Gastric outlet obstruction: Difference between revisions

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==Differentiating {{PAGENAME}} from Other Diseases==
==Differentiating {{PAGENAME}} from Other Diseases==
==Table==
<div style="width: 85%;"><small>
{| class="wikitable"
! rowspan="3" |Disease
! rowspan="3" |Cause
! colspan="9" |Symptoms
!Diagnosis
! rowspan="3" |Other findings
|-
! colspan="3" |Pain
! rowspan="2" |Nausea
&
Vomiting
! rowspan="2" |Heartburn
! rowspan="2" |Belching or
Bloating
! rowspan="2" |Weight loss
! rowspan="2" |Loss of
Appetite
! rowspan="2" |Stools
! rowspan="2" |Endoscopy findings
|-
!Location
!Aggravating Factors
!Alleviating Factors
|-
!Gastric outlet obstruction
|
*[[Peptic ulcer|PUD]]: 5% cases (most commonly affecting [[pylorus]] and initial part of the [[duodenum]])
*[[Polyps|Gastric polyps]]<ref name="pmid7129059">{{cite journal |vauthors=Miner PB, Harri JE, McPhee MS |title=Intermittent gastric outlet obstruction from a pedunculated gastric polyp |journal=Gastrointest. Endosc. |volume=28 |issue=3 |pages=219–20 |year=1982 |pmid=7129059 |doi= |url=}}</ref><ref name="pmid12831404">{{cite journal |vauthors=Gencosmanoglu R, Sen-Oran E, Kurtkaya-Yapicier O, Tozun N |title=Antral hyperplastic polyp causing intermittent gastric outlet obstruction: case report |journal=BMC Gastroenterol |volume=3 |issue= |pages=16 |year=2003 |pmid=12831404 |pmc=166166 |doi=10.1186/1471-230X-3-16 |url=}}</ref>
*[[Caustic|Caustic ingestion]]<ref name="pmid2753330">{{cite journal |vauthors=Zargar SA, Kochhar R, Nagi B, Mehta S, Mehta SK |title=Ingestion of corrosive acids. Spectrum of injury to upper gastrointestinal tract and natural history |journal=Gastroenterology |volume=97 |issue=3 |pages=702–7 |year=1989 |pmid=2753330 |doi= |url=}}</ref>
*[[Stenosis|Duodenal stricture]] <ref name="pmid2000520">{{cite journal |vauthors=Taylor SM, Adams DB, Anderson MC |title=Duodenal stricture: a complication of chronic fibrocalcific pancreatitis |journal=South. Med. J. |volume=84 |issue=3 |pages=338–41 |year=1991 |pmid=2000520 |doi= |url=}}</ref>
*Systemic [[amyloidosis]] of the [[gastrointestinal tract]] <ref name="pmid8331978">{{cite journal |vauthors=Menke DM, Kyle RA, Fleming CR, Wolfe JT, Kurtin PJ, Oldenburg WA |title=Symptomatic gastric amyloidosis in patients with primary systemic amyloidosis |journal=Mayo Clin. Proc. |volume=68 |issue=8 |pages=763–7 |year=1993 |pmid=8331978 |doi= |url=}}</ref><ref name="pmid9891699">{{cite journal |vauthors=Friedman S, Janowitz HD |title=Systemic amyloidosis and the gastrointestinal tract |journal=Gastroenterol. Clin. North Am. |volume=27 |issue=3 |pages=595–614, vi |year=1998 |pmid=9891699 |doi= |url=}}</ref>
*Eosinophillic [[gastroenteritis]] <ref name="pmid10660821">{{cite journal |vauthors=Khan S, Orenstein SR |title=Eosinophilic gastroenteritis masquerading as pyloric stenosis |journal=Clin Pediatr (Phila) |volume=39 |issue=1 |pages=55–7 |year=2000 |pmid=10660821 |doi=10.1177/000992280003900109 |url=}}</ref><ref name="pmid11400803">{{cite journal |vauthors=Chaudhary R, Shrivastava RK, Mukhopadhyay HG, Diwan RN, Das AK |title=Eosinophilic gastritis--an unusual cause of gastric outlet obstruction |journal=Indian J Gastroenterol |volume=20 |issue=3 |pages=110 |year=2001 |pmid=11400803 |doi= |url=}}</ref><ref name="pmid17614041">{{cite journal |vauthors=Tursi A, Rella G, Inchingolo