Acute
Gastric
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E. A. FRANKEN,
Dilatation
JR.,’
MARK
FOX,
in Neglected JOHN
the acute of acute
suggest
Discussion Child abuse occurs in a spectrum ranging from infanticide to physical, nutritional, and emotional neglect [14]. In 1969 Silver and Finkelstein [5] described the syndrome which they entitled deprivational dwarfism, a condition characterized by the triad of extreme short stature, voracious appetite, and lack of sexual maturation. They attributed the pathogenesis of the syndrome to social and emotional neglect, with hypothalamic mediated metabolic deficit. However, later investigators determined that these children failed to thrive and exhibited a voracious appetite when institutionalized because they were chronically starved at home [6]. The patients in this report fit the syndrome of deprivational dwarfism, although several had signs of direct physical abuse as well. Acute gastric dilatation (gastrectasia, gastric atony) is a paralytic phenomenon; that is, it results from loss of muscle tonus rather than mechanical gastric outlet obstruction [7]. Although its usual occurrence is in the postoperative patient, acute gastric dilatation has also been described in many other acute and chronic conditions [7-11], including starvation [12]. The common physiologic mechanism seen in most instances is autonomically mediated inhibition of normal muscular tonus of the stomach, with subsequent inflow of gastric juice, retrograde spill of biliary and pancreatic secretions, and accumulation of swallowed air, saliva, and food or drink [9]. Considerable structural and physiologic changes are found in the stomach as a result of chronic starvation. There is atrophy of the muscular layers to the point that the stomach and intestines are described as ‘tissue paper thin” [13]; the distal intestines are relatively less affected than are the stomach and proximal small bowel. Mucosal atrophy with hypochlorhydria is seen in young starved rats; older animals have mucosal ulcerations and submucosal edema [14]. Degenerative changes in Auerbach’s plexus are frequently noted [15, 16]. Physio-
Material
Acute gastric dilatation in abused children has been recognized at this institution in five children. After detailed social investigation, physical and/or historical evidence of abuse and deprivation was noted in all patients. All cases were characterized by ingestion of a large amount of food, subsequent acute gastric dilatation, return
treatment
to normal
(table
gastric
emptying
after
appropriate
1).
Representative
Case
Report
S. L. , a 3-year-old boy, was brought to the hospital because he had been observed drinking from a toilet recently cleansed with alkali. At physical examination there were no signs of acute gastrointestinal injury. He was below the third percentile in height and weight. Because the boy was small for age and showed
several
scars
over
his
body,
he
was
admitted
for
evaluation. Subsequent social investigation of the child and his family revealed definite evidence of social and nutritional deprivation, and the possibility of active abuse. On admission the patient was given milk, which the nursing attendants noted was drunk ravenously. Because of his voracious appetite he was given multiple other snacks over the next few hours, all of which were promptly devoured. About 12 hr after admission he became acutely ill with abdominal distention, pain, and vomiting. Supine and upright views of the abdomen (fig. 1A) showed enormous distention of the stomach with intraluminal fluid, chyme, and air. A nasogastric tube was “
passed
into the stomach
and suction
‘
“
instituted.
Gastric
suction
logic
was discontinued 12 hr later, and the patient was begun on a graduated diet, initially consisting of liquids, progressing to a regular diet over the next 2 days. He subsequently did well, gained weight, and became active and cheerful. An upper
Received September20, ‘All authors: Department requests to E. A. Franken, Am J Roentgenol © 1978 American
1977; accepted November 7, 1977. of Radiology, Indiana University Medical Jr.
130-.297-299, February Roentgen Ray Society
1978
L. SMITH
the
Acute gastric dilatation occurs as a complication of diverse diseases. We report acute gastric dilatation as a manifestation of child neglect and abuse; recognition of this association by the radiologist not only results in correct treatment of the gastric dilatation but also allows identification of child abuse in the affected patient.
and
WILBUR
ingestion of a large meal. gastric dilatation in a child
who Is not postoperative or Intoxicated should presence of chronic starvation and child neglect.
Case
AND
gastrointestinal series performed 7 days after admission (fig. 18) was normal. After 15 days the patient was discharged from the hospital with subsequent supervision by the child welfare agency.
Acute gastric dIlatation occurred in five children suffering from parental neglect or deprivational dwarfism. Pathogenesis of acute gastric stony in the deprived child Is related to structural and functional changes in the stomach due to chronic starvation, and RadIographIc recognition
A. SMITH,
Children
chronic ondary obscure
Center,
297
1100 West
studies
indicate
starvation to protein [14].
