Dilated Stomach



Dilated Stomach


Michael Nasser, MD



DIFFERENTIAL DIAGNOSIS


Common



  • Aerophagia


  • Hypertrophic Pyloric Stenosis


  • Midgut Volvulus


Less Common



  • Duodenal Hematoma


  • Duodenal Atresia or Stenosis


  • Bezoar


  • Ileus


Rare but Important



  • Gastric Volvulus


  • Gastrointestinal Duplication Cysts


ESSENTIAL INFORMATION


Key Differential Diagnosis Issues



  • Abdominal obstructions should be divided between proximal and distal etiologies


  • Dilated stomach is considered a proximal obstruction


  • Plain film findings include



    • Air-filled, distended stomach; minimal to no distal bowel gas


    • Patient may present with nonbilious emesis


  • Age of patient may help to narrow differential diagnosis


  • Trauma history also help to limit different etiologies


Helpful Clues for Common Diagnoses



  • Aerophagia



    • Swallowed air usually associated with crying


    • Most common cause for distended stomach in pediatric patients


    • Nonobstructive bowel gas pattern, with air distal to distended stomach


  • Hypertrophic Pyloric Stenosis



    • Presents with nonbilious projectile vomiting


    • Age range is 2-12 weeks


    • Conventional radiographic findings



      • Air-filled distended stomach, excessive gastric motility (“caterpillar” sign), minimal to no distal bowel gas


    • Ultrasound findings



      • Preferred modality for diagnosis


      • Single wall thickness > 3.0 mm, channel length > 16 mm


      • No passage of fluids from stomach into duodenal bulb on cine images


      • Note: Spasm of gastric antrum mimics pyloric stenosis but does not persist on delayed images


  • Midgut Volvulus



    • Surgical emergency



      • Twisting of small bowel about superior mesenteric artery can result in obstruction and ischemia/infarction


Helpful Clues for Less Common Diagnoses



  • Duodenal Hematoma



    • Most common cause is blunt trauma to abdomen (i.e., handle bar injury)



      • Other etiologies include child abuse, biopsy, bleeding disorder, and Henoch-Schönlein purpura


    • Most commonly located in 2nd or 3rd portion of duodenum


    • Plain film may show air-filled distended stomach with minimal or no distal bowel gas


    • CT findings



      • Duodenal hematoma may be eccentric or circumferential with narrowing of bowel lumen


      • May be distention of stomach and proximal duodenum with minimal distal bowel gas


      • Acute hematoma is high in attenuation and decreases with time


      • Signs of perforation include extraluminal air, extraluminal contrast, and retroperitoneal fluid


  • Duodenal Atresia or Stenosis



    • Conventional radiographic findings



      • Dilated stomach and duodenal bulb, “double bubble” sign


      • Duodenal atresia has no distal bowel gas (→ low probability for midgut volvulus in differential)


      • Duodenal stenosis has some degree of air in distal bowel (midgut volvulus cannot be excluded from differential)


    • Fluoroscopic findings



      • Upper GI is not often performed for duodenal atresia; plain film diagnosis



      • Duodenal stenosis requires upper GI to confirm diagnosis and exclude midgut volvulus from differential


  • Bezoar



    • Mottled-appearing filling defect in distended stomach


    • Bezoar is compliant and conforms to contour of stomach


    • Food debris may have similar mottled appearance


    • Upper GI may help to further delineate size and extent of bezoar


  • Ileus



    • Postoperative, drugs, metabolic, etc.


Helpful Clues for Rare Diagnoses

Tags:
Aug 10, 2016 | Posted by in PEDIATRICS | Comments Off on Dilated Stomach

Full access? Get Clinical Tree
Get Clinical Tree app for offline access