CD, Maiorano M |title=Gastric outlet obstruction due to gastroduodenal eosinophilic gastroenteritis |journal=Endoscopy |volume=39 Suppl 1 |issue= |pages=E184 |year=2007 |pmid=17614041 |doi=10.1055/s-2006-945125 |url=}}</ref><ref name="pmid14669340">{{cite journal |vauthors=Chen MJ, Chu CH, Lin SC, Shih SC, Wang TE |title=Eosinophilic gastroenteritis: clinical experience with 15 patients |journal=World J. Gastroenterol. |volume=9 |issue=12 |pages=2813–6 |year=2003 |pmid=14669340 |pmc=4612059 |doi= |url=}}</ref><ref name="pmid8420276">{{cite journal |vauthors=Lee CM, Changchien CS, Chen PC, Lin DY, Sheen IS, Wang CS, Tai DI, Sheen-Chen SM, Chen WJ, Wu CS |title=Eosinophilic gastroenteritis: 10 years experience |journal=Am. J. Gastroenterol. |volume=88 |issue=1 |pages=70–4 |year=1993 |pmid=8420276 |doi= |url=}}</ref>
*[[Obstruction]] by [[Gallstone disease|gallstones]] (Bouveret syndrome)
*Complication of [[acute pancreatitis]]: [[pancreatic pseudocyst]] formation<ref name="pmid6732492">{{cite journal |vauthors=Aranha GV, Prinz RA, Greenlee HB, Freeark RJ |title=Gastric outlet and duodenal obstruction from inflammatory pancreatic disease |journal=Arch Surg |volume=119 |issue=7 |pages=833–5 |year=1984 |pmid=6732492 |doi= |url=}}</ref><ref name="pmid4811173">{{cite journal |vauthors=Agrawal NM, Gyr N, McDowell W, Font RG |title=Intestinal obstruction due to acute pancreatitis. Case report and review of literature |journal=Am J Dig Dis |volume=19 |issue=2 |pages=179–85 |year=1974 |pmid=4811173 |doi= |url=}}</ref>
*[[Chronic pancreatitis]] <ref name="pmid2658160">{{cite journal |vauthors=Bradley EL |title=Complications of chronic pancreatitis |journal=Surg. Clin. North Am. |volume=69 |issue=3 |pages=481–97 |year=1989 |pmid=2658160 |doi= |url=}}</ref><ref name="pmid19629001">{{cite journal |vauthors=Levenick JM, Gordon SR, Sutton JE, Suriawinata A, Gardner TB |title=A comprehensive, case-based review of groove pancreatitis |journal=Pancreas |volume=38 |issue=6 |pages=e169–75 |year=2009 |pmid=19629001 |doi=10.1097/MPA.0b013e3181ac73f1 |url=}}</ref>
*[[Sarcoidosis]] of the [[Gastrointestinal tract|GIT]] <ref name="pmid2180656">{{cite journal |vauthors=Stampfl DA, Grimm IS, Barbot DJ, Rosato FE, Gordon SJ |title=Sarcoidosis causing duodenal obstruction. Case report and review of gastrointestinal manifestations |journal=Dig. Dis. Sci. |volume=35 |issue=4 |pages=526–32 |year=1990 |pmid=2180656 |doi= |url=}}</ref><ref name="pmid807981">{{cite journal |vauthors=Johnson FE, Humbert JR, Kuzela DC, Todd JK, Lilly JR |title=Gastric outlet obstruction due to X-linked chronic granulomatous disease |journal=Surgery |volume=78 |issue=2 |pages=217–23 |year=1975 |pmid=807981 |doi= |url=}}</ref><ref name="pmid6623357">{{cite journal |vauthors=Mulholland MW, Delaney JP, Simmons RL |title=Gastrointestinal complications of chronic granulomatous disease: surgical implications |journal=Surgery |volume=94 |issue=4 |pages=569–75 |year=1983 |pmid=6623357 |doi= |url=}}</ref><ref name="pmid16970572">{{cite journal |vauthors=Huang A, Abbasakoor F, Vaizey CJ |title=Gastrointestinal manifestations of chronic granulomatous disease |journal=Colorectal Dis |volume=8 |issue=8 |pages=637–44 |year=2006 |pmid=16970572 |doi=10.1111/j.1463-1318.2006.01030.x |url=}}</ref>