Michigan
delayed
gastric
emptying
[15]; this is probably specifically deficit, although the mechanism
Street,
Indianapolis,
Indiana
0361 -803X/78/0200
46202.
Address
-0297
in
secis
reprint
$02.00
298
FRANKEN
ET
TABLE Summary Age(years)
Patient
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S. L
an
Clinicai
ex
3, M
......
Admitted alkali
Presentation
for question of ingestion; short
2, M
Sudden
Sudden after
distention ingestion
Radiographic
Findings
Symptoms
Abdominai
abdominal distention ingestion of large
amount
Enormous on initial
food when
hospitalized Same as clinical
abdominal
1
and
Abdominai
stature D. K
of Clinical
AL.
presentation
Acute film; days
T. N
8, M
T. T
4, M
Brought to hospital by relative for suspected
5, F
Brought to hospital by relative for suspected parental abuse
Same
as clinical
dilatation of stomach film; normal upper GI
Several scars
series 7 days later
after of large
meal at grandmother’s home Sudden abdominal distention after ingestion of large
Other Evidence of Negiect and Physicai Abuse
Radiograph
presentation
gastric normal later
distention upper
on
body on initial GI series
Burn
7
scars
on
Acute gastric dilatation initially; normal upper GI series 8 days later
legs
.
.
meal at home parental D. T.’
.
.
.
Note. -The . Sister
.
height of T. T.
Fig. 1 -A, gastrointestinal
and weight
Supine series
abuse
of au patients
abdominal 7 days
later
Sudden abdominal with shock after
were
Acute gastric distention initially; normal plain film 3 days later
Dirty and unkempt
Acute gastric distention initially; normal plain film 3 days later
Dirty and unkempt
of large meal in hospital
beiow
radiograph showing
distention ingestion
normal
Sudden abdominal distention with shock after ingestion of large meal in hospital
the third
showing stomach
percentiie.
massively
Au patients
distended
had
voracious
stomach
or
huge’
appetites
filled
with
ingested
and all had historic
food,
secretions,
evidence
and
of deprivation.
air.
B,
Upper
and duodenum.
Hormonal alterations in starvation are substantial, particularly in acute stages; chronically there is an attempt at protein conservation mediated primarily by breakdown products of muscle [17]. Effects of these metabolic
events on the gastrointestinal tract are unknown. Reduction in pancreatic secretions and damage to mucosal cells may result in maiabsorption [16, 18]. Acute gastric distention has previously been reported
GASTRIC
IN NEGLECTED
DILATATION
in chronic starvation in various groups: volunteers in the starvation experiments at the University of Minnesota [15], prisoners of war [19], and children with anorexia nervosa [12]. The same phenomenon has been noted in deprived children (W. E. Berdon, personal communica-
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tion),
and
GloebI
et
al.
[20]
reported
dilatation
of
the
stomach in such children. The stomach remains somewhat distended in chronic starvation, partially due to ingestion of large quantities of very low calorie food [19]. Acute gastric distention occurs when the chronically starved individual suddenly ingests a large quantity of high calorie food. Subsequent to the distention of the stomach by intraluminal contents, there is decompensation with acute gastric dilatation. Radiographic recognition of acute gastric dilatation is not difficult. An enormous left upper quadrant soft tissue mass in the region of the stomach with displacement of adjacent viscera laterally and interiorly is seen in the supine film, and an air-fluid level within the stomach on upright or decubitus examination [9]. If there is a question of mechanical gastric outlet obstruction, an upper gastrointestinal series can be performed in the convalescent period. Radiographic studies are of no particular value in determining that the cause of acute gastric distention in the individual child is the result of nutritional deprivation, unless there is other radiographic evidence of child abuse. However, the presence of this condition in the child who is not postoperative or pharmacologically intoxicated should raise the suspicion of nutritional deprivation. It is of interest that the diagnosis of acute gastric distention secondary to nutritional deprivation was suggested initially by the radiologist in all the cases reported here; the clinicians were unaware of this association. Treatment of acute gastric distention involves decompression of the stomach by nasogastric intubation, appropriate intravenous fluids to counteract shock, and slow resumption of small but frequent oral feedings after 12-24 hr. Treatment of the child and family in which child abuse and deprivation occur is beyond the scope of this paper.
CHILDREN
299
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