1.How to treat duodenal diverticulum?
(A) Treatment principles: no treatment is needed for duodenal diverticulum without symptoms. When there are certain clinical symptoms and no other lesions exist, medical treatment should be used first, including diet regulation, acidulants, antispasmodics, etc., and can take a lateral position or change a variety of different positions to help the evacuation of food accumulation within the diverticulum. Because the diverticulum is located in the second part of the duodenum, or even buried in the pancreatic tissue, surgical removal is difficult, so only in the internal treatment is ineffective and repeated diverticulitis, bleeding or compression of adjacent organs to consider surgery.
(B) surgical methods: In principle, diverticulectomy is the most ideal surgical method. Smaller diverticula can be made for endorectomy alone. At the same time there are multiple diverticula and in case of technical difficulties in resection, can be used to reroute surgery, that is, to perform Bi II (Billroth II) type partial gastrectomy and selective vagotomy. If it is difficult to find the diverticulum for a while, the duodenum can be cut open from the lumen to find the opening of the diverticulum, and its bottom will be turned into the intestinal cavity for resection. After diverticulum removal, the intestinal wall incision should be sutured in the direction perpendicular to the long axis of the intestinal curvature (see below) to avoid intestinal stenosis.
(1) The peritoneum is incised laterally in the duodenum, and the duodenum is freed and retracted medially to expose the diverticulum
(2) After diverticulectomy, the intestinal wall incision is closed with a transverse (i.e., in the direction perpendicular to the long axis of the intestinal curvature) inversion suture
Schematic diagram of duodenal descending diverticulotomy
2.Is there a high chance of gastric injury? What are the signs of injury?
Due to the large mobility of the stomach, and protected by the rib arch, the incidence of simple gastric injury in blunt abdominal injuries accounted for only 1-5% of intra-abdominal organ injuries; but in penetrating abdominal injuries (especially gunshot wounds), the rate of gastric injury is higher, accounting for about 10-13%, ranking fourth in visceral injuries. Because of the anatomical relationship, stomach injury often combined with other visceral injuries, abdominal penetrating injuries in particular, combined with liver injury accounted for 34%, spleen injury accounted for 30%, small intestine injury accounted for 31%, large intestine injury accounted for 32%, pancreatic injury accounted for 11%. The mortality rate of gastric injury alone is 7.3%, and the mortality rate of combined injuries is up to 40% or more.
The clinical manifestations of gastric injury depend on the extent of the injury, the degree, and the presence of other organ injuries. A partial injury to the stomach wall may be asymptomatic. Gastric wall rupture, gastric contents with strong chemical irritation, into the abdominal cavity caused severe abdominal pain and signs of peritoneal irritation, can vomit bloody material, liver turbid boundary disappeared, the diaphragm has free gas.
3, stomach injury can have what treatment?
Once the diagnosis should be timely surgery, surgery should pay attention to the presence of other organs combined injury to prevent missed diagnosis so as not to delay treatment. The anterior gastric wall injury is easy to find, but the posterior gastric wall, gastric fundus and cardia incomplete gastric wall injury may be missed, the exploration should be exhaustive. 1/3 cases of gastric anterior and posterior wall have perforation, should be incised gastrocolic ligament, reveal the posterior gastric wall, pay special attention to the small and large omental attachment, beware of missing small perforation. Although the gas or methylene blue solution injected through the gastric tube can help intraoperative localization and diagnosis, there is a risk of increased abdominal contamination, which should be used with caution.
Gastric injuries are treated separately according to the site, extent and nature of the injury. Gastric injury involves only the mucosal layer and is diagnosed before the proposed surgery, the bleeding is small, and there are no other combined injuries to the organs, which can be treated non-operatively. If hemorrhagic shock occurs, surgical treatment is appropriate. For simple gastric mucosal lacerations, the bleeding volume can be as much as 2L, which requires surgical incision of the gastric wall to find the bleeding point at the tear site under direct vision, suturing the gastric mucosal vessels or adding sodium cod liver oil and gelatin sponge to stop bleeding, and then suturing the torn gastric mucosa. The hematoma of the gastric wall may be accompanied by “perforation through the wall”, so the plasma membrane layer at the edge of the hematoma should be incised to remove the hematoma and stop the hemorrhage, and depending on the depth of the gastric wall injury, the whole layer of the gastric wall or the plasma muscle layer should be sutured and repaired. For neat fissures, direct sutures can be used after hemostasis, and for those with contused marginal tissues or those who have lost vitality, sutures after trimming are appropriate. Gastrectomy is generally not used unless the destruction of the gastric wall is extensive and severe. Other combined injuries should be treated accordingly according to their damage. Before closing the abdomen, the gastric contents of the abdominal cavity should be thoroughly aspirated and flushed with plenty of saline. Simple gastric injury does not require drainage. Postoperatively, continue to apply antibiotics to maintain nutrition and water and electrolyte balance.
