February 10, 2021 – Dr. Kelly Diehl talks about bloat in dogs (also known as gastric dilatation and volvulus) with Dr. Elizabeth Rozanski, an associate professor at the Cummings School of Veterinary Medicine at Tufts University. Rozanski discusses the physiology of bloat, factors affecting prognosis, and prevention. She also covers her Foundation-funded research, which studied how bloat affected blood clotting and heart function.
0:00:11.6 Dr. Kelly Diehl: Welcome to Fresh Scoop, Episode 29. We will be talking about bloat in dogs. I'm your host, Dr. Kelly Diehl, Morris Animal Foundation's Senior Director of Science and Communication. And today we'll be talking with Dr. Elizabeth Rozanski. Dr. Rozanski is an Associate Professor at the Cummings School of Veterinary Medicine at Tufts University, and a Morris Animal Foundation funded researcher. Dr. Rozanski is a diplomate of both the American College of Veterinary Internal Medicine and the Veterinary Emergency and Critical Care Society. Dr. Rozanski's research has covered a number of areas of interest, particularly in emergency medicine. She appeared on a previous podcast to discuss one of her most recent Foundation-funded grants looking at the early diagnosis of hypertrophic cardiomyopathy in cats. And you can find that on our website, if you want to listen to that podcast, but today, we're actually going to turn back the clock a bit. And I asked Dr. Rozanski to discuss gastric dilatation volvulus, sometimes known as bloat, of course, in dogs, which was the subject of an earlier Foundation grant. So Liz, thanks for joining us today again on the podcast.
0:01:24.8 Dr. Elizabeth Rozanski: Great. Well, it's super to be here, and you always pick some of my favorite topics.
0:01:28.2 DD: Oh, good, good. And I think this is a really timely one. But before we get into your work, can you tell us a little bit about yourself and what led you to become a veterinarian?
0:01:39.3 DR: Oh, sure. So I grew up outside of Chicago, and I think I was one of those people that wanted to be a veterinarian from the moment I heard that it was a career possibility. And so I think a lot of vets fall into that category, where it was just always something you wanted to do. And then I was lucky enough to go to Illinois for veterinary school, and then I kind of took a milling path around here and ended up in emergency and critical care for the excitement factor and for the chances to make a difference.
0:02:07.3 DD: Great. Yeah, I think emergency medicine is that front line, just as in people, and it's a specific branch and a specialty all in its own. So we'll talk about bloat, and most of our listeners are veterinarians or vet techs or veterinary students, but for other folks, can you remind us what dog breeds are most commonly affected by gastric dilatation volvulus or GDV... So I'm going to abbreviate that. And are there any differences between males and females when we talk about incidence?
0:02:41.6 DR: Sure, so that's a great question. So GDV primarily affects large breed deep-chested dogs. So kind of the typical breed we think about is the Great Dane. And there are some studies that suggest Great Danes have up to a third of... Great Danes are affected over their course of their lifetime if they're not having a preventive surgery to remove that risk. The most common other breed, across the board, the most common breed is the German Shepherd, and that's because German Shepherds are pretty common dogs. But we can see it in any breed of dog. Just last year, we had it in a 17-year-old dachshund, so an elderly little dachshund but they're kind of deep-chested as well. And when we look at the sex distribution, males... I think probably because they tend to be a little bit larger, are a little more commonly affected, but it certainly can affect female dogs as well. So any deep-chested dog.
0:03:31.5 DD: Okay, and that brings me to a question. And I know this has been discussed a lot in veterinary medicine, but can you update us on the pathophysiology? I know it's been debated why it happens, but anything that you can tell us about, again, why this happens in certain dogs?
0:03:53.4 DR: Yeah. No, that's a great question about why it happens. And I think you're right, we don't really know for sure why it happens in one dog and not another. In the bigger, deep-chested dogs, we do know that the ligaments that support the stomach are longer in those breeds of dogs, longer proportionate to their body size than they are in different, more stocky breeds of dogs. So there's some anatomic differences that predispose dogs to it, so it makes them more likely to develop it. Other things that are thought to potentially play a role is dogs that have a higher rate of nervousness or anxiety that may slow down gastric motility.
0:04:28.5 DR: And so if you don't have a lot of forward gastric motility, if a lot of things aren't leaving the stomach, you can have an increased amount of fermentation in the stomach, and that's actually one of the neater, more interesting studies that's just come out in the last couple of years, showing that the stomach contents are not swallowed air, but rather fermentation. And so they have a high carbon dioxide content, so that for whatever reason... And we think most likely the stomach flips on itself first and then things are unable to leave and it gets bigger and bigger and affects the dogs how they feel and makes them feel like they need to vomit and can affect their perfusion.
