History

Fact Explanation
Abdominal pain Most of the time patients complain of vague abdominal pain and distension. [1]
Vomiting Nausea and vomiting are seen in more than 90% of patients with acute gastric dilatation. [1,2]
History of eating disorders Patients with eating disorders (anorexia nervosa) and psychogenic polyphagia can suffer from acute gastric dilatation. These patients have decreased gastric motility and delayed gastric emptying predisposing them to acute gastric dilatation after an episode of binge eating. Gastric volume of about 3L will distend the stomach to such an extent that causes venous insufficiency. This process finally leads to diminished perfusion and gastric perforation. [1,2]
Cardiopulmonary resuscitation [1] Cardiopulmonary resuscitation can increase the gastric pressure resulting in gastric dilatation and venous insufficiency.
Symptoms of gastric perforation Patients with acute gastric dilatation may progress in to gastric rupture. This will lead you the development of peritonitis. If peritonitis is present patient will be febrile and lie still on the bed. [1]
Collapse Patients with peritonitis and sepsis collapse due to hypotension and septic shock. The aorta can be compressed by the dilated stomach which reduces the cardiac output. This can be another cause for collapse. [1]
Oliguria and or anuria Intra-thoracic pressure increases in response to acute dilatation of the stomach. This will lead to reduced arterload and reduced cardiac output, resulting diminished renal perfusion. This leads to the development of oliguria and later if untreated progress to anuria. [3]
History of gastrointestinal diseases Gastroduodenal Crohn’s disease, gastro duodenal tuberculosis, annular pancreas, gastrointestinal tumors, volvulus of hiatal hernia and bezoars are other etiological factors for acute gastric dilatation. In addition diabetes, ingestion of caustic substances can also cause acute gastric dilatation. [1,2,4]
History of gastrointestinal surgery Patients can develop acute gastric dilatation as a postoperative complication of splenectomy and abdominal surgery. Disruption of blood supply to the stomach can also predispose to acute gastric dilatation. [5]
References
  1. STEEN S, LAMONT J, PETREY L. Acute gastric dilation and ischemia secondary to small bowel obstruction Proc (Bayl Univ Med Cent) [online] 2008 Jan, 21(1):15-17 [viewed 28 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2190544
  2. TWEED-KENT AM, FAGENHOLZ PJ, ALAM HB. Acute gastric dilatation in a patient with anorexia nervosa binge/purge subtype J Emerg Trauma Shock [online] 2010, 3(4):403-405 [viewed 29 July 2014] Available from: doi:10.4103/0974-2700.70774
  3. MAHAJNA AHMAD, MITKAL SHARON, KRAUSZ MICHAEL M. Postoperative gastric dilatation causing abdominal compartment syndrome. Array [online] 2008 December [viewed 29 July 2014] Available from: doi:10.1186/1749-7922-3-7
  4. AYDIN IBRAHIM, PERGEL AHMET, YUCEL AHMET FIKRET, SAHIN DURSUN ALI, OZER ENDER. Gastric Necrosis due to Acute Massive Gastric Dilatation. Case Reports in Medicine [online] 2013 December, 2013:1-3 [viewed 29 July 2014] Available from: doi:10.1155/2013/847238
  5. JUNG . Gastric Perforation Caused by Acute Massive Gastric Dilatation: Report of a Case. J Med Cases [online] 2012 December [viewed 29 July 2014] Available from: doi:10.4021/jmc635w

Examination

Fact Explanation
BMI Patients with anorexia nervosa are extremely thin built and have very low BMI. [2]
Febrile Patients are febrile if they develop peritonitis and or sepsis. [1]
Abdominal examination Abdomen is distended in almost every patient with acute gastric dilatation. If peritonitis develops secondary to gastric perforation, diffuse abdominal tenderness, board like rigidity and guarding can be elicited. [1,2]
Blood pressure Patients with septic shock have low blood pressure and small volume pulse. Aortic compression can be another cause for the hypotension. [1]
Signs of dehydration Patients develop signs of dehydration secondary to severe vomiting. Reduced skin turgor, dry mucous membranes, dry skin and sunken eyes are indicative of dehydration.
References
  1. STEEN S, LAMONT J, PETREY L. Acute gastric dilation and ischemia secondary to small bowel obstruction Proc (Bayl Univ Med Cent) [online] 2008 Jan, 21(1):15-17 [viewed 28 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2190544
  2. AYDIN IBRAHIM, PERGEL AHMET, YUCEL AHMET FIKRET, SAHIN DURSUN ALI, OZER ENDER. Gastric Necrosis due to Acute Massive Gastric Dilatation. Case Reports in Medicine [online] 2013 December, 2013:1-3 [viewed 29 July 2014] Available from: doi:10.1155/2013/847238

