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Gastric volvulus. Gastroptosis. Bezoars and Foreign Bodies

Gastric volvulus

  • Twist in the axis of the stomach
    • Rotation occurs around the axis made by two fixed points – the cardia and pylorus
  • The condition can be idiopathic or secondary to hiatus hernia, eventration, adhesions, pyloric obstruction
Types of rotation
  • Organo-axial (horizontal) – more common in the elderly
    • Stomach is rotated along its long axis
    • Complete rotation presents with obstruction and ischemia
    • Incomplete rotation is usually asymptomatic
  • Mesenterico-axial (vertical) – more common in children
    • Stomach is rotated around its short axis
    • Causes displacement of the antrum above the gastro-oesophageal junction – stomach appears upside down

Clinical features – Borchardt’s triad

  • Acute epigastric pain
  • Intractable retching without vomiting
  • Inability to pass nasogastric tube

Complications

  • Perforation
  • Gangrene of stomach
  • Bleeding

Investigations

  • Chest XR – gas filled viscus (intrathoracic stomach)
  • Abdomen XR – massively dilated viscus in upper abdomen
  • Barium meal XR
  • CT abdomen

Treatment

  • Untwisting of volvulus and gastropexy (suturing of the stomach to the abdominal wall or diaphragm)
  • Gastrectomy when stomach is gangrenous
  • Treating hiatus hernia or eventration
  • Displacing colon downwards by dividing gastrocolic omentum – Tanner’s operation

Gastroptosis

  • Characterised by abnormal downward displacement of the stomach
  • Main symptoms – pain, nausea , loss of appetite

Etiology

  • Primary – growth and congenital abnormalities, abnormal bowel movements, lengthened mesentery of an organ
  • Secondary – weight loss, post-operative (surgery to remove ascites), frequent laborious activity, large tumours

Pathology

  • 1st stage – 2cm above pectineal line
  • 2nd stage – at the pectineal line
  • 3rd stage – below the pectineal line

Clinical features

  • Initially, minor abdominal pain after eating, nausea, malaise
  • Eventually, severe stomach pain in lumbar region, increased gas formation, nausea, fatigue, reluctance to eat

Diagnosis

  • Barium swallow
  • Oesophagogastroduodenoscopy

Treatment

  • Diet – frequent meals at the regular times, thorough chewing
  • Medications – antispasmodics
  • Surgery only indicated if there is obstruction (rare)

Bezoar

  • Indigestible masses trapped in the gastrointestinal tract

Types

  • Food bolus – seeds, fruit pits
  • Lactobezoar – inspissated milk, especially in premature infants
  • Pharmacobezoar – tablets/semi-liquid mass of drugs
  • Phytobezoar – indigestible plant material (cellulose)
  • Trichobezoar – hair, Rapunzel syndrome

Clinical features

  • Pain, weight loss
  • Obstructive symptoms – loss of appetite, vomiting, abdominal discomfort
  • Complications – ulceration, bleeding, peritonitis

Investigations

  • XR
  • CT
  • Ultrasound
  • Endoscopy

Treatment

  • Chemical dissolution
  • Endoscopic removal
  • Surgery – rarely needed

Foreign bodies

  • Variety of swallowed objects can become lodged in stomach or intestines
  • Can cause obstruction or perforation

Clinical features

  • Oesophagus – asymptomatic unless there perforation/obstruction
  • Perforation of stomach/intestines – peritonitis, abdominal pain, guarding, rebound tenderness
  • Obstruction of intestines – abdominal pain, distension, vomiting

Diagnosis

  • Abdominal XR – to see progression of objection through GIT
  • Metal detector – to localise metallic foreign body
  • CT if XR is negative

Treatment

  • Observation
  • Endoscopic removal
  • Drug packages
    • Immediately treat symptoms of drugs
    • Intensive care
    • Endoscopic removal is not recommended due to risk of perforation
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