Acute gastric dilatation

Background

• Rare event
• Invariable leads to necrosis with or without perforation
• Most commonly a post-operative complication

Etiologies

• Occurs after binge eating episodes, typically in those with an eating disorder
• Psychogenic polyphagia
• Other etiologies including Diabetes mellitus, trauma, Gastric volvulus, gastric outlet obstruction Pyloric stenosis, SMA syndrome, spinal conditions

Pathogenesis

• Intragastric pressure >20mmHg leads to impaired intramural blood flow and mucosal necrosis
• Gastric volumes greater than 4 liters lead to regular mucosal tears
• Patients with pathologic eating disorders can have larger gastric volumes at baseline
• Acute massive gastric dilation is an extreme form (intragastric pressure >30)

Clinical Features

• Emesis is typical symptom in 90% of cases
• Inability to vomit seen in massive distention
• Other features include:
  • Abdominal distention
  • Abdominal pain
  • Signs of peritonitis after perforation

Differential Diagnosis

By organ system

• GI
  • Peptic ulcer disease
  • Gastritis
    • Strangulated hernia
  • Pancreatitis
  • Appendicitis
  • Cholecystitis, Cholangitis
  • Acute Hepatitis
  • IBD
  • Intussusception
  • Malignancy
  • Mesenteric ischemia
  • Esophageal disorders (e.g. achalasia, GERD, esophagitis)
  • Functional disorders such as Irritable Bowel Syndrome
• Neurologic
  • Cannabinoid hyperemesis syndrome
• Infectious
  • Spontaneous bacterial peritonitis
  • Urinary tract infection
  • Bacterial toxins, Viruses (adeno, norwalk, rota)
• Drugs/Toxins
  • Heavy metal poisoning
  • Methanol poisoning
• Endocrine
  • Diabetic ketoacidosis
  • Thyroid/parathyroid disorders
  • Uremia
• Miscellaneous
  • Anorexia nervosa, Bulimia nervosa

Evaluation

• Typical work up for abdominal pain
• Upright chest x-ray and abdominal series to assess for free air
  • Can identify large distended stomach on x-ray
• CT imaging if safe and indicated

Management

• Nasogastric or orogastric decompression is first line therapy
  • Typically a large special tube required which is placed under anesthesiologist supervision in OR
• Resuscitation with fluids and intravenous antibiotics as indicated
• If conservative measures fail or gastric infarction suspected, surgical intervention mandatory
• If gastric necrosis or perforation not recognized and treatment delayed, mortality reaches 80%

Disposition

• Patient may require emergent surgical decompression
• If improvement with non-operative decompression, may require admission for continued monitoring