Epigastric Distension Research Articles

Early diagnostic clues in neonatal chronic gastric volvulus

Neonatal gastric volvulus (GV) is a rare clinical entity with a challenging diagnosis. In this study, we aimed to identify clinical and radiological findings to aid in early diagnosis in neonatal GV. The medical records of all neonates with GV were retrospectively reviewed. Diagnosis was made based on clinical findings and radiological images, and was documented by an upper gastrointestinal (UGI) contrast study. A total of eight neonates were included in the study. The most common clinical presentations were non-bilious vomiting and epigastric distention. The findings highly suggestive for GV in plain radiographs include gastric double bubble, abnormal gastric distention despite a nasogastric tube, distended stomach lying in a horizontal plane and an air-fluid level in the epigastrium. GV should be suspected in any newborn with non-bilious vomiting and epigastric distention. It is also important to focus on the clues in the plain radiographs. Gastric double bubble, abnormal gastric distention despite a nasogastric tube, distended stomach lying in a horizontal plane and an air-fluid level in the epigastrium must alert the physicians to the possibility of GV.

The role of intercostal cryoanalgesia in post-thoracotomy analgesia

Patients undergoing thoracotomy were studied to compare the effects of cryoanalgesia, combined with intravenous patient-controlled analgesia (IVPCA), against IVPCA alone during the four days following surgery. Fifty patients were randomized into two groups: an IVPCA group (n = 25) and an IVPCA-cryo group (n = 25). Subjective pain intensity was assessed on a verbal analogue scale at rest and during coughing. The intensity and the incidence of post-thoracotomy pain, numbness, epigastric distension and/or back pain, the analgesic requirements, as well as the blood gas values and respiratory function tests were evaluated up to the second postoperative (postop) month. Haemodynamic data and episodes of nausea and/or vomiting were recorded over the four postop days. In the cryo group there was a statistically significant improvement in postop pain scores (P = 10(-4)), reduction in consumption of morphine (P = 10(-4)) and other analgesics (P = 10(-4)), optimization (less acidosis) of the pH values of blood gases (P < 0.015 over 72 hours postop and P < 0.03 on the first and second postop months), increase in systolic blood pressure (P < 0.05 over 96 hours postop), reduction in heart rate (P < 0.05 over 96 hours postop), increase in values of FEV1 (P < 0.02) and FVC (P < 0.05) at the first and second postop months, reduction in the incidence of nausea (0.05 < P < 0.1 over 18 hours postop), numbness, epigastric distension and back pain (P < 0.05 at days 5, 6, 7, 14, 30 and 60 following surgery). We suggest that cryoanalgesia be considered as a simple, safe, inexpensive, long-term form of post-thoracotomy pain relief. Cryoanalgesia effectively restores FEV1 values at the second postop month.

Iatrogenic Splenic Artery Pseudoaneurysm: Case Report and Review of Literature

Splenic artery pseudoaneurysm is a known but uncommon complication of pancreatitis and a blunt abdominal trauma which can also be iatrogenic. A case study of a 58-year-old male who presented with epigastric pain and abdominal distension is reported. An initial ultrasound and computerized tomography showed a pseudocyst of the pancreas with the splenic artery passing through it. An attempt to do computerized tomography guided drainage of the cyst resulted in a rupture of the splenic artery inside the cyst. He was managed conservatively and discharged. Six months later, the patient came in with progressive distension of the abdomen. Endovascular embolization of splenic artery failed, thus, he was treated surgically. This case highlights the importance of a thorough evaluation of pseudocysts to identify any vessels in their cavity or wall, and that radiological aspiration of pseudopancreatic cyst should be done by senior, experienced radiologist.

Gastric Volvulus Complication in an Infant With Undiagnosed Congenital Diaphragmatic Hernia Presenting With Acute Respiratory Distress

