Stomach damage

Introduction to gastric injury Various injury factors with a certain intensity can cause gastric damage. However, since the stomach is in a protected anatomical position in the abdominal cavity, the gastric cavity is mostly in an empty state and can move within a certain range in the abdominal cavity. There are not many opportunities for injury from outside violence. Even if injured, it is often accompanied by other organ damage in the abdomen. basic knowledge The proportion of illness: 1% Susceptible people: no specific population Mode of infection: non-infectious Complications: peritonitis septic shock mediastinal emphysema pneumothorax subcutaneous emphysema

Cause of gastric injury

(1) Causes of the disease

Stomach damage is caused by the following reasons:

Traumatic violence

Traumatic violence can cause stomach damage in the chest, abdomen or lower back. According to the nature of trauma, it can be divided into:

(1) blunt injury: This kind of violence acts on the body surface and does not cause the body cavity to communicate with the outside world. The common way is from punching, kicking, and car accidents. According to Barry's quote, in industrialized countries, about 70% Blunt abdominal injury is caused by a car accident.

(2) Through damage: the wound of the body surface and the body cavity caused by a knife or a gunshot wound.

2. Chemical damage

Due to the ingestion of acid, alkali and other corrosive poisons.

3. Iatrogenic injury

Including the trauma caused by gastroscopy and accidental injury during surgery, etc., because the current application of the gastroscope is mostly flexible fiber optic gastroscope, the gastric wall damage caused by gastroscopy has been greatly reduced, but in some cases, the stomach There are lesions such as inflammation, ulcers or tumors. This operation can sometimes cause complications such as stomach bleeding and perforation.

The iatrogenic injury in the operation can be caused by anatomical difficulties and operational errors. For example, when the splenectomy is used to ligature the short gastric vessels, the vascular clamp is too close to the stomach to damage the stomach wall; the highly selective vagus nerve is used to tear the card or anatomy. Localized ischemic necrosis caused by small curvature of the stomach; separation of gastric mucosa around the antrum and duodenum during biliary or right colectomy to damage the antrum of the stomach; small curvature of the stomach may be needled when the esophagus repairs the esophageal hiatus Such as tearing, these accidents can generally be found at the time of surgery and immediately repaired without adverse consequences, a small number of cases due to improper operation caused by ischemia caused by postoperative peritonitis or stomach cramps and other complications.

In addition to the above reasons, there have been reports of gastric perforation due to excessive force of extracorporeal cardiac compression during cardiopulmonary resuscitation.

4. Foreign body in the stomach

Occasionally negligent, deliberate suicide or mentally ill patients may swallow foreign matter into the stomach, most foreign objects can be discharged by themselves, when the object is too large, both ends sharp or jagged objects are difficult to discharge, can lead to obstruction, bleeding, or even perforation.

5. Spontaneous rupture

Spontaneous gastric rupture in adults is extremely rare. This name does not actually mean a sudden rupture of the stomach without any background factors. It is generally believed that the important predisposing factor for this disease is the obstruction of the stomach exit (cardiac or pylorus). Severe vomiting occurs when the stomach has been inflated, excessive force, or weight bearing can cause the stomach wall to rupture due to excessive tension. It has also been reported in the literature that a large amount of baking soda or anesthesia is used to swallow a large amount of narcotic gas. Cases of gastric rupture caused by excessive gastric expansion.

(two) pathogenesis

The damage caused by external violence and its pathological changes will be described in detail below.

Non-penetrating injury

When the upper abdomen suffers from blunt injury, the stomach damage is less common, because it is not like the liver, the spleen tissue is prone to fragmentation, unlike the duodenum and duodenum jejunum, and it is also affected by the ribs. The protection is only when the stomach is filled with food or gas liquid; when the front wall of the stomach and the large curvature have more contact with the peritoneum of the abdominal wall, the possibility of gastric rupture is greatly increased when the filling stomach cannot move freely.

Under blunt force (stolen, kick, impact, etc.), the abdominal wall can be completely free of morphological damage, while the stomach wall shows varying degrees of damage, and the muscle layer of the stomach (mostly in small bends) has lacerations. There may be no obvious clinical symptoms at all, the stomach wall is contused and hematoma is formed in the stomach wall. At that time, there may be no symptoms, but once the hematoma is infected, an abscess is formed, and the stomach wall is necrotic and pierced, causing secondary peritonitis. The damage caused by the full-layer rupture of the stomach wall is the greatest risk. At this time, the liver, spleen, colon, ribs, etc. may also rupture at the same time. The turbulence or water waves formed during the rupture may also cause part of the stomach wall. Or full-thickness rupture, the patient occasionally after severe vomiting or retching, may be due to esophageal mucosal laceration followed by hematemesis, is called Mollary-Weiss syndrome, is a rare upper gastrointestinal bleeding, Gan Jianhui et al A male patient after a high-voltage electric shock was surgically explored for acute peritonitis, and a perforation of the stomach and jejunum occurred.

