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Spontaneous rupture of the stomach
Spontaneous Rupture of the Stomach
KOTA L. CHANDRASEKHARA, SWAMINATH K. IYER, M.D. ALFRED L. SUTTON, M.D. ALBERT E. STANEK, M.D. Brooklyn,
M.D. *
A case of spontaneous rupture of the stomach associated with perforation of the diaphragm is reported. Spontaneous rupture of the stomach is a rare but fatal condition. The pathophysiologic features, clinical manifestations, and treatment are discussed.
New York
Spontaneous rupture of the stomach is a rare but fatal condition [l] and refers to rupture of the gastric wall in a zone devoid of any pathology [2]. After the description of this condition by Percy and Lerent in 1818, all perforations were thought to be spontaneous until Cruveilhier introduced the concept of peptic perforation in 1829 [3]. Thereafter, spontaneous rupture of the stomach became less well known [2]. The case reported herein is unique because the patient had a left diaphragmatic perforation along with spontaneous rupture of the stomach.
CASEREPORT
From the Kings County Hospital Center, Downstate Medical Center, Brooklyn, New York. Requests for reprints should be addressed to Dr. Swaminath K. lyer, Division of Gastroenterology, State University of New York, Downstate Medical Center, Kings County Hospital Center, Box 1199X, 450 Clarkson Avenue, Brooklyn, New York 11203. Manuscript submitted April 23, 1985, and accepted June 21, 1985. *Current address: Peninsula General Hospital Medical Center, 100 East Carroll Street, Salisbury, Maryland 2 1801.
1062
December
1966
The American
Journal
A 53-year-old black woman was brought to the emergency room of Kings County Hospital Center in acute distress and a semicomatose condition. No history was available. The patient was cyanotic and tachypneic. The blood pressure was 50 mm Hg. Physical examination revealed subcutaneous emphysema of the neck and chest, left pneumothorax, and a tense, distended abdomen. Respiratory arrest developed, and the patient underwent intubation and resuscitation. A central venous line was placed. A nasogastric tube was inserted, and dark brown fluid was aspirated. Chest radiography revealed subcutaneous emphysema and left pneumothorax (Figure 1). A chest tube was inserted, and air plus 800 ml of dark foul-smelling fluid was obtained from the left pleural space. A peritoneal tap revealed pneumoperitoneum. The clinical impression was ruptured esophagus. Arrest recurred, and the patient died two hours after admission. Postmortem examination revealed a massively dilated stomach with rupture in the cardia and extension through the left leaf of the diaphragm (Figure 2). Leakage of gastric contents into the left pleural space and peritoneal cavity was noted. Microscopic study revealed attenuation of the wall of the cardia. There was no significant inflammation. The pylorus was scarred with a healed pyloric channel ulcer. The muscularis mucosa was hypertrophic. The pleura showed minimal inflammatory changes.
COMMENTS Perforation of the stomach, either traumatic or spontaneous, is rare [ 11. The stomach is a mobile and distensible organ deeply situated in the upper abdomen, protected by the ribs and liver anteriorly. In a study of blunt abdominal injury, gastric rupture was seen in only 1 percent of the patients [4]. The flaccid walls of the stomach can distend enormously [5]. Ravilliod demonstrated that the stomach can be distended up to a volume of 4 liters before it ruptures [3]. Further, the stomach can decompress
of Medicine
Volume
61
SPONTANEOUSRUPTUREOFTHESTOMACH--CHANDRASEKHARAETAL
through the pyloric and cardioesophageal vents. Hence, spontaneous rupture of the stomach is preceded by gastric dilatation and disturbance in the emptying mechanism. A review of 43 cases of spontaneous rupture of the stomach by Albo et al [I] showed that the condition has a female preponderence, with a mean age of 43 years. Distention of the stomach caused by over-indulgence was observed in 27 of 43 cases. The other causes of gastric dilatation include air sucking [5], pylorospasm, and peptic ulcer disease with scarring [6]. Distention of the stomach causing rupture is also seen with insufflation of oxygen [7], gastric hemorrhage [8], abdominal injury or surgery [2], shock [9], postpartum state [lo], and ingestion of sodium bicarbonate [ Ill. The exact mechanism of gastric rupture is not known. When the stomach is over-distended, the angle between the stomach and the esophagus is acutely increased, occluding the cardioesophageal junction, which then acts like a one-way valve [ 1,6]. Aerophagia and gastric secretion may add to further distention leading to rupture. Once acute distention has developed, factors that increase the intra-abdominal pressure like labored coughing, vomiting [2], and grand mal seizures [I] can precipitate rupture. It has been postulated that distention causes marked stretching of the relatively fixed mucosa along the lesser curvature causing ischemic necrosis and tearing [ 1,6]. In the review of 43 cases, 30 patients (73 percent) had rupture along the lesser curvature [I]. The cardinal symptoms of gastric rupture are abdomiFigure 2. Gross photograph of esophagus, stomach, diaphragm. The fundus of the stomach is dilated thinned. The diaphragm shows a large defect (arrow).