0:05:05.6 DR: But the million-dollar question is, "Why does a dog's stomach flip?" We know that if you go in surgically and you try to mal-position a stomach... So if you took a healthy dog and flipped their stomach over and just watched, it would flip itself back in the right place pretty quickly. So it's still very unclear as to why a stomach would go to the wrong position.
0:05:25.9 DD: Okay, that's a really... I think that's a question, and we'll get to it later, that a lot of our clients have. And anxiety. So before we get there, though, can you give us a sense... You just did a little bit with some statistics about Great Danes, but a sense for this disease as you see in the emergency clinic. Like how many cases do you think you see? Do we have any sense of the mortality rate when a patient hits the emergency room?
0:05:54.6 DR: Sure, so it obviously depends on what kind of medicine or what kind of hospital you have. In a busy emergency hospital, we see about 14,000 or 15,000 cases of dogs and cats through our emergency service a year. And we probably see somewhere between one and four cases a week of bloat. We certainly see more sometimes in the summer months when dogs are maybe a little bit more active, but it's kind of one of those common diseases that we see regularly. And it's also a disease that typically, people will bring their animals in on an emergency basis to. When we just went back and we looked at recent data, the majority of the dogs come in in the evening and early morning hours. And whether that's because people are home from work or not, but that's... Even during the COVID time, we were seeing that. So definitely, that sort of thing. Breed of dog-wise, it's really, again, the bigger deep-chested dogs.
0:06:50.4 DR: And prognosis has been... About 80% to 85% survival since the early 1990s. And so GDV was first published in the veterinary literature around 1916, so a long, long time ago. And earlier reports would be like, people recognize that dogs had this and then they died. And then in the early 70s, people identified you could go into surgery and put the stomach back in the correct spot, and some of those dogs would survive. And then through the late 70s and early 1980s, people identified methods of keeping the stomach from flipping with a gastropexy and emergency and critical care techniques, including emergency surgery and fluid resuscitation. We're kind of getting improved overall to get a better outcome. So when we tell people if their dog comes in with a bloat, if we treat that promptly with surgery, the majority of dogs do well. So somewhere between 80 and 90% of those dogs do well with that, but not all of them. So it's certainly something where they can individually be affected.
0:07:57.1 DD: So I have... That actually makes me think of another question. So I'm actually surprised that we have known about bloat for more than 100 years. I think of it more as something more recent. But what are still some of the big unknowns about this disease?
0:08:18.8 DR: I think the biggest unknown about the disease is why do some dogs get it and why do some dogs not get it? That's a huge question, and that's obviously probably the most straightforward question to think about. The second question that we struggle with, or we try to get the answer to is, why do some dogs come in... And when we again, looked at the dogs in our hospital just recently, the majority of the dogs that came in and the family's elected to pursue surgery went home either the following day or the day after. A small percentage of dogs have a very complicated recovery associated with the disease, and that's a really interesting…as to why one dog would be so badly affected and other dogs would actually do very well and recover very quickly. Some of that's probably thought to be associated or it's definitely associated with if they also have some of their stomach necrose or die. And so if you can think about it, when the stomach flips over, it's losing its blood supply to part of the stomach. And if it's returned to its normal position fairly quickly, that stomach is going to do fine.
0:09:18.1 DR: But if the stomach is very badly affected, it's not getting a lot of blood flow at all, and some of the stomach actually dies that needs to be removed, that can be something that really sets the dog up for what we term multiple organ dysfunction or development of complications associated with that. And that's really what happens to critically ill dogs that don't get better, is that they don't necessarily die of the initial disease, they die of the ongoing insults to the rest of their body from that disease. So they can develop kidney dysfunction, clotting dysfunction is what we've been looking at a little bit, respiratory dysfunction, cardiac dysfunction, kind of all associated with that critical illness. So when we think about that subset of dogs that we lose associated with GDV, it very much is associated with development of multiple organ dysfunction.
0:10:08.6 DD: And I'm going to take a slight digression here, because as a clinician, I think the greatest anxiety I had was what you alluded to, which is necrosis. And I can think of one dog that sailed through surgery and everything looked okay, and then two days later was dead because of complications from necrosis that was not evident. I think there's dogs that are obvious at surgery. But just to humor me in this digression is, what are we learning about necrosis and identifying necrosis maybe during surgery, or what are some tips for people out there who might be listening who do these surgeries?
