gastric torsion
Introduction
Introduction to gastric torsion The lower end of the normal stomach is fixed by the duodenum, and its shape is maintained by the gastric spleen ligament, the gastroduodenal ligament, the gastric ligament and the gastric ligament, so it cannot be rotated by 180°. The gastric torsion (volvulus ofstomach) is a fixed mechanism disorder of the normal position of the stomach or its adjacent organ lesions cause gastric displacement, causing the stomach itself to undergo a full or partial abnormal torsion along different axial directions. It can be transient, with few symptoms and can cause obstruction or even ischemic necrosis. Chronic gastric torsion patients often have non-specific symptoms such as stomach discomfort, indigestion, burning sensation, upper abdominal fullness or abdominal vomiting, more than post-prandial induction, although patients rarely have symptoms of gastroesophageal reflux. Acute gastric torsion has a rapid onset, which is manifested as pain in the upper abdomen (infraorbital type) or left chest (squat type). The patient's upper abdomen is significantly inflated while the lower abdomen remains flat and soft. Acute gastric torsion often requires surgery. Surgical objectives include gastric decompression, gastric torsion reduction, gastric fixation, and correction or repair incentives. basic knowledge The proportion of illness: 0.004% Susceptible people: no specific population Mode of infection: non-infectious Complications: gastrointestinal bleeding, shock, upper gastrointestinal bleeding, abdominal pain, gastric perforation
Cause
Cause of gastric torsion
Congenital malformation (30%):
Neonatal gastric torsion is a congenital malformation, which may be related to poor rotation of the small intestine, which causes the spleen and stomach ligament or the gastric colon ligament to relax and cause poor gastric fixation. Most can be corrected by the baby's growth and development.
Anatomical factors (26%):
Most of the adult gastric torsion has anatomical factors and is caused by different incentives. The normal position of the stomach mainly depends on the fixation of the lower end of the esophagus and the pylorus. The ligament of the liver and stomach and the ligament of the stomach and the spleen and stomach ligament also have a certain fixed effect on the stomach and small curvature. Larger esophageal hiatus hernia, septum, bulge and excessive relaxation of the peritoneum of the duodenal descending segment make the lower esophageal and pyloric parts of the esophageal hiatus difficult to fix. In addition, the sagging of the stomach and the large or small ligaments of the small curved side are loose or too long, which are the anatomical factors of the onset of gastric torsion.
Other (10%):
Acute gastric dilatation, acute colonic flatulence, overeating, severe vomiting, and reverse peristalsis of the stomach can be the driving force for sudden changes in the position of the stomach, so it is often the cause of acute gastric torsion. Inflammation and adhesion around the stomach can involve the stomach wall and cause it to be fixed in an abnormal position. These lesions are often the cause of chronic gastric torsion.
Pathogenesis
1, according to the rotational orientation
(1) Torsion along the long axis: that is, the line connecting the cardia and the pylorus is the axis, and it is turned upside down. This type of disease is rapidly onset, showing a closed obstruction and rapid gastric expansion.
(2) Left and right twist: The midpoint of the curve of the stomach is the axis, which is twisted to the left or to the right, which is chronic or intermittent, and the obstructive symptoms are not obvious.
2, according to the range of torsion
(1) Complete torsion: Except for the sacral portion, the entire stomach is twisted forward and upward, with a large bend on the upper side, between the liver and the diaphragm, and the posterior wall of the stomach forward.
(2) Partial torsion: mostly distal to the stomach, partially twisted forward or backward.
3, according to the process of twisting
(1) Acute torsion: the attack is sharp and the symptoms are severe.
(2) Chronic torsion: manifested as persistent or recurrent, easily mistaken for gastric ulcer or hiatal hernia.
Prevention
Stomach torsion prevention
Early detection of anatomical and pathological abnormalities that can lead to gastric torsion, and the elimination of such causes, attention to the cause of the disease, early detection, early treatment.
Complication
Gastric torsion complications Complications, gastrointestinal bleeding, upper gastrointestinal bleeding, abdominal pain, gastric perforation
1, acute gastric torsion: late vascular occlusion, gastric wall necrosis, severe gastrointestinal bleeding, and even shock, death, mortality can be as high as 30% to 50%.
2, chronic gastric torsion: a small number of lesions due to mucosal damage to the torsion site or the stomach itself, may have upper gastrointestinal bleeding.
Symptom
Symptoms of gastric torsion Common symptoms Stomach torsion obstruction Symptoms Indigestion Upper abdominal pain Breathing difficulty Abdominal bloating Myocardial infarction Triads Chest pain Abdominal pain with shock
The clinical symptoms of gastric torsion depend on the extent and extent of its acute and chronic and torsional.
