Gastric mucosal prolapse syndrome

　　1. Etiology

　　When there is inflammation in the antrum of the stomach, the submucosal connective tissue becomes relaxed, the gastric mucosa and submucosa become edematous, hyperplastic, and thickened, forming hyperplastic and elongated mucosal folds. At the same time, the enhanced peristalsis of the stomach can easily push the mucosal folds into the pylorus to form gastric mucosal prolapse; in addition, if the mucosal muscle layer is dysfunctional, it cannot maintain the normal longitudinal folds of the antrum mucosa during the contraction of the antrum, instead curling into a ring shape, which is then pushed into the pylorus by the contracted antrum to form gastric mucosal prolapse; when malignant lesions infiltrate the mucosa, they can cause hyperplasia and elongation of the mucosa, loss of activity of the normal gastric mucosa, and the hypertrophied mucosa acts as a foreign body, being pushed out of the pyloric canal by the enhanced peristalsis of the stomach, leading to gastric mucosal prolapse; when there is an anatomical abnormality in the stomach, that is, there is a mucosal septum in the antrum, which prevents the retrograde peristalsis of the mucosa, it is easy to produce this disease. In addition, factors such as stress, smoking, alcohol, coffee stimulation, chemical factors, and mechanical stimulation can cause severe peristalsis of the stomach and can also lead to gastric mucosal prolapse.

　　2. Pathogenesis

　　Under normal circumstances, the mucosa at the gastric pylorus is thicker, and the mucosa and submucosa together form folds, which are irregularly arranged. The mucosa inside the pyloric sphincter forms folds, known as the pyloric valve. Its physiological function is: when the pyloric sphincter contracts, it closes the pylorus to prevent the contents of the stomach from entering the duodenum. Therefore, when the stomach contracts, there is a tendency to push the mucosa at the pylorus out and prolapse into the duodenum. However, due to the action of the mucosal muscle, the mucosa of the antrum can change its size, shape, position, and direction of movement autonomously, without being controlled by the contraction of the gastric muscle layer. Before the contraction of the antrum, the mucosal folds at this site are arranged in a longitudinal manner parallel to the gastric longitudinal axis. Due to the contraction of the gastric mucosal muscle, the folds have a tendency to move away from the pylorus, thus ensuring that the mucosa at this site is not pushed into the duodenum during the contraction of the antrum.

　　1. In patients with gastric mucosal prolapse, more than half of them have chronic gastritis simultaneously, so chronic gastritis should be treated first to reduce the factors leading to gastric mucosal prolapse. Therefore, it is necessary to eliminate various possible pathogenic factors: such as thoroughly treating acute gastritis and chronic infections in the oral cavity and pharynx, avoiding taking foods and drugs that irritate the stomach; for those with dyspeptic symptoms, drugs should be used according to the treatment principles of peptic ulcer, such as various acid inhibitors and gastric mucosal protective agents; thoroughly eradicate Hp, because it is currently believed that Hp infection is closely related to chronic gastritis, so it is necessary to actively treat it; for patients with bile reflux gastritis, gastric anxiolysis and bile tyrosine can be used for treatment, metoclopramide (gastric anxiolysis) has the effect of promoting the motility of the stomach and duodenum, accelerating the emptying of the stomach, and reducing bile reflux; bile tyrosine can combine with bile salts in the stomach and accelerate the excretion of bile salts.

　　2. Concurrent peptic ulcer: In patients with gastric mucosal prolapse, some may have concurrent peptic ulcer, so it is necessary to treat the peptic ulcer and reduce its pathogenic factors. First, drugs that reduce damage factors should be used: such as acid-suppressing agents, anticholinergic drugs, H2 receptor antagonists, proglumide, prostaglandin E2 synthetic agents, and omeprazole, etc. At the same time, drugs that protect the gastric mucosa should be given: such as sucralfate, bismuth preparations, glycyrrhizin (Shengweikang), and the use of antibiotics.

