Dilatation of the Stomach.
Synonyms:—Gastrectasis; gastric ectasy; gastrectasia.
Definition:—A stretching of the walls of the stomach from loss of muscular tone, propulsive power or contractility, thus increasing the capacity of the stomach by increasing the size of the gastric cavity. The condition may be either acute in character, or it may develop gradually and assume a chronic form.
The average capacity of the adult stomach is about three pints (1,600 cc, Ewald). This may be increased to six or eight pints (3,000 or 4,000 cc). In exceptional cases the distention may become enormous.
There may be an overgrowth of the muscular structure of the walls, the fibers becoming thicker as they increase in length, but usually the walls become thin and stretched, and occasionally the muscular fibers become atrophied and disappear, and their place is filled by connective tissue. Neither is the dilatation uniform in all portions of the stomach wall. The stretching may occur in the greater curvature or in the fundus, leaving the structure of the lesser curvature undisturbed, thus causing the cardiac and pyloric orifices to seem to be nearer to each other than normal. Or the dilatation may occur in pockets or in irregularly shaped bulgings, with bands or cicatrices between them, causing the so-called hour-glass stomach. The muscular structure in the region of the pyloric and cardiac orifices when undilated may be thickened, while the walls of the expanded portion may be greatly thinned.
The stomach is usually found to contain a large quantity of dark colored fluid. The walls are usually thinned, except at the pyloric opening, where they are thickened. The rugae are effaced, the mucous membrane is smooth and softened, and presents the picture of chronic catarrhal gastritis in its various stages. Microscopically the glandular structure is seen to have suffered extensively; the tubes may be visible, but are widely separated. The muscle fiber may be normal in appearance, but interspaces between the muscular fasciculi are enlarged and traversed by strands of connective tissue.
Etiology:—Acute dilatation is a rare form of this disorder. It results from degeneration of the structure of the stomach walls during the course of the severe infectious fevers. It may occur from the drinking of effervescing drinks, or the drinking of effervescing substances in suspension, which dissolve, react and liberate gas after being drunk; it occurs from sudden obstruction of the pylorus, and also after the prolonged administration of anesthetics; from extreme muscular relaxation; from severe nervous shock, and from paralytic distention (Flagge). The chronic form is usually the result of pyloric stenosis.
Tumors of the pylorus or adjacent organs, cicatricial contraction due to ulcer, or hypertrophy of the muscular fibers of the stomach in the pyloric region from any cause, may result in dilatation. Repeated overdistention with food or drink is a frequent cause of atonic dilatation. The stomachs of all habitual beer drinkers are usually dilated.
Gastroptosis, produced by muscular strain, tight lacing, enlargement of the liver or spleen, is occasionally among the causal factors. Gastrectasis is not uncommon in children, especially in those poorly nourished. The symptoms may be so masked, however, that a diagnosis is not made, but the fact has been frequently verified by autopsy. It is usually a disease of middle life.
Symptomatology:—Dyspeptic symptoms are the first to appear. There is fulness after eating, pyrosis, belching of gas, pain on pressure over the stomach, a foul breath, coated tongue, constipation and occasionally vomiting, anorexia and discomfort. The vomiting is characteristic. It is not frequent, but may occur at intervals of from three to five days, usually in the night, and is large in quantity. The vomitus is dark brown in color, acid in reaction, and consists of the food in various stages of digestion and decomposition which may have been eaten several days before. In cases where there is extreme dilatation the vomiting does not give the desired relief, as it is seldom that all of the contents of the stomach will be evacuated in a single attack of vomiting.
The formation of gases due to food decomposition further distends the already dilated stomach, while the weight of the food accumulation tends to drag the stomach lower in the abdominal cavity. This causes a distressing sensation of dragging down and distention, finally very difficult to bear.
Compensatory hypertrophy may take place for a time in the walls, but sooner or later an absolute insufficiency and atony occur and the stomach becomes enormously dilated. There is an abnormal dryness of the tissues of the body and frequently peculiar nervous symptoms are present. These show themselves first as a spasm of the muscles of the leg and arm, the pain extending over the body generally, and there may be loss of consciousness. Kussmaul was the first to associate these tetanic spells with gastrectasis. During all the time there is a ravenous appetite and great thirst.
Diagnosis:—The physical examination will show a depression in the gastric region when the patient is standing and a bulging at or just above the umbilicus. With the patient supine this is not so noticeable. Occasionally peristaltic waves may be seen, but they are rare. The outlines of the stomach may be made quite distinct by inflating it with an effervescing draught, always remembering that a large quantity may be necessary to fill it sufficiently full for diagnostic purposes. Percussion will at this time aid in outlining the dilatation, determining its location and extent. The viscus should then be filled with water, its quantity noted and the location verified. The deglutition murmurs should be noted, as they may be of value in determining the amount of displacement. The length of the stomach tube is also noted, remembering that in the normal condition the tube will pass about twenty-four inches before it comes in contact with the greater curvature, while in gastrectasis it may pass twenty-eight inches or more. Absorption is tested by giving potassium iodid in two grain doses, in a capsule, and the saliva tested every five minutes until the presence of iodin is demonstrated by its well known reaction with starch. The motility is best judged by the salol test. The chemistry of the stomach contents should here be noted. Hydrochloric acid may be found absent or in excess. The organic acids are usually present—i. e., lactic, butyric or acetic acids. Carbonic dioxid, hydrogen sulphid and other gases are formed. With these clinical evidences and with the recognition of a causal factor it should not be difficult to make a diagnosis. (N. A. Graves.)