Congenital diaphragmatic hernia is an embryologic defect that creates a passage for herniation of abdominal structures into the thoracic cavity. This can lead to a variety of complications, including gastric volvulus that can present acutely with epigastric distention and vomiting. In cases of late-onset congenital diaphragmatic hernia, symptoms may be vague and often necessitate further investigation. Our patient is a 12-month-old previously healthy female infant who presented to the emergency department with a history of vomiting and acute onset respiratory distress. Her SaO(2) was 94% to 98% on room air, her respiratory rate was in the 80s breaths per minute, and she was noted to have severe retractions. Her chest examination revealed absent breath sounds on the left side. Her abdominal examination was unremarkable. The acute presentation of respiratory distress was initially concerning for a foreign body aspiration, but a chest radiograph demonstrated left-sided opacification and mediastinal shift to the right. The patient required intubation for respiratory decompensation and a subsequent computed tomographic scan showed diaphragmatic hernia with gastric volvulus. This patient's presentation highlights one of the complications that may occur owing to congenital diaphragmatic hernia. Computed tomographic scan is the confirmatory test for diaphragmatic hernia and, in this case, also uncovered a concomitant gastric volvulus. Treatment includes early resuscitation, a definitive airway, and emergent surgery to prevent ischemic necrosis of the stomach owing to strangulation, gastric perforation, and serious cardiorespiratory decompensation.

Sister Mary Joseph’s Nodule Originating From Primary Duodenal Adenocarcinoma

A 74-year-old man felt epigastric distention pain and simultaneously noticed an indurated mass at the umbilicus for 3months. Physical examination revealed an erythematous firm nodule within the umbilicus, with superficial necrosis and pus discharge, which measured 2.5cm in diameter (Figure 1). Abdominal computed tomography scan revealed a mass in the intestinal wall of pars horizontalis duodeni with heterogeneous enhancement, the thickness being 1.2cm in diameter. Duodenoscope confirmed a spastic, irregular and fragile eminence at the posterior wall of pars horizontalis duodeni occupying half of the enteric cavity and was 5cm in length (Figure 2, arrow).

Idiopathic accelerated gastric emptying presenting in adults with post-prandial diarrhea and reactive hypoglycemia: a case series

IntroductionWe have previously reported the association of gastrointestinal and hypoglycemic symptoms, with idiopathic accelerated gastric emptying. We now report the first series of six similar cases.Case presentationsPatient 1: A 24-year-old Caucasian man presented to our facility with a six-month history of post-prandial nausea, flatulence, bloating, abdominal discomfort and associated diarrhea. He had associated episodes of fatigue, sweating, anxiety, confusion and craving for sweet foods. Patient 2: A 52-year-old Caucasian woman presented to our facility with a 15-year history of post-prandial bloating, abdominal pain and diarrhea, often associated with nausea, severe sweating, and fatigue. Patient 3: An 18-year-old Caucasian woman presented to our facility with a nine-year history of post-prandial diarrhea, abdominal bloating and pain. There was associated nausea, tremor, lethargy, and craving for sweet foods. Patient 4: A 77-year-old Caucasian woman presented to our facility with a four-month history of epigastric distension, pain after eating and a change in bowel habit. She experienced intermittent severe diarrhea and marked fatigue, nausea and sweating. Patient 5: A 23-year-old Caucasian woman presented to our facility with a two-year history of early satiety, and diarrhea after eating. She also complained of feeling faint and weak between meals, when she became cold and clammy, and on several occasions lost consciousness during these episodes. Patient 6: A 64-year-old Caucasian woman presented to our facility with a 10-year history of nausea, early satiety and profound bloating followed by diarrhea. All symptoms predominantly occurred in the first three hours after eating, when she felt faint, lethargic, and had a craving for sweet foods. In all cases, symptoms were alleviated or resolved by taking sweet food or drink and response to treatment was 90% or greater in all cases.ConclusionsThis series extends our description of this new clinical syndrome. All patients responded well to treatment for accelerated gastric emptying. Clinicians in the disciplines of endocrinology, gastroenterology, neurology and general practice are likely to find this information useful as they will consult patients with some or all of these symptoms and in a proportion of these patients idiopathic accelerated gastric emptying may be present and provide a useful avenue for therapeutic intervention.

Pediatric gastric outlet obstruction following corrosive ingestion

Corrosive substance ingestion is still a major medical and social problem for children. Gastric injury after corrosive ingestion is relatively uncommon as compared with esophageal injury. Gastric outlet obstruction (GOO) is a significant complication of corrosive ingestion. Medical records of 20 consecutive patients with GOO due to corrosive ingestion during an 8-year period between 2002 and 2009 were retrospectively reviewed. There were 10 boys and 10 girls with a mean age of 5.1 years (1.5-15 years). Ingested material was acid in all the patients. Two patients had associated esophageal stricture. The mean time between the ingestion and the development of GOO was 27.8 days (range 21-45 days) and all the patients presented with postprandial epigastric distension, nonbilious vomiting and weight loss. Surgical treatment included gastroduodenostomy (n = 8), Billroth I (n = 7), pyloroplasty (n = 5), and gastrojejunostomy (n = 2) procedures for GOO. Anastomotic stricture requiring a second operation developed in two patients. There was no surgical mortality. The mean follow-up is 3.3 years and all patients are free of symptoms. GOO is one of the most common gastric complications of corrosive ingestion that may require surgical treatment. Prevention of corrosive ingestion has great importance to avoid such complications.

