Transcript post gastrectomy syndrome

POST GASTRECTOMY
SYNDROME
By Karl
1. Functional efferent /afferent
loop syndrome
2. post gastrectomy asthenia
3. Post gastrectomy anemia
Functional Efferent/
afferent loop
syndrome
Afferent loop syndrome - is
a violation of the afferent
loop emptying.
It is caused by acute
(complete) or chronic
(intermittent) obstruction of the
afferent jejunal loop.
Etiology.
Factors that lead to
the development of
the syndrome are divided into
1. Organic
2. functional.
Organic causes:
1. An acute angle is created,
after gastro-jejunostomy, between
the loop and the anastomosis
line. As a result, the it bends and the
food mostly comes into
the resulting loop.
2. Infringement of afferent loop in the
crevices of the mesentery and small
intestine.
3. Volvulus, and rotation of a
long afferent loop.
4. Intussusception of the afferent loop .
5. Compression of the afferent
loop forming adhesions
6. compression by mesenteric artery onto
the distal part of duodenum
7. Compression of the afferent loop by
tumor.
8. The capture of a large amount of the
intestinal wall by stitches(sutures) during
the operation.
Functional causes are:
1. decrease in tone and motility of the
duodenum (duodenostasis).
Pathogenesis.
As a result of obstruction there is a
pile up of bile, pancreatic juice and
food in the loop.
The non-participation of enzymes in
digestion leads to a violation of the
normal function. In the loop pressure
increases. Bacteria from the loop go
to the liver, gall bladder, pancreas.
Due to the increase
in intracolonic pressure, vomiting
develops. As a result of
vomiting there is disruption of
water and electrolyte balance.
The function of the lower
esophageal sphincter is disrupted
therefore reflux oesophagitis
develops.
Also a result of acute afferent
loop syndrome (resulting
from invagination or inflection) the
blood circulation can be disturbed
and this may lead to gangrene
of intestine and peritonitis.
The clinical picture.
There are acute and chronic forms
of afferent loop syndrome.
The acute form - is characterized by
intense pain in
the epigastrium, nausea, vomiting
without bile. In the case
of bowel necrosis develops peritonitis.
The chronic form - is characterized
by upper quadrant pain, retching,
vomiting bile.
There are three degrees of severity
of the syndrome:
1. mild - the pain is not constant, and
occurs during intake of large
amounts of fatty foods. There is no
loss of weight or if any its
insignificant.
2. Moderate - the pain becomes more
pronounced. Appears 10-15 minutes
after eating.
At the height of pain there is
vomiting. Vomiting occurs - 3-4 times a
week. The deficit in body weight - up to
10 kg.
3. Severe - characterized by severe
pain. the phenomenon of
cholecystitis,
pancreatitis, esophagitis may
occur. Person Vomits every day.
Diagnosis.
Physical examination -palpable
mass in abdomen . Find asymmetry
of abdomen
Ultrasound - expanding gut is
visible, with accumulation of fluid
and gas in it.
X-ray examination. Can see
enlarged gut, horizontally can
see fluid levels.
In some cases (due to increased
pressure in the loop, compression
and necrosis) the contrast media
can’t fill the affected loop.
Treatment.
Conservative treatment is not so
effective.
 it involves:
- Dieting
- Exclusion of fatty foods
- Decompression of the stomach by
probe
- Intake of antacids, antispasmodics.
For surgical correction - the following
operations are conducted:
1. Gastroenterostomosis by Roux.
2. Reconstruction of
the gastrojejunal anastomosis to ga
strodoudenal.
3. Formation of the Braun
anastomosis.
4. If there is still a dumping syndrome then a reconstructive
gastrojejunoduodenoplasty of Zakha
rov-Henley is performed together
with stem vagotomy.
anastomosis_Roux-en-Y
Braun anastomosis.
Braun anastomosis.
Prophylaxis
Afferent loop syndrome prevention:
during gastrojejunostomy, use loop of
jejunum, length of 8-10 cm, from the
ligament Treitz
 suturing afferent loop to the lesser
curvature of the loop in order to create
a valve
 fixation of the gastric stump in the
window of the mesentery of the
transverse colon.
Postgastrectomy (agastria
) asthenia.
Pathogenesis.
Removal of the stomach leads to
the rapid emptying of the
stomach contents. This means
that little or no digestion occurs in
the stomach. Thus there’s
no enzymatic breakdown of
complex substances to simple
blocks.
This leads to metabolic
disorders. The small
intestine receives chemically
and mechanically unprepared foo
d. As a result there is Violation in
vitamin absorption. There occurs
anemia (iron and B12 deficiency).
Clinical Picture
Violation of protein metabolism leads to edema.
Patients complains of
diarrhea, skin changes,
weakness, loss of appetite,
weight loss.
There are three degrees of severity of
asthenia (agastria):
Grade 1 - mild
Grade 2 - moderate - with
diarrhea, edema, anemia
Grade 3 - severe with cachexia, beriberi, osteopathy.
Diagnosis
is based on the clinics.
Treatment.
Conservative treatment
 A balanced diet.
Use of anabolic hormones
(retabolil, Anabol),
enzymes (mezim).
Surgical treatment
 involves the inclusion of duodenum
in the process of digestion ,
 Increasing the volume of gastric
stump,
 Reducing the rate of gastric
emptying. It is used in cases
of severe athenia