acute gastric dilatation
Introduction
Brief introduction of acute gastric expansion Acutedilatation of stomach refers to the high expansion of the upper part of the stomach and duodenum due to large amounts of gas, liquid or food retention in the stomach and duodenum. Rokitansky first described 1 case of acute gastric dilatation in 1842. At autopsy results, Fagge described the clinical features and treatment of acute gastric dilatation in 1873, and began an in-depth study of the disease. When the stomach is acutely dilated, the contents are retained in the stomach and duodenum and cannot be absorbed. Therefore, repeated vomiting often occurs, resulting in loss of water and electrolytes, acid-base imbalance, blood volume reduction and peripheral circulatory failure. The stomach wall is excessively stretched, thinned or thickened due to inflammatory edema, or due to necrosis and perforation of the stomach wall due to blood circulation disorder, causing peritonitis and causing shock. The duodenum is compressed by the superior mesenteric artery, and pressure ulcer may occur. Acute gastric dilatation is usually a serious complication of abdominal surgery or some chronic wasting diseases and long-term bedridden patients. Domestic reports are mostly caused by overeating. basic knowledge The proportion of illness: 0.15% Susceptible people: no special people Mode of infection: non-infectious Complications: hyponatremia, hypovolemic shock, acute renal failure, cardiac dysfunction
Cause
Acute dilatation of the stomach
(1) Causes of the disease
The pathogenesis of acute gastric dilatation is not well understood, and its pathogenesis may be related to the following factors:
1. Neuromuscular dysfunction due to severe trauma, infection, anesthesia, emotional stress, surgery, etc. can strongly stimulate the nervous system (including the body and splanchnic nerves), causing dysfunction, especially sympathetic and vagus nerve dysfunction, causing The reflex inhibition of the stomach wall reduces the muscle tension of the stomach wall and further expands.
2. Overeating, eating too much food in a short period of time, especially foods rich in gas and cellulose, such as sweet potatoes, radishes, etc., so that the muscles of the stomach are excessively stretched beyond their limits, and the stomach wall is reflexive paralysis. expansion.
This is also the reason for the misplacement of the tracheal tube during anesthesia for acute gastric dilatation caused by intragastric pressurized oxygen and rickets.
3. Acute mechanical gastroduodenal obstruction The mechanical obstruction of the stomach and duodenum can be the cause of acute gastric dilatation. The following conditions are often seen:
(1) Acute gastric torsion: due to the relaxation of the ligaments around the stomach, when the tumor occurs after eating or in the stomach, the stomach may be completely or incompletely twisted due to gravity and the duodenum may be twisted and compressed, so that the stomach contents are discharged. The air restriction is stagnant and the stomach wall is dilated.
(2) superior mesenteric artery compression: the duodenal horizontal segment is located between the superior mesenteric artery and the abdominal aorta. If the angle between the abdominal aorta and the superior mesenteric artery is small, the duodenal horizontal segment is acute or chronic. After being stressed or overeating, the gravity of the stomach is excessively pulled downward to make the stomach sag, and the inflated stomach pushes the colon and the small intestine into the pelvic cavity, making the superior mesenteric artery more tense and aggravating the pressure on the horizontal part of the duodenum. The dilatation of the stomach and duodenum is aggravated, forming a vicious circle, leading to the occurrence of acute gastric dilatation.
(3) Congenital malformations: acute gastric dilatation caused by this cause occurs mostly in children, which can be seen in the following situations:
1 The position of the superior mesenteric artery is too low and the blood vessel is too short.
2 congenital gastric muscle defect: the loss of muscle wall muscle loss due to tension.
3 annular pancreas, pyloric hypertrophy and so on.
(4) Other causes: such as spinal cord disease, inflammation of the duodenum and pylorus, tumor, stenosis, imbalance of water and electrolytes, excessive oxygen inhalation, taking gas-producing drugs, toxins, and over-tightening of the torso gypsum pants. Cause of the disease.
The above factors may become one or more interactions that cause disease and affect each other.
(two) pathogenesis
After the stomach is dilated, the small intestine will be pushed downwards, the superior mesenteric artery and mesentery will be tightened, and the transverse part of the duodenum will be pressed to make the stomach and duodenum stagnant; the retention of gastric juice, bile and pancreatic juice will stimulate the stomach and twelve. Increased intestinal mucosal secretion, further exacerbate gastric dilatation; aggravated gastric dilatation further pushes the small intestine and pulls the mesentery, stimulates the splanchnic nerve, aggravates the stomach, duodenal paralysis, and so on, forming a vicious circle.
Pathophysiology
In acute gastric dilatation, due to mechanical stimulation of the antrum, gastrin secretion is increased, which promotes the secretion of gastric acid. When the transverse part of the duodenum is compressed by the superior mesenteric artery and mesentery, bile and pancreatic juice cannot descend. It also flows back into the stomach, causing the stomach to expand significantly. In the early stage of the disease, patients may have frequent vomiting, but when the stomach wall is completely paralyzed and becomes meager with the increase in content, the patient can not vomit to relieve the stomach. Internal tension causes the stomach to continue to rise, sometimes occupying almost the entire abdominal cavity.