0:10:57.8 DR: That's a great question. I think that you're 100% right. Sometimes, unfortunately, we get in there and the stomach is very clearly black. Sometimes it even has a hole through it where it's already ruptured, and that's clearly stomach that needs to come out, and that's also a dog that's going to be at risk of a longer recovery and potentially not recovering associated with that. I think the things I think about are, if in doubt, you should remove that. And I think the challenge that you're up against is the stomach is pretty large. You can remove quite a bit of it without any long-term sequelae, but if you don't remove enough and it doesn't return blood flow, and that can die down the road, is that's where you lose those patients. So making sure you take out stomach that looks diseased, and I think that is really hard to tell, because sometimes it can look really reddish-purple-y but actually do okay.
0:11:48.2 DR: If it's grey or black, that's very hard. And there's different techniques some people use, trying to see if it bleeds when you cut it. Some people try to look with a fluorescein dye or with ultrasound, and those things are a little bit harder to be really sure that they're helpful. So I think you're 100% correct. If the stomach looks bad, you need to remove it. And the things that we're looking for are the same things that people who are doing surgery regularly are looking for is, very discolored, lack of pulses to that area, lack of bleeding when that part of that stomach is resected. If you're not removing back to an area that's bleeding back appropriately, that's something that we worry about as well.
0:12:30.1 DD: So that's really helpful to know. I think that's a big area of concern. Do you think is... Again, this is a little off the beaten path. Do you think surgeons are getting better at recognizing that or being more... I think there was always a lot of anxiety about resecting parts of the stomach. And is that changing, do you think, with people? I see people be a little bit more not so nervous about it as some of my surgeons used to be.
0:12:57.7 DR: Oh, that's a great question as well. I think it's really surgeon-dependent and it's really location-dependent. And so that's what I think we look at across, basically, the world. There's a number of people that do surgery. Some of the people who are doing bloat surgery have been doing bloat surgery since the 1980s, and are really, really good at it. It's also an emergency surgery a lot of the time, so it may be done by somebody who is doing the best they can but haven't had a lot of experience with that. And this is one of the challenging surgeries because it's not an easy thing to wait till somebody else gets there or put in a car and ship two mile or two hours down the road for somebody else to operate. So they can be really challenging surgeries. It's one of the classic ones that we think about with emergency surgery. And again, many of them go just fine, but there are some that can be really bad. And that's that population of dogs we're looking to really try to help, but it can be challenging to figure out what to do.
0:13:52.2 DD: Right. So well, let's move on to your study. And as I said, it was a couple of years ago, but tell us about what your research question was and the methods you used.
0:14:07.2 DR: Sure. So we, basically... We have two studies that we did a part of that, and then we did a couple of other little side projects associated with it. So the first thing that we were looking at was dogs that came in with bloat, so naturally occurring disease. The nice part about the research that we do here is we wait for the diseases to come in, so we're not creating it. We're looking at the real disease, so dogs that came in. And then we monitored their clotting status in particular, looking for the development of a disease, called DIC. And what we also looked at was a new clotting test called a thromboelastogram, which is a global measure of clotting function to try and to see. And what we've identified is when dogs are really sick, that they will have a very poor ability to form clots. But when they're initially sick, and they might clinically look that sick, instead they'll form clots too enthusiastically. So they'll be hyper-coagulable. And so what we looked at is, what did they look like when they came in, and what did they look like? Did they survive uneventfully, or did they develop complications down the road? And luckily for the dogs, we had very few dogs that didn't survive. But the dogs that didn't survive definitely had changes in their clotting that were apparent from kind of when they hit the door, even though the dogs looked maybe similar.
0:15:23.6 DR: So kind of looking for an early warning of the potential for development of multiple organ dysfunction. And so I think that's a really important thing to recognize is, are they going to go ahead? They look okay. To your eye, they look fine, but are they somebody who's at risk of that? And so early changes. So an early hyper-coagulable state where they're forming clots too quickly can be associated with the later development of a bleeding tendency. And so I think that's an important piece of information that we got. The other area that we were really looking at was what happens with their heart. And as I think most people are aware, dogs with GDV are very likely to develop arrhythmias. So they'll typically have ventricular arrhythmias or abnormal heart beats that are starting in the ventricle or the lower chamber. And what we found with this was that a lot of dogs had them. Some dogs had a very high evidence as marked by troponin, which is a biochemical change of when the heart gets a thrombus in it.