Treatment of endoscopic sphincterotomy by endoscope to the patients with common duct stones after their gallbladders resected

Objective To evaluate the safety and therapeutic value of endoscopic sphincterotomy by endoscope to the patients with common duct stones after their gallbladders resected. Methods 158 patients with common duct stones after their gallbladders resected were given the treatments of endoscopic sphincterotomy and nasobiliary drainage in recent 4 years. Results 153 of 158 patients got succeed. The symptoms obviously improved such as jaundice and fever and epigastric distention and so on. As for the postoperative complications, the hyperamylasemia occurred in 85 patients of all patients,and active hemorrhage in 2 patients,and acute pancreatitis in 16 patients,and cholangitis in 5 patients,but no one occurred biliary fistula,no one died,too. Conclusion EST is the best way for us to treat the patients with common duct stones after their gallhladders resected by endoscope,and its curative effect is sure and its safety coefficient is higher. Key words: Custic Duct; Calculi Endoscopes

Management of hepatic arterial variants in living donor liver transplantation

AIM: To explore the management of hepatic arterial variants in living donor liver transplantation. METHODS: A retrospective analysis was made in management of hepatic arterial variants in two cases of living donor liver transplantations. The experience of management was summarized up in the study. RESULTS: CTA was a simple but effective approach to evaluating the hepatic artery before operation. Under the circumstance of hepatic arterial variants or quite small artery diameter, the quality of artery anastomosis could be strengthened through fully removing a piece of hepatic artery and anastomosis was conducted with hepatic artery from liver donor under powerful microscope. CTA was benefi cial to describe the situation of hepatic artery in the case of poor results detected with ultrasound due to postoperative epigastric distension. Hepatic artery thrombosis should be avoided if anti-coagulation was well prepared pre-operatively. CONCLUSION: Pre-operative valuation of hepatic artery, the highly qualif ied anastomosis and anticoagulation are important factors in prevention of postoperative hepatic arterial complications.

Gastric Volvulus in Infants and Children

Gastric volvulus is an important cause of nonbilious emesis that must be recognized early to ensure a good outcome. We reviewed 7 cases from our institution, Children's Healthcare of Atlanta (Egleston campus). In addition, we reviewed all gastric volvulus cases in children published to date in the English literature to draw general conclusions about the presentation and treatment of this unusual disease. An electronic literature search was performed to find all published cases of pediatric gastric volvulus. The care of all children from January 2002 to December 2007 who were treated for gastric volvulus was also reviewed. There have been 581 cases of gastric volvulus in children published in English between 1929 and 2007. Of these, 252 were acute and 329 were chronic cases. The most common presentation of acute gastric volvulus is in a child <5 years old with nonbilious emesis, epigastric distention, and abdominal pain. Acute gastric volvulus is often associated with deformities of adjacent organs. Definitive diagnosis is made with upper gastrointestinal studies, and definitive therapy requires repair of associated defects and anterior fixation of the stomach to the abdominal wall. The most common presentation of chronic volvulus is in an infant <1 year old with emesis, epigastric distention, feeding difficulties, and growth failure. Treatment may be medical or surgical depending on the underlying etiology of the volvulus. Acute gastric volvulus is a potentially life-threatening occurrence with a good outcome when treated in a timely fashion. Chronic volvulus may be more difficult to recognize. The common features of acute and chronic gastric volvulus described in this review should assist pediatric health care providers in promptly diagnosing and treating this disease.

