Gastric Lesions : Gastric Bezoar

Some gastric cavity lesions are important to know, as they are commonly seen in the emergency department and the emergency surgery department. In this blog, we will read about some of them. You can find a detailed version of the notes and the related video by signing up on the PrepLadder app.

Gastric Bezoar

Gastric bezoars are characterized by the collection of nondigestible materials in the stomach.

Types of Gastric Bezoars

1. Phytobezoar
   1. Phytobezoars are the most common type, characterized by the collection of vegetable material.
   2. Typically seen in patients with a history of prior gastric surgery, gastroparesis, or gastric outlet obstruction.
2. Trichobezoar
   1. Trichobezoars are most common in children, involving the collection of hair.
   2. Associated with a patient's habit of eating their own hair.
3. Pharmacobezoar
   1. Pharmacobezoars involve the collection of larger medications or tablets in the stomach.
4. Lactobezoar
   1. Lactobezoar consists of undigested milk concretions collected in the stomach.

Causes of Gastric Bezoars

Gastric bezoars are most commonly found in patients with gastric dysmotility issues:

• History of prior gastric surgery
• Gastroparesis: Prior vagotomy and diabetic patients. 
• Gastric outlet obstruction.

Pathogenic Causes Of Gastric Bezoar

• Impaired Grinding Mechanism of the stomach and Impaired Migrating Motor Complexes
• Trichobezoar in Females with Long Hair: This condition is linked to a psychiatric disorder known as trichophagia, where individuals have the habit of eating their own hair.

Clinical Features Of Gastric Bezoar

• Asymptomatic Onset- Initially, patients with gastric bezoars are asymptomatic due to a small amount of nondigestible materials collected in the stomach.
• Gradual Onset of Symptoms over the years.
• Symptoms Arising from Limited Space
  • Early Satiety: Feeling full quickly.
  • Gastric Outlet Obstruction: This leads to pain, nausea, and vomiting.
  • Weight Loss: Occurs as the stomach's capacity is reduced by non-digestible materials.

Clinical Examination Of Gastric Bezoar

It is mostly insignificant, but sometimes, a large palpable mass may be detected in the abdomen, but this is not common.

Diagnosis Of Gastric Bezoar 

• For diagnosis, abdominal radiographs or CT scans may be used to identify a mass or filling defect within the stomach.
• Diagnosis is confirmed through endoscopy

Management of Gastric Bezoars

• Enzymatic or Chemical Therapy
• Enzymatic Debridement Followed by Endoscopic Fragmentation can be an effective approach. If enzymatic debridement and endoscopic fragmentation fail to resolve the issue, surgical removal becomes the last resort.

There are topics like Trichobezoar, Symptoms of Trichobezoar, Rapunzel's Syndrome, Surgical Removal for Trichobezoar, Decontamination for Pharmacobezoar and Trichobezoar and Psychiatric Referral, Gastric volvulus, Primary and Secondary gastric volvulus, causes and characteristics of gastric volvulus, diagnosis and management of gastric vulvulus, Dieulafoy Gastric Lesion can be read in detail from the prepladder SS Surgery notes from the chapter of gastric lesions. With the notes it is highly recommended that you watch the video as well to get a much more better understanding of all the topics.

Hypertrophic Gastritis or Menetrier’s Disease

Menetrier's disease, also known as Hypoproteinemic hypertrophic gastropathy, is a rare and acquired condition often associated with an increased risk of gastric carcinoma, making it a premalignant condition. The exact cause of Menetrier’s disease is unknown.

Clinical Features of Hypertrophic Gastritis or Menetrier’s Disease

Menetrier’s disease is characterized by massive gastric folds in the stomach's fundus and corpus. The mucosa has a cobblestone or cerebriform appearance.

Etiology of Hypertrophic Gastritis or Menetrier’s Disease

It is associated with cytomegalovirus infection in children and with Helicobacter pylori (H. pylori) infection in adults.

Treatment Hypertrophic Gastritis or Menetrier’s Disease

Medical treatment:

• Albumin replacement due to gastrointestinal protein loss.
• Adequate nutrition.
• Acid suppression.
• Somatostatin analogue, such as Octreotide, to decrease GIT secretions.
• H. pylori or cytomegalovirus eradication as necessary.

