Difference between revisions of "Acute gastric dilation"

(→‎Etiologies)
 
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*Most commonly a post-operative complication
 
*Most commonly a post-operative complication
  
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==Etiologies==
+
===Etiologies===
 +
*Post-operative complication (Nissen fundoplication)
 
*Occurs after binge eating episodes, typically in those with an eating disorder
 
*Occurs after binge eating episodes, typically in those with an eating disorder
−
**[[Anorexia nervosa]]
 
 
**[[Bulimia nervosa]]  
 
**[[Bulimia nervosa]]  
−
**Also Psychogenic [[polyphagia]]
+
**Also psychogenic polyphagia
 
*Mechanical obstruction
 
*Mechanical obstruction
 
**[[Pyloric stenosis]]
 
**[[Pyloric stenosis]]
 
**Stricture/adhesions
 
**Stricture/adhesions
 
**[[SMA syndrome]]
 
**[[SMA syndrome]]
−
**Gastric [[volvulus]]
+
**[[Gastric volvulus]]
−
*Other etiologies including [[Diabetes mellitus]], trauma, spinal conditions
+
*Other etiologies including [[Diabetes mellitus]], [[trauma]], spinal conditions
  
−
==Pathogenesis==
+
===Pathogenesis===
 
*Intragastric pressure >20mmHg leads to impaired intramural blood flow and mucosal necrosis
 
*Intragastric pressure >20mmHg leads to impaired intramural blood flow and mucosal necrosis
 
*Gastric volumes greater than 4 liters lead to regular mucosal tears
 
*Gastric volumes greater than 4 liters lead to regular mucosal tears
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==Clinical Features==
 
==Clinical Features==
−
*Emesis is typical symptom in 90% of cases
+
*[[vomiting|Emesis]] is typical symptom in 90% of cases
 
*Inability to vomit seen in massive distention
 
*Inability to vomit seen in massive distention
 
*Other features include:  
 
*Other features include:  
 
**Abdominal distention
 
**Abdominal distention
−
**Abdominal pain
+
**[[Abdominal pain]]
−
**Signs of peritonitis after perforation  
+
**Signs of [[peritonitis]] after perforation
  
 
==Differential Diagnosis==
 
==Differential Diagnosis==
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===By organ system===
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{{Nausea and vomiting DDX}}
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*GI
 
−
**[[Peptic ulcer disease]]
 
−
**[[Gastritis]]
 
−
***Strangulated hernia
 
−
**[[Pancreatitis]]
 
−
**[[Appendicitis]]
 
−
**[[Cholecystitis]], [[Cholangitis]]
 
−
**[[Acute Hepatitis]]
 
−
**[[IBD]]
 
−
**[[Intussusception]]
 
−
**Malignancy
 
−
**[[Mesenteric ischemia]]
 
−
**Esophageal disorders (e.g. achalasia, GERD, [[esophagitis]])
 
−
**Functional disorders such as [[Irritable Bowel Syndrome]]
 
−
*Neurologic
 
−
**[[Cannabinoid hyperemesis syndrome]]
 
−
*Infectious
 
−
**[[Spontaneous bacterial peritonitis]]
 
−
**[[Urinary tract infection]]
 
−
**Bacterial toxins, Viruses (adeno, norwalk, rota)
 
−
*Drugs/Toxins
 
−
**Heavy metal poisoning
 
−
**Methanol poisoning
 
−
*Endocrine
 
−
**[[Diabetic ketoacidosis]]
 
−
**Thyroid/parathyroid disorders
 
−
**[[Uremia]]
 
−
*Miscellaneous
 
−
**[[Anorexia nervosa]], [[Bulimia nervosa]]
 
  
 
==Evaluation==
 
==Evaluation==
 
*Typical work up for abdominal pain
 
*Typical work up for abdominal pain
−
*Upright chest x-ray and abdominal series to assess for free air
+
*Upright [[chest x-ray]] and [[acute abdominal series|abdominal series]] to assess for free air
 
**Can identify large distended stomach on x-ray  
 
**Can identify large distended stomach on x-ray  
 
*CT imaging if safe and indicated
 
*CT imaging if safe and indicated
 +
 +
[[File:Acutegastricdilation.png|thumb|Large distended stomach consistent with gastric dilation]]
  
