LECTURE No. 10. Gastric obstruction

Congenital gastric obstruction in children in the first days of life can be caused by abnormalities in the development of the prepyloric region or pyloric stenosis. Some of these anomalies lead to emergency conditions that require urgent surgical intervention.

1. Prepyloric obstruction of the stomach

Malformations of the stomach, localized in its prepyloric section, are an extremely rare pathology. Violation of the patency of the stomach usually cause atresia and stenosis, most often of the membranous type.

According to the classification, there are three main variants of gastric anomalies: membranous, cord-like and segmental aplasia of the mucosa. With all types of atresia and stenosis of the stomach, the obstruction is localized only in the mucous and submucosal layers, the muscular and serous membranes retain their continuity.

The membrane can close the lumen of the stomach completely (atresia) or partially (stenosis), having holes of various sizes on the side or in the center of the septum: from a pinpoint to a large one, occupying more than half of the membrane. The thickness of the latter ranges from a thin sheet to a thick folded "hypertrophied" wall protruding into the pyloric canal of the stomach.

Histological examination of the membranes reveals an altered gastric mucosa with a submucosal layer and muscle tissue in the form of single fibers. The thick septum has the structure of the wall of the stomach.

clinical picture

The time and intensity of manifestation of symptoms of the disease depend on the degree of stenosis of the lumen of the stomach, the general condition of the child, and the presence of concomitant diseases.

Prepyloric atresia of the stomach and decompensated stenosis usually appear from the first hours or days of life. The main symptom is profuse vomiting of gastric contents without an admixture of bile. Due to overstretching of the stomach and irritation of its walls from frequent vomiting, a "hemorrhagic symptom" often joins (vomit of the color of coffee grounds or with streaks of blood and tarry color of the stool - with stenosis). In children, meconium passes in sufficient quantities.

Frequent, vomiting usually leads to exsicosis with a large drop in body weight (0,25-0,3 kg per day). On examination, swelling of the epigastric region is revealed, which disappears after vomiting or suction of gastric contents. On palpation, waves of peristalsis and the contours of a distended stomach are visible, often descending below the navel.

X-ray examination

X-ray examination is one of the main diagnostic methods. On the survey radiograph of the abdominal cavity in a vertical position, a large gas bubble and a liquid level are noted, corresponding to a distended stomach, there is no gas in the intestinal loops. Sometimes a "silent belly" is detected - the absence of gas throughout the gastrointestinal tract. In the presence of a similar x-ray picture, other research methods are usually not required. Some surgeons suggest introducing iodolipol into the stomach - with gastric atresia, a protrusion of the pyloric membrane into the lumen of the duodenum is observed.

Prepyloric stenosis may appear days or weeks after the baby is born. The time of onset of symptoms depends on the size of the hole in the membrane. The disease begins with regurgitation without an admixture of bile, turning into vomiting. Soon vomiting takes on the character of vomiting "fountain" Decreased body weight. The chair becomes more scarce. On examination, swelling of the epigastric region and visible peristalsis of the distended stomach are revealed.

X-ray examination is of great help in establishing the correct diagnosis. Plain radiographs of the abdominal cavity with the child in an upright position show a large level of fluid in the stomach and a small amount of gas in the bowel loops. In such cases, a contrast study with iodolipol is undertaken, in which a long-term retention of iodolipolam in the stomach is detected.

Complications

The most common complication of congenital obstruction of the stomach is aspiration pneumonia, resulting from the ingestion of vomit into the respiratory tract.

Frequent vomiting leads to a violation of water and electrolyte metabolism. Perforation of the atrezirovanny stomach is possible.

Differential diagnosis

The differential diagnosis has to be carried out with diseases that occur in the first days and weeks of life and are accompanied by regurgitation and vomiting that does not contain bile. First of all, this applies to malformations of the output section of the stomach.

Pyloric stenosis. It is most difficult to differentiate this anomaly from prepyloric stenosis of the stomach, if the symptoms of the latter arose from the 2-3rd week of the child's life. The clinical manifestations of the diseases are extremely similar. In all cases, it is necessary to produce an X-ray examination with a contrast agent. Often, this examination does not definitively establish the cause of gastric obstruction. In such cases, the diagnosis is made on the data of laparotomy, in which one should be very careful and remember this such a rare malformation. Otherwise, even during the operation, an error may occur.

Pylorospasm. Due to the fact that with this pathology, symptoms occur from the first days of a child's life, it is necessary to differentiate pyloric spasm with atresia or decompensated gastric stenosis. Persistent numerous vomiting, causing a violation of the general condition of the child and leading to a sharp drop in body weight, are not characteristic of pylorospasm. In addition, the effectiveness of antispasmodic drugs indicates the functional nature of the disease.

