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506 ManipalManualofSurgery

Dumpingsyndrome-postcibal syndromes
Early Late

l. Onset Increasedemptyingimmediatelyaftermeals Onetotwo hoursafterwards.


2. Causes Rapidpassageoffoodofhighosmolarityfrom Initialhyperglycaemiacausesincreasedrelease of
stomachintosmallintestine causeshypovolaemia of insulinwhich isfollowedbyhypoglycaemia.
3. Relief Lyingdown Glucose
4. Aggravatingfactors Morefood,glucose,fullness Exercise
5. Symptoms Epigastricdistension,sweating,diarrhoea Tremors,faintingattacks(releaseofadrenaline)
6. Treatment Smallquantity,dryfood.Overa periodoftime, Dietaryadjustmentoffood
symptomssettledown,lesssugarcontent

Comparisonofchronicafferentlimbsyndromeandalkalinerefluxgastritis
Chronicafferentlimbsyndrome Alkalinerefluxgastritis

Pain Aftermeals Unrelatedto meals


Vomitus Bile Bileandfood
Relievespain Nochangesinpain
Projectile Nonprojectile
Occultbleeding Rare Common
Cause Limbobstruction-longloop Enterogastricreflux(noobstruction)
Treatment Avoidalongloop atsurgery Highfat,aminoacidregimen
ConvertBillrothIItoBillrothI Protonpumpinhibitors
Roux-en-Yjejunostomy Ursodeoxycholicacid
Jejunojejunostomy,convertingBillroth II toBillrothIcan bedone

Diarrhoeaisduetovagotomycausingintestinalhurryor Severeupperabdominal
duetodumping. painandguarding,rigidity,
Duetopoornutrition,thereisweightlossandtheyare hypotensionandshock-like I
susceptibleforpulmonary tuberculosis. featuresofbiliaryperitonitis
developifthere
2.DUODENALFISTULA(duodenalblowout)
isnodrainagetube.
Itistheleakageofduodenalcontentstotheexterior.It commonly
Ifdrainagetubeiskeptin
occurs aftersurgery.
thefirst surgery,bileflows
Causes totheexterior.Insuchcases,
Afterapartialgastrectomy/totalgastrectomy,wherethe signs of peritonitis are
closureofduodenumwas difficult. usuallynotpresent.How- Fig. 23.117: Duodenal blow
Afterclosureofperforatedduodenalulcer,whichgivesway
onceagain. imbalancecan occur(Fig.23.117).
Injuriestoduodenumduringrighthemicolectomy,right
nephrectomy,etc. Treatment
Conservativetreatmentissuccessfulinmajorityofthe
Precipitatingfactors
cases.Fistulahealsinafewdays,providedthere isno
Faultytechniqueofclosureofduodenalstump. distalobstruction.Duringthistimehydration,electrolyte
Severelyinflamed duodenumduetoanactiveulcer.
careisessential.Appropriateantibioticsaregiven.
Ifthereisadistalobstruction,itincreasestension111
duodenalloop andmayresultinfistula. Surgical-ifthefistulapersists,laparotomyandclosure
Ischaemiaofduodenalstump. ofthefistulacanbe donebyrepairingwithnonabsorbable
sutures.
Clinical features
Signsandsymptomsdevelopusuallyafter4to 5dayswhen Complications
oralfluidsarecommenced.Thesestimulateoutpouringof Biliaryperitonitis
biliary andpancreaticjuices. Septicaemiaifbileisnotdrainedoutside.
Stomach andDuodenum 507

