Gastric stone disease

　　One, Etiology

　　5. Hair balls are more common, accounting for about 55% of the reported cases of hair stones. This disease affects 90% of women, especially nervous girls who often have the habit of biting and swallowing hair, making it the most likely to occur. Hair balls are mainly composed of a large amount of hair of varying lengths, and may also contain wool, yarn, and plant fibers. Due to the presence of various decomposed products of food, their color is usually dark green or black, and they often have an abnormal foul odor.

　　4. Plant balls are formed by clumps of various plants' bark, seeds, leaves, roots, and fibers, accounting for about 40% of the total. The most common type is formed after eating persimmons, and there are also those formed by eating coconuts, celery, and pumpkins, etc. The easiest way to form plant balls is after eating raw persimmons, as raw persimmons contain a large amount of persimmon tannic acid, which, when combined with gastric acid, becomes a very thick gelatinous substance, which can then combine the fibers and bark, seeds, etc. of plants to form plant balls.

　　3. Stones are the rarest type, accounting for only 3% to 5% of the total. The most peculiar case is that of a painter who has the habit of sucking paint water (an alcohol solution of shellac) and can form large stones in the stomach due to the gradual sedimentation of rosin or resin. Certain drugs such as barium sulfate taken during gastrointestinal contrast studies, magnesium carbonate or bismuth subsalicylate taken by ulcer patients, may also form stones in the stomach.

　　Two, Pathogenesis

　　1. Persimmons contain tannins (phlobatannins), gum, and pectin. Under the action of gastric acid, tannins combine with proteins to form tannic protein, which then combines with pectin, gum, and cellulose to form gastric stones. High acid environment is a condition for the occurrence of gastric stones. Hawthorns, black jujubes, and other fruits also contain a large amount of pectin and tannins, which can often form gastric stones. Persimmons produced in the south have loose and juicy flesh and are not easy to form stones. Gastric stone disease in the remnant stomach generally occurs in patients with residual stomach accompanied by gastric motility disorders, and is mostly of plant origin. The reasons such as high dietary fiber content, reduced output of drainage after surgery, and less food mastication cause the roots, leaves, and bark of plants to coagulate with mucus in the stomach to form stones.

　　2. Hair stones are hair entering the stomach and adhering to the mucosa and not easy to be excreted. Repeated intake can form a ball due to intertwining and entanglement. Hair stones are mostly in the shape of J or U, with a rough and uneven surface, coated with mucus, and have a foul smell. Long-term stimulation of the stomach can cause ulcers or perforations.

　　3. Lactic acid stones are more common in low birth weight newborns fed with high-concentration milk. Low birth weight newborns have weak gastric motility, and high-concentration milk can form lactic acid gastric stones in the stomach. Resin stone is common in painters with the habit of sucking resin alcohol. Some drug components such as calcium carbonate, bismuth preparations, and some hard traditional Chinese medicine pills, as well as barium sulfate used for contrast, have also been reported to form gastric stones in the stomach.

　　The common complications in clinical practice are superficial gastritis and gastric ulcer, with an incidence rate of 60% to 70%. If patients have gastritis, gastric ulcer, gastric hemorrhage, or pyloric stenosis, they may have corresponding clinical manifestations such as recurrent abdominal pain or hematemesis, vomiting, etc. Occasionally, massive hemorrhage, perforation, or gastric stone entering the intestine causing intestinal obstruction may occur, and the clinical symptoms and signs are more obvious and severe.

　　Gastric stone disease is more likely to occur in patients after partial gastrectomy and vagotomy, and in patients with gastroparesis syndrome. It seems to be related to the disorder of gastric motility function in these patients. It can be divided into acute and chronic types. The course of the disease within 6 months is acute, and more than 6 months is chronic. Acute cases are more common. Acute cases may appear symptoms within 1-2 hours after eating a large amount of persimmons, hawthorn, etc., with more than half of the patients experiencing upper abdominal pain and distension, nausea, and vomiting. The amount of vomiting is usually not much, and coffee-colored or bloody vomit may occur, but massive hemorrhage is rare. Physical examination shows that 30% of cases can touch a sliding mass in the upper abdomen. Due to the stimulation and injury caused by the gastric stone to the local mucosa, it often complicates gastric ulcer, gastric mucosal erosion, pyloric stenosis, intestinal obstruction, and occasionally perforation and peritonitis.

　　1. Avoid eating a large amount of persimmons, jujubes, and other fruits on an empty stomach, overcome the bad habit of chewing hair, and actively treat gastrointestinal motility disorders to prevent the recurrence of gastric stones.