Congenital obstruction of the duodenum when the obstacle is located above the Vater nipple has a similar clinical and radiological picture. Usually the final diagnosis is made during surgery. In other types of congenital intestinal obstruction, vomit contains bile, which makes it possible to exclude an anomaly in the development of the stomach.

Congenital diaphragmatic hiatal hernia in some cases is manifested by vomiting from the first day of a child's life, but the vomit usually contains bile or blood. In addition, X-ray contrast studies help the diagnosis, in which a diaphragmatic hernia is confirmed by the location of the stomach above the level of the abdominal obstruction.

Treatment

Establishing the diagnosis of congenital obstruction of the stomach is an indication for surgery.

Preoperative preparation for atresias and decompensated stenoses usually does not exceed 24 hours and is aimed at restoring homeostasis, treating aspiration pneumonia or preventing the latter (suction of gastric contents after 2-3 hours). In case of stenosis, preparation for surgery, if necessary, can be extended to several days.

Postoperative treatment is aimed at correcting impaired water-salt metabolism, restoring the functioning of the gastrointestinal tract, preventing and treating aspiration pneumonia.

Within 2-3 days the child is on parenteral nutrition, which is calculated depending on the body weight of the patient's age, violations of water and electrolyte metabolism, the presence of combined anomalies or complications.

If the patient had a probe below the anastomosis site during the operation, then a day later they begin to introduce breast milk (5-10 ml every 3 hours), increasing the amount of the latter by 10 ml per feeding daily. The probe is removed after 4-5 days and oral feeding is started. The child receives antibiotic therapy, blood transfusions, administration of plasma, albumin. In the presence of pneumonia, aerosols are used up to 5-6 times a day. physiotherapy. The stitches are removed on the 10-12th day.

2. Pyloric stenosis

Acute forms of pyloric stenosis include such a kind of clinical manifestation of this malformation, in which the symptoms of the disease begin suddenly and proceed rapidly.

clinical picture

The time of onset of symptoms of the disease depends on the degree of narrowing of the pyloric canal and the compensatory capabilities of the body. In addition, the layering of pylorospasm plays an important role, which, apparently, is the reason that leads to the rapid onset and course of the disease. The first signs of the disease appear between the ages of several days and 1 month. The main symptom of the acute form of pyloric stenosis is “fountain” vomiting, which begins suddenly in the middle of full health. Vomit does not contain bile; its amount exceeds the amount of milk sucked during the last feeding. Often, vomit has a stagnant, sour odor, which indicates retention of gastric contents. In some cases, streaks of blood can be seen in the vomit. Sometimes quite severe stomach bleeding occurs. Prolonged, debilitating vomiting leads to a deterioration in the child’s general condition and disruption of water-salt metabolism (hypochloremia, exicosis, and sometimes hypokalemia). The acute stage of the disease is characterized by the fact that the child develops complete obstruction of the gastric patency within a few days. Feeding becomes impossible; a few sips of milk cause vomiting. Children lose up to 1-2 kg of body weight in 0,4-0,5 days. The number of urinations decreases. There is stool retention or dyspeptic “hungry” stool appears.

Upon admission to the department, patients with an acute form of pyloric stenosis rarely worry, greedily grab the pacifier, but soon severe vomiting appears. If hospitalization is carried out on the 2-3rd day from the onset of the disease, then the child’s condition is severe, symptoms of exicosis are pronounced, and there is a large loss of body weight. An indicator of the serious condition of a child with pyloric stenosis is the daily loss of body weight in relation to birth weight (as a percentage). This classification distinguishes three forms of the disease: mild (0-0,1%), moderate (0,2-0,3%) and severe (0,4% and above). In children with acute pyloric stenosis, weight loss reaches 6-8%. Upon examination, the child reacts poorly to his surroundings, with a pained expression on his face. The skin is pale, mucous membranes are bright and dry. The fontanelle sinks. Noteworthy is the swelling of the epigastric region, which decreases or disappears after vomiting. When stroking the abdominal wall or after several sips of food, you can notice waves of stomach peristalsis. Often the stomach takes on an hourglass shape. This symptom is a constant sign of congenital pyloric stenosis and is of great importance for establishing the diagnosis. Another symptom characteristic of pyloric stenosis - palpation of a thickened pylorus through the anterior abdominal wall - is variable, since it is not possible to determine it in all children.