Electronic Clinical Challenges and Images in GI

Question: A 68-yearold man presented with nausea and vomiting. He had been healthy until 3 weeks before, when he was diagnosed with stage T3N0M0 sigmoidal adenocarcinoma and underwent left hemicolectomy. The course of recovery was smooth and he had been discharged 7 days previously. He experienced dysphagia and fullness 4 days after discharge, and developed nausea and vomiting the next day; he visited our emergency room after 2 days and was readmitted. Physical examination revealed epigastric tenderness and distension, but no rebounding pain. The surgical wound was clean and healing well. Laboratory tests revealed leukocytosis with a shift to the left. Upper gastrointestinal (UGI) endoscopy revealed gastric distension and a convergent fold over the antrum (Figure A), but he scope could not pass into the duodenum. Computed tomography also demonstrated gastric distension and a shift of the gastric utlet to the left side with near obstruction (Figure B, C ). An UGI series with guided wire revealed that the axis turned from the left to the right side and then passed into the duodenum (Figure D ). The patient then underwent emergency surgery. What was the diagnosis? See the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

Endometrial stromal sarcoma associated with extrauterine endometriosis: a case report and literature review

Endometrial stromal sarcoma (ESS) that arises from extrauterine endometriosis is a rare form of malignancy. We report the case of a 37-year-old ESS patient with extrauterine endometriosis who was treated with ifosfamide/cisplatin chemotherapy. A woman presented with epigastric pain and abdominal distension. Computed tomography imaging revealed a profuse amount of ascites, including a 12.4×12.3 cm sized posterior cul-de-sac mass composed of solid and cystic components. Cytoreductive surgery was performed to remove the mass and the histopathologic findings indicated ESS associated with extrauterine endometriosis. Six cycles of combination chemotherapy [ifosfamide (5 g/m 2 ) with mesna (1 g/m 2 ) and cisplatin (50 mg/m 2 ) (IP)] were administered. After a six-month of disease-free interval, recurrent ESS developed in the pelvic cavity and in both lung fields. Megace medication decreased tumor marker CA-125 for six weeks. However, the patient expired sixteen months after the cytoreductive surgery. ESS associated with extrauterine endometriosis showed response to IP chemotherapy and megace.

Hepatic angiosarcoma arising in an adult mesenchymal hamartoma

The histogenesis of the hepatic sarcoma and its association with hamartoma is not well understood. We hereby present a Chinese patient with hepatic angiosarcoma arising from an adult mesenchymal hamartoma of liver. A 33-yr-old woman was diagnosed hepatic hamartoma eight years ago and presented with epigastric distention recently. Now she was admitted to our hospital with some unusual features: (a) this patient was diagnosed in mid-twenties, (b) the tumor occupied the whole liver and most importantly (c) the hepatic angiosarcoma appeared 8 years after the diagnosis of hamartoma. Based on this case and some reports, hepatic hamartoma may develop to hepatic angiosarcoma.

Duodeno-jejunal junction dyssynergia: Description of a novel syndrome

To investigate the hypothesis that duodeno-jejunal dyssynergia existed at the duodeno-jejunal junction. Of 112 patients who complained of epigastric distension and discomfort after meals, we encountered nine patients in whom the duodeno-jejunal junction did not open on duodenal contraction. Seven healthy volunteers were included in the study. A condom which was inserted into the 1st duodenum was filled up to 10 mL with saline in increments of 2 mL and pressure response to duodenal distension was recorded from the duodenum, duodeno-jejunal junction and the jejunum. In healthy volunteers, duodenal distension with 2 and 4 mL did not produce pressure changes, while 6 and up to 10 mL distension effected significant duodenal pressure increase, duodeno-jejunal junction pressure decrease but no jejunal pressure change. In patients, resting pressure and duodeno-jejunal junction and jejunal pressure response to 2 and 4 mL duodenal distension were similar to those of healthy volunteers. Six and up to 10 mL 1st duodenal distension produced significant duodenal and duodeno-jejunal junction pressure increase and no jejunal pressure change. Duodeno-jejunal junction failed to open on duodenal contraction, a condition we call 'duodeno-jejunal junction dyssynergia syndrome' which probably leads to stagnation of chyme in the duodenum and explains patients' manifestations.

Hepatoblastoma in adults: a report of 12 cases

目的 探讨成年人肝母细胞瘤的临床特点和诊治方法.方法 回顾性分析我院1963年5月至2005年3月收治的12例成年人肝母细胞瘤病人的诊治和随访情况.结果 对于40～60岁病人,症状在3个月以内,以腹胀、腹痛为主诉,AFP(+),瘤体较大(＞10 cm),CT发现肝脏占位伴钙化或囊性变应考虑成年人肝母细胞瘤的可能.手术切除是主要的治疗手段.结论 成年人肝母细胞瘤具有病程短、进展快、恶性程度高、预后差的特点,早期诊断,尽早手术切除,术后紧密随访,综合治疗是提高生存率的关键。

Acute gastric volvulus secondary to eventration of the diaphragm in a child

We report an 18-month-old boy who presented with acute organoaxial volvulus of stomach secondary to eventration of diaphragm. Clinically, the child exhibited classical triad of epigastric distension, unproductive retching and inability to pass a nasogastric tube. Successful operative management is presented and relevant literature is discussed.