　　2. It is best not to eat hawthorn on an empty stomach, and it is even more important to avoid eating milk, sweet potatoes, coffee, seafood, and other foods rich in protein and stimulating gastric acid secretion at the same time.

　　Some patients may present with small cell hypochromic anemia, and some patients may have positive fecal occult blood test. In the early stage, persimmon-like objects can be seen, and the analysis of gastric juice shows that the free acid in the stomach is higher than that of normal people.

　　1. X-ray examination

　　X-ray barium meal examination or barium double-contrast imaging can reveal the phenomenon of分流in the stomach, showing the floating free nature of the barium agent on the upper layer, in the form of mass-like, round or elliptical areas of filling defect, while the gastric mucosal structure is smooth, and the gastric wall is soft. After the barium in the stomach is evacuated, the mass shadow can still be seen with cord-like, reticular, or plate-like barium spots adhering, and there is no obvious tenderness when pressing the mass shadow, and the contour shape and position can change with the force, indicating that the mass has a certain compressibility and mobility.

　　2. Fiberoptic endoscopy examination

　　Under fiberoptic endoscopy, the morphology and characteristics of gastric stones can be directly observed. Plant gastric stones, due to different components of the lump, can be yellow, brown, brown, or green, often circular or elliptical, single or multiple free lumps. The hairy gastric stone is usually black or brown, in the shape of a 'J' or kidney, which can fill the stomach or extend into the duodenum. Fiberoptic endoscopy can also determine whether there are other signs such as gastritis or ulcer disease in the stomach. If necessary, it can also remove the lump components or tissue of complications for analysis. Therefore, hospitals with conditions should consider fiberoptic endoscopy as the first diagnostic method for suspected gastric stone syndrome.

　　3. Ultrasound examination

　　Ultrasound can help in the diagnosis of gastric stones, usually instructing the patient to drink 500 to 1000ml of water, sit or semi-reclining for examination, where clear boundaries of strong echo lumps in the stomach can be seen floating on the water surface, and they can change positions with changes in body position or the stomach's peristalsis.

　　Eating a large amount of persimmons and other fruits rich in tannins is prone to induce gastric stone syndrome. Gastric stone syndrome is a relatively common acute stomach disease, with symptoms such as discomfort in the upper abdomen, fullness, dull pain, loss of appetite, nausea, and vomiting. Common complications include gastric mucosal erosion, ulcer bleeding, and in severe cases, it can lead to gastric perforation and peritonitis. Gastric stones entering the intestines may also cause intestinal obstruction.

　　Experts point out that most of the gastric stone syndromes that have emerged recently are plant gastric stones, which are often caused by eating a large amount of persimmons, jujube, or hawthorn on an empty stomach. Due to the strong astringent tannins contained in these fruits, especially in the unripe fruits, which form tannic protein when they come into contact with gastric acid, which is difficult to dissolve in water. When combined with pectin and plant fibers, they condense into lumps, forming gastric stones.

　　There are many methods for treating gastric stones, and the specific treatment measures adopted depend on the nature of the gastric stone, the patient's physiological and pathological condition, and the equipment conditions of the hospital, among other specific circumstances.

　　1. The treatment of gastric stone with internal medicine includes the use of both Chinese and Western medicine to change the internal environment of the stomach, making the stone soft, soluble, and smaller, improving the stomach's motility function, and promoting its natural excretion. The history of using sodium bicarbonate to treat plant gastric stones is long-standing, with an oral dose of 3 to 4g per time, 3 times a day, and a course of 7 to 10 days. It is also possible to take an equal amount of foaming agent at the same time to enhance the efficacy and shorten the course. Some people advocate adding 0.5 to 1g of pepsin or trypsin on the basis of the above treatment, or using 5 to 10mg of chymotrypsin (alpha-chymotrypsin) dissolved in 50 to 100ml of water for oral administration or injection through a gastric tube. It is also possible to add 0.5g of acetylcysteine dissolved in 50ml of physiological saline for injection through a gastric tube, for 2 to 3 consecutive days, to digest some components of the gastric stone, causing the stone structure to disintegrate and dissolve for excretion. For patients with poor gastric motility, metoclopramide (antivert), domperidone, or cisapride can be used to promote gastric peristalsis for stone excretion. In addition, there are reports that adding 50mg of papain or 5mg of cellulase dissolved in 1000ml of water and taking it for 2 consecutive days can also be effective.