If in children with a chronic form of pyloric stenosis in the biochemical blood test there are moderate changes due to a gradual increase in the symptoms of the disease, then in patients with an acute form (especially with late diagnosis), there is a sharp increase in hematocrit, a decrease in chlorine, metabolic alkalosis and sometimes hypokalemia. Changes in proteins and protein fractions are rare. In urine tests, traces of protein, single erythrocytes can be detected. The oliguria is distinctly expressed.

X-ray examination

X-ray examination of children with suspected pyloric stenosis is of decisive diagnostic importance. First, a survey radiograph of the abdominal cavity is made in the vertical position of the child. At the same time, a large gas bubble and a high level of liquid are found in the distended stomach. There is little gas in the intestinal loops, or the latter is absent. Then they proceed to a contrast study. In newborns of the first days of life, iodolipol (5 ml) is used as a contrast, observing its passage through the gastrointestinal tract. The absence of evacuation from the stomach for more than 24 hours indicates an obstruction in the pyloric region.

Differential diagnosis

The differential diagnosis of the acute form of pyloric stenosis should be carried out with pylorospasm, obstruction of the stomach, congenital high intestinal obstruction, habitual vomiting.

In children of the first days of life, differentiation with pylorospasm is of the greatest importance due to the different tactics used in their treatment. It should be borne in mind that with spasm, the disease begins gradually, with regurgitation, which is intermittent, without significantly affecting the general condition of the child and his body weight. In addition, the acute form of pyloric stenosis is so acute and violent that the attending physicians assume an "acute surgical disease" and refer the child to the surgical department. In those cases when an X-ray examination is performed to differentiate these conditions, it should be borne in mind that with pylorospasm, gastric emptying begins 10 minutes after taking a contrast agent and ends after 3-6 hours.

Congenital obstruction of the stomach is clinically and radiographically extremely difficult to distinguish from the acute form of pyloric stenosis. Usually the final diagnosis is established during surgery.

Congenital anomalies of the duodenum, in which the obstruction is located below the nipple of Vater, is usually easy to distinguish from pyloric stenosis by bile-stained vomit and a characteristic x-ray picture. In those cases of obstruction of the duodenum, when the obstruction is located above the nipple of Vater, the diagnosis becomes difficult. It should be remembered that with congenital intestinal obstruction, vomiting usually begins from the first day of life, while with pyloric stenosis, it starts much later.

Palpation determination of the thickened pylorus and the establishment of lengthening and narrowing of the pyloric canal during x-ray examination speak in favor of pyloric stenosis. Sometimes the contrast agent (with pyloric stenosis) remaining in the stomach may appear on the x-ray as two depots located on both sides of the spine, which is similar to the x-ray picture with high intestinal obstruction. In these cases, the diagnosis is aided by lateral radiography—the dilated duodenum is usually located posterior to the stomach.

Habitual vomiting and regurgitation are quite common in children in the first months of life, but this dysfunction of the stomach usually does not change the general condition of the child, does not cause a drop in body weight.

Treatment

The only treatment for acute pyloric stenosis is surgery.

Preoperative preparation. The duration and intensity of preoperative preparation depend on the timing of the child's admission to the department, the severity of his condition. Preparation for surgery, together with the examination, does not exceed 24 hours and is aimed at reducing disturbances in water-salt metabolism, as well as treating aspiration pneumonia. Immediately before the operation, the gastric contents are aspirated.

As a rule, endotracheal anesthesia is chosen as the method of anesthesia.

postoperative treatment. 3-4 hours after the operation, if there was no injury to the mucous membrane of the stomach or duodenum, the child is given 7-10 ml of a 5% glucose solution through the nipple, after 1 hour - 10 ml of expressed breast milk, and then (in the absence of vomiting) is prescribed every 2 hours for 10 ml of milk. Subsequently, 100 ml of milk per day is added daily. After 7-10 days, the child is applied to the breast with a transfer to 7 meals a day.

In cases of damage to the mucous membrane of the duodenum, feeding is started no earlier than 24 hours after the operation. If the child continues to vomit, then the amount of milk is somewhat reduced and a 1% solution of novocaine is prescribed, one teaspoon three times a day. The missing amount of fluid and salts is replenished by the parenteral method, taking into account comparative data from blood tests, the child's body weight, and his condition.

In case of aspiration pneumonia, active therapy started in the preoperative period is continued. To prevent wound infection and complications, antibiotics are used (6-7 days). Vitamin therapy is prescribed. Sutures are removed on the 10-12th day after surgery.

Authors: Drozdov A.A., Drozdova M.V.

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