing. Discuss with your veterinarian whether referral to a specialist would be best for you and your pet.

Many injuries and physical disorders represent life-threatening emergencies, but there is only one condition so drastic that it overshadows them all in terms of rapidity of consequences and effort in emergency treatment: the gastric dilatation and volvulus – the bloat.

What is it, and Why Is It So Serious?

What Are the Risk Factors for Developing Bloat?

Dogs weighing more than 99 pounds have an approximate 20 percent risk of bloat. The risk of bloating increases with age.

Classically, this condition affects dog breeds that are said to be deep-chested, meaning the length of their chest from backbone to sternum is relatively long while the chest width from right to left is narrow. Examples of deep-chested breeds would be the Great Dane, Greyhound, and the setter breeds. Still, any dog can bloat, even dachshunds and chihuahuas.

Classically, the bloated dog has recently eaten a large meal and exercised heavily shortly thereafter. Still, we usually do not know why a given dog bloats on an individual basis. No specific diet or dietary ingredient has been proven to be associated with bloat. Some factors found to increase and decrease the risk of bloat are listed below:

In the 1993 study from Germany (see below), the German shepherd dog and the boxer had the highest risk for bloat.

How to Tell if Your Dog Has Bloated

Classically, the dog is distressed and makes multiple attempts to vomit, and the upper abdomen is hard and distended from the gas within, though in a well-muscled or overweight dog, the distention may not be obvious. There are other potential emergencies (sudden abdominal bleeding from a ruptured tumor, for example) that might have a similar presentation, so radiographs may be needed to determine what has happened. The hallmark presentation of bloat is a sudden onset of abdominal distention, distress, anxiety, and pain (panting, guarding the belly, anguished facial expression), and multiple attempts at vomiting that are frequently unproductive. Not every dog will have a classic appearance, and some dogs will not have obvious abdominal distention because of their body configuration. If you are not sure, it is best to err on the side of caution and rush your dog to the veterinarian immediately.

What Has To Be Done

There are several steps to saving a bloated dog’s life. Part of the problem is that all steps should be done at the same time and as quickly as possible.

First: The Stomach Must be Decompressed

The huge stomach is by now pressing on the major blood vessels, carrying blood back to the heart. This stops normal circulation and sends the dog into shock. Making matters worse, the stomach tissue is dying because it is stretched too tightly to allow blood circulation through it. There can be no recovery until the stomach is untwisted and the gas is released. A stomach tube and stomach pump are generally used for this, but sometime surgery is needed to achieve stomach decompression.

Also First: Rapid IV Fluids Must be Given to Reverse the Shock

Intravenous catheters are placed, and life-giving fluid solutions are rushed in to replace the blood that cannot get past the bloated stomach to return to the heart. The intense pain associated with this disease causes the heart rate to race at such a high rate that heart failure will result. Medication to resolve the pain is needed if the patient’s heart rate is to slow down. Medication for shock, antibiotics, and electrolytes are all vital in stabilizing the patient.

Also First: The Heart Rhythm is Assessed and Stabilized

A special and very dangerous rhythm problem called a premature ventricular contraction, or “PVC,” is associated with bloat and it must be ruled out. If this is the case, intravenous medications are needed to stabilize the rhythm. Since this rhythm problem may not be evident until even the next day, continual EKG monitoring may be necessary. If the disturbed heart rhythm is noted at the very beginning of treatment, this is associated with a 38% mortality rate.

Getting the bloated dog’s stomach decompressed and reversing the shock is an adventure in itself, but the work is not yet half finished.

Surgery

All bloated dogs, once stable, should have surgery. Without surgery, the damage done inside cannot be assessed or repaired, plus bloat may recur at any point, even within the next few hours, and the above adventure must be repeated. If the stomach has not untwisted with decompression, the surgeon untwists it and determines what tissue is viable and what is not. If there is a section of dying tissue on the stomach wall, this must be discovered and removed, or the dog will die despite the heroics described above. Also, the spleen, which is located adjacent to the stomach, may twist with the stomach, necessitating removal of the spleen or part of the spleen as well. After the nonviable tissue is removed, a surgery called a gastropexy is done to tack the stomach into its normal position to prevent future twisting.

If the tissue damage is so bad that part of the stomach must be removed, the mortality rate jumps to 28 – 38 percent.

