有食管裂孔疝史应警惕胃扭转

新奥尔良(EGMN)——梅奥医院胃肠病专家Conor G.Loftus博士在美国内科医师协会年会上报告称，如果食管裂孔疝史患者出现诸如吞咽困难和餐后不适饱腹感等非典型症状，应考虑是否患有慢性胃扭转。

胃扭转是一种尚缺乏足够认识的食管裂孔疝并发症，多见于较大食管旁型食管裂孔疝或胸腔胃患者。急性胃扭转属外科急症，通常突发胸腔下部或上腹部严重疼痛，并伴有持续性干呕，常被误认为急性心肌梗死。但急性胃扭转仍属严重事件。相比而言，慢性胃扭转的特点是症状轻微且无特异性。若疑似慢性胃扭转，最佳确诊手段是钡餐检查。

Loftus博士报告了一个典型病例：男性，70岁，主诉非疼痛性吞咽困难(仅限于吞咽固体食物)数年。有食管裂孔疝史，长期每日服用1次质子泵抑制剂控制胃食管反流病，体重未见下降。胃镜检查过程中，虽然探头通过扭曲的食管和胃部稍有困难，但检查结果总体正常。

Loftus博士指出，该病例的临床表现和内镜检查结果提醒我们应警惕慢性胃扭转，特别是胃镜最初插入困难表明存在解剖性疾病。如果怀疑胃动力障碍，行食管测压检查是最正确的选择。然而，老年患者新发发生胃动力障碍并不常见，并且胃动力障碍通常表现为液体和固体食物均吞咽困难。若怀疑恶性病变，行胃食管结合处内镜超声或胸部CT扫描将是最恰当的影像学检查，但3年症状史患者未见体重下降与上述怀疑严重不符。如果怀疑是嗜酸细胞性食管炎，应重复胃镜检查，行食管活检，但该疾病罕见于高龄患者。

Loftus博士报告无相关利益冲突。

NEW ORLEANS (EGMN) – Think ‘chronic gastric volvulus’ when a patient with a history of hiatal hernia presents with nonspecific symptoms such as difficulty in swallowing food and uncomfortable fullness after eating.

Gastric volvulus – a torsional twisting of the stomach – is an underrecognized complication of hiatal hernia. It occurs most often in patients with a large paraesophageal hiatal hernia or with an intrathoracic stomach that has come loose from its abdominal moorings, Dr. Conor G. Loftus explained at the conference.

Acute gastric volvulus is a surgical emergency. It typically presents suddenly with severe pain in the lower chest or upper abdomen, often accompanied by persistent nonproductive retching. It’s often mistaken for an acute MI. Yet acute gastric volvulus is no less serious an event, according to Dr. Loftus, a gastroenterologist at the Mayo Clinic, Rochester, Minnesota.

In contrast, chronic gastric volvulus is characterized by considerably milder, nonspecific symptoms. When clinical suspicion focuses on this possible diagnosis, the best confirmatory test is a barium esophagram.

Dr. Loftus presented an illustrative case: a 70-year-old man who presents complaining of nonpainful difficulty in swallowing solid food but not liquids for the past several years. He has a history of hiatal hernia as well as long-standing gastroesophageal reflux disease controlled with once-daily proton pump inhibitor therapy. He hasn’t lost weight. A gastroenterologist performed upper endoscopy with grossly normal findings, albeit with a notation that it was somewhat difficult to pass the probe across a tortuous esophagus and stomach.

In this vignette, Dr. Loftus observed, the clinical presentation and endoscopic findings raise a red flag for chronic gastric volvulus. In particular, the reported earlier difficulty in passing the endoscope suggests a mechanical problem.

Ordering esophageal manometry would be the right choice if a dysmotility disorder were suspected; however, a recent-onset dysmotility disorder would be unusual in an aged individual and, in any case, it would typically present with both liquid and solid food dysphagia.

Endoscopic ultrasound of the gastroesophageal junction or CT scan of the chest would be the appropriate imaging study if a malignancy was suspected. But the lack of weight loss in a patient with a 3-year history of symptoms argues strongly against that possibility, he continued.

Repeating the earlier upper endoscopy, this time obtaining esophageal biopsies, would be a good move if eosinophilic esophagitis was suspected; however, this disorder is uncommon at an advanced age, Dr. Loftus noted.

He reported having no financial conflicts.