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Emergency Medicine/Critical Care

Perianesthetic Gastroesophageal Reflux

The incidence of GER is increased in the perianesthetic period due to suppression of normal esophageal motility and a decrease in lower esophageal sphincter pressure.

November 13, 2025 | 

Issue: Digital Exclusive

Kathryn Martell

DVM

Dr. Kathryn Martell is a Regional Medical Director for VCA, supporting hospitals in Washington, Oregon, Alaska, Idaho and Hawaii. She obtained her Doctor of Veterinary Medicine degree from Texas A&M University in 1997. After practicing in Florida and Oregon, she joined VCA in 2000 as a small animal general practitioner in Alaska and has been in medical leadership with VCA since 2002. In addition to her interest in leadership, she enjoys flexible endoscopy and endocrine cases.

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Marie Kerl

DVM, MPH, MBA, DACVIM (SAIM), DACVECC

Marie Kerl obtained her DVM from Auburn University and Masters of Public Health and Masters of Business Administration from the University of Missouri. She completed specialty training at the Animal Medical Center in New York, and is a diplomate of the American College of Veterinary Internal Medicine and the American College of Veterinary Emergency and Critical Care. Dr. Kerl is currently Vice President of Medical Operations and Chief Medical Officer for VCA Animal Hospitals. Her duties include ensuring the highest quality veterinary care through education and support of hospital teams by providing medical guidance within our hospitals. Additional professional activities include online teaching at the undergraduate and graduate level, and veterinary disaster response. Dr. Kerl has received the Norden Distinguished Teaching Award from the students at the University of Missouri, and the Ira Zaslow Service Award from the Veterinary Emergency and Critical Care Society. 

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Marie Kerl - Featured Image
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Abstract

Perianesthetic gastroesophageal reflux (GER) is a complication veterinarians face on a regular basis. The incidence of GER is increased in the perianesthetic period due to suppression of normal esophageal motility and a decrease in lower esophageal sphincter (LES) pressure. LES incompetence can occur secondary to common anesthetic medications, length of anesthesia, and type of procedure being performed. Brachycephalic anatomy, respiratory and neurologic diseases, length and type of surgery, and use of opioids are all factors that can increase a patient’s risk of GER. Prevention strategies for high-risk patients include reducing repositioning as much as possible, substituting or reducing the dose of preoperative opioids, adjusting fasting time, using a GER premedication protocol for several days before the procedure, and using metoclopramide at induction. When GER is identified, treatment should be immediate and include esophageal lavage and follow-up medications for 7 days to prevent esophagitis. During this time, patients should be closely observed for a decrease in appetite or the acute onset of vomiting, regurgitation, respiratory difficulty, or coughing. The hallmark sign of an esophageal stricture is regurgitation after eating.

Take-Home Points

  • Perianesthetic gastroesophageal reflux (GER) is a complication veterinarians face on a regular basis; it has severe potential phenotypes, including esophagitis, esophageal stricture, sinusitis, and aspiration pneumonia.
  • Prevention strategies include employing premedication protocols, identifying high-risk patients, and targeting surgeries that pose the most risk of GER.
  • Treatment for GER should be immediate: lavage the esophagus with saline/bicarbonate solution with follow-up medications to prevent esophagitis.
  • The hallmark sign of an esophageal stricture is regurgitation after eating.
  • Prevention and treatment of GER events should be part of your hospital’s anesthesia safety protocol.

Perianesthetic gastroesophageal reflux (GER) is a complication veterinarians face on a regular basis, occurring in 12.5% to 55% of canine patients1-7 and 12% to 23% of feline patients.8 While it’s challenging to manage these cases during a busy surgical day, evaluating and treating for GER events should be a routine part of anesthesia monitoring and recovery.

Gastroesophageal reflux is the passive retrograde flow of stomach contents through the lower esophageal sphincter (LES) into the esophagus. The incidence of GER is increased in the perianesthetic period due to suppression of normal esophageal motility and a decrease in LES pressure.9 LES incompetence can occur secondary to common anesthetic medications, length of anesthesia, and type of procedure being performed. Identifying high-risk patients prior to anesthesia, following premedication protocols, and implementing other preventive strategies  are all useful ways to reduce GER events.

