Gastric Injury

　　Although the stomach is in a protected anatomical position in the abdominal cavity, it is unavoidable to form gastric injury in some cases. Common causes of gastric injury include:

　　1. Traumatic violence

　　External violence can act on the chest, abdomen, or lumbar spine to cause gastric injury. According to the nature of the trauma, it can be divided into:

　　(1) Blunt injury: This kind of violence acts on the body surface without causing communication between the cavity and the outside world. Common ways include punches, kicks, and traffic accidents. According to Barry's citation, in industrialized countries, about 70% of blunt abdominal injuries are caused by traffic accidents.

　　(2) Penetrating injury: Trauma caused by knife, gun wounds, and other penetrating injuries to the body surface and cavity.

　　2. Chemical injury

　　Due to the ingestion of corrosive substances such as acid and alkali.

　　3. Foreign bodies in the stomach

　　Occasionally, neglect, deliberate suicide, or psychiatric patients may swallow foreign objects into the stomach. Most foreign objects can be excreted spontaneously. When the object is too large, both ends are sharp, or the object is saw-toothed, it is difficult to be excreted, which can lead to obstruction, bleeding, or even perforation.

　　4. Spontaneous rupture

　　Spontaneous gastric rupture in adults is extremely rare. This name does not actually mean that there is no background factor leading to the sudden rupture of the stomach. It is generally believed that an important prerequisite for this condition is the spasm and obstruction of the gastric outlet (cardia or pylorus). Severe vomiting, excessive force, or carrying heavy loads may cause the gastric wall to rupture due to excessive tension when the stomach is already distended. There have also been reports in the literature of cases of gastric rupture caused by excessive intake of baking soda or swallowing a large amount of anesthetic gas during anesthesia, leading to excessive expansion of the stomach.

　　Common complications of gastric injury may include diffuse peritonitis, hemorrhagic shock, infectious shock, mediastinal emphysema, hydropneumothorax, subcutaneous emphysema of the chest, and other complications, which are often the main symptoms in clinical practice. Gastric fistula is rare but extremely serious.

　　Gastric injury is often caused by various injury factors of certain intensity. However, due to the protected anatomical position of the stomach in the abdominal cavity and the fact that the gastric lumen is often in a defecated state and can move within a certain range in the abdominal cavity, the opportunity for injury caused by external violence is not very common. Once injured, it often accompanies injury to other abdominal organs.

　　Gastric wall injuries without full-thickness rupture may not have obvious clinical symptoms, or there may only be mild pain in the upper abdomen, which gradually improves after clinical observation.

　　After gastric rupture, abdominal pain, distension, and diffuse peritoneal irritation are often immediately present, with vomiting being rare. Severe distension can lead to respiratory distress. When the rupture site is close to the esophagus or the esophageal area, mediastinal emphysema, hydropneumothorax, and subcutaneous emphysema of the chest can occur due to air entering the mediastinum. When the gastric injury is large, undigested food, bile, and gas can gush out from the abdominal wound; occasionally, a ruptured stomach can also be seen. Some cases may present with varying degrees of subcutaneous emphysema of the abdominal wall. The liver dullness may decrease or disappear, and the shifting dullness may be positive, with reduced or absent bowel sounds. If there is concurrent injury to other organs, corresponding symptoms and signs may be present.

　　休克出现较早，并在80％的严重病例中成为主要症状。如果不伴有其他脏器损伤，休克可能主要是由于胃液对腹膜的化学性刺激和严重腹腔污染所造成。

　　How to prevent gastric injury

　　Gastric injury can be caused by gastric foreign bodies, spontaneous rupture, chemical injury, and traumatic violence, and can cause symptoms such as pain and hematemesis, which can be very harmful to the body. To prevent the occurrence of this disease, the following points should be noted:

　　1. Maintain a good attitude and face problems optimistically;

　　2. Do not talk loudly with foreign objects in the mouth, and do not think too much;

　　3. Pay attention to safety when going out and reduce conflicts with others;

　　4. When abdominal surgery is required, adequate preparation should be made to reduce unnecessary harm.

　　Gastric injury can be caused by various reasons, and the onset form is also diverse. To diagnose this disease, the following examinations need to be performed:

　　1. X-ray examination

　　All patients with severe abdominal trauma should have an upright chest X-ray; abdominal X-rays in supine and upright positions (or left lateral position). The purpose is to clarify whether there is fracture, pneumothorax, hemothorax, pulmonary contusion, diaphragmatic rupture, and free gas under the diaphragm, etc. Free gas under the diaphragm has special significance for diagnosis; however, the absence of free gas under the diaphragm cannot negate the existence of gastric rupture.

