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.