Excoriationofabdominalskincanbepreventedbyzinc Symptoms
oxideapplication. Appearswithin1 to2 yearsaftertheoperation.
Fluid andelectrolyteimbalance. Severepersistentpain,'boring' type,whichgetsworse
3.RECURRENTULCER withinafewminutes oftakingfood.Thepainisfeltonthe
leftsideoftheabdomen, neartheumbilicalregionandit
Itcanbetrueanastomoticulcer(gastrojejunal,gastroduodenal or passesdownwards.
jejuna!ulcer),oragastriculcer intheremnant,orrecurrent Thepainisfeltinthelower left chestfollowingantecolic
ulcerfollowinghighlyselectivevagotomy(RSV). anastomosis.Itisnotrelievedbyantacidsormilkunlike
pepticulcer.Bleeding maymanifestashaematemesis,
Incidence
melaena oranaemia.Perforationcanoccur,resultingin
3% afterBillrothIIgastrectomy
peritonitis.
5 to8%aftervagotomyandGJ
40%aftergastrojejunostomy Diagnosis
Gastroscopygivesthecorrectdiagnosis.
10to12%followingRSV.
Hypercalcaemiaandhypergastrinaemiashouldberuledout.
Causesofrecurrent ulcer (Fig.23.118)
Management(Table23.12)
1. Incompletevagotomy ConservativetreatmentwithH 2receptorblockersisnearly
2.GJalone
always effectivebutrelapseoccursiftheyarestopped.
3.Inadequategastrectomy
Smokingshouldbestopped.
4.Narrowstoma However,definitivesurgeryisindicatedinappropriatecases.
5.Zollinger-Ellisonsyndrome
6.Hyperparathyroidism
ACIDFUNCTIONTESTS

Thesetestsarenotroutinelydonenowadaysdueto the
availabilityofendoscopy facilities.However,inrarecasesof
6
recurrentpepticulcer diseaseor as inZollinger-Ellison
syndrome,thesetestsare done. Hence,thesearediscussedin
thelastpages.

PENTAGASTRINTEST
Itisdone toassesspeakacidoutput.
Principle
Pentagastrinstimulatesparietalcellmassresulting tn
outpouringofgastricacid.
Procedure
Basalsecretionoffastingstomachismeasured.
6mg/kg bodyweightofpentagastrinisadministered
Fig.23.118: Various causesofrecurrentulcer (seethe textfor
subcutaneouslyorintramuscularly.
numbers)

Managementofrecurrentulcer
Typeoffirstsurgery Correctivesurgery

1. GJalone Vagotomy
2.Vagotomy+GJ(incompletevagotomy) Incompletevagotomyisthecause.Usually
posteriorvagusisfoundandithastobedivided
3.Vagotomy+GJ(completevagotomy) Stomaisnotadequate.Partialgastrectomyisthe
idealtreatment
4.Billrothpartialgastrectomy Vagotomywithorwithoutrevisiongastrectomy
5.HSY Vagotomy+partialgastrectomy
508 ManipalManualofSurgery
4samplesofstomach secretionarecollectedforonehour, Procedure
onceevery15minutes. IntroduceaRyle'stubeandaspiratethestomachcontentsfo
Byusingsuitable formula, peakacidoutputismeasured. 12hoursfrom9PMto9AM.ThevolumeandHClinthi:
gastricjuicearemeasured.
Results
VeryhighvaluesarefoundinZollinger-Ellisonsyndrome. Results
Itsvalues areveryhighinduodenalulcerpatients. In normalpatients,thetotalamountofgastricsecretioni:
Vagotomyandantrectomymaybethetreatmentofchoice. around400ml.Abovethis,it suggestsvagalhyperactivity
Ithasaroleinrecurrentulcer. InZollinger-Ellisonsyndromethe levelsmaybeashigha:
Inpatientswithgastrinoma,thebasalacidoutput is onelitre.
unusuallyhighandtheremaybealittle responseto FreeHCIinnormalpatientsis10-20mEq/L,induodena
pentagastrinstimulation. ulcer60-80mEq/L, ingastriculcer10-20mEq/L,andir
Zollinger-Ellisonsyndrome,itmaybearound 100-30(
HOLLANDER'STEST(INSULINTEST)1 mEq/L.
It isdonetoknowthecompletenessofvagotomy.