1, acute gastric torsion
The onset is rapid, manifested as pain in the upper abdomen (infraorbital type) or left chest (squat type), and the inferior abdomen type of stomach twisting patient significantly expands in the upper abdomen while the lower abdomen remains flat and soft. The supra-abdominal stomach torsion patients have chest symptoms and the upper abdomen can be normal. Chest pain can be radiated to the arms. The neck is accompanied by difficulty breathing, so it is often misdiagnosed as myocardial infarction. Patients with acute gastric torsion often have persistent retching. There is very little vomit, and hematemesis rarely occurs. If there is hematemesis, it often suggests mucosal ischemia or esophageal laceration. In 1904, BoIrchardt described the characteristic triad of acute gastric torsion:
(1) persistent retching with little or no vomit.
(2) Sudden and severe chest or upper abdominal pain.
(3) It is difficult to insert a stomach tube into the stomach.
2, chronic gastric torsion
Chronic gastric torsion patients often have non-specific symptoms such as stomach discomfort, indigestion, burning sensation, upper abdominal fullness or abdominal vomiting, more than post-meal induction, although patients rarely have symptoms of gastroesophageal reflux, but endoscopy often Esophagitis can be found. The pain of intermittent gastric torsion is similar to that of acute gastric torsion, but to a lesser extent. It is often mistaken for the origin of pancreaticobiliary tract due to its transient characteristics. Intermittent upper abdomen occurs in patients with esophageal fistula. Pain, especially with vomiting or retching, should consider chronic intermittent gastric torsion.
Examine
Stomach torsion check
Laboratory inspection
When complications occur (upper gastrointestinal bleeding), blood tests routinely check the total amount of hemoglobin.
Film degree exam
1, X-ray examination: standing chest and abdomen plain film can be seen two liquid gas plane, one is located in the proximal stomach below the left half of the sputum, the other is located in the distal stomach of the posterior mediastinum, if there is pneumoperitoneum Tips for concurrent gastric perforation.
2, upper digestive tract barium meal examination: mesenteric axis type torsion patient can be seen in the abnormal low position of the gastroesophageal junction, while the distal stomach is located on the cephalic side, the corpus, antrum overlap, the cardia and pylorus can be at the same level, organs The axial torsion shows that the stomach is upside down, the stomach curvature is located above the small curvature of the stomach, the liquid level of the fundus is not connected with the stomach, the stomach is deformed, the pylorus is downward, the gastric mucosal folds can be twisted, and the lower end of the esophagus is obstructed. Sharp shadows.
3, endoscopy: endoscopic examination of the stomach torsion has a certain degree of difficulty, visible front and rear walls of the stomach or large bends, the position of the small bend changes, some patients can find esophagitis, tumor or ulcer.
Diagnosis
Differential diagnosis of gastric torsion
diagnosis
X-ray examination can often help to confirm the diagnosis when the patient has the above clinical features and suspected gastric torsion. For acute gastric torsion, as long as the disease can be thought of, the diagnosis is more difficult. If the stomach tube is used to confirm, it should be inserted slowly. Can not be forced, so as not to cause damage or perforation of the stomach wall, chronic gastric torsion due to no complete obstruction, the symptoms are non-specific, clinical diagnosis is difficult.
Differential diagnosis
1, acute gastric dilatation: the disease is not serious abdominal pain, and the above abdominal distension is mainly, nausea and frequent vomiting, vomit contains bile, vomiting amount; can be inserted into the stomach tube and extract a large amount of gas and liquid, patients often have Dehydration and signs of alkalosis.
2, esophageal hiatus hernia: the main symptoms are burning or burning sensation after the sternum, accompanied by hernia or hiccups, the disease occurs more than 1h after meals, can produce symptoms of compression such as shortness of breath, heart palpitations, cough, etc., but sometimes combined The stomach is twisted and the X-ray barium meal test helps to identify.
3, myocardial infarction: more elderly patients with severe arrhythmia, before the onset of heart palpitations, angina and other signs, a characteristic ECG can be differentiated from gastric torsion.
4, stomach cancer: upper abdomen pain is lighter, abdominal mass in the upper abdomen near the pylorus, nodular, X-ray signs or endoscopy can be identified with gastric torsion.
5, pyloric obstruction: a history of peptic ulcer, vomiting and eating, vomiting more, X-ray examination found pyloric obstruction, endoscopy examination of ulcers and pyloric obstruction.
6, chronic cholecystitis: non-acute episodes, patients with upper abdominal pain and dyspepsia symptoms, induced by greasy food, right quarter ribs have tenderness, radiation to the right shoulder, but no severe abdominal pain and nausea, retching , can be smoothly inserted into the stomach tube, duodenal drainage and gallbladder angiography can have a positive discovery.
7, adhesive intestinal obstruction: patients with a history of abdominal surgery, manifested as sudden paroxysmal abdominal pain, exhaust defecation stopped, vomit has fecal odor, full abdominal pain; visible intestinal type, early bowel sounds The late stage is weakened, the stomach tube can be inserted smoothly, and the X-ray abdominal fluoroscopy shows a trapezoidal liquid level in the intestinal lumen.