The potential consequences of acidic gastric contents entering the esophagus and upper respiratory tract include esophagitis, esophageal stricture, and aspiration pneumonia.4,10 The majority of patients with perianesthetic GER will not develop complications, but when they occur, it can be devastating. It’s been reported that dogs with postanesthetic esophageal dysfunction have a 23% mortality rate.4

In an anesthetized patient, GER is a “see something, do something” moment and should be managed immediately. In many cases, GER is “silent” and gastric fluid remains in the esophagus and is unobservable, which makes prevention of the utmost importance through the use of premedications and awareness of which anesthetic cases are of greatest concern.2

Although maropitant has been reported ineffective in reducing GER,11,12 it is commonly used in small animal anesthetic protocols to reduce opioid-related emesis, which may reduce the risk of aspiration.11,13

While there are conflicting reports on contributing factors and prevention strategies for perianesthetic GER, studies have identified patient risk factors and support the effectiveness of premedication to reduce GER or increase esophageal pH. The following is a summary of risk factors, recommendations, and best practices that may decrease GER events in anesthetized patients.

Identification of High-Risk Patients

  • Brachycephalic anatomy10
  • Abdominal surgeries1,2
  • Long procedures, especially orthopedics1,14,15
  • Procedures with frequent changes in position1,9
  • Large patient size1,14,15
  • Use of high- or repeated-dose opioids6,9
  • Neurologic conditions of the respiratory or gastrointestinal tract (e.g., laryngeal paralysis, hiatal hernia)16,17
  • Patients with a history of GER, with or without anesthesia18
  • Prolonged fasting >18 hours3,19,20

Prevention

  • Reduce repositioning as much as possible.5
  • Substitute or reduce the dose of preoperative opioids in high-risk patients.9,12
  • Feed a small meal of canned dog food in the morning for procedures postponed to the afternoon.3,19
  • Use premedication for high-risk patients in advance of the procedure:
    • Omeprazole 1 mg/kg PO the night before and 4 hours prior to induction10,11 or
  • Famotidine 1 mg/kg IV or SC and metoclopramide 0.5 mg/kg SC as preanesthetic18
  • Administer metoclopramide 1.0 mg/kg IV at induction followed by continuous-rate infusion of 1.0 mg/kg/h for high-risk patients.21

Treatment

During Anesthesia and Recovery

If any fluid is noted in the oral cavity, around the endotracheal tube, or coming from the nose during anesthesia or in recovery:

  • Measure pH with a test strip: pH <4 indicates gastric contents are present and lavage is recommended.22-24
  • Clear fluid from the mouth and oropharynx.
  • Perform esophageal lavage before extubation. Reintubate if reflux is noted after extubation.
    • Position in left lateral recumbency with the head below vertical.22
    • Using a double-lumen sump catheter or red rubber catheter, gently suction and lavage the esophagus with 10 to 30 mL dilute (1% or 2%) bicarbonate solution25 or straight 0.9% sodium chloride.23
  • If a flexible gastrointestinal endoscope is available, inspect the esophagus/LES, and lavage/suction the esophagus and remove fluid from the stomach.1
  • Recover the patient in sternal recumbency with the head above vertical, and extubate with the cuff partially inflated.25

After Recovery

Treat for potential esophagitis for at least 7 days:

  • Omeprazole: 1 mg/kg PO q12h22,26
  • Prokinetics: cisapride 0.5 mg/kg PO q8h (preferred to metoclopramide )27

Follow-up

If patients have a decrease in appetite or start vomiting, regurgitating, having respiratory difficulty, or coughing during the first week postanesthesia, they should be evaluated for esophagitis and stricture formation.4 These patients should be considered suspect for esophageal injury until proven otherwise. Esophageal strictures can occur 5 to 21 days after anesthesia.28

The hallmark sign of an esophageal stricture is regurgitation after eating.4 Thoracic radiographs are indicated to evaluate for aspiration pneumonia in patients with an elevated respiratory rate or cough during the postoperative period. Preanesthetic thoracic radiographs should be considered for any patient with a previous history of GER or brachycephalic anatomy because they have an increased incidence of preexisting aspiration pneumonia.16,18

Why This Is Important

With identification of high-risk patients, careful observation during the perianesthetic period, and immediate treatment when GER has occurred, the incidence of GER can be reduced. Subsequent complications, including esophagitis, esophageal stricture, sinusitis, and aspiration pneumonia, can also be minimized. Prevention and treatment of GER events should be part of your hospital’s anesthesia safety protocol.