Principles ACUTEDILATATIONOFSTOMACH
Insulinproduceshypoglycaemiawhichstimulatesvaguswhich in
turnstimulatestheparietalcellmasstosecreteacid. Aetiopathogenesis
Ifvagotomyiscomplete,thereisnochangeinacid output I. Canoccurafteranyoperation,particularlysplenectomyand
duringinsulintest-Hollander'stest. pelvicprocedures.
2. Itcanoccurfollowingfracturefemur,applicationofplaster
Procedure ofParis,etc.Malnutrition,excessive distensionofthe
Aspirate thefastingstomachcontents stomach duetoventilation,aerophagiaareother
precipitatingfactors.
Toafastingpatient,0.2unitsI1 0kgbodyweightofinsulin
isgivensubcutaneously. Thereisasudden lossofsympathetictoneresultingin
Bloodsugarisestimatedat 15-minuteintervalsanditis massivedilatationofstomach.ImproperRyle'stubeaspiration
maintainedbetween30and40mg%aftertwo hours. andpermittingintakeoforalfluidstooearlybeforeparalytic
ileussettlesdownareadditionalfactors.
Results
Clinicalfeatures
Acid outputismeasuredforonehour.Ifthereisnochangein
acidoutput,vagotomyiscomplete.If thereisarisein Historyofsurgery
concentrationof20mmolperlitreabovethebasallevelinthe first Hiccoughs-duetoirritationof under surface ofthe
hour,itsuggestsincompletevagotomy. diaphragm,bythehugelydistendedstomach.
Abdominalpain,vomiting,distension.Vomiting contains
Usefulness foulsmellingdirtyfluid andbloodandiseffortless.
Inrecurrentulcerstoknowwhethervagotomyiscomplete ornot. Featuresof shock. Inuntreated cases,can
TodiagnoseZollinger-Ellison syndrome,whereveryhigh leadtocardiovascularcollapse.
valuesofacidareseen. Effortlessvomitingoflitresofdarkwateryfluid 1s
characteristicofthiscondition.
Complications
Hypoglycaemiaandcoma.Thistestisobsoletenow. Treatment: Urgent resuscitation
IntroduceaRyle'stubeandaspiratethestomach.Itis
NIGHTFASTINGSECRETION(DRAGSTEDTEST) The thelife-savinguseofRyle'stube(Fig.23.119).
secretionsofthe stomachin the restingperiod or RapidIVfluidreplacement,withnormalsalineanddextrose
interdigestiveperiod for12hoursinthenightaremeasured. saline.Bothcrystalloids andcolloidsmaybenecessaryto
treattheshockandelectrolyteabnormalities.

1Manydeathshaveoccurreddue tothistestinthepast.
Stomachand Duodenum 509

Treatment
Reduce thevolvulusbydividinggastrocolicomentum
Fixthegreatercurvatureofthestomachtotheduodeno-
jejunalflexureorperformaGJwithout stoma.
Repairofeventration
Fixingbytubegastrostomycanalso bedone.

BEZOARS

Bezoars arecollectionsofnondigestiblematerials,usually of
vegetable origin (phytobezoar)butalso of
hair(trichobezoar).
Trichobezoars areconcentrationsofhair,generally found
inlong-hairedgirls orwomen whooftendenyeatingtheir
ownhair(trichophagy)(Figs23.120and23.121).

Fig.23.119: PlainX-rayshowingacutedilatationofthestomach. Ryle's


tube insertionis alife-saving simple procedureinthis condition

Complications
Pulmonary:Indebilitatedpatients,aspirationmayresultin
aspirationpneumonitis(Mendelsonsyndrome).
Itcarriessignificantmortality.

VOLVULUSOFTHESTOMACH
Fig.23.120: Trichobezoar:Appreciatetheshapeof stomachand
Itisarareconditioninwhichstomachrotatesinahorizontal firstpartoftheduodenuminbezoars(Courtesy: DrRajivShetty,
(organoaxial) andvertical(mesentericoaxial) direction Prof&Head, DeptofSurgery, BangaloreMedicalCollege and
resulting inanacuteabdomen. MedicalSuperintendent,BowringHospital,Karnataka)
Organoaxialismorecommon.
Manytimes,volvulusisintermittent.
Ingeneral,initiallythecolonmovesupwardsandlater
greatercurvatureofthestomach.
Thereisassociatedeventrationofthediaphragmwhichalso
precipitatesthiscondition(inchildren,congenital).
Inadults,diaphragmaticdefects aremorecommonly
traumaticorparaoesophagealherniation.
Clinicalfeaturesincludeepigastricpain,fullnessand
tenderness.

Borchardt'striad
1.Sudden,constant,severeupperabdominalpain
2.Recurrentretchingwithproductionoflittlevomitus
3.Inabilitytopassanasogastrictube.

Diagnosis
PlainX-rayabdomen/chest:Gasfilledviscus
Bariummealcandemonstratetwistedstomach Fig.23.121: Trichobezoar(Courtesy: DrYVKrishna Rao, Profof
UpperGIscopy. Surgery, MamataMedicalCollegeandHospital,Khammam,Andhra
Pradesh)