Figure 1. Chest x-ray film showing left pneumothorax subcutaneous emphysema (arrow).
and
December
and and
nal distention, shock, subcutaneous emphysema, and signs of peritoneal irritation [ 11. The patient described herein was a 59year-old black woman who had all the cardinal signs of gastric rupture. Peptic ulceration and scarring of the pylorus was the cause of the gastric distention in our patient. Rupture occurred in the fundus and was associated with perforation of the left leaf of the diaphragm. The outcome in this condition is grave. The review by Albo et al [l] showed a 65 percent mortality rate in the patients who underwent surgery and a 100 percent rate in those who did not, with an overall mortality rate of 85 percent. The high mortality rate may be due to associated factors, e.g., shock, peritonitis, respiratory embarrassment [I], and air embolism [6]. In summary, a case of fatal spontaneous rupture of the stomach is presented. Pyloric channel ulceration and scarring caused the gastric distention leading to rupture in our case. Although the mortality rate is high in this condition, early surgical intervention seems to reduce it somewhat.
1966
The
American
Journal
of Medicine
Volume
61
1063
SPONTANEOUS
RUPTURE
OF THE ~TOMAOH-OHANORA~EKHARA
ET AL
REFERENCES 1. 2. 3. 4.
5. 6.
1064
7.
Albo R, De Lorimier AA, Silen W: Spontaneous rupture of the stomach in the adult. Surgery 1963; 53: 797-805. Baglio CM, Fattal GA: Spontaneous rupture of the stomach in the adult. Am J Dig Dis 1962; 7: 75-83. Glassman 0: Subcutaneous rupture of the stomach, traumatic and spontaneous. Ann Surg 1929; 89: 247-263. Fitzerald JM, Crawford ES, De Bakey M: Surgical consideration of non-penetrating abdominal injuries: an analysis of 200 cases. Am J Surg 1961; 100: 22-29. Morris CR, Ivy AC, Maddock WG: Mechanism of acute abdominal distention. Arch Surg 1947; 55: 101-124. Millar TM, Bruce J, Paterson JRS: Spontaneous rupture of the stomach. Br J Surg 1957; 44: 513-516.
December
1966
The American
Journal
of Medicine
Walstad PM, Conklin WS: Rupture of the normal stomach after therapeutic oxygen administration. N Engl J Med 1961; 264: 1201-1202. Bolt DE, Hennessy WB: Rupture of the stomach complicating gastric hemorrhage. Lancet 1955; II: 485-486. Mirsky S, Garlock JH: Spontaneous rupture of the stomach. Ann Surg 1965; 161: 466-468. Christoph RF, Pinkham EW Jr: Unexpected rupture of the stomach in the postpartum period. Ann Surg 1961; 154: 100-102. Zer M, Chaimoff C, Dintsman M: Spontaneous rupture of the stomach following ingestion of sodium bicarbonate. Arch Surg 1970; 101: 532-533.
