Disease name: Gastric torsion English name: volvulus of stomach Abbreviation: Alias: stomach volvulusICD number: K31, 8 Classification: Gastroenterology Overview: The lower end of the normal stomach is fixed by the duodenum, and its form is maintained by the gastrosplenic ligament, gastroduodenal ligament, gastric diaphragmatic ligament and gastrohepatic ligament, so it cannot make 180° rotation. Gastric torsion (volvulus of stomach) is a disorder of the fixation mechanism of the normal position of the stomach or a lesion of its neighboring organs that leads to the displacement of the stomach by Xu Meng in the emergency department of Qilu Hospital of Shandong University, resulting in a total or partial abnormal torsion of the stomach itself along different axes. It can be transient and almost asymptomatic, or it can lead to obstruction or even ischemic necrosis.
Epidemiology: Berti first reported in 1866 that gastric torsion was found in a 60-year-old woman at autopsy. Since then. More than 350 cases have been reported in the foreign literature, while only sporadic reports have been made in China. The first successful surgical correction of gastric torsion was performed by Berg in 1897, and the radiographic signs of gastric torsion were first described by Rosselet in 1920. Gastric torsion can be seen at any age, in similar proportions in both sexes, with a peak incidence between 40 and 60 years of age, and about 15-20% of gastric torsions occur in children, usually before the age of 1 year, and are associated with congenital diaphragmatic defects.
Etiology: Gastric torsion often coexists with paraesophageal fissure, diaphragmatic hernia is thought to be the cause of gastric torsion, laxity of the supporting ligaments of the stomach, gastric dilatation due to pyloric or duodenal obstruction, and proximity of the cardia to the pylorus after a full meal. All contribute to gastric torsion.
Pathogenesis.
1, according to the rotational orientation is divided into (1) along the long axis of torsion: that is, the cardia and the pylorus of the line as the axis, turning upward. The onset of this type of rapid, closed-loop obstruction, rapid gastric expansion.
(2) Left-right torsion: The midpoint of the large and small curves of the stomach is the axis, and it is torsion to the left or right. It is chronic or intermittent, and the obstructive symptoms are not obvious.
2, according to the scope of torsion is divided into (1) complete torsion: in addition to the part attached to the diaphragm, the entire stomach twisted forward and upward, the large bend in the upper, located between the liver and the diaphragm, the wall after the stomach forward.
(2) partial torsion: mostly distal to the stomach, part of the forward or backward torsion.
3, according to the process of torsion is divided into (1) acute torsion: the onset of acute, severe symptoms.
(2) chronic torsion: persistent or recurrent, easily mistaken for gastric ulcer or esophageal hiatal hernia.
Clinical manifestations: The clinical symptoms of gastric torsion depend on its acute and chronic nature and the extent and degree of torsion.
1, acute gastric torsion The onset of acute gastric torsion is rapid, manifested as pain in the upper abdomen (subdiaphragmatic) or left chest (supra-diaphragmatic). In patients with subdiaphragmatic gastric torsion, the upper abdomen is significantly distended while the lower abdomen remains flat and soft, while in patients with supradiaphragmatic gastric torsion, chest symptoms appear while the upper abdomen can be normal. Chest pain may radiate to the arms and neck and be accompanied by dyspnea, so it is often misdiagnosed as myocardial infarction. Patients with acute gastric torsion often have persistent dry vomiting with minimal vomiting. In 1904, BoIrchardt described the characteristic triad of acute gastric torsion.
(1) Persistent dry vomiting with little or no vomitus.
(2) Severe and transient chest or epigastric pain of sudden onset.
(3) Difficulty in inserting a gastric tube in the stomach.
2, chronic gastric torsion Patients with chronic gastric torsion often have nonspecific symptoms such as gastric discomfort, indigestion, burning sensation, epigastric fullness or abdominal tinnitus, mostly induced after meals. Although patients rarely have symptoms of GERD, endoscopy often reveals esophagitis. The pain of intermittent gastric torsion is similar to that of acute gastric torsion, but to a lesser degree, and is often mistaken for a pancreaticobiliary origin precisely because of its transient character. Chronic intermittent gastric torsion should be considered in patients with intermittent epigastric pain in the presence of a paraesophageal hernia, especially if accompanied by vomiting or dry heaving.
Complications.