Total Gastrectomy Indications:

• Bleeding.
• Severe hypoproteinemia.
• Cancer (malignancy).

Post-Treatment Surveillance

• Endoscopic surveillance recommended every one to two years.
• Increased risk of gastric neoplasm due to the pre-malignant nature of Menetrier’s disease.

Mallory Weiss Tear

Mallory Weiss's Tear is characterized by partial tears involving mucosa and submucosa. The typical location is just below the gastroesophageal (GE) junction. The most common site for this tear is the Cardiac area of Stomach.

Risk factors of Mallory Weiss Tear

• More common in alcoholic males due to forceful vomiting, retching, coughing, and straining, which leads to longitudinal tears at the cardia.
• Responsible for 10 to 15 percent of cases of acute gastrointestinal bleeding.
• The left gastric artery is the artery responsible for bleeding.
• The mortality rate is low: around 3 to 5%
• The greatest risk of massive hemorrhage in alcoholic patients with pre-existing portal hypertension.

Diagnosis of Mallory Weiss Tear

Endoscopy is the investigation of choice.

Management of Mallory Weiss Tear

• Endoscopic methods for minor bleeding include multipolar electrocoagulation, epinephrine injection, endoscopic band ligation, and endoscopic hemoclipping.
• For persistent or recurrent bleeding after endoscopy, angiography + transarterial embolization may be required.
• Operative intervention is rarely needed. If required, anterior gastrotomy is performed to identify and ligate the bleeding site with deep 2-0 silk ligatures to approximate the mucosa.

Gastric Varices

Gastric Varices are characterized by dilated submucosal veins found in patients with portal hypertension and cirrhosis. The Prevalence of Gastric varices accounts for 10 to 30% of variceal hemorrhage cases and can lead to severe bleeding. There are two main types:  Isolated gastric varices and Gastroesophageal varices.

• ISOLATED GASTRIC VARICES are more prone to bleeding and found only in the stomach, often in relation to splenic vein thrombosis. The isolated Gastric Varices is further divided into:
  • Type 1 is located in the fundus and is associated with sinistral hypertension or left-sided portal hypertension. Sinistral hypertension, or left-sided portal hypertension, is typically caused by splenic vein thrombosis. The most common cause of splenic vein thrombosis is acute pancreatitis.
  • Type 2, known as isolated ectopic varices, can be located anywhere in the stomach.
• GASTROESOPHAGEAL VARICES are located in both the stomach and esophagus and are related to portal hypertension. Gastroesophageal varices are more common overall. The Causes of Gastroesophageal Varices: Gastroesophageal varices are associated with esophageal varices and are caused by portal hypertension, which increases portal pressure which is transmitted by the left gastric vein to the esophageal varices and by short and posterior gastric vein, it is transmitted to the fundic plexus and cardia veins.

Incidence of Gastric Varices Bleeding

The incidence of bleeding from gastric varices ranges from 3 to 30%, higher than that seen in splenic vein thrombosis and fundic varices.

Risk Factors for Gastric  Varices Bleeding

Increased risk of bleeding in gastric varices is associated with larger varices and decompensated cirrhosis.

Diagnosis of Gastric Varices Bleeding

The diagnosis involves imaging studies to confirm splenic vein thrombosis in cases associated with Sinistral hypertension.

Treatment of Gastric Varices Bleeding

Treatment for gastric varices in the presence of splenic vein thrombosis often involves Splenectomy to address left-sided portal hypertension.

Also Read: Clostridium Difficile Infection and Surgical Treatment

Frequently Asked Questions:

Q: What is Rapunzel’s Syndrome?

Answer: Rapunzel's syndrome is a unique condition where a gastric trichobezoar extends with long extensions of hair into the duodenum.

Q: What are the components of Borchardt’s Triad?

Answer: The Components of Borchardt's triad are: 

• Sudden onset abdominal pain
• Recurrent retching without vomiting or very little vomitus.
• Inability to pass Nasogastric tube.

Q: What method of investigation is used to confirm the diagnosis of gastric volvulus?

Answer: CT Scan 

Hope you found this blog helpful for your GIT, Hepatobiliary and Pancreatic Surgery preparation. For more informative and interesting posts like these, keep reading PrepLadder’s blogs.