4.Is duodenal injury common? What are its characteristics and manifestations?
Duodenal injury is a serious intra-abdominal injury, accounting for about 3-5% of intra-abdominal organ injuries. Duodenum and liver, bile, pancreas and large blood vessels adjacent, therefore, duodenal injury is often combined with one or more organ injuries. Duodenal injury is divided into penetrating, blunt and medically induced injuries. Foreign penetrating injuries are predominant, and domestic mainly blunt injuries. Blunt injuries cause duodenal rupture mechanism or direct violence to squeeze the duodenum to the spine; or violence caused by the sudden closure of the pylorus and duodenal jejunal bend, so that the duodenum formed closed loop intestinal segment, luminal pressure suddenly increased, resulting in rupture, causing serious retroperitoneal infection. The injury site is most common in the second and third part of the duodenum. The possibility of duodenal injury should be considered for penetrating injuries to the upper abdomen. However, the preoperative diagnosis of blunt duodenal injury is extremely difficult, for the following reasons.
(i) the incidence of duodenal injury is low, and surgeons are not alert to it.
② Duodenum is located in the retroperitoneum except for the first part, the symptoms and signs are not obvious after the injury, and some patients have no special discomfort after the injury, and delayed rupture occurs several days later, before obvious symptoms and signs appear. Some patients with duodenal injury show only mild pain in the right upper abdomen after injury and can continue to move and eat, but abdominal pain increases more than 10 hours or days after injury and diffuse peritonitis develops. Although intense abdominal pain and peritoneal irritation signs appear immediately after duodenal rupture, they are common manifestations of intra-abdominal organ injuries and are not unique to duodenal injuries, and the combination of multiple intra-abdominal organ injuries adds to the difficulty of diagnosis. Therefore, the key to preoperative diagnosis is to consider the possibility of duodenal injury, especially for patients with severe abdominal pain and peritonitis after blunt injury to the lower chest or upper abdomen, or patients with right upper abdominal or low back pain radiating to the right shoulder and inner thigh after several hours of upper abdominal pain relief. Symptoms of testicular pain and penile erection may be associated with irritation of the retroperitoneal testicular nerve and the sympathetic nerve accompanying the spermatic artery due to intestinal spillage. Duodenal injury should be suspected when accompanied by hypotension, vomiting of bloody gastric contents, and twisted pronation on palpation in the rectal fossa.
The diagnosis of duodenal injury is facilitated by abdominal radiography, which reveals air accumulation under the right diaphragm or around the right kidney, loss of shadowing or blurring of the psoas major muscle, and scoliosis. The diagnosis can be confirmed if the film is taken after oral administration of water-soluble contrast agent and if extravasation of contrast agent is seen.
5.What are the treatment measures for duodenal injury?
Abdominal injury should be operated as soon as there is an indication for dissection. It is important to explore thoroughly during surgery to avoid leakage. Lucos (1977) divided duodenal injury into four grades: grade I: duodenal contusion, with duodenal wall hematoma, but no perforation and pancreatic injury; grade II: duodenal rupture, no pancreatic injury; grade III: duodenal injury with mild pancreatic contusion; grade IV: duodenal injury combined with severe pancreatic injury. Duodenal lacerations can be classified according to their size
① perforation injury;
② transmural injury less than 20% of the circumference;
(③) transmural injury accounts for 20-70% of the circumference;
④ transmural injury is more than 70% of the circumference. The local treatment of duodenal injury is.
(1) duodenal wall hematoma without rupture, non-surgical treatment is feasible, including gastrointestinal decompression, intravenous fluids and nutrition, injection of antibiotics to prevent infection. Most hematomas can be absorbed and heal spontaneously by mechanization. If the hematoma is not absorbed for more than 2 weeks and leads to obstruction, we can consider incising the intestinal wall, removing the hematoma and then suturing or making a gastrojejunostomy.
(2) Duodenal fissure is small, the edges are neat and can be repaired by simple sutures, in order to avoid stenosis, transverse sutures are appropriate, 80% of duodenal fissures can be treated by this method. If the injury is serious and not suitable for suture repair, the damaged intestine can be excised for end-to-end anastomosis, and if the tension is too great for anastomosis, the distal end can be closed and the proximal end can be made with the jejunum for end-to-side anastomosis.