2. Penetrating injury

The penetrating injury of the stomach often occurs simultaneously with the damage of its adjacent organs, and the damage of the stomach itself is often more than one place, often penetrating wounds. 628 cases of abdominal wounds reported by Ogilvie (1944), including 22 cases of gastric injury The case fatality rate is 50%. Wolff (1955) analyzed 416 cases of gastric penetrating injury, which accounted for 13.2% of all abdominal injuries; 90% of cases were accompanied by other intra-abdominal injuries, especially with transverse injury. See (47.10%), the case fatality rate is 40.6%, higher than the colon, small intestine and liver, the mortality rate of spleen injury, the penetrating injury rate of the stomach is very high, because the stomach damage often has other organs damage. Therefore, simple gastric injury is better, because the stomach wall is more resistant to injury, and the contents of the stomach do not contain a large amount of bacteria like the contents of the colon and small intestine.

3. Surgical injury

The accidental injury of the stomach wall during surgery is most common in splenectomy. When the gastric spleen ligament is cut, the stomach wall of the large curved part of the stomach may be clamped and cut. When the biliary tract is repeated, due to its own lesions and The second operation often makes the stomach and duodenum together with the transverse colon and the omentum stick together, and even difficult to separate from the abdominal wall, so the possibility of accidentally injuring the stomach and duodenum during surgery is also very high. If the accident is detected at the time, the damage to the stomach wall is generally not difficult to mend, and usually does not cause serious consequences; but if it is not detected in time, the person who is seriously sewed will form peritonitis or fistula.

Stomach injury prevention

First, avoid mental stress When a person is nervous, troubled, angry, his negative emotions can spread to the limbic system through the cerebral cortex, affecting the autonomic nervous system, directly leading to gastrointestinal dysfunction.

Second, avoid excessive fatigue Whether it is physical labor or mental work, if fatigue is excessive, it will cause insufficient gastrointestinal blood supply, secretion dysfunction, excessive gastric acid and decreased mucus, causing damage to the mucosa.

Third, avoid alcohol abuse alcohol can directly damage the gastric mucosa, alcohol can also cause cirrhosis and chronic pancreatitis, which in turn aggravates the stomach damage.

Fourth, avoid smoking, smoking, smoking can promote gastric mucosal vasoconstriction, reduce the synthesis of prostaglandins in the gastric mucosa, which is a mucosal protective factor. Smoking also stimulates the secretion of gastric acid and protease, which aggravates the damage to the mucosa.

Fifth, avoid hunger and inequality.

Six, avoid eating unclean.

Stomach injury complications Complications peritonitis septic shock mediastinal emphysema pneumothorax chest wall subcutaneous emphysema

The disease may have diffuse peritonitis, hemorrhagic shock, septic shock, mediastinal emphysema, liquid pneumothorax, subcutaneous emphysema of the chest wall and other complications, and often the main clinical symptoms.

Symptoms of gastric injury Common symptoms Dyspnea peritoneal irritation, bowel, abdominal pain, subcutaneous emphysema, gastric mucosal injury, abdominal distension, liver dullness, shrinking or disappearing, mobile dullness

Gastric wall injury without full-thickness rupture, no obvious clinical symptoms, or only mild pain in the upper abdomen, gradually improved after clinical observation.

The main systemic manifestations of gastric rupture injury are shock and hemorrhage; the abdomen is often characterized by peritoneal irritation.

Immediately after the rupture of the stomach, abdominal pain, abdominal distension and diffuse peritoneal irritation, vomiting is rare, dyspnea may occur in patients with severe abdominal distension, the damaged mouth is close to the cardia, and the air can enter the mediastinum and cause mediastinal emphysema. Liquid pneumothorax, subcutaneous emphysema of the chest, when the stomach is damaged, undigested food, bile and gas can be poured out from the abdominal wound; occasionally, the cracked stomach can be seen, and in some cases, the abdominal wall subcutaneous emphysema can be different degrees. The liver dullness circle shrinks or disappears, the mobile dullness can be positive, the bowel sounds weaken or disappear, and if there are other organ damages, it may be accompanied by corresponding symptoms and signs.

Shock appears earlier and becomes the main symptom in 80% of severe cases. If it is not accompanied by other organ damage, shock may be mainly caused by chemical stimulation of the peritoneum by gastric juice and severe abdominal cavity contamination.

