Acute gastric dilation

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

Nausea and vomiting

Critical

• ACS/MI
• Boerhaave's
• DKA
• Intracranial Hemorrhage
• Ischemic bowel
• Meningitis
• Sepsis

Emergent

• Acute radiation syndrome
• Acute gastric dilation
• Acetaminophen toxicity
• Adrenal insufficiency
• Appendicitis
• Aspirin toxicity
• Bowel obstruction/ileus
• Carbon monoxide poisoning
• Cholecystitis
• CNS tumor
• Digoxin toxicity
• Electrolyte abnormalities
• Elevated ICP
• Gastric outlet obstruction
• Hyperemesis gravidarum
• Pancreatitis
• Peritonitis
• Ruptured viscus
• Testicular torsion/ovarian torsion
• Theophyline toxicity

Nonemergent

• Biliary colic
• Cannabinoid hyperemesis syndrome
• Chemotherapy
• Disulfiram effect
• Erythromycin
• ETOH
• Gastritis
• Gastroenteritis
• Gastroparesis
• Hepatitis
• Ibuprofen
• Labyrinthitis
• Migraine
• Motion sickness
• Narcotic withdrawal
• Thyroid
• Pregnancy
• Peptic ulcer disease
• Renal colic
• UTI

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

Large distended stomach consistent with gastric dilation

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

Disposition

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

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%

See Also

• Bariatric surgery complications

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.

Authors

Meagan Mackey, Ross Donaldson, Michael O'Brien, MD