(3) For large duodenal defects, severe contusion and edema at the edge of the laceration can be used to divert the flow. The purpose is to divert duodenal fluid and decompress the intestinal cavity to facilitate healing. There are two methods of diversion: one is jejuno-duodenal anastomosis, which is the easiest and most reliable method to use duodenal rupture and jejunum for terminal or lateral Roux-en-Y anastomosis; the other method is duodenal diverticulization, which is after repairing duodenal rupture, removing gastric sinus, cutting vagus nerve, making gastrojejunostomy and duodenostomy for decompression, so that duodenum is open for healing. It is suitable for those with severe duodenal injury or pancreatic injury, but this operation is complicated and time-consuming, and its application is limited. Some authors propose not to remove the gastric sinus, but to incise the greater curvature of the gastric sinus side, before the absorption of the sutured intestinal line, food temporarily can not enter the duodenum, the intestinal line absorption after the pylorus function to regain, so called temporary duodenal diverticulization. For large duodenal defects, the defect can also be repaired with a tipped jejunum piece, called the “patching method”.
(4) For late diagnosis, serious infection or abscess formation around the injury, it is not suitable for suture repair, and can be used to make duodenostomy, which can heal by itself after treatment. If it does not heal, fistulotomy is feasible after the inflammation subsides.
(5) The treatment of serious combined injuries of the duodenum and pancreas is the most difficult. Generally, duodenal diverticulization or pancreaticoduodenectomy is used, with the latter having a mortality rate of 30-60%, and only when the duodenum and head of the pancreas are extensively injured and beyond repair.
Regardless of the procedure chosen, effective duodenal decompression is extremely important for wound healing. Some scholars reported 237 cases of duodenal injury in the repair of lacerations after the routine application of duodenal decompression, only 1 case of duodenal fistula, while 23 cases did not do duodenal decompression, 7 cases of duodenal fistula, which shows the importance of duodenal decompression. The main methods of duodenal decompression are nasogastric tube decompression or gastrostomy or fistula through the duodenal repair and retrograde intubation through the jejunostomy. In recent years, three-tube decompression has been advocated, i.e., two catheters are inserted via gastrostomy and upper jejunostomy, one catheter is inserted retrogradely into the duodenum for decompression, and the other catheter is inserted into the distal jejunum for nutritional support. Adequate extraperitoneal drainage and early nutritional support are important for duodenal injury. The most common complications after surgery are duodenal fistula, abdominal and subdiaphragmatic abscess, duodenal stricture, etc.
6.What is esophageal cardia mucosal tear syndrome? What tests are needed when this syndrome is suspected?
Mallory-Weiss syndrome is a syndrome in which the lower esophagus and/or the esophagogastric cardia junction or gastric mucosa is torn due to frequent and violent vomiting or other conditions that cause a sudden increase in intra-abdominal pressure (such as violent coughing, weight lifting, forceful defecation, etc.), causing mainly upper gastrointestinal bleeding.
The following tests are feasible when this syndrome is suspected.
(1) X-ray gas-barium double imaging: irregular filling defects are seen, sometimes the barium is located within the ulcer niche, sometimes the barium can be seen near the bleeding foci located within the ulcer niche, and sometimes the barium filling defect area near the bleeding foci can be seen.
(2) Fiberoptic endoscopy: Emergency endoscopy performed 24 to 48 hours after the onset of the disease reveals longitudinal tears at the junction of the esophagus and stomach and in the submucosa of the distal esophagus, mostly single, but also multiple; in mild lesions, only one hemorrhagic fissure is seen, and the inflammatory reaction of the surrounding mucosa is not obvious; in severe lesions, the fissure is often locally covered with a clot, and there may be fresh bleeding at the edges, and the surrounding mucosa is congested and edematous.
(3) Selective abdominal arteriography: bleeding at a rate of 0.5 ml per minute can be detected. The contrast agent can be seen to spill from the junction of the esophagus and stomach and flow along the upper or lower esophagus, which can show the outline of the esophageal mucosa, and is suitable for patients with negative barium meal and endoscopy.
7.How to diagnose esophageal cardia mucosal tear syndrome? What treatments are available?
The diagnosis is based on the following.
(1) Triggers and obvious medical history leading to increased intra-abdominal pressure.
(2) Clinical manifestations of frequent vomiting followed by vomiting of blood.
(3) X-ray gas-barium dual imaging, selective abdominal arteriography and fiberoptic endoscopy have confirmatory value.