　　3. Concurrent upper gastrointestinal bleeding: In patients with gastric mucosal prolapse, some may have concurrent upper gastrointestinal bleeding, so it is also necessary to actively treat this condition. When patients experience upper gastrointestinal bleeding, they should rest in bed and closely monitor their blood pressure, pulse, and changes in blood loss, ensuring a clear airway. At the same time, if the patient's hemoglobin is less than 90g/L, or the systolic blood pressure is less than 12kPa (90mmHg), sufficient whole blood should be administered. At this time, if the bleeding is still not controlled, oral thrombin, batroxobin (Liqizhi), or ice water solution containing norepinephrine can be taken. If the aforementioned methods and conservative medical treatment with internal medicine drugs cannot control the bleeding, hemostasis can be performed under endoscopic visualization using high-frequency electro-laser. If all the aforementioned methods are ineffective, surgical treatment can be performed.

　　1. Abdominal pain

　　Abdominal pain is the most common symptom, without clear periodicity or rhythm. Pain may be induced after eating, often presenting as intermittent pain, burning pain, irregular bloating or pricking pain, etc. Generally, there is no radiation pain, and it is often accompanied by discomfort and fullness in the upper abdomen, belching, loss of appetite, and other symptoms. Sometimes, the onset of pain is also related to body position, with pain more likely to occur in the right lateral position, while pain is less likely or does not occur in the left lateral position. Some believe that this point is a characteristic manifestation of the disease. Antacid treatment is generally ineffective, and alkaline drugs are also not easy to alleviate. Sometimes, when the prolapsed mucosa blocks the pyloric canal, causing incarceration or stenosis, persistent and severe pain in the upper abdomen may occur, accompanied by symptoms such as nausea and vomiting.

　　2. Upper gastrointestinal bleeding

　　Gastric mucosal prolapse is relatively common, with most cases showing minor bleeding, while a few may lead to massive hemorrhage, even resulting in hemorrhagic shock. In the 370 cases of gastric mucosal prolapse reported by Feldman, 22% experienced bleeding, with massive hemorrhage reaching 9.4%. Bleeding can be caused by erosion or ulceration on the prolapsed mucosal surface, or by the prolapsed mucosa becoming incarcerated, and due to the frequent coexistence of gastric and duodenal ampulla ulcers, the cause of bleeding is sometimes difficult to distinguish. Therefore, it is necessary to carefully inquire about the medical history, conduct a thorough physical examination, and rely on endoscopic examination for diagnosis.

　　3. Pyloric stenosis

　　Its incidence is very low. Most patients have nausea and vomiting during attacks, which can occur after eating. There is often severe pain in the upper abdomen, which may subside or disappear after vomiting.

　　4. Signs

　　Patients may have weight loss, mild anemia, mild tenderness in the upper abdomen, no rebound tenderness. When the mucosa is incarcerated in the pyloric canal, there may be a gastric shape or gastric peristalsis wave, and a soft mass can be felt in the upper abdomen. There may be a tympany sound in the upper abdomen.

　　Gastroenterologists suggest mainly adopting a diet of eating less and more frequently, lying on the left side, and using measures such as sedatives and anticholinergic drugs at the same time.

　　1. Maintain a cheerful mood. Emotional factors have a great impact on appetite, digestion, and absorption. Stress and emotional excitement can cause strong peristalsis of the stomach, induce gastric mucosal prolapse, or worsen the condition. Therefore, it is necessary to maintain a good mood in daily life to help the normal operation of the gastrointestinal system.

　　2. Pay attention to eating less and more frequently, and avoid spicy and刺激性 foods. Eat less刺激性 and difficult-to-digest foods, such as spicy, fried, hard, sticky foods, and try to eat less cold foods. Also, quit smoking and reduce alcohol intake to minimize further damage to the already damaged gastric mucosa.

　　3. Actively treat diseases such as gastric antrum inflammation. Since diseases such as gastric antrum inflammation are the main factors causing gastric mucosal prolapse, the treatment of gastric antrum inflammation has also become the focus of prevention and treatment of gastric mucosal prolapse.

　　Fecal occult blood test may be positive; gastric juice analysis is normal. If hyperacidity occurs, there may be a possibility of a duodenal ampulla ulcer.