　　2. Abdominal puncture and lavage

　　Abdominal puncture is a simple, rapid, and minimally invasive examination method, which can be performed in four quadrants: upper left, upper right, lower left, and lower right abdomen. Generally, the midpoint of the right lower abdominal rectus sheath is taken as the first puncture point, and a fine needle is gently and slowly inserted into the abdomen with a 10ml syringe and aspirated. If more than 0.1ml of non-coagulated blood, bile, pus, or air can be aspirated, it can be considered positive, indicating the indication for laparotomy. The diagnostic accuracy of this examination is about 90%.

　　For those with negative puncture but unable to exclude gastric injury, abdominal lavage can be performed. In cases of blunt abdominal trauma, the diagnostic accuracy of abdominal lavage is about 97%. Barry pointed out that when using the above criteria to judge blunt abdominal trauma, its sensitivity is 98%, specificity is 97%, and accuracy is 93%. If the positive standard for abdominal lavage red blood cell count is changed to (20～100)109/L (20,000～100,000/mm3), the sensitivity of the diagnosis remains 98%, while the specificity and accuracy can both increase to 97%. He also noted that for patients with negative red blood cell and white blood cell counts in the lavage fluid, the amylase measurement of the lavage fluid may be the only useful indicator for diagnosing rupture of hollow organs.

　　3. CT examination

　　CT can detect when there is 5ml of accumulated gas in the abdomen. However, X-ray only shows a positive result when there is more than 50ml of abdominal effusion. Therefore, when there is a suspicion of gastrointestinal perforation and X-ray plain film or gastrointestinal contrast study is difficult to diagnose, if the patient's overall condition permits, CT examination can be performed. CT imaging of gastrointestinal injury can manifest as:

　　①There is no significant organ damage but there is abdominal effusion.

　　②Free abdominal gas.

　　③ There are signs of contrast medium leakage into the gastrointestinal tract.

　　④ Localized蜂窝组织炎性 soft tissue mass near the perforation has uneven density.

　　⑤ The interface between mesentery thickening, mesenteric pleats, and mesenteric fat is blurred and unclear.

　　4. Ultrasound examination

　　In the case of excluding injury to solid abdominal organs, when ultrasound detects effusion in the abdomen, combined with medical history and clinical manifestations, the possibility of gastric injury can be considered. Free intraperitoneal gas exists below the diaphragm or in the space between the anterior liver and the abdominal wall, manifested as a bright area, with echoes reflecting a symmetrical transverse strip, which can change with the change of body position. While the reflection of gastrointestinal gas is often diffuse and turbid, with attenuation at the back, which is significantly different from the echo of free gas. At the same time, gastrointestinal gas cannot extend to the space between the anterior liver and the abdominal wall.

　　After confirming the diagnosis of gastric injury, surgical treatment should be carried out in time. For the first few days after surgery, patients should fast. After the gastrointestinal function recovers, attention should also be paid not to eat the following foods:

　　1. Fried chicken

　　High calorie and high fat, which can lead to an increase in body fat and is not conducive to the energy metabolism of the liver. Avoid eating.

　　2. Preserved pork

　　High fat content, eating can increase the amount of fat in the body. Try to avoid eating.

　　3. Chili

　　Spicy and stimulating, which can lead to hyperactivity of the liver fire and is not conducive to the fat metabolism of the liver. Avoid eating. You can choose non-spicy bell peppers.

　　4. Alcohol

　　High calorie, which can be converted into fat. Alcohol has a damaging effect on the liver, affecting the normal energy metabolism of the liver. Avoid drinking, except for cooking with cooking wine.

　　Gastric injury only involves the mucosal layer, with small amount of bleeding and no associated injury to other organs, can be treated without surgery. In cases of penetrating abdominal injuries or closed injuries, if there is shock, diffuse peritonitis, gastrointestinal bleeding, free intraperitoneal gas, wound leakage of gastric contents and gas, direct exposure of the gastric cavity, and concurrent injury to other organs, immediate surgical treatment should be performed. During surgery, attention should be paid to the presence of associated injuries to other organs to prevent missed diagnosis and delay in treatment.

　　Postoperative use of broad-spectrum antibiotics, intravenous fluid, and blood transfusion if necessary until gastrointestinal function returns to normal. Semi-recumbent position, postural drainage. Continue intravenous blood transfusion and fluid infusion, and pay attention to water and electrolyte balance. Early mobilization, early ambulation, and more deep breathing to avoid pulmonary complications.