Other gastric conditions

Acute gastric dilatation

This condition usually occurs in association with some form of ileus which is not treated by nasogastric suction. The stomach, which may also be atonic, dilates enormously. Often the patient is also dehydrated and has electrolyte disturbances. Failure to treat this condition can result in a sudden massive vomit with aspiration into the lungs. The treatment is nasogastric suction, fluid replacement and treatment of the underlying condition. 

Trichobezoar and phytobezoar

Trichobezoar (hair balls) (Fig. 51.36) are unusual and are virtually exclusively found in female psychiatric patients, often young. It is caused by the pathological ingestion of hair which remains undigested in the stomach. The hair ball can lead to ulceration and gastrointestinal bleeding, perforation or obstruction. The diagnosis is made easily at endoscopy or, indeed, from a plain radiograph. Treatment consists of removal of the bezoar which may require open surgical treatment. Phytobezoars are made of the vegetable matter and found principally in patients who have gastric stasis.

Foreign bodies in the stomach

A variety of ingested foreign bodies reaches the stomach and very often these can be seen on a plain radiograph. If possible they should be removed endoscopically but if not most can be left to pass normally. Even objects such as needles, with which there is understandable anxiety, will seldom cause harm. In general, an object which leaves the stomach will pass spontaneously. By contrast, attempted removal at laparotomy can be very difficult as the object may be much more difficult to find than might be expected. Most adults who swallow foreign bodies have ill-defined psychiatric problems and may appear to relish the attention associated with serial laparotomies. The treatment should therefore be expectant and intervention reserved for patients with symptoms in whom the foreign body is failing to progress. 

Volvulus of the stomach

Rotation of the stomach usually occurs around the axis and between its two fixed points, i.e. the cardia and the pylorus. Iii theory, rotation can occur in the horizontal (organoaxial) or vertical (mesenterioaxial) direction but commonly it is the former which occurs. This condition is usually associated with a large diaphragmatic defect around the oesophagus (paraoesophageal herniation) (Fig. 51.37). What commonly happens is that the transverse colon moves upwards to lie under the left diaphragm, thus taking the stomach with it, and the stomach and colon may both enter the chest through the eventration of the diaphragm. The condition is commonly chronic, the patient presenting with difficulty in eating. An acute presentation with ischaemia may occur.

Endoscopically, it can be extremely difficult to sort out the anatomy and this is one situation in which the contrast radiograph is superior. 

Treatment

If the problem is causing symptoms then surgical treatment is the only satisfactory approach. ‘Iraditionahly open surgery has been employed but this problem is suitable for laparoscopic treatment if appropriate skill is available. If there is a hernia, the sac and its contents (usually the stomach) should he reduced. the defect in the diaphragm should he closed, if necessary, with a mesh. It is advisable to separate the stomach from the transverse colon and then perform an anterior gastropexy to fix the stomach to the anterior abdominal wall. The results from this treatment are good.