Treatment includes conservative therapies such as sedation and antiemetic, reduction or avoidance of increased abdominal pressure, blood volume supplementation, pharmacological hemostasis and interventional therapy, and if ineffective, surgical ligation of bleeding vessels and suturing of torn mucosa should be performed.
8.What is hypogastric prolapse? What are the manifestations of gastric prolapse?
Gastric prolapse means that when standing, the lower edge of the stomach reaches the pelvis and the lowest point of the arc of the gastric bend descends below the line of the iliac crest, which is called gastric prolapse. The occurrence of gastric prolapse is mostly due to low diaphragmatic position, insufficient diaphragmatic suspension force, hepatogastric and diaphragmatic gastric ligaments decreasing in function and loosening, decreasing intra-abdominal pressure and loosening of abdominal muscles, and other factors such as body shape or physique, so that the stomach is in the shape of a fish structure with a very low bottom, that is, a tension-free stomach seen as gastric prolapse.
Mild prolapse is generally asymptomatic, while those with obvious prolapse have epigastric discomfort, fullness, obvious after meals, accompanied by nausea, belching, anorexia, constipation, etc. Sometimes there is deep vague pain in the abdomen, often aggravated after meals, standing and exertion. Long-term hypogastric patients often have symptoms such as wasting, weakness, standing fainting, hypotension, palpitations, insomnia and headache. The epigastric pressure pain is not fixed and can change with the position. In some patients, the sound of water vibrating under the umbilicus can be heard on palpation, and there are also a few cases of obvious prolapse with signs of liver, right kidney and colonic prolapse at the same time.
9.How to determine whether there is hypogastric prolapse? What treatment measures are available?
(1) Wasting, weakness, stomach distension and discomfort, more so after eating, abdomen seems to be falling down, which is relieved when lying down, abdominal pain is not periodic and rhythmic, often with vomiting and belching, and the lower part of the umbilicus is seen to be elevated after a full meal, while the upper abdomen is sunken. A strong aortic pulsation can be felt in the upper abdomen.
(2) Ultrasonography: After drinking water to fill the gastric cavity, the lower edge of the stomach is measured by ultrasound to move down into the pelvis.
(3) X-ray barium meal examination: the most reliable diagnostic method for gastric prolapse. The degree of gastric prolapse is mild if the incision of the lesser curvature of the stomach is 1-5 cm below the level of the skeletal crag line, moderate if it is 6-10 cm, and severe if it is 11 cm or more.
Western medical treatment: epigastric discomfort, vague pain, indigestion, etc. can be treated with reference to chronic gastritis. Those with abdominal distension and slow gastric emptying can be supplied with morpholine 19mg 3 times a day or gastroflucan 5-10mg 3 times a day. Try ATP treatment with 20mg intramuscularly half an hour before breakfast and lunch twice a day for 25 days as a course of treatment, followed by a second course of treatment after an interval of 5 days. If necessary, a gastric tray can be placed.
Chinese medicine treatment: Ear acupuncture: use the handle of a milli-needle to press on the “gastrointestinal area” of the ear shell to find the sensitive point and apply pressure on this point for 2-3 minutes, once a day. Moxibustion: take Qihai, Guanyuan, Feet Three Miles and Stomach Yu points to apply moxibustion. Qigong: lying breathing method: the patient takes the supine position, the buttocks are properly padded or the foot of the bed is padded by 5 cm, first inhale and then exhale, stop and close, repeat; when inhaling line lick the palate, meditate on the first word of the word, when exhaling drop the tongue, meditate on the second word, stop and close when the tongue does not move, meditate on the rest of the word, meditate on the word can be “stomach rising”, “stomach body rising”, etc. “stomach body up” and so on.
10, how to prevent gastric prolapse?
Do not overeat, it is advisable to eat less and more meals. Quit smoking and alcohol, forbid fatty, spicy and stimulating products, easy to digest, nutritious food. Do not participate in heavy physical labor and strenuous activities, especially after eating. Take a walk after meals to help the recovery of ptosis. Keep optimistic mood, do not get angry or depressed. Be patient and persistent in treatment, food conditioning and rehabilitation exercises, and have the confidence to overcome the disease.
You should develop good eating habits, eat in moderation, regular and quantitative, and increase nutrition for those who are thin. You should actively participate in physical exercise, such as walking, practicing qigong, playing tai chi, etc. To prevent gastric prolapse, it is also necessary to maintain an optimistic mood. If you are suffering from chronic digestive diseases, you should actively and thoroughly treat them to reduce the occurrence of gastric prolapse.