Stenosis of the outlet stomach

Stenosis of the outlet stomach - violation of evacuation of food from the stomach, caused by scarring of the initial part of the bulb of the duodenum or pyloric part of the stomach as a result of peptic ulcer, cancer of the antrum, burn, rarely hypertrophy of the pylorus. 7-11%. All duodenal ulcers are complicated by stenosis. Development of cicatricial stenosis is preceded by a different duration of ulcerative anamnesis.

Symptoms, course. Allocate a compensated, subcompensated and decompensated stage of stenosis. With a compensated stage of severe clinical signs, there is no disease: against the background of the usual symptoms of peptic ulcer there is a feeling of heaviness in the epigastrium, heartburn becomes frequent, vomiting of gastric contents with acidic aftertaste, vomiting brings considerable relief. Radiographically, some increase in the size of the stomach, increased peristalsis, narrowing of the pyloroduodenal canal. Deceleration of evacuation from the stomach to 6-12 hours.

The stage of subcompensation: the feeling of heaviness and fullness in the epigastrium is amplified, an eructation with an unpleasant smell of rotten eggs. Sometimes - a sharp colic pain in the epigastrium, associated with increased peristalsis of the stomach; Pain accompanied by a pouring and rumbling in the abdomen. Almost daily vomiting, bringing relief. Patients themselves often cause vomiting. Typical weakness, fatigue, weight loss. When examining the abdomen, the peristalsis of the stomach visible to the eye, the noise of splashing in the epigastrium can be determined. X-ray-gastrectasia, fasting fluid in the stomach, slowing evacuation with weakening of peristalsis. After a day, there is no contrast in the stomach.

Stage decompensation: a feeling of bursting into epigastrium, daily abundant vomiting. Vomit contains malodorous, decomposing food residues. Patients are depleted, dehydrated, adynamic. Thirst, skin dry, turgor reduced. Through the abdominal wall are visible contours of the stretched stomach, the noise of splashing in the epigastrium. When X-ray examination, the stomach is significantly expanded, contains a large amount of fluid, the peristalsis is sharply weakened. The evacuation of contrast mass from the stomach was delayed more than 24 hours.

Pathophysiology of stenosis of the outlet stomach. The basis of the violation of nutrition and water-electrolyte disorders. The consequence of violations of the water-electrolyte balance is a decrease in the volume of the circulating fluid, blood thickening, "centralization of the circulation", hypokalemia, hypochloraemia, metabolic alkalosis. Signs of volemic disorders: dizziness, fainting on getting up from bed, tachycardia, lowering blood pressure, paleness and cooling of the skin, decreased diuresis. With hypokalemia associated with dynamic intestinal obstruction (flatulence).

As a result of volemic disorders, renal blood flow decreases, diuresis decreases, and azotemia appears. In connection with renal insufficiency, blood products are not derived from the blood, alkalosis passes into acidosis. In alkalosis, the plasma calcium level decreases due to its attachment to albumin. Decrease in the level of ionized calcium plasma changes neuromuscular excitability, develops gastrogenic tetany ("chloroprive tetany" of the old authors). Clinical manifestations of it: convulsions, trismus, a symptom of Tissot ("hand of an obstetrician"), a symptom of Khvostek.

Hypochloremic and hypokalemic alkalosis, combined with azotemia, in the absence of proper treatment can lead to death.

Differential diagnosis. Cancerous stenosis: very short anamnesis, rapid exhaustion. When palpating the abdomen, sometimes it is possible to probe the tumor. X-ray is not gastrectacies and hyperperistalsis (infiltration of the stomach wall by a tumor), filling defect in the antrum. The most informative method of diagnosis is a gastroscopy with biopsy.

With an active ulcer of the bulb of the duodenum, edema and periulcerous infiltrate can lead to narrowing of the outlet stomach ("functional" stenosis). Anti-ulcer treatment for 2-3 weeks leads to a reduction in edema and infiltration with the elimination of the phenomena of stenosis.

Treatment. The presence of organic pyloroduodenal stenosis serves as an indication for the operation. Preoperative preparation should be aimed at correcting water-electrolyte disturbances. Parenteral nutrition, gastric lavage is shown daily. The choice of the method of operation depends on the stage of stenosis: with compensated stenosis, it is possible to recommend selective proximal vagotomy with obligatory examination during the pyloroduodenal patency operation (if a thick gastric tube passes through the pyloric and the narrowing site, then there is no need for draining surgery). With subcompensated stenosis, vagotomy is shown with a stomach-draining operation. With decompensated stenosis or with a combination of stenosis with a stomach ulcer, a typical resection of 2/3 of the stomach or a stem vagotomy with an antrum resection is shown.

The prognosis is favorable.

Prevention - timely treatment (including surgical) of peptic ulcer.