 
==Management==
 
==Management==
−
*Nasogastric or orogastric decompression is first line therapy  
+
*[[nasogastric tube|Nasogastric]] or orogastric decompression is first line therapy  
 
**Typically a large special tube required which is placed under anesthesiologist supervision in OR
 
**Typically a large special tube required which is placed under anesthesiologist supervision in OR
 
*Resuscitation with fluids and intravenous antibiotics as indicated
 
*Resuscitation with fluids and intravenous antibiotics as indicated
 
*If conservative measures fail or gastric infarction suspected, surgical intervention mandatory
 
*If conservative measures fail or gastric infarction suspected, surgical intervention mandatory
−
*If gastric necrosis or perforation not recognized and treatment delayed, mortality reaches 80%
 
  
 
==Disposition==
 
==Disposition==
 
*Patient may require emergent surgical decompression  
 
*Patient may require emergent surgical decompression  
 
*If improvement with non-operative decompression, may require admission for continued monitoring
 
*If improvement with non-operative decompression, may require admission for continued monitoring
 +
 +
==Complications==
 +
*[[ischemic bowel|Bowel necrosis]] with or without perforation
 +
*[[Abdominal compartment syndrome]]
 +
*[[Sepsis]]/[[Septic shock]]
 +
*If gastric necrosis and/or perforation not recognized and treatment delayed, mortality reaches 80%
  
 
==See Also==
 
==See Also==
 +
*[[Bariatric surgery complications]]
  
 
==External Links==
 
==External Links==
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==References==
 
==References==
 
<references/>
 
<references/>
 +
#Dewangan M, Khare MK, Mishra S, and Marhual JC. Binge eating leading to acute gastric dilation, ischemic necrosis and rupture. ''Journal of Clinical and Diagnostic Research." 2016; 10(3): 6-7.
 +
#Lunca S, Rikkers A, and Stanescu A. Acute massive gastric dilation: Severe ischemia and gastric necrosis without perforation. ''Romanian Journal of Gastroenterology'. 2005; 14(3): 279-283.
 +
#Santos T, Freitas C, and Pinto-de-Sousa J. Gastric wall ischemia following massive gastric distention due to pyloric stenosis: a case report. ''Journal of Surgical Case Reports''. 2016; 2: 1-3.
 +
 +
[[Category:GI]]

Latest revision as of 18:34, 29 September 2019

Background

  • Rare event
  • Invariable leads to necrosis with or without perforation
  • Most commonly a post-operative complication

Etiologies

Pathogenesis

  • Intragastric pressure >20mmHg leads to impaired intramural blood flow and mucosal necrosis
  • Gastric volumes greater than 4 liters lead to regular mucosal tears
  • Patients with pathologic eating disorders can have larger gastric volumes at baseline
  • Acute massive gastric dilation is an extreme form (intragastric pressure >30)

Clinical Features

  • Emesis is typical symptom in 90% of cases
  • Inability to vomit seen in massive distention
  • Other features include:

Differential Diagnosis

Nausea and vomiting

Critical

Emergent

Nonemergent

Evaluation

  • Typical work up for abdominal pain
  • Upright chest x-ray and abdominal series to assess for free air
    • Can identify large distended stomach on x-ray
  • CT imaging if safe and indicated
Large distended stomach consistent with gastric dilation

Management

  • Nasogastric or orogastric decompression is first line therapy
    • Typically a large special tube required which is placed under anesthesiologist supervision in OR
  • Resuscitation with fluids and intravenous antibiotics as indicated
  • If conservative measures fail or gastric infarction suspected, surgical intervention mandatory

Disposition

  • Patient may require emergent surgical decompression
  • If improvement with non-operative decompression, may require admission for continued monitoring

Complications

See Also

External Links

References

  1. Dewangan M, Khare MK, Mishra S, and Marhual JC. Binge eating leading to acute gastric dilation, ischemic necrosis and rupture. Journal of Clinical and Diagnostic Research." 2016; 10(3): 6-7.
  2. Lunca S, Rikkers A, and Stanescu A. Acute massive gastric dilation: Severe ischemia and gastric necrosis without perforation. Romanian Journal of Gastroenterology'. 2005; 14(3): 279-283.
  3. Santos T, Freitas C, and Pinto-de-Sousa J. Gastric wall ischemia following massive gastric distention due to pyloric stenosis: a case report. Journal of Surgical Case Reports. 2016; 2: 1-3.
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