Temporary transgastric fistula occlusion as salvage procedure in neonates with esophageal atresia with wide distal fistula and moderate to severe pneumonia

A method to achieve distal fistula occlusion by inflating the balloon of a catheter placed at the gastroesophageal junction via a transgastric route was tried in seven consecutive neonates with esophageal atresia and wide distal fistula. Due to associated moderate or severe pneumonia, these infants were at poor anesthetic risk for the definitive repair. The procedure was done under local anesthesia with mild sedation and took an average of half an hour for completion. Another feeding tube was negotiated through another gastrotomy across the pylorus to allow early enteral feeds. Temporary transgastric fistula occlusion (TTFO) allowed better ventilation of the hypocompliant lungs (by increasing resistance at the fistulous end), prevented lung injury due to aspiration of the refluxing gastric juices, and facilitated optimal ventilation by preventing epigastric distension. All study subjects survived this procedure except for one of our earlier study subjects who died of massive pneumothorax that was a procedure-related complication. None of the remaining subjects required mechanical ventilation either after TTFO or after the definitive esophageal repair that was carried out 5-7 days subsequent to TTFO, except for one other neonate with right lung aplasia who began deteriorating 48 h after thoracotomy and died of cardiac failure. There were no anastomosis-related problems among the survivors over a 12-month follow-up. The gratifying results of our study prompt us to suggest that this procedure deserves attention, and its role should be explored for salvaging neonates with type C esophageal atresia with wide fistula and pneumonia in developing countries with few neonatal intensive care services.

Laparoscopic Treatment for Pediatric Gastric Volvulus

Background and Purpose: Gastric volvulus in children may be a surgical emergency or may present more subtly. The classic symptoms of gastric volvulus include the triad of unproductive retching, epigastric distention, and the inability to pass a nasogastric tube, but these symptoms are inconsistent in children. The accepted surgical treatment for acute, subacute, or intermittent gastric volvulus is anterior gastropexy, and others have reported that this can be accomplished laparoscopically. We present further clinical experience documenting the safety and efficacy of a laparoscopic approach to gastric volvulus. Methods: This is a case series of 4 children (2 girls and 2 boys, ranging in age from 8 months to 12 years) with gastric volvulus. Two presented as emergencies, one was asymptomatic, and one presented with a feeding problem. Results: Gastric volvulus was successfully treated by laparoscopic gastropexy in all cases. Two children also had a gastrostomy tube placed for postoperative feeding. Postoperative hospital stay ranged from 3 to 12 days, the latter due to unrelated medical problems in one child. There were no direct surgical complications or noted recurrence of volvulus. All children were well at follow-up. Conclusion: Our small experience supports laparoscopic gastropexy as a safe and effective treatment for gastric volvulus in children, with no serious complications, and minimal postoperative morbidity.

Index of Suspicion

Index of Suspicion

Evaluation of gastric antral motor performance in patients with dysmotility-like dyspepsia using real-time high-resolution ultrasound.

Although manometric antral hypomotility and delayed gastric emptying have been reported separately in patients with dyspepsia, relationships between symptoms, antral contractility and emptying rate have not been sought. The present study therefore aimed to evaluate, simultaneously, gastric antral excursion characteristics and emptying in a sub-group of patients with severe functional dyspepsia using high-resolution real-time ultrasound. The circumference of the relaxed and contracted antrum was measured at 15-min intervals after ingestion of a 360 mL mixed nutrient meal in 36 chronic dyspepsia patients with symptoms of post-prandial bloating and epigastric distension, and in 25 healthy volunteers. Antral emptying (measured as the rate of decrease in circumference of the relaxed antrum) was slower in patients than normals (P = 0.02). In both groups, the average values for antral excursion were similar but the range of excursion in patients was significantly wider than in controls (F < 0.001), with 11 patients showing values above, and 8 showing values below the normal range. There was no relationship between antral emptying and antral excursion in either patients or volunteers. In conclusion, patients with severe functional dyspepsia show a wide range of antral performance characteristics, suggesting not only that the mechanisms responsible for the control of antral motor function are disturbed but also that the cause of the symptoms and the disturbed antral motor function are probably not directly related.