1, acute gastric torsion Late vascular occlusion, necrotic perforation of the gastric wall, severe gastrointestinal bleeding, and even shock and death can occur. The mortality rate can be as high as 30% to 50%.
2, chronic gastric torsion A small number of mucosal damage at the site of torsion or lesions of the stomach itself, there can be upper gastrointestinal bleeding.
Laboratory tests: When complications appear (upper gastrointestinal bleeding), the total amount of hemoglobin in routine blood tests decreases.
Other auxiliary examinations.
1.X-ray examination The standing chest and abdomen plain film shows two liquid and gas planes, one located in the proximal stomach under the left hemidiaphragm and the other located in the distal stomach in the posterior mediastinum, if there is pneumoperitoneum, it indicates complication of gastric perforation.
2, upper gastrointestinal tract barium meal examination patients with tethered axial torsion can be seen in the abnormally low position of the gastroesophageal junction under the diaphragm, while the distal stomach is located cephalad, gastric body, sinus overlap, cardia and pylorus can be at the same level. In organ-axis torsion, the stomach is upside down, the greater curvature lies above the lesser curvature, the fundic plane is not connected to the gastric body, the gastric body is distorted, the pylorus is downward, and the gastric mucosal folds may be twisted. The lower end of the esophagus is obstructed and shows a sharp shadow.
3.Endoscopic examination Endoscopic examination is difficult in gastric torsion, the anterior and posterior walls of the stomach or the position of the greater or lesser curvature can be seen to change, and some patients can find esophagitis, tumors or ulcers.
Diagnosis: When a patient presents with the above clinical features and gastric torsion is suspected, x-ray examination can often help confirm the diagnosis. In acute gastric torsion, the diagnosis is not difficult as long as the disease can be thought of. If gastric tube insertion is tried to confirm, it should be inserted slowly and not forcibly to avoid damage or perforation of the gastric wall. Chronic gastric torsion is difficult to diagnose clinically because there is no complete obstruction and its symptoms are non-specific.
Differential diagnosis: Gastric torsion needs to be differentiated from the following diseases.
1, acute gastric dilatation This disease is not serious abdominal pain, but mainly upper abdominal distension, nausea and frequent weak vomiting, vomit contains bile, vomiting large amount; can be inserted into the gastric tube and pumping out large amounts of gas and liquid. Patients often have signs of dehydration and alkalosis.
2, esophageal hiatal hernia The main symptom is burning pain or burning sensation behind the sternum, accompanied by belching or eructation. It occurs mostly within 1 h after a meal and can produce symptoms of pressure such as shortness of breath, palpitations, and cough. However, sometimes it can be combined with hernia gastric torsion, barium X-ray examination can help to identify.
3, myocardial infarction Mostly occurs in elderly patients, with severe arrhythmia, palpitations, angina and other aura before the attack, with characteristic electrocardiogram performance can be distinguished from gastric torsion.
4.Gastric cancer has mild pain in the upper abdomen, and the abdominal mass is mostly in the right side of the upper abdomen near the pylorus, nodular in shape.
It can be distinguished from gastric torsion by X-ray signs or endoscopic examination.
5.Pyloric obstruction Most of the patients have a history of peptic ulcer, can vomit the food, the amount of vomit is large, X-ray examination reveals pyloric obstruction, endoscopy can see ulcer and pyloric obstruction.
6, chronic cholecystitis Non-acute attacks, the patient shows symptoms of vague pain in the upper abdomen and indigestion, induced by eating greasy food. There is pressure pain in the right quarter rib area, radiating to the right shoulder, but there is no severe abdominal pain and nausea and dry vomiting. Gastric tube can be inserted smoothly, and positive findings can be found in duodenal drainage and cholecystography.
7, adhesive intestinal obstruction Patients mostly have a history of abdominal surgery, manifesting as sudden paroxysmal abdominal pain, exhaustion and defecation stop, vomit with fecal odor, distension and pain in the whole abdomen; visible intestinal pattern, intestinal sounds are hyperactive in the early stage and diminished in the late stage. The gastric tube could be inserted smoothly, and X-ray abdominal fluoroscopy revealed a trapezoidal fluid level in the intestinal cavity.
Treatment.