　　1. Endoscopic examination

　　Its value is limited and can only be used as a means. During the examination, the gastric antrum mucosa may be normal or show punctate congestion, edema, and sometimes punctate hemorrhage, erosion, or superficial ulcers. When the gastric antrum contracts, the mucosal folds are very obvious, forming a chrysanthemum-like shape, covering the pyloric orifice. When the gastric antrum relaxes, the folds prolapsing into the duodenum can be seen to reflux into the gastric cavity through the pyloric canal.

　　2. Barium meal X-ray examination

　　Barium meal X-ray examination is an important basis for diagnosing gastric mucosal prolapse, but the X-ray manifestations are diverse and often transient. When examined in the right anterior oblique position, the positive detection rate is high. At the same time, the X-ray manifestations depend on the amount, degree, and severity of the prolapsed mucosa. When there is slight prolapse, only a strip-shaped mucosal fold can be seen in the pyloric canal, slightly extending beyond the pyloric ring into the fundus. It usually appears easily under strong peristalsis. The typical X-ray manifestation is that there is a concave filling defect at the base of the duodenal ampulla, which appears like a vegetable, mushroom, or umbrella. The gastric mucosa prolapsing into the duodenal ampulla can form small circular or semi-circular translucent areas in the fundus. The pyloric canal is often wider than normal, and it can be seen that normal or slightly enlarged gastric mucosal folds pass through the pylorus to the duodenal ampulla. Gastric peristalsis is often enhanced, and sometimes the translucent area prolapsing into the duodenum is biased to one side. With the gastric peristalsis, contraction, and the pushing method during the examination, the prolapsed mucosal folds can vary in number or appear and disappear. Therefore, the above manifestations can be light or heavy, or appear and disappear intermittently.

　　What kind of food is good for the body for gastric mucosal prolapse:Eating fungi is helpful to protect the gastric mucosa. The sun mushroom is now known as a delicacy because of its high nutritional value, mainly due to its rich sulfur content, which has a good therapeutic effect on various chronic gastritis. It can be used to make soup, or if it is not convenient, you can choose an oral liquid, which is small in molecules and easy to absorb. I heard that the Taiyang Shen Sun Mushroom gastrointestinal health oral liquid is quite good, and you should try it. But the most important thing is to 'nourish' the stomach, eat less and more frequently. Eat more fluid foods that are easy to absorb, such as white rice porridge.

　　First, treatment

　　1. Pay attention to diet in general treatment

      Eat less and more frequently, quit smoking and alcohol, avoid刺激性 food; pay attention to body position, adopt a left lateral position, and try to avoid a right lateral position; sedative drugs and anticholinergic drugs can be given to suppress excessive gastric peristalsis and reduce the chance of prolapse. Patients with pyloric stenosis should fast, apply gastric decompression, and supplement fluids and correct water and electrolyte imbalances; patients with gastritis and ulcer or upper gastrointestinal bleeding should receive appropriate treatment.

　　2. Treatment under gastroscopy

　　(1) Microwave therapy: under endoscopic vision, microwave coaxial cable is introduced through the biopsy hole. According to the volume and length of the prolapsed mucosa, the cable is aimed at the head and body of the prolapsed mucosa within or near the pyloric canal. The working current is 150mA, and the treatment time is until the mucosa at that place is coagulated and whitened, generally about 2 to 4 seconds. The treatment site is from 1 to 8 points. The thermal effect of microwave can cause protein coagulation and denaturation, water vaporization and evaporation, and the treated tissue to contract and shrink. The local tissue is repaired and flattened, so it can treat partial obstruction caused by prolapsed mucosa at the pylorus, with an overall effective rate of 85.7%.

　　(2) Treatment by high-frequency electric knife: preoperative coagulation time, platelet count, and prothrombin time should be checked; 10mg of diazepam (安定) and 10mg of anisodamine hydrobromide (654-2) are injected intramuscularly 30 minutes before the operation. Under endoscopic vision, the coagulation ring is aimed at the distal side of the prolapsed mucosa within or near the pyloric canal, and the ring is opened to wrap around the prolapsed fold, making the wrapped mucosa 0.5 to 0.7cm higher than the ring to prevent contact with other parts. The ring is tightened to make the wrapped tissue dark red, and it is strictly forbidden to use excessive force to avoid mechanical amputation. The wrapped tissue is cut using PSD-10 mixed current '3' to '4', and the通电 time is not specified.

