Acute gastric dilatation: Difference between revisions
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*Most commonly a post-operative complication | *Most commonly a post-operative complication | ||
==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 | ||
**[[Bulimia nervosa]] | **[[Bulimia nervosa]] | ||
**Also | **Also psychogenic polyphagia | ||
*Mechanical obstruction | *Mechanical obstruction | ||
**[[Pyloric stenosis]] | **[[Pyloric stenosis]] | ||
**Stricture/adhesions | **Stricture/adhesions | ||
**[[SMA syndrome]] | **[[SMA syndrome]] | ||
** | **[[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== | ||
{{Nausea and vomiting DDX}} | |||
==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 | ||
==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]] | |||
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
- Post-operative complication (Nissen fundoplication)
- Occurs after binge eating episodes, typically in those with an eating disorder
- Bulimia nervosa
- Also psychogenic polyphagia
- Mechanical obstruction
- Pyloric stenosis
- Stricture/adhesions
- SMA syndrome
- Gastric volvulus
- Other etiologies including Diabetes mellitus, trauma, spinal conditions
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:
- Abdominal distention
- Abdominal pain
- Signs of peritonitis after perforation
Differential Diagnosis
Nausea and vomiting
Critical
Emergent
- Acute radiation syndrome
- Acute gastric dilation
- Adrenal insufficiency
- Appendicitis
- Bowel obstruction/ileus
- Carbon monoxide poisoning
- Cholecystitis
- CNS tumor
- Electrolyte abnormalities
- Elevated ICP
- Gastric outlet obstruction, gastric volvulus
- Hyperemesis gravidarum
- Medication related
- Pancreatitis
- Peritonitis
- Ruptured viscus
- Testicular torsion/ovarian torsion
Nonemergent
- Acute gastroenteritis
- Biliary colic
- Cannabinoid hyperemesis syndrome
- Chemotherapy
- Cyclic vomiting syndrome
- ETOH
- Gastritis
- Gastroenteritis
- Gastroparesis
- Hepatitis
- Labyrinthitis
- Migraine
- Medication related
- Motion sickness
- Narcotic withdrawal
- Thyroid
- Pregnancy
- Peptic ulcer disease
- Renal colic
- UTI
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
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
- 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
External Links
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.