Differential Diagnoses

Fact Explanation
Pyloric tumor Pyloric tumors can cause gastric outlet obstruction, nausea, vomiting and acute gastric dilatation. [5]
Perforated peptic ulcers Burning epigastric pain can occur in peptic ulcer disease. Perforation of the peptic ulcers can cause pneumo-peritoneum, peritonitis and sepsis. [4]
Intestinal obstruction Obstruction of the small intestine can cause colicky abdominal pain and vomiting with minimal abdominal distension whereas large bowel obstruction can cause significant abdominal distension and minimal vomiting.
Ectopic pregnancy Females with ectopic pregnancy presents with abdominal pain, vaginal bleeding, nausea, vomiting and amenorrhea. [1,2]
Appendicitis Appendicitis can present with acute abdomen and can have signs of peritoneal irritation in the presence of perforated appendix. [3]
References
  1. FATMIR K, ARBEN R, NIKITA M. Ectopic pregnancy comparison of different treatments. J Prenat Med. [online] 2010: 4(2): 30–34. [viewed 29 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3279172/
  2. JANET M. T., ALISON E. B., ROBERT M. G., Ectopic Pregnancy. JAMA. [online] 2012;308(8):829. [viewed 29 July 2014] Available from: doi:10.1001/jama.2012.6215.
  3. NGUYEN H., KHANH L., CONNIE L., HANH N., Concurrent Ruptured Ectopic Pregnancy and Appendicitis. J Am Board Fam Med [online] January 1, 2005: 18 (1) 63-66. [viewed 29 July 2014] Available from: doi: 10.3122/jabfm.18.1.63
  4. KURKCIYAN I, SCHIRMAIER E, FROSSARD M, SCHREIBER W, LANGLE F, HUEMER G, STERZ F. Concomitant perforated ulcer and acute myocardial infarct--a diagnostic challenge in emergency medicine. Wien Klin Wochenschr. [online] 1994;106(20):660-3. [viewed 29 July 2014]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/7810150
  5. KIM JAE-HYUN, LEE HYUN-SUNG, KIM MOON SOO, LEE JONG MOG, KIM SEOK KI, ZO JAE ILL. Balloon dilatation of the pylorus for delayed gastric emptying after esophagectomy☆. European Journal of Cardio-Thoracic Surgery [online] 2008 June, 33(6):1105-1111 [viewed 29 July 2014] Available from: doi:10.1016/j.ejcts.2008.03.012

Investigations - for Diagnosis

Fact Explanation
X-ray Abdominal X-ray will reveal a massively dilated stomach. In the presence of gastric perforation pneumo-peritoneum can be detected by erect chest X-ray. [1,3]
CT scan CT scan of the stomach is helpful in detecting massively dilated stomach. CT scan is considered superior to the X-ray in making the diagnosis. [1]
Upper gastrointestinal endoscopy (UGIE) UGIE is helpful in stable patients. Ischemic changes can be observed mainly over the greater curvature of the stomach sparing the lesser curvature and the pyloric regions. [1]
Measurement of intra-abdominal pressure Measurement of intraabdominal pressure, especially if acute gastric dilatation is anticipated (eg: after abdominal surgery) will help for the early detection of acute gastric dilatation. [2]
References
  1. STEEN S, LAMONT J, PETREY L. Acute gastric dilation and ischemia secondary to small bowel obstruction Proc (Bayl Univ Med Cent) [online] 2008 Jan, 21(1):15-17 [viewed 28 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2190544
  2. MAHAJNA AHMAD, MITKAL SHARON, KRAUSZ MICHAEL M. Postoperative gastric dilatation causing abdominal compartment syndrome. Array [online] 2008 December [viewed 29 July 2014] Available from: doi:10.1186/1749-7922-3-7
  3. AYDIN IBRAHIM, PERGEL AHMET, YUCEL AHMET FIKRET, SAHIN DURSUN ALI, OZER ENDER. Gastric Necrosis due to Acute Massive Gastric Dilatation. Case Reports in Medicine [online] 2013 December, 2013:1-3 [viewed 29 July 2014] Available from: doi:10.1155/2013/847238