If the tissue damage is so bad that the spleen must be removed, the mortality rate is 32 – 38 percent.

After the expense and effort of the stomach decompression, it is tempting to forgo the further expense of surgery. However, consider that the next time your dog bloats, you may not be there to catch it in time and, according the study described below, without surgery, there is a 24 percent mortality rate and a 76 percent chance of re-bloating at some point. The best choice is to finish the treatment that has been started and have the abdomen explored. If the stomach can be surgically tacked into place, the recurrence rate drops to 6 percent.

Surgery will prevent the stomach from twisting in the future, but the stomach is still able to periodically distend with gas. This is uncomfortable but not life-threatening.

Results of a Statistical Study

In 1993, a study involving 134 dogs with gastric dilatation and volvulus was conducted by the School of Veterinary Medicine in Hanover, Germany.

Out of 134 dogs that came into the hospital with this condition:

• 10% died or were euthanized prior to surgery (factors involved included expense of treatment, severity/advancement of disease, etc.)
  
• 33 dogs were treated with decompression and no surgery. Of these dogs, eight (24%) died or were euthanized within the next 48 hours due to poor response to treatment. (Six of these eight had actually re-bloated.)
  
• Of the dogs that did not have surgical treatment but did survive to go home, 76% had another episode of gastric dilatation and volvulus eventually.
  
• 88 dogs were treated with both decompression and surgery. Of these dogs, 10% (nine dogs) died in surgery, 18% (16 dogs) died in the week after surgery, and 71.5% (63 dogs) went home in good condition. Of the dogs that went home in good condition, 6% (four dogs) had a second episode of bloat later in life.
  
• In this study, 66.4% of the bloated dogs were male, and 33.6% were female. Most dogs were between ages seven and 12 years old. The German Shepherd dog and the Boxer appeared to have a greater risk for bloating than did other breeds.

(Meyer-Lindenberg A., Harder A., Fehr M., Luerssen D., Brunnberg L. Treatment of gastric dilatation-volvulus and a rapid method for prevention of relapse in dogs: 134 cases (1988-1991) Journal of the AVMA, Vol 23, No 9, Nov 1, 1993, 1301-1307.)

Another study published in December of 2006 looked at 166 dogs that received surgery for gastric dilatation and volvulus. The point of the study was to identify factors that led to poor prognosis.

• A 16.2% mortality rate was observed. The mortality rate for dogs over the age 10 years was 21%.
  
• Of the 166 going to surgery, 4.8% were euthanized during surgery, and the other 11.4% died during hospitalization (two dogs died during surgery). All dogs that survived to go home were still alive at the time of suture removal.
  
• 34 out of 166 dogs had gastric necrosis (dead stomach tissue that had to be removed). Of these dogs, 26% died or were euthanized.
  
• Post-operative complications of some sort occurred in 75.9% of patients. Approximately 50% of these dogs developed a cardiac arrhythmia.
  
• Risk factors significantly associated with death prior to suture removal included clinical signs of bloating for greater than six hours before seeing the vet, partial stomach removal combined with spleen removal, need for blood transfusion, low blood pressure at any time during hospitalization, sepsis (blood infection, and peritonitis (infection of the abdominal membranes).

(Beck, J.J., Staatz, A.J., Pelsue, D.H., Kudnig, S.T., MacPhail, C.M., Seim H.B, and Monnet, E. Risk factors associated with short-term outcome and development of perioperative complications in dogs undergoing surgery because of gastric dilatation-volvulus: 166 cases (1992-2003). Journal of the AVMA, Vol 229, No 12, December 15, 2006, p 1934-1939.)

It is crucially important that the owners of big dogs be aware of this condition and prepared for it. Know where to take your dog during overnight or Sunday hours for emergency care. Avoid exercising your dog after a large meal. Know what to watch for. Enjoy the special friendship a large dog provides, but at the same time, be aware of the large dog’s special needs and concerns.

Prevention: Gastropexy Surgery

A study by Ward, Patonek, and Glickman reviewed the benefit of prophylactic surgery for bloat. The lifetime risk of death from bloat was calculated, along with estimated treatment for bloat versus the cost of prophylactic gastropexy. Prophylactic gastropexy was found to make sense for at-risk breeds, especially the Great Dane, which is at the highest risk for bloat.