　　The treatment of gastric stones with traditional Chinese medicine is one of the traditional internal medicine treatment methods in China. According to TCM, the pathogenesis of gastric stones belongs to food accumulation and retention, which is retained in the stomach. Therefore, it is treated with methods such as reducing food accumulation, softening hard lumps, harmonizing the stomach and spleen, and promoting qi and blood circulation. Commonly used drugs include huanglian, jishu, shenqu, maiya, jinejin, pangolia, sanlie, yangju, taoren, Danshen, etc. They are decocted in water and taken 2 to 3 times a day for 5 to 7 days, and added or reduced according to the condition. For example, for abdominal pain, add yuanhu, baishao, and gancao; for vomiting, add banxia and zhuru; for occult blood in stools, add baijie and chao da huang; for weak constitution, add dangshen and taizishen; for constipation, add da huang or fangjiaoye, etc.

　　For the treatment of gastric stones with Western medicine or traditional Chinese medicine, the medication should be taken between meals or on an empty stomach, which is conducive to the full interaction of the drug with the gastric stone and improves the therapeutic effect.

　　2. Manual lithotripsy therapy can be tried for patients with gastric stones without obvious symptoms and complications, such as persimmon stones, hawthorn stones, etc. Abdominal external massage and compression can be performed to break the gastric lump into small pieces, and then washing the stomach or giving laxatives can accelerate the excretion of the lump.

　　3. The X-ray meshing lithotripsy method was used in the past to make a mesh using metal wire and insert it into the stomach tube. When the barium agent showed the gastric stone, the mesh was allowed to envelop and the wire was tightened to cut the gastric stone. Repeated operations cut it into pieces and allow them to be naturally excreted. Carbonic anhydrase inhibitors, metoclopramide (stomach anesthetic), and other drugs can also be taken to promote stone excretion.

　　4. The application of fiberendoscopic lithotripsy for the treatment of gastric stones has developed rapidly, with many methods. The gastric stone envelope or shell can be broken by biting, cutting, pounding, and piercing with biopsy forceps under the endoscope, and cleaned repeatedly with water; or the endoscopic surgical knife can be used to repeatedly cut the gastric stone envelope and lumps. Alternatively, a wire loop can be used under the fiber endoscope to cut the stone body, and then the fragments can be caught with a scoop clamp to allow them to be naturally excreted. In recent years, laser lithotripsy under fiberendoscopy has become a new effective method for treating gastric stones in China, especially for larger and harder stones. After inserting the fiber endoscope to see the gastric stone clearly, rinse it clean with normal saline to expose it fully. Then, normal saline is injected to allow the gastric stone to be half-submerged in water, giving it certain buffering force during explosion. Then, the optical fiber bullet is inserted through the gastroscopy biopsy forceps tube and made to rest on the surface of the center of the stone. At this point, the laser generator is charged and ignited, which can break the stone or create a small hole. After that, by repeatedly igniting 3 to 5 bullets along the cracks or small holes, the stone can be shattered into small pieces or granular form. In addition, microwave lithotripsy under fiberendoscopy is also a simple method recently applied in the treatment of gastric stones. Under routine endoscopy, expose the stone, insert a microwave antenna through the biopsy forceps hole, select a power of 60 to 90W, and aim the microwave electrode head at the gastric stone, apply power to repeatedly burn it, and change the position of the stone until it is burned into a honeycomb shape or broken into pieces.

　　During the process of碎stone under fiberoptic endoscopy, a thin plastic tube can be inserted through a biopsy forceps, and 10% sodium bicarbonate 150 to 200ml can be injected into the shattered gastric stone, which is conducive to the softening and excretion of the stone, and improves the cure rate. If the patient with gallstones does not have gastritis, ulcer disease, or other complications, no special treatment is needed after the stone is broken. It is recommended to eat a low-fiber diet for 3 days and reexamine after 1 week; if complications such as gastritis and ulcer disease are present, antibiotics, gastric mucosal protective agents, and antihistamines, H2 receptor antagonists, and other corresponding treatments should be administered.

　　5. Extracorporeal Shock Wave Therapy Extracorporeal shock wave therapy, which has developed from treating kidney stones to treating gallstones, has recently been successfully tested for treating gastric stones. Two days before treatment, a liquid diet should be consumed. No anesthesia is required during treatment. Patients are instructed to drink 500ml of water to fill the stomach, then lie on their stomach for B-ultrasound localization. At a voltage of 12kv, 80 discharges per minute are applied for a total of 1500 to 2000 times, and the stones generally appear as broken shadows. There is no discomfort to the patient during the treatment, and it does not cause damage to the gastric mucosa. Three days after treatment, a B-ultrasound reexamination is conducted to determine if the stones have been completely expelled.

　　6. For large, hard gallstones that are difficult to dissolve and for those who have not responded to medical treatment, endoscopic碎石, microwave or shock wave therapy, or have complications such as severe gastric ulcers, bleeding, perforation, or obstruction, surgical treatment is recommended.