References

References

  1. Torrente C, Vigueras I, Manzanilla G, Villaverde C, Fresno L, Carvajal B, et al. Prevalence and risk factors for intraoperative gastroesophageal reflux and postanesthetic vomiting and diarrhea in dogs undergoing general anesthesia. J Vet Emerg Crit Care. 2017;27(4):397-408. doi:10.1111/vec.12613
  2. Galatos AD, Raptopoulos D. Gastro-oesophageal reflux during anesthesia in dogs. Vet Rec. 1995;137(20):513-516. doi:10.1136/vr.137.20.513
  3. Galatos AD, Raptopoulos D, Gastro-oesophageal reflux during anesthesia in the dog: the effect of preoperative fasting and premedication. Vet Rec. 1995;137(19):479-483. doi:10.1136/vr.137.19.479
  4. Wilson DV, Walshaw R. Postanesthetic esophageal dysfunction in 13 dogs. JAAHA. 2004;40(6):455-460. doi:10.5326/0400455
  5. Wilson D. Boruta D, Evans T. Influence of halothane, isoflurane, and sevoflurane on gastroesophageal reflux during anesthesia in dogs. Am J Vet Res. 2006;76(11):1821-1825. doi:10.2460/ajvr.67.11.1821
  6. Flouraki E, Savvas I, Kazakos G, Anagnostou T, Raptopoulos D. The effect of premedication on the incidence of gastroesophageal reflux in 270 dogs undergoing general anesthesia. Animals (Basel). 2022;12(19):2667. doi:10.3390/ani12192667
  7. Paran E, Major A, Warren-Smith C, Hezzell M, MacFarlane P. Prevalence of gastroesophageal reflux in dogs undergoing MRI for a thoracolumbar vertebral column pathology. J Small Anim Pract. 2023;64(5):321-329. doi:10.1111/jsap.13585
  8. Garcia RS, Belafsky PC, Maggiore AD, Osborn JM, Pypendop BH, Pierce T, et al. Prevalence of gastroesophageal reflux in cats during anesthesia and effect of omeprazole on gastric pH. J Vet Intern Med. 2017;31(3):734-742. doi:10.1111/jvim.14704
  9. Wilson DV, Evans AT, Miller R. Effects of preanesthetic administration of morphine on gastroesophageal reflux and regurgitation during anesthesia in dogs. Am J Vet Res. 2005;66(3):386-390. doi:10.2460/ajvr.2005.66.386
  10. Downing F, Gibson S. Anaesthesia of brachycephalic dogs. J Small Anim Pract. 2018;59(12):725-733. doi:10.1111/jsap.12948
  11. Johnson RA, Maropitant prevented vomiting but not gastroesophageal reflux in anesthetized dogs premedicated with acepromazine-hydromorphone. Vet Anaesth Analg. 2014;41(4):406-410. doi:10.1111/vaa.12120
  12. Lotti F, Boscan P, Twedt D, Warrit K, Weir H, Vogel P, et al. Effect of maropitant, maropitant with omeprazole and esophageal lavage on gastroesophageal reflux in anesthetized dogs. Vet Anaesth Analg. 2018;45(6):885.e8-885.e9. doi:10.1016/j.vaa.2018.09.023
  13. Hay Kraus BL. Spotlight on the perioperative use of maropitant citrate. Vet Med (Auckl). 2017;8:41-51. doi:10.2147/VMRR.S126469
  14. Anagnostou TL, Kazakos GM, Savvas I, Kostakis C, Pàpadopoulou P. Gastro-oesophageal reflux in large-sized, deep-chested versus small-sized, barrel-chested dogs undergoing spinal surgery in sternal recumbency. Vet Anaesth Analg. 2017;44(1):35-41. doi:10.1111/vaa.12404
  15. Lamata C, Loughton V, Jones M, Alibhai H, Armitage-Chan E, Walsh K, Brodbelt D. The risk of passive regurgitation during general anaesthesia in a population of referred dogs in the UK. Vet Anaesth Analg. 2012;39(3):266-274. doi:10.1111/j.1467-2995.2011.00704.x