Investigations - Fitness for Management

Fact Explanation
Serum electrolytes Patients with eating disorders especially anorexia nervosa can have low serum potassium levels which should be corrected prior to surgery.
Full blood count Sepsis is a possible complication of perforation of the stomach and peritonitis. [1]
References
  1. STEEN S, LAMONT J, PETREY L. Acute gastric dilation and ischemia secondary to small bowel obstruction Proc (Bayl Univ Med Cent) [online] 2008 Jan, 21(1):15-17 [viewed 28 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2190544

Management - General Measures

Fact Explanation
Fluid management Patients can be dehydrated because of severe vomiting. Intravenous fluid replacement is essential in the patient management. [1,2]
References
  1. TWEED-KENT AM, FAGENHOLZ PJ, ALAM HB. Acute gastric dilatation in a patient with anorexia nervosa binge/purge subtype J Emerg Trauma Shock [online] 2010, 3(4):403-405 [viewed 29 July 2014] Available from: doi:10.4103/0974-2700.70774
  2. AYDIN IBRAHIM, PERGEL AHMET, YUCEL AHMET FIKRET, SAHIN DURSUN ALI, OZER ENDER. Gastric Necrosis due to Acute Massive Gastric Dilatation. Case Reports in Medicine [online] 2013 December, 2013:1-3 [viewed 29 July 2014] Available from: doi:10.1155/2013/847238

Management - Specific Treatments

Fact Explanation
Staged decompression of the stomach Decompression of the stomach is first attempted via a nasogastric tube. If the aorta is being compressed by the dilated stomach sudden decompression of the stomach can lead to quick restoration of the systemic perfusion. This leads to sudden release of lactic acid which was a byproduct of anaerobic metabolism. This adverse squeal is prevented by staged decompression of the stomach. Even after successful decompression of the stomach perforation and hemorrhage can occur. So patient should be kept monitoring. [1,2,3]
Surgery Early diagnosis and treatment is crucial in preventing ischemic necrosis and perforation of the stomach. Surgical exploration (diagnostic laparotomy) is mandatory in unstable patients, because gastric perforation should always be kept in mind. In the presence of ischemic necrosis, surgical resection of the gangrenous segment should be done. If the total stomach is gangrenous total gastrectomy is done. If the patient is stable esophagojejunostomy can be done for reconstruction, however if the patient is unstable esophagostomy is done. [1,2,4]
References
  1. STEEN S, LAMONT J, PETREY L. Acute gastric dilation and ischemia secondary to small bowel obstruction Proc (Bayl Univ Med Cent) [online] 2008 Jan, 21(1):15-17 [viewed 28 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2190544
  2. TWEED-KENT AM, FAGENHOLZ PJ, ALAM HB. Acute gastric dilatation in a patient with anorexia nervosa binge/purge subtype J Emerg Trauma Shock [online] 2010, 3(4):403-405 [viewed 29 July 2014] Available from: doi:10.4103/0974-2700.70774
  3. MAHAJNA AHMAD, MITKAL SHARON, KRAUSZ MICHAEL M. Postoperative gastric dilatation causing abdominal compartment syndrome. Array [online] 2008 December [viewed 29 July 2014] Available from: doi:10.1186/1749-7922-3-7
  4. AYDIN IBRAHIM, PERGEL AHMET, YUCEL AHMET FIKRET, SAHIN DURSUN ALI, OZER ENDER. Gastric Necrosis due to Acute Massive Gastric Dilatation. Case Reports in Medicine [online] 2013 December, 2013:1-3 [viewed 29 July 2014] Available from: doi:10.1155/2013/847238