1, the treatment of acute gastric torsion (1) surgical treatment: acute gastric torsion often requires surgical treatment. First of all, the water-electrolyte disorder should be corrected. Patients who are accompanied by vomiting, dry vomiting, vibrating water sounds or X-ray examination proves that there is gastric dilatation, the nasogastric tube should be inserted to decompress, decompression is the only means to prevent recurrence of gastric torsion. However, the esophagogastric junction is often obstructed by torsion, and insertion of a nasogastric tube is often difficult or impossible. Because perforation of the esophagus or stomach during intubation has been reported, especially in pediatric patients, it is recommended that forced intubation should be avoided when intubation is difficult or resistant. If further efforts are to be made, they can be performed under X-ray guidance using a gastric tube containing a contrast agent.
If the patient is stable, emergency surgery is feasible. Surgical objectives include gastric decompression, gastric torsional repositioning, gastric immobilization, and correction or repair of the causative agent. A transabdominal wall approach is usually used, but a transthoracic approach may be used for repair and repositioning of gastric torsion due to diaphragmatic trauma. If infarction of the gastric wall is found, subtotal or total gastrectomy is chosen depending on the degree of ischemic gastric injury. Anterior gastric fixation is generally recommended to immobilize the stomach, or if the surgical risk is high, a temporary gastrostomy is performed after release of the torsion.
Surgery should also correct or repair pro-torsional factors, including diaphragmatic hernias or abdominal herniations, adhesions, and ulcers. If endoscopy reveals esophagitis in a patient with a paraesophageal hernia, surgical repair may also include anti-reflux maneuvers such as fundoplication, but is not recommended as a routine procedure for gastric torsion.
(2) Endoscopic treatment: Endoscopy can be used to examine the patient for esophagitis, tumors or ulcers. If a nasogastric tube cannot be inserted the patient can be decompressed by endoscopic intragastric suction. Both acute or chronic gastric torsion has been reported to be released by endoscopy by locking the end of the endoscope and rotating it 180° as it passes through the torsion. Eckhauser and Ferron recently reported the successful treatment of chronic intermittent gastric torsion by bilateral percutaneous endoscopic gastrostomy in a patient with chronic intermittent gastric torsion, in which the two mirrors were placed in the gastric body and sinus, and the two mirrors were used to release the torsion.
2, treatment of chronic gastric torsion The choice of surgery for patients with chronic gastric torsion is difficult. Doctors and patients should weigh the advantages and disadvantages of surgery. If the surgeon does not recommend surgery or if the patient does not want to undergo surgery, the patient should be aware of the possibility of developing acute gastric torsion in the future and its complications. Surgery can be used to relieve nasty chronic recurrent symptoms and prevent their acute onset and complications. If the whole stomach is located in the chest or if a paraesophageal hernia is present, surgery should be performed to prevent an acute attack. Iron deficiency anemia has long been found to be associated with large hiatal hernias, and recent reports suggest that the explanation for this association is that mechanical injury to the hernia as it slides anteriorly and posteriorly in the diaphragm can cause linear erosion of the stomach, so that a person with severe concurrent iron deficiency anemia may also be an indication for surgery.
Tanner published a comprehensive review of surgical treatment of chronic recurrent gastric torsion. He and others recommended repositioning of gastric torsion, gastric fixation, and subdiaphragmatic colonic transposition for gastric torsion due to protrusion of the diaphragm into the abdomen. Gastric fixation and diaphragmatic hernia repair are required for organ-axis gastric torsion and “upside-down” stomachs associated with paraesophageal hernias. If endoscopy reveals esophagitis, fundoplication is recommended. In children with thoracoabdominal hiatal hernia, the defect should be closed transabdominally. If intrinsic gastric damage is found, sinus resection or combined vagotomy is indicated, as well as gastroduodenal anastomosis (Billroth I), or gastrojejunostomy (Billroth I) if the duodenal stump is not suitable for anastomosis or is required. In order to prevent torsion of the remnant stomach, a colonic displacement gastric fixation is performed, which involves cutting the gastrocolic ligament from the pylorus to the fundus, moving the transverse colon and the greater omentum to the subdiaphragmatic interval, and then fixing the stomach to the hepatic round ligament and the transverse colonic mesentery, which removes the excessive diaphragmatic pull on the greater curvature of the stomach and thus reduces the chance of recurrence.
Prognosis: Due to the rapid diagnosis and modern treatment of gastric torsion, the mortality rate of acute gastric torsion has been reduced to less than 16%. The literature reports a 0% to 13% morbidity and mortality rate for chronic gastric torsion.