　　Observe for 5 to 7 days, and especially instruct the patient to pay attention to whether there is black stool; if there is, visit the doctor promptly.

　　It is not advisable to eat hard and rough foods within 7 days; semi-liquid foods are recommended.

　　③All use acid inhibitors, mucosal protective agents, and oral antibiotics to promote the healing of the wound surface.

　　The symptoms caused by this disease are only a small segment of mucosal folds blocking the pyloric canal, PSD-10 mixed current has the advantages of cutting and coagulating, the removal of the small segment of mucosa causing symptoms can achieve the therapeutic purpose, the total effective rate is 95％.

　　3. Traditional Chinese Medicine Treatment

　　(1) Acupuncture Treatment:

　　①Neiguan (PC 6), Zu San Li (ST 36), and Zhongwan (CV 12) are the main acupoints. Spleen Shu (BL 21), Stomach Shu (BL 25), Zhangmen (LR 13), and Qimen (LR 14) can be selected 1-2 acupoints.实证 use purgation method, deficiency use tonification method, retention needle for about 20 minutes or use electric needle.

　　②Moxibustion at Stomach 36 (Zu San Li), Shenque (CV 8), and Neiguan (PC 6) is suitable for deficiency-cold syndrome.

　　(2) Traditional Chinese Medicine Treatment: This condition belongs to the category of traditional Chinese medicine diseases such as 'reverse gastritis' and 'epigastric pain', and the effect of TCM syndrome differentiation and treatment is relatively satisfactory.

　　①Spleen and stomach cold: Symptoms include epigastric hidden pain, bloating after eating, epigastric stuffiness, preference for warmth and pressure, aversion to cold and limb coolness, fatigue, shortness of breath, drowsiness, poor appetite and loose stools, pale and bloated tongue with white greasy fur, wiry and slippery pulse. Treatment with warming the middle-jiao and dispersing cold, invigorating the spleen and transforming dampness, the formula is Qikui Pingwei Powder with modification.

　　②Spleen and stomach damp-heat: Symptoms include epigastric burning pain, severe pain after intake, especially severe with hot food, pain拒按, nausea and vomiting, dry mouth and thirst, dry stools or uncomfortable, yellow and red urine, red tongue with yellow greasy fur, wiry and slippery pulse. Treatment with clearing heat and removing dampness, harmonizing the stomach and reversing, the formula is Erhuang Yindan Decoction with modification.

　　③Cold and heat, deficiency and excess mixed: Symptoms include epigastric stuffiness and pain, aggravation after intake, accompanied by acid regurgitation and nausea, frequent belching, dry mouth and bitter taste, aversion to cold and preference for warmth, poor appetite and fatigue, stools dry or loose or uncomfortable, yellow or yellow and white intermingled tongue fur, wiry and thin pulse. Treatment with acrid opening and bitter descending, and balancing cold and heat, the formula is half Buzhong Yixiao Decoction combined with Zijin Pill with modification.

　　4. Surgical Treatment

　　Severe and recurrent upper gastrointestinal bleeding, pyloric obstruction with persistent vomiting or severe upper abdominal pain, ineffective after internal medicine treatment, suspected of malignancy may consider surgical treatment. As for the type of surgery, it is currently considered that subtotal gastrectomy and gastrojejunal anastomosis have the best efficacy.

　　II. Prognosis

　　The pathogenesis of this disease is not yet clear. As far as is known, any factor that can cause severe peristalsis of the stomach can cause this disease. The main treatment for this disease is internal medicine, but there is no specific drug. The principle of drug treatment is to reduce peristalsis of the stomach, avoid the mucosal invagination into the pyloric canal, and also actively treat coexisting diseases.

　　Severe and recurrent upper gastrointestinal bleeding, pyloric obstruction with persistent vomiting or severe upper abdominal pain, ineffective after internal medicine treatment, suspected of malignancy may consider surgical treatment. As for the type of surgery, it is currently considered that subtotal gastrectomy and gastrojejunal anastomosis have the best efficacy.