0:16:23.5 DR: We had very high evidence of myocardial damage associated with GDV, but not all of them. So it was a variable as to if a dog actually developed heart disease or not. And then the other thing that we found that we're actually still trying to look into a little bit more, as many of you are familiar with, a marker called NT-proBNP, which is a marker of atrial stretch. And we use that a lot in cats. We use that a lot in dogs with mitral valve disease or dilated cardiomyopathy, trying to look to see what type of... How bad or how their heart is biochemically dealing with heart disease. And what we've found in this study was dogs with normal echocardiogram or relatively normal echocardiograms had actually very high NT-proBNP levels, which could be consistent with an earlier heart disease. So we couldn't find anything on echo, the troponin, which we would have expected to be high was normal, but they still were biochemically affected by their bloat and by the subsequent surgery.
0:17:22.3 DR: And so that's something that's really interesting that's been reported in people with critical illness, but it was one of the first times we were able to document it in dogs with critical illness. So those were the two big arms we were looking at. The other things that we found recently that are also kind of in that same population, is we identified that dogs that were older, were more likely to get euthanized at diagnosis, so kind of at the same time frame. But if they went to surgery, they were equally likely to survive and do well. And so I think that's a really important thing. I think a lot of times, as a clinician, people ask you, are they too old for surgery or those kind of questions, and we have some pretty good evidence that, at least with GDV, that if you're willing to go to surgery, you can expect your dog to do fine.
0:18:09.6 DD: That's actually pretty interesting because I think that comes up a lot. And I would say... I'm sure I was as guilty as anybody in thinking that maybe it was going to be dicier with an older patient. So I think that's really important information for people who are practicing. Did anything... You talked about your findings. Did anything surprise you, Liz, when you were looking at this that you weren't expecting?
0:18:36.0 DR: I guess the biggest thing is the two things that surprised me the most was that even with relatively normal echocardiograms and without horrible arrhythmias, these dogs still had evidence that their heart wasn't quite perfect, and I think that that's a really interesting finding. I think the second thing that was really interesting was that we only had a couple of dogs that really changed dramatically through the study. One was a Weimaraner called Shadow, and that dog came in fairly sick and had a very, very abnormal thromboelastogram when we hit the door, and unfortunately, over the next four to five days declined tremendously and ended up being euthanized due to multiple organ dysfunction, and you could see those changes happening with the clotting tests as we're monitoring them. So I think we found out a lot of stuff. I think the question of what's really surprising is, again, the questions I always have is, how can you tell who's going to not do well? And I think that's always the million-dollar questions for owners as far as, I want to have them have surgery, but I don't want to put them through anything that's too dramatic. Well, we don't want to do that either, but we think he has a good chance. And so I think we're still trying to really streamline the ability to say, this dog is going to do great, this dog is not going to do as well. And then so I think that's one of the really big areas of interest as well.
0:19:54.5 DD: Right. And are you using... First of all, are you using... Probably you are because some of the stuff you found, but do you see other clinics accepting it? I'm pretty interested in... I know that the thromboelastograms, I think are becoming more available to a lot of practitioners, and I think we're still sorting out how to use those, but do you see acceptance of, and maybe even just at academic institutions of what you found?
0:20:24.6 DR: Yeah, I think for sure. I think people are more and more interested in the moving GDV from a clearly disease in surgical realm, and I think that the challenge with it is, again, a lot of these dogs do great, come in, have surgery, go home, no worries, but there's this subset of dogs that really struggle with the disease. And I think certainly in the critical care world, this is one of the big diseases that we always struggle with, and we just don't want to lose dogs to this. And so getting more information out there, the thromboelastogram is a very helpful test from that standpoint. There's also a new point-of-care one called the BCM, that is making a good... It's just a cartridge-based test, so it's a lot. The thromboelastogram requires pipettes and calibration and things that are not super hard, but it's a little more of a fragile machine. The BCM is one that was designed for battle work, kind of take it in the field with you. And so I think we're looking at our hospital at those dogs as well, using that new technology to see if we can say something different with that. But I think those looking for earlier warning signs is really gaining popularity, and I see a lot of people looking for that as well.
0:21:30.0 DD: Good. We've made a lot of advances, as you mentioned, in treating this disease, even for an old person like me, I think we were by the late '80s, early '90s, doing a fairly good job with these guys. But is there anything new coming down the pike or that people are looking at as far as therapy, when you're thinking not surgery necessarily but medical therapy surrounding this condition?