  16. Darcy HP, Humm K, Ter Haar G. Retrospective analysis of incidence, clinical features, potential risk factors, and prognostic indicators for aspiration pneumonia in three brachycephalic dog breeds. JAVMA. 2018;253(7):869-876. doi:10.2460/javma.253.7.869
  17. Poncet CM, Dupre GP, Freiche VG, Estrada MM, Poubanne YA, Bouvy BM. Prevalence of gastrointestinal tract lesions in 73 brachycephalic dogs with upper respiratory syndrome. J Small Anim Pract. 2005;46(6):273-279. doi:10.1111/j.1748-5827.2005.tb00320.x
  18. Costa RS, Abelson AL, Lindsey JC, Wetmore LA. Postoperative regurgitation and respiratory complications in brachycephalic dogs undergoing airway surgery before and after implementation of a standardized perianesthetic protocol. JAVMA. 2020;256(8):899-905. doi:10.2460/javma.256.8.899
  19. Savvas I, Raptopoulos D, Rallis T. A light meal 3 hours preoperatively decreases the incidence of gastro-esophageal reflux in dogs. JAAHA. 2016;52(6):357-363. doi:10.5326/JAAHA-MS-6399
  20. Tsompanidou P, Robben JH, Savvas I, Anagnostou T, Prassinos NN, Kazakos GM. The effect of the preoperative fasting regimen on the incidence of gastro-oesophageal reflux in 90 dogs. Animals (Basel). 2022;12(1):64. doi:10.3390/ani12010064
  21. Wilson DV, Evans AT, Mauer WA. Influence of metoclopramide on gastroesophageal reflux in anesthetized dogs. Am J Vet Res. 2006;67(1):26-31. doi:10.2460/ajvr.67.1.26
  22. Lotti F, Boscan P, Kanawee W, Twedt D. Strongly acidic gastroesophageal reflux and esophageal lumen pH before and after esophageal lavage with water or two bicarbonate concentrations in anesthetized dogs. Am J Vet Res. 2022;83(11):1-7. doi:10.2460/ajvr.22.05.0081
  23. Allison A, Italiano M, Robinson R. Comparison of two topical treatments of gastro-oesophageal regurgitation in dogs during general anaesthesia. Vet Anaesth Analg. 2020 Sep;47(5):672-675. doi:10.1016/j.vaa.2020.04.010
  24. Wilson DV, Evans AT. The effect of topical treatment on esophageal pH during acid reflux in dogs. Vet Anaesth Analg. 2007;34(5):339-343. doi:10.1111/j.1467-2995.2006.00340.x
  25. Hopkins A. Brachycephalic breeds and anesthesia. In: Niemiec BA, ed. Breed Predispositions to Dental and Oral Disease in Dogs. John Wiley & Sons, Inc.; 2021:143-155.
  26. Marks SL, Kook PH, Papich MG, Tolbert MK, Willard MD. ACVIM consensus statement: support for rational administration of gastrointestinal protectants to dogs and cats. J Vet Intern Med. 2018;32(6):1823-1840. doi:10.1111/jvim.15337
  27. Kempf J, Lewis F, Reusch CE, Kook PH. High-resolution manometric evaluation of the effects of cisapride and metoclopramide hydrochloride administered orally on lower esophageal sphincter pressure in awake dogs. Am J Vet Res. 2014;75(4):361-366. doi:10.2460/ajvr.75.4.361
  28. Tams TR. Diseases of the esophagus. In: Tams TR, ed. Handbook of Small Animal Gastroenterology. 2nd ed. Saunders; 2003:118-158.

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