In cases of penetrating gastric injury, if the stomach contents can be seen from the abdominal wound or the cracked stomach is found, the diagnosis is very clear. However, the gastric rupture caused by blunt abdominal injury, or the penetrating injury alone, is clinically The performance is difficult to distinguish from the general abdominal injury and needs further examination.

Indwelling gastric tube, patients suspected of intra-abdominal cavity organ injury should be placed in the stomach tube, if blood or blood is taken from the stomach tube, it can be established as gastric damage, and in addition, can be injected into the stomach tube by water. After the contrast agent is used for abdominal X-ray examination to identify the site of perforation, and the aspiration of the stomach contents without blood may not completely rule out the possibility of gastric injury.

Stomach injury examination

X-ray inspection

Patients with severe abdominal injuries should take an upright chest radiograph; a supine position in the supine and upright position (or left lateral position) for the purpose of identifying fractures, pneumothorax, hemothorax, pulmonary contusion, rupture and underarm Free gas, etc., free gas under the armpit has special significance for the diagnosis of rupture; but free gas under the armpit can not negate the existence of gastric rupture.

2. Abdominal puncture and lavage

Abdominal puncture is a simple and rapid method with less complications. It can be puncture in the upper quadrant of the abdomen and the left and right lower abdomen. Generally, the midpoint of the right lower abdomen rectus sheath is taken as the first puncture point. Use a fine needle to connect with a 10ml syringe gently, slowly puncture the abdominal cavity and pump. If you can pump more than 0.1ml of non-coagulated blood, bile, pus or air can be considered positive, indicating that there is an indication for laparotomy. The correct rate is about 90%.

If the puncture is negative but the stomach injury cannot be ruled out, the peritoneal lavage can be changed. In the case of blunt abdominal injury, the diagnostic accuracy of peritoneal lavage is about 97%. Barry pointed out that when the above criteria are used to determine blunt abdominal injury The sensitivity is 98%, the specificity is 97%, and the correctness is 93%. If the positive standard of red blood cell count for peritoneal lavage is changed to (20100)×109/L (20,000-100,000/mm3) The sensitivity of the diagnosis is still 98%, and the specificity and correctness can be increased to 97%. He also noticed that the amylase of the lavage fluid was negative in the erythrocyte and white blood cell counts in the lavage fluid. Measurement may be the only useful indicator for diagnosing rupture of a hollow organ.

3. CT examination

When the abdominal cavity is filled with 5ml of gas, CT can be found, and the X-ray needs to be positive for 50ml or more of the peritoneal cavity. Therefore, if the gastrointestinal perforation is suspected and the X-ray film or gastrointestinal angiography is difficult to confirm, if the patient is fully Situation permit, feasible CT examination, CT images of gastrointestinal injury can be expressed as:

1 no parenchymal effusion without parenchymal organ damage; 2 free gas in the peritoneal cavity; 3 leakage of gastrointestinal signs with contrast agent; 4 localized inflammatory soft tissue mass near the perforation, uneven density; 5 mesenteric thickening, The interface between membrane wrinkles and mesangial fat is blurred.

4.B-ultrasound

In the case of excluding abdominal organ damage, when B-ultrasound is found in the peritoneal cavity, combined with medical history and clinical manifestations, the possibility of gastric injury may be considered. The free gas in the abdominal cavity exists between the armpit or the anterior hepatic space and the abdominal wall. It is a bright area, and the reflection is a strong echo of equidistant transverse stripes, which can change with the change of body position. The gas reflection in the gastrointestinal tract is mostly diffuse, turbid, and there is sound attenuation behind, which is obviously different from the free gas echo. Gastrointestinal gas cannot extend between the anterior hepatic space and the abdominal wall.

Diagnosis of gastric injury

diagnosis

According to the medical history, clinical symptoms, laboratory tests can be diagnosed.

Differential diagnosis

1. Peritonitis

A serious disease common to surgery caused by bacterial infection, chemical irritation or injury. Most of them are secondary peritonitis, which originates from abdominal organ infection, necrotic perforation and trauma. Its main clinical manifestations are abdominal pain, abdominal muscle tension, as well as nausea, vomiting, fever, severe blood pressure drop and systemic toxic reactions. If not treated promptly, it can die of toxic shock. According to the presence or absence of plate-shaped abdomen and medical history can be identified.

2, gastric perforation

Sudden abdominal pain, nausea, vomiting, abdominal plate, obvious tenderness and rebound tenderness, liver dullness and bowel sounds disappeared, abdominal fluoroscopy sees free gas under the armpit, some patients are in shock state, in In this situation, the patient should be treated immediately in an emergency, otherwise there is a danger to life at any time, and a diagnostic puncture is generally required to confirm the diagnosis.

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