After the gastric dilatation occurs, the stomach wall expands and thins, so that the low pressure in the stomach wall, the thin venous blood flow is blocked first, and the wall thickness, the pressure of the arterial blood flow can still flow, the blood stasis occurs, the venous pressure increases, and the passive Sexual exudation; due to the absorption function of the gastric mucosa and the emptying function of the stomach, a large amount of liquid and gas are retained in the stomach, causing a large loss of body fluid, and at the same time losing a large amount of electrolyte, resulting in imbalance of water, electrolyte and acid-base balance, and aggravation The condition of gastric dilatation, dehydration, hypokalemia, low chlorine, hyponatremia, and finally low-chlorine and low-potassium alkalosis. At this time, the pH value and carbon dioxide binding force in the blood rise, and the potassium, sodium, and chlorine values decrease.
After the acute gastric dilatation develops to a certain extent, it can cause a series of hemodynamic changes. The visceral congestion and portal pressure increase due to portal pressure; when the inferior vena cava is also compressed, it will further reduce the blood volume and heart. Reduced blood output, dehydration, insufficient blood volume, decreased blood pressure and hypovolemic shock; renal renal perfusion can cause acute renal failure; electrolyte and acid-base balance disorders can lead to arrhythmia, cardiac dysfunction, circulation Respiratory failure, if not treated, eventually leads to death.
2. Pathological morphology
Due to the expansion of the stomach wall, the mucous membrane becomes smooth, the wrinkles disappear, the surface has extensive bleeding, erosion or ulceration, the stomach wall may be partially necrotic, become dark gray, the stomach bottom is more common, the stomach has a lot of gas and dark brown liquid or There is a large amount of undigested food ingested, and the amount of liquid can reach 3000-8000ml or even more.
Prevention
Acute gastric dilatation prevention
1. Strengthen the promotion of food hygiene, prevent overeating, and avoid strong physical labor immediately after excessive eating, especially during the busy season.
2. Under the stress condition of trauma, surgery, anesthesia, etc., when the upper abdomen is full and frequent vomiting, the stomach tube should be placed early for effective gastrointestinal decompression and attention should be paid to correct water, electrolyte and acid-base balance disorder.
3. In abdominal surgery, tissues and organs should be taken care of, minimizing the turnover of organs and reducing irritation, so as to restore their function as soon as possible after surgery.
4. Patients should perform bed and bed activities as soon as possible to change their position and avoid the compression of the duodenum by the superior mesenteric artery, especially those with superior mesenteric artery compression syndrome or congenital malformation.
Complication
Acute gastric dilatation complications Complications, hyponatremia, hypovolemic shock, acute renal failure, cardiac dysfunction
Extreme expansion of the stomach, water, electrolyte, acid-base balance disorder, can be complicated by low potassium, low chlorine, hyponatremia and low chloride and low potassium alkalosis; effective reduction of circulating blood volume and increased portal system pressure , can cause hemodynamic abnormalities, hypovolemic shock, acute renal failure, cardiac dysfunction, resulting in circulatory respiratory failure, which is the main cause of death in patients with gastric dilatation.
Symptom
Symptoms of acute dilatation of the stomach Common symptoms Acute gastric dilatation Acute abdomen Abdominal pain Chest breathing shock Abdominal swelling No urine pain Painful coma
The onset is often 1 to 2 hours after overeating or after surgery, and symptoms appear several hours to 1 to 2 weeks after trauma.
1. Abdominal pain, sudden or sudden abdominal distension or pain in the upper abdomen or umbilical cord, paroxysmal aggravation, abdominal pain is often not severe.
As abdominal pain occurs, abdominal distension occurs, and the upper abdomen is full and bulging. The stomach type is visible but there is no gastric peristaltic wave. The abdominal distension is gradually aggravated. The range is extended to the whole abdomen. The whole abdomen is bulging. The patient feels that the abdominal distension is particularly serious. Sound, can smell the sound of water, such as the stomach is a liquid or food, the percussion drum sound is not significant and is voiced or real, the bowel sounds weaken or disappear, the upper abdomen or the umbilical cord may have tenderness, no muscle tension and rebound Pain, if there is gastric perforation or rupture, tenderness and rebound tenderness are very obvious and there is obvious rebound and muscle tension, body temperature rises, and the symptoms of infection poisoning appear.
2. nausea, vomiting with abdominal pain, abdominal distension, nausea and vomiting also increased, vomiting is characterized by frequent and weak, even involuntary spillage-like vomiting, vomit for food and brown-green or tan humic acid Stinky liquid, there may be bile in the early stage, sometimes there is bloody liquid, bloating is still not relieved after vomiting, and the systemic symptoms are not improved, but the condition is gradually worsened. There may be a small amount of exhaust in the early stage of the disease, defecation, and most patients stop later. Defecation.
