Acute gastric dilatation

Background

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

Etiologies

• Post-operative complication (Nissen flundoplication)
• Occurs after binge eating episodes, typically in those with an eating disorder
  • Anorexia nervosa
  • Bulimia nervosa
  • Also Psychogenic polyphagia
• Mechanical obstruction
  • Pyloric stenosis
  • Stricture/adhesions
  • SMA syndrome
  • Gastric volvulus
• Other etiologies including Diabetes mellitus, trauma, 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

• See Abdominal Pain
• See Nausea and vomiting

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

Complications

• Bowel necrosis with or without perforation
• Abdominal compartment syndrome
• Sepsis/Septic shock
• If gastric necrosis and/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

References

• 1.Dewangan M, Khare MK, Mishra S, and Marhual JC. Binge eating leading to acute gastric dilation, ischemic necrosis and rupture. Journal of Clinical and Diagnostic Research." 2016; 10(3): 6-7.
• 2. Lunca S, Rikkers A, and Stanescu A. Acute massive gastric dilation: Severe ischemia and gastric necrosis without perforation. Romanian Journal of Gastroenterology'. 2005; 14(3): 279-283.
• 3.Santos T, Freitas C, and Pinto-de-Sousa J. Gastric wall ischemia following massive gastric distention due to pyloric stenosis: a case report. Journal of Surgical Case Reports. 2016; 2: 1-3.