8. 9. 10.
11.
Volume
61
KOTA L. CHANDRASEKHARA, SWAMINATH K. IYER, M.D. ALFRED L. SUTTON, M.D. ALBERT E. STANEK, M.D. Brooklyn,
M.D. *
A case of spontaneous rupture of the stomach associated with perforation of the diaphragm is reported. Spontaneous rupture of the stomach is a rare but fatal condition. The pathophysiologic features, clinical manifestations, and treatment are discussed.
New York
Spontaneous rupture of the stomach is a rare but fatal condition [l] and refers to rupture of the gastric wall in a zone devoid of any pathology [2]. After the description of this condition by Percy and Lerent in 1818, all perforations were thought to be spontaneous until Cruveilhier introduced the concept of peptic perforation in 1829 [3]. Thereafter, spontaneous rupture of the stomach became less well known [2]. The case reported herein is unique because the patient had a left diaphragmatic perforation along with spontaneous rupture of the stomach.
CASEREPORT
From the Kings County Hospital Center, Downstate Medical Center, Brooklyn, New York. Requests for reprints should be addressed to Dr. Swaminath K. lyer, Division of Gastroenterology, State University of New York, Downstate Medical Center, Kings County Hospital Center, Box 1199X, 450 Clarkson Avenue, Brooklyn, New York 11203. Manuscript submitted April 23, 1985, and accepted June 21, 1985. *Current address: Peninsula General Hospital Medical Center, 100 East Carroll Street, Salisbury, Maryland 2 1801.
1062
December
1966
The American
Journal
A 53-year-old black woman was brought to the emergency room of Kings County Hospital Center in acute distress and a semicomatose condition. No history was available. The patient was cyanotic and tachypneic. The blood pressure was 50 mm Hg. Physical examination revealed subcutaneous emphysema of the neck and chest, left pneumothorax, and a tense, distended abdomen. Respiratory arrest developed, and the patient underwent intubation and resuscitation. A central venous line was placed. A nasogastric tube was inserted, and dark brown fluid was aspirated. Chest radiography revealed subcutaneous emphysema and left pneumothorax (Figure 1). A chest tube was inserted, and air plus 800 ml of dark foul-smelling fluid was obtained from the left pleural space. A peritoneal tap revealed pneumoperitoneum. The clinical impression was ruptured esophagus. Arrest recurred, and the patient died two hours after admission. Postmortem examination revealed a massively dilated stomach with rupture in the cardia and extension through the left leaf of the diaphragm (Figure 2). Leakage of gastric contents into the left pleural space and peritoneal cavity was noted. Microscopic study revealed attenuation of the wall of the cardia. There was no significant inflammation. The pylorus was scarred with a healed pyloric channel ulcer. The muscularis mucosa was hypertrophic. The pleura showed minimal inflammatory changes.
COMMENTS Perforation of the stomach, either traumatic or spontaneous, is rare [ 11. The stomach is a mobile and distensible organ deeply situated in the upper abdomen, protected by the ribs and liver anteriorly. In a study of blunt abdominal injury, gastric rupture was seen in only 1 percent of the patients [4]. The flaccid walls of the stomach can distend enormously [5]. Ravilliod demonstrated that the stomach can be distended up to a volume of 4 liters before it ruptures [3]. Further, the stomach can decompress
of Medicine
Volume
61
SPONTANEOUSRUPTUREOFTHESTOMACH--CHANDRASEKHARAETAL
through the pyloric and cardioesophageal vents. Hence, spontaneous rupture of the stomach is preceded by gastric dilatation and disturbance in the emptying mechanism. A review of 43 cases of spontaneous rupture of the stomach by Albo et al [I] showed that the condition has a female preponderence, with a mean age of 43 years. Distention of the stomach caused by over-indulgence was observed in 27 of 43 cases. The other causes of gastric dilatation include air sucking [5], pylorospasm, and peptic ulcer disease with scarring [6]. Distention of the stomach causing rupture is also seen with insufflation of oxygen [7], gastric hemorrhage [8], abdominal injury or surgery [2], shock [9], postpartum state [lo], and ingestion of sodium bicarbonate [ Ill. The exact mechanism of gastric rupture is not known. When the stomach is over-distended, the angle between the stomach and the esophagus is acutely increased, occluding the cardioesophageal junction, which then acts like a one-way valve [ 1,6]. Aerophagia and gastric secretion may add to further distention leading to rupture. Once acute distention has developed, factors that increase the intra-abdominal pressure like labored coughing, vomiting [2], and grand mal seizures [I] can precipitate rupture. It has been postulated that distention causes marked stretching of the relatively fixed mucosa along the lesser curvature causing ischemic necrosis and tearing [ 1,6]. In the review of 43 cases, 30 patients (73 percent) had rupture along the lesser curvature [I]. The cardinal symptoms of gastric rupture are abdomiFigure 2. Gross photograph of esophagus, stomach, diaphragm. The fundus of the stomach is dilated thinned. The diaphragm shows a large defect (arrow).