3. Water, electrolytes and acid-base balance disorder due to frequent vomiting and large amount of fluid retention in the stomach, leading to loss of electrolytes and gastric acid, water, electrolyte and acid-base balance disorder and even shock, manifested as pale, indifferent, restless, irritated Severe thirst, eye socket depression, cold and dry skin, cold blood pressure, blood pressure drop, no blood pressure, no urine or no urine, shortness of breath, chest breathing, and then sleepiness or coma, body temperature is reduced, not even rising Such as exhaustion performance.
Examine
Acute dilatation of the stomach
1. Blood routine hemoglobin, red blood cells are increased, the total number of white blood cells is often not high, but white blood cells can be significantly increased after gastric perforation and left nucleus.
2. Serum electrolyte potassium, sodium, chlorine decreased, blood potassium can sometimes be as low as 3mmol / L, sodium can be as low as 96mmol / L, chlorine can be as low as 66.6mmol / L or lower.
3. Blood gas analysis can be found in severe alkalosis, and the carbon dioxide binding capacity can be as high as 49.39mmol/L (110Vol%).
4. Blood biochemical non-protein nitrogen increased.
5. Urine routine urine specific gravity increased, protein and tube type may appear.
Auxiliary inspection
X-ray inspection
(1) Standing flat abdomen: It can be seen that the density of the left upper abdomen is increased, the gastric cavity is obviously dilated, and there are 1 to 2 large liquid-gas planes in the stomach. The width of the liquid plane is more than half of the transverse diameter of the abdomen. It is 2 layers, the upper layer is a thin liquid, and the lower layer is an undigested solid food with a higher density.
(2) Lyrs in the abdomen: A large, apparently inflated stomach cavity is visible from the upper abdomen to the pelvis, occupying most of the abdomen. The rest of the large and small intestines also have a little gas accumulation, but no expansion.
(3) Dilution of sputum: It shows that the expectorant enters the dilated gastric cavity. If it is obstructive gastric dilatation, the stomach wall has a notch formed by peristaltic waves. For the paralyzed gastric dilatation, the stomach wall is smooth.
2. B-ultrasound examination of gastric expansion of the sound image characteristics: fasting examination of the gastric cavity significantly expanded; gastric cavity see a large amount of liquid and scattered in the shape of high echo particles; stomach wall thinning, creeping disappeared.
Diagnosis
Diagnosis and differentiation of acute gastric dilatation
diagnosis
According to the history of overeating or trauma, surgery, sudden or gradually appearing in the upper abdomen or total abdominal pain, abdominal distension, frequent and weak vomiting, vomit for food or tan acid odorous liquid, bloating after vomiting does not relieve the condition Gradually worsened, dehydration and shock occur rapidly. If acute gastric dilatation is considered, there is no difficulty in diagnosis. Atypical or pediatric acute gastric dilatation is often misdiagnosed as other acute abdomen.
Differential diagnosis
Acute mechanical intestinal obstruction
Often a mid-abdominal pain accompanied by persistent colic paroxysmal aggravation, showing intestinal and peristaltic waves, bowel sounds are hyperactive and have metal sounds, vomiting is spray, vomit can have intestinal contents, body temperature and white blood cells increase The abdominal X-ray plain film can be seen in a plurality of stepped intestinal gas-liquid level or small intestine flatulence, no huge stomach bubble and wide gas-liquid level, the above can be distinguished from acute gastric dilatation.
2. Peritonitis
Peritonitis itself can induce acute gastric dilatation. If it is simple peritonitis without acute gastric dilatation, it is easy to identify. Peritonitis often has clinical manifestations of primary lesions and then develops into a history of peritonitis. It has a long history, vomiting is not frequent, vomiting The amount is not much, there is no brown and sour stomach content, the abdominal has obvious peritoneal irritation, white blood cells and body temperature increase, and intestinal paralysis caused by late peritonitis is sometimes difficult to distinguish from acute gastric dilatation.
3. Intestinal paralysis
It is difficult to distinguish from acute gastric dilatation. Intestinal paralysis is often caused by surgery, trauma or other stressful conditions or is the late manifestation of peritonitis, mainly involving the small intestine. Therefore, the small intestine is most obvious, and the middle part of the abdomen is visible in the middle of the abdomen. Water sound, vomiting is more obvious, vomiting is more, there may be brown-yellow fecal scent-like intestinal contents, and the amount of gas and liquid extracted in the stomach is also less than that of the stomach.
4. Acute pancreatitis
In the early stage of the disease, there is a history of overeating, abdominal distension, abdominal pain, vomiting and fever. It is often difficult to distinguish from acute gastric dilatation, but acute abdominal pain can be caused by acute pancreatitis, abdominal distension is mild, tenderness in the upper abdomen, mild muscle tension. , amylase increased, X-ray no specific performance, B-ultrasound and CT can be found in the enlarged pancreas or mass (cyst), gastric juice extracted from the gastrointestinal decompression is not much, and no acid stinky brown gastric juice, etc., detailed Physical examination and inquiry history can be identified.