0:22:01.5 DR: I don't know if there's anything really good coming out that we should be really chasing down. I think the big bulk of the research that people are really interested in is, again, understanding better why a dog develops it, so understanding the preventative strategy. There is some genetic data coming out of different places looking at... Kind of the holy grail that people have always looked for with this is, is there a genetic marker that we can use? So similar to some of the diseases where you can breed this out of the dog. So people have looked at that a lot and there have been finding some genetic differences in dogs that are affected versus dogs that aren't, but it's probably not going to be something where you can take a dog and say, ‘Oh, this dog is GDV3, you should let this dog have puppies’, and I think one of the challenges with that, like we touched on earlier, is GDV can happen at any age, but it happens more and more as dogs get older. It's uncommon to see a 2-year-old dog with the GDV, the most common is probably 8 to 10, or 11 years of age, so that if you are looking to remove GDV from a breeding line, that's really hard to do, it's so multi-factorial.
0:23:10.9 DR: So I think genetics is really interesting, I think other characteristics of dogs are interesting, there's always been a lot of concern and debate about feeding or not feeding, feeding from a height, feeding big food, feeding small food, being raw food, feeding non-raw food, feeding... All those sorts of questions. So I think there are a lot of things that are really interesting, and I think we're just continuing to try to figure out what's the best thing to really chase down.
0:23:37.1 DD: Right, and that really is a beautiful lead-in to what I was going to ask you about. What I would get from my clients all the time is about prevention and, as in specialty practice, a lot of times these guys had GDV, but maybe the owners had another dog at home, or I'd be seeing them for a problem and they would ask me about it, and then from a personal aspect, I have Labradors, and I will admit I had them gastropexied when they were being spayed, and that was actually, my surgeon friend recommended it. But I don't know that we'd know any science behind that. So is there anything with science behind it, and as far as prevention, when you counsel people, because I'm sure you get it too.
0:24:28.7 DR: For sure. And I think the challenge is, GDV is so preventable with a gastropexy. And Labradors are interesting, they're obviously great dogs, they're not super commonly affected with bloat but we see a number of them because there's such common dogs, so certainly they're out there with it, particularly the bigger dogs. And to me, if you have a big breed dog, go ahead and gastropexy them, is really good common sense. We spend a lot of time with our students trying to get them to recognize that sort of thing, that this is a helpful thing to combine with the spay or even with the neuter that you may not need it. And that's, I think one of the big questions that people always struggle with is, we know that in Danes it's maybe a 30% chance, and so most Danes do get themselves gastropexied, but in other breeds of dogs, standard poodles are really commonly affected, bassets, other of the breeds you might not think about, just any big dog that looks like it might have a deep chest or a retriever, any big dog, you're in the belly, you should gastropexy them.
0:25:27.2 DR: And I think the other question is, should you be going in to do that? As everybody's probably aware, there's a lot of new changing evidence about the age to spay and neuter at, and I think that's obviously not my area, but a hot topic, so thinking about that as well. But early gastropexy is so helpful. And I think the pushback with that again is, I'm not sure if they're going to need it, what if they never bloated? And my answer to that always is, well, if they never bloated, you didn't do anything to hurt them. If they did bloat, you saved them an awful lot of pain, you saved your wallet a lot of money, and you saved their potential death. So to me, it's absolutely straightforward to gastropexy any of those deep-chested dogs and to really encourage that amongst your clients. And when you think about what... It does take a little more time to do it, even if you're in there doing a spay, it adds time. But the benefit to it is so great that it's really something we strongly recommend.
0:26:19.2 DD: Good. Yeah, I noticed a difference in... And again, this is a friend who's a surgeon, and of course, I'm lucky enough to be when I was in practice where they would do it and they more strongly recommended it with my second Labrador, and they even spayed her laparoscopically and they were able to gastropexy her laparoscopically, which is pretty cool. So I think the techniques are also getting slick. I think the question comes sometimes with male dogs because you're not in the belly necessarily, but are you... Yeah, and Morris, of course, that's a big whole question about timing of spay and neuter. We just had a big paper that came out last year looking at that, not for this disease.
0:27:06.9 DR: Right.
0:27:08.8 DD: But what do you tell people with male dogs? And what do you guys do at Tufts? Just out of curiosity.