The diagnosis is facilitated by the use of the electric light method (Einhorn), or by the gastric sound (Turck). In using the electric light the stomach is filled with water and the light is introduced into the fluid. In a dark room, with a patient who has no excess of fat over the abdominal walls, the size of the stomach can be readily determined by the area of the light, which is clearly outlined. If forty grains of sodium bicarbonate be added to each pint of water before introduction, or if other fluorescent solutions be used, the outline is more distinct.
With the gastric sounds introduced and passed against the walls, the tip is felt for, from the outside, and followed as it is moved around within the expanded cavity.
The diagnostic symptoms of the acute form are sudden occurrence of the symptoms, incessant vomiting, greatly relaxed abdominal walls, and especially the profound prostration and threatened collapse. In the chronic form there are the physical signs above named, and the occasional vomiting of large quantities of food which has remained in the stomach for one or more meals, and the chemical character, also, of the vomitus.
Prognosis:—Chronic gastritis offers a very unfavorable prognosis, especially when the disease is recognized late and is associated with nervous symptoms.
Treatment:—In the treatment of this condition an effort should be constantly made to reduce the amount of work the stomach must do, either in the digestion or in peristaltic action, in evacuating its contents into the intestines. Fluid and food must not be allowed to accumulate in the stomach. The food should be selected with the utmost care, and taken at regular intervals during the day. At night, before the patient retires, the stomach should be thoroughly washed out during the early part of the treatment; later, after perhaps two or three weeks of favorable progress, lavage should be performed every two, three or four days.
The patient should early be taught to wash out his own stomach, as it is often necessary to continue this measure for a long period. For this stomach lavage, a mild solution of sodium sulphite, two per cent, or sodium bicarbonate, or a three per cent solution of boric acid is of service; occasionally a one per cent solution may be used. This process prevents fermentation and further dilatation, cleanses the walls of the stomach, removes all irritation, especially nausea and vomiting, and conduces to inactivity and complete rest.
In the administration of food, there should be considered: (a) an exact and regular quantity; (b) the selection of that which will digest readily and does not tend to ferment; (c) the taking of an abundance of time for each meal, with avoidance of haste, anxiety and worry; (d) the thorough mastication and insalivation of the food; (e) the use of properly selected artificial digestives.
The patient should have the largest meal in the morning; it should consist of peptonized milk, six or eight ounces, an egg, with stale bread, toast or zwieback. He may also have some scraped beef, or a small piece of rare broiled steak. Following this, there should be some digestive, such as the essence of pepsin or pancreatin, the latter being best taken an hour after breakfast. At noon he should have a meal similar to the one taken in the morning, with the addition perhaps of a baked potato. He may at this time have a small piece of roast beef, well done. Perhaps half an hour after eating, the stomach should be submitted to gentle massage, the hand passing from below upward, and from the left to the right, or from the fundus of the stomach to the pyloris, in order to assist the stomach in emptying its contents into the duodenum. For the evening meal there should be a small quantity of peptonized milk, or cream, or a teaspoonful or two of bovinine; a small piece of toast over which hot water is poured, the toast then well buttered; or graham crackers with a small bowl of hot beef tea may be given.
The physician should study to select those foods the larger portion of the digestion of which is accomplished in the intestinal canal. The free drinking of water, or the taking of a large quantity of fluids, must be persistently avoided. The patient must eat but little food that contains free starch or sugar, and alcoholic drinks of all kinds must be avoided. Occasionally it will be desirable to give the stomach a complete rest for a time after lavage, and to feed the patient by rectal enemata.
In the selection of medicines, those which increase muscular tone and improve the nerve power are of the most importance. For this purpose strychnin and hydrastis, with electricity, either the galvanic or the faradic current, selected according to the immediate indications, will be serviceable. Any excess of acids must be neutralized, and a tendency to fermentation must be anticipated or antagonized by the use of sodium sulphite, or a drop or two of carbolic acid in emulsion. Charcoal tablets are a mild and efficient antifermentative. Occasionally it will be well to give the patient hydrastis, ten minims; collinsonia, fifteen minims; ergot, five minims; with thirty minims of syrup of licorice, half an hour before meals and at bed time.
The treatment of acute cases should be conducted with great caution, and with consideration of the serious nature of the condition. The patient should be kept perfectly quiet, and all anxiety and worry must be rigidly excluded. The stomach should be at once thoroughly washed out, and all food for three or four days should be given by enema. To satisfy thirst, the patient may have water by the rectum or an injection of the normal salt solution every ten or twelve hours. A tight bandage around the stomach should be applied and strychnin, one-fortieth of a grain, or atropin, one one-hundredth of a grain, or hydrochlorate of hydrastin, one-fourth of a grain, should be given every two hours.