Figure 1. Chest x-ray film showing left pneumothorax subcutaneous emphysema (arrow).
and
December
and and
nal distention, shock, subcutaneous emphysema, and signs of peritoneal irritation [ 11. The patient described herein was a 59year-old black woman who had all the cardinal signs of gastric rupture. Peptic ulceration and scarring of the pylorus was the cause of the gastric distention in our patient. Rupture occurred in the fundus and was associated with perforation of the left leaf of the diaphragm. The outcome in this condition is grave. The review by Albo et al [l] showed a 65 percent mortality rate in the patients who underwent surgery and a 100 percent rate in those who did not, with an overall mortality rate of 85 percent. The high mortality rate may be due to associated factors, e.g., shock, peritonitis, respiratory embarrassment [I], and air embolism [6]. In summary, a case of fatal spontaneous rupture of the stomach is presented. Pyloric channel ulceration and scarring caused the gastric distention leading to rupture in our case. Although the mortality rate is high in this condition, early surgical intervention seems to reduce it somewhat.
1966
The
American
Journal
of Medicine
Volume
61
1063
SPONTANEOUS
RUPTURE
OF THE ~TOMAOH-OHANORA~EKHARA
ET AL
REFERENCES 1. 2. 3. 4.
5. 6.
1064
7.
Albo R, De Lorimier AA, Silen W: Spontaneous rupture of the stomach in the adult. Surgery 1963; 53: 797-805. Baglio CM, Fattal GA: Spontaneous rupture of the stomach in the adult. Am J Dig Dis 1962; 7: 75-83. Glassman 0: Subcutaneous rupture of the stomach, traumatic and spontaneous. Ann Surg 1929; 89: 247-263. Fitzerald JM, Crawford ES, De Bakey M: Surgical consideration of non-penetrating abdominal injuries: an analysis of 200 cases. Am J Surg 1961; 100: 22-29. Morris CR, Ivy AC, Maddock WG: Mechanism of acute abdominal distention. Arch Surg 1947; 55: 101-124. Millar TM, Bruce J, Paterson JRS: Spontaneous rupture of the stomach. Br J Surg 1957; 44: 513-516.
December
1966
The American
Journal
of Medicine
Walstad PM, Conklin WS: Rupture of the normal stomach after therapeutic oxygen administration. N Engl J Med 1961; 264: 1201-1202. Bolt DE, Hennessy WB: Rupture of the stomach complicating gastric hemorrhage. Lancet 1955; II: 485-486. Mirsky S, Garlock JH: Spontaneous rupture of the stomach. Ann Surg 1965; 161: 466-468. Christoph RF, Pinkham EW Jr: Unexpected rupture of the stomach in the postpartum period. Ann Surg 1961; 154: 100-102. Zer M, Chaimoff C, Dintsman M: Spontaneous rupture of the stomach following ingestion of sodium bicarbonate. Arch Surg 1970; 101: 532-533.
8. 9. 10.
11.
Volume
61