0:27:14.6 DR: That's a great question. We do a lot of lap gastropexies, and so we might do a lap gastropexy and we sometimes... One of our surgeons is very into vasectomies as well, so they might do a vasectomy lap gastropexy in the big breed dogs. And so, I think we do even if they're male dogs, doing it with a laparoscopic approach is certainly a pretty quick recovery. I think the challenge with that is you all of a sudden... The equipment is expensive, the time is expensive, the surgeon's expertise is obviously appropriately expensive so you can price some of the stuff out, so trying to figure out the most cost-effective way of doing it is always really important. We also have a spay-neuter clinic in our hospital that will, when they work with the shelter animals, that they work... Doing a lot with one of the Dane rescues, they gastropexied all of those dogs at the same time. They do those open and teach the students how to do that, to combine that.
0:28:10.0 DR: So I think that one of the challenges to me always is that if you're a dog that lives with an affluent family, it's a pretty easy disease. It's a harder disease if it's a family with more financial limitations. The gastropexies can be a little pricey to do, even though they subsequently would save you a lot of money, and I think trying to figure that part out is always really important as well. But anyway, we gastropexy even if they're boys, will go in there without lap gastropexy.
0:28:37.8 DD: Right. Oh, great. Well, that's really cool, and I think that's a big change probably in the last 20 years, what we told people, and I think a lot of people know about it, so I appreciate that. Just to wrap up, what is your take-home message for our listeners, both those in the veterinary profession and dog owners about this disease?
0:29:00.9 DR: Well, that's a great question. My take-home message is, it's still a big disease, it's really, really important to recognize the diseases there. If you're a veterinarian, the feedback I've gotten, particularly for people who are newer, is sometimes the owners will come in worried their dog is bloating and they'll report back to us later that that was uncomfortable taking a film because they didn't feel anything, and I 100% think that most dogs you can palpate that in their abdomen, but some of the really deep-chested dogs, the setters, the standard poodles, you can't feel a big stomach. So if the owner is worried about bloat, take a right lateral film, put everyone's mind at ease. If you're a veterinarian, you should be strongly recommending gastropexy, it's absolutely something you can do in practice if you're doing spays and neuters. I think it's easier than a big fat Labrador spay and so you can absolutely do that. If you're a pet owner, talk to your veterinarian about getting your dog gastropexied if it's a breed that's considered at risk or a cross-breed that's considered at risk. And I think one of the interesting areas is a lot of people get rescue dogs that may come already spayed or neutered and so you might not have had that opportunity to ask that question about gastropexying them, but it's not a big deal to do it when they're not sick, and it really has very little potentially bad things that can happen. So I really encourage people to do that. That's a great question.
0:30:19.7 DD: Yeah, no, that's a great recommendation. I appreciate you discussing that, because I think that's a change for those of us who went to school quite a while ago, you know what I mean? It was often not taken lightly doing that, but I think it's a great piece of information. So Liz, thanks so much again for joining us today again, and I'm going to put in a plug for Liz's podcast. She was my third podcast guest. Thank you, Liz. Way back when we started and talking about hypertrophic cardiomyopathy in cats, and a great little screening tool. So if you're an animal lover, or you have a cat and dog, take a listen to that as well. And I look forward to reading more of your work on this topic because I think it's a super important disease that is a huge concern for all of us who own dogs, large breed dogs, and even my Labradors, as you mentioned, they're not the most common breed that jumps to my mind for risk, but you're right. We saw a fair number when I was in practice just because they're common. So for all of us with dogs and I, ironically, had a dachshund was my only small breed bloat GDV that I saw, and I was in referral practice, so we saw a lot of cases of bloat. So that's interesting that that was one that jumped to your mind as well. So problem in all our dogs. So thanks again, Liz, for coming on, I appreciate it.
0:31:53.4 DR: Oh, great. It was great to be here. And everyone, have a great day. Stay safe and healthy.
0:31:55.9 DD: Yup. So that does it for this episode of Fresh Scoop. And once again, thanks to Dr. Elizabeth Rozanski for joining us. We'll be back with another episode next month that we hope you'll find just as informative. And as we all know, the science of animal health is ever-changing, and veterinarians and owners need cutting edge research information to give their patients and their pets the best possible care and that's why we're here. You can find us on iTunes, Spotify, Google Play Music, and Stitcher. And if you like today's episode, we'd sure appreciate it if you could take a moment to rate us because that will help others find our podcast. And to learn more about Morris Animal Foundation's work, again, go to morrisanimalfoundation.org. There, you'll see just how we bridge science and resources to advance the health of animals. And you can also follow us on Facebook, Twitter and Instagram. I'm Dr. Kelly Diehl, and we'll talk soon.