*[[Bezoar|Bezoars]]<ref name="pmid9291515">{{cite journal |vauthors=Bakken DA, Abramo TJ |title=Gastric lactobezoar: a rare cause of gastric outlet obstruction |journal=Pediatr Emerg Care |volume=13 |issue=4 |pages=264–7 |year=1997 |pmid=9291515 |doi= |url=}}</ref><ref name="pmid10328129">{{cite journal |vauthors=De Backer A, Van Nooten V, Vandenplas Y |title=Huge gastric trichobezoar in a 10-year-old girl: case report with emphasis on endoscopy in diagnosis and therapy |journal=J. Pediatr. Gastroenterol. Nutr. |volume=28 |issue=5 |pages=513–5 |year=1999 |pmid=10328129 |doi= |url=}}</ref><ref name="pmid9663194">{{cite journal |vauthors=Phillips MR, Zaheer S, Drugas GT |title=Gastric trichobezoar: case report and literature review |journal=Mayo Clin. Proc. |volume=73 |issue=7 |pages=653–6 |year=1998 |pmid=9663194 |doi=10.1016/S0025-6196(11)64889-1 |url=}}</ref><ref name="pmid14738689">{{cite journal |vauthors=White NB, Gibbs KE, Goodwin A, Teixeira J |title=Gastric bezoar complicating laparoscopic adjustable gastric banding, and review of literature |journal=Obes Surg |volume=13 |issue=6 |pages=948–50 |year=2003 |pmid=14738689 |doi=10.1381/096089203322618849 |url=}}</ref><ref name="pmid16448609">{{cite journal |vauthors=Zapata R, Castillo F, Córdova A |title=[Gastric food bezoar as a complication of bariatric surgery. Case report and review of the literature] |language=Spanish; Castilian |journal=Gastroenterol Hepatol |volume=29 |issue=2 |pages=77–80 |year=2006 |pmid=16448609 |doi= |url=}}</ref>
*[[Crohn's disease]] involving the [[duodenum]] <ref name="pmid2919581">{{cite journal |vauthors=Nugent FW, Roy MA |title=Duodenal Crohn's disease: an analysis of 89 cases |journal=Am. J. Gastroenterol. |volume=84 |issue=3 |pages=249–54 |year=1989 |pmid=2919581 |doi= |url=}}</ref><ref name="pmid16278730">{{cite journal |vauthors=Kefalas CH |title=Gastroduodenal Crohn's disease |journal=Proc (Bayl Univ Med Cent) |volume=16 |issue=2 |pages=147–51 |year=2003 |pmid=16278730 |pmc=1201000 |doi= |url=}}</ref><ref name="pmid9360875">{{cite journal |vauthors=Matsui T, Hatakeyama S, Ikeda K, Yao T, Takenaka K, Sakurai T |title=Long-term outcome of endoscopic balloon dilation in obstructive gastroduodenal Crohn's disease |journal=Endoscopy |volume=29 |issue=7 |pages=640–5 |year=1997 |pmid=9360875 |doi=10.1055/s-2007-1004271 |url=}}</ref><ref name="pmid6106466">{{cite journal |vauthors=Fitzgibbons TJ, Green G, Silberman H, Eliasoph J, Halls JM, Yellin AE |title=Management of Crohn's disease involving the duodenum, including duodenal cutaneous fistula |journal=Arch Surg |volume=115 |issue=9 |pages=1022–8 |year=1980 |pmid=6106466 |doi= |url=}}</ref>
*[[Stomach|Gastro]]-[[Duodenum|duodenal]] [[tuberculosis]]<ref name="pmid12703983">{{cite journal |vauthors=Amarapurkar DN, Patel ND, Amarapurkar AD |title=Primary gastric tuberculosis--report of 5 cases |journal=BMC Gastroenterol |volume=3 |issue= |pages=6 |year=2003 |pmid=12703983 |pmc=155648 |doi= |url=}}</ref><ref name="pmid15540690">{{cite journal |vauthors=Rao YG, Pande GK, Sahni P, Chattopadhyay TK |title=Gastroduodenal tuberculosis management guidelines, based on a large experience and a review of the literature |journal=Can J Surg |volume=47 |issue=5 |pages=364–8 |year=2004 |pmid=15540690 |pmc=3211943 |doi= |url=}}</ref><ref name="pmid16217956">{{cite journal |vauthors=Padussis J, Loffredo B, McAneny D |title=Minimally invasive management of obstructive gastroduodenal tuberculosis |journal=Am Surg |volume=71 |issue=8 |pages=698–700 |year=2005 |pmid=16217956 |doi= |url=}}</ref><ref name="pmid8677960">{{cite journal |vauthors=Di Placido R, Pietroletti R, Leardi S, Simi M |title=Primary gastroduodenal tuberculous infection presenting as pyloric outlet obstruction |journal=Am. J. Gastroenterol. |volume=91 |issue=4 |pages=807–8 |year=1996 |pmid=8677960 |doi= |url=}}</ref><ref name="pmid3605037">{{cite journal |vauthors=Subei I, Attar B, Schmitt G, Levendoglu H |title=Primary gastric tuberculosis: a case report and literature review |journal=Am. J. Gastroenterol. |volume=82 |issue=8 |pages=769–72 |year=1987 |pmid=3605037 |doi= |url=}}</ref>
* Pyloric stenosis
* Ingestion of [[corrosive|corrosives]]
|
*Early stages:<ref name="pmid7129059">{{cite journal |vauthors=Miner PB, Harri JE, McPhee MS |title=Intermittent gastric outlet obstruction from a pedunculated gastric polyp |journal=Gastrointest. Endosc. |volume=28 |issue=3 |pages=219–20 |year=1982 |pmid=7129059 |doi= |url=}}</ref><ref name="pmid7771437">{{cite journal |vauthors=Urayama S, Kozarek R, Ball T, Brandabur J, Traverso L, Ryan J, Wechter D |title=Presentation and treatment of annular pancreas in an adult population |journal=Am. J. Gastroenterol. |volume=90 |issue=6 |pages=995–9 |year=1995 |pmid=7771437 |doi= |url=}}</ref>
* [[Nausea and vomiting|Nausea]]
* [[Nausea and vomiting|Vomiting]]: characteristic feature
** Intermittent
** Occurs one hour after [[ingestion]]
** Non [[Bile|bilious]]
** Contains undigested particles of food
** Patient has intolerance to solids, followed by liquids
** [[Dehydration]]
** [[Electrolyte disturbance|Electrolyte abnormalities]]
Late stages:<ref name="pmid2207566">{{cite journal |vauthors=Johnson CD, Ellis H |title=Gastric outlet obstruction now predicts malignancy |journal=Br J Surg |volume=77 |issue=9 |pages=1023–4 |year=1990 |pmid=2207566 |doi= |url=}}</ref><ref name="pmid7572891">{{cite journal |vauthors=Shone DN, Nikoomanesh P, Smith-Meek MM, Bender JS |title=Malignancy is the most common cause of gastric outlet obstruction in the era of H2 blockers |journal=Am. J. Gastroenterol. |volume=90 |issue=10 |pages=1769–70 |year=1995 |pmid=7572891 |doi= |url=}}</ref><ref name="pmid16817848">{{cite journal |vauthors=Cappell MS, Davis M |title=Characterization of Bouveret's syndrome: a comprehensive review of 128 cases |journal=Am. J. Gastroenterol. |volume=101 |issue=9 |pages=2139–46 |year=2006 |pmid=16817848 |doi=10.1111/j.1572-0241.2006.00645.x |url=}}</ref><ref name="pmid717362">{{cite journal |vauthors=Dubois A, Price SF, Castell DO |title=Gastric retention in peptic ulcer disease. A reappraisal |journal=Am J Dig Dis |volume=23 |issue=11 |pages=993–7 |year=1978 |pmid=717362 |doi= |url=}}</ref>
* [[Weight loss]]
* [[Malnutrition]]: more pronounced in patients with [[Cancer|malignancy]]
* [[Abdominal distension]]
* Features of incomplete [[obstruction]]
* [[Stomach|Gastric]] retention: presenting as early [[satiety]]
* [[Bloating]]
* Fullness of [[epigastrium]]
* [[Aspiration pneumonia]]: due to [[Dilation|dilatation]] of [[stomach]], loss of [[contractility]] and accumulation of undigested food contents
|Food
|-
|✔
|✔
|✔
|may be present in case of GOO due to malignancy
|✔
|[[Melena|Black stools]] in case of GOO due to PUD
|
*Helps in the determination of site of [[obstruction]]
*Helps in the visualization of the [[Stomach|gastric]] silhouette:
*Helps note the following:
**[[Stomach|Gastric]] [[dilation]]
**Narrowing of the [[pylorus]]
**Presence of [[Ulcer|ulcers]]
**[[Tumor|Tumors]]
**Differentiation of GOO from [[gastroparesis]] where gastric [[dilation]] is not associated with the narrowing of the [[pylorus]]
|<nowiki>-</nowiki>
|-
![[Acute gastritis]]
|
* ''[[H. pylori]]''
* [[NSAIDS]]
* [[Corticosteroids]]
* [[Alcohol]]
* Spicy food
* Viral infections
* [[Crohn's disease]]
* [[Autoimmune diseases]]
* Bile reflux
* [[Cocaine]] use
* Breathing machine or ventilator
* Ingestion of [[corrosive|corrosives]]
|
* [[Epigastric pain]]
|Food
|[[Antacids]]
|✔
|✔
|✔
|<nowiki>-</nowiki>
|✔
|[[Melena|Black stools]]
|
* Pangastritis or antral [[gastritis]]
* [[Gastric erosion|Erosive]] (Superficial, deep, hemorrhagic)
* Nonerosive (''[[H. pylori]]'')
|<nowiki>-</nowiki>
|-
![[Gastritis|Chronic gastritis]]
|
* ''[[H. pylori]]''
* [[Alcohol]]
* Medications
* [[Autoimmune diseases]]
* Chronic stress
|
* [[Epigastric pain]]
|Food
|[[Antacids]]
|✔
|✔
|✔
|✔
|✔
|<nowiki>-</nowiki>
|''[[H. pylori]] [[gastritis]]''
* [[Atrophy]]
* Intestinal [[metaplasia]]
Lymphocytic gastritis
* Enlarged folds
* Aphthoid erosions
|<nowiki>-</nowiki>
|-
![[Atrophic gastritis]]
|
* ''[[H. pylori]]''
* [[Autoimmune disease]]
|[[Epigastric pain]]
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|✔
|<nowiki>-</nowiki>
|
|✔
|✔
|<nowiki>-</nowiki>
|''[[H. pylori]]''
* Mucosal [[atrophy]]
[[Autoimmune]]
* Mucosal [[atrophy]]
|
* [[Iron deficiency anemia]]
Autoimmune gastritis diagnosis include:
* Antiparietal and anti-IF antibodies
* [[Achlorhydria]] and hypergastrinemia
* Low serum [[vitamin B12|cobalamine]]
|-
![[Crohn's disease]]
|
* [[Autoimmune disease]]
|
* [[Abdominal pain]]
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|✔
|✔
|
* Chronic [[diarrhea]] often bloody with [[pus]] or [[mucus]]
* [[Rectal bleeding]]
|
* Mucosal nodularity with cobblestoning
* Multiple [[aphthous ulcers]]
* Linier or serpiginous ulcerations
* Thickened antral folds
* Antral narrowing
* Hypoperistalsis
* Duodenal strictures
|
* [[Fever]]
* [[Fatigue]]
* [[Anemia]] ([[pernicious anemia]])
|-
![[GERD]]
|
* Lower esophageal sphincter abnormalities
* [[Hiatal hernia]]
* Abnormal esophageal contractions
* Prolonged emptying of [[stomach]]
* [[Gastrinomas]]
|
* [[Epigastric pain]]
|
* Spicy food
* Tight fitting clothing
|
* [[Antacids]]
* Head elevation during sleep
|✔
(Suspect delayed gastric emptying)
|✔
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|
* [[Esophagitis]]
* Barrette esophagus
* [[Strictures]]
|Other symptoms:
* [[Dysphagia]]
* [[Regurgitation]]
* [[Cough|Nocturnal cough]]
* [[Hoarseness]]
Complications
* [[Esophagitis]]
* [[Strictures]]
* Barrette esophagus
|-
![[Peptic ulcer disease]]
|
* ''[[H. pylori]]''
* [[Smoking]]
* [[Alcohol]]
* [[Radiation therapy]]
* Medications
* Zollinger-ellison syndrome
|
* [[Epigastric pain]] sometimes extending to back
* [[Right upper quadrant pain]]
|
'''[[Duodenal ulcer]]'''
*Pain aggravates with empty stomach
'''[[Gastric ulcer]]'''
*Pain aggravates with food
|
* [[Antacids]]
* [[Duodenal ulcer]]
:*Pain alleviates with food
|✔
|✔
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|
* [[Melena|Black stools]]
|'''Gastric ulcers'''
* Discrete mucosal lesions with a punched-out smooth ulcer base with whitish fibrinoid base
* Most [[ulcers]] are at the junction of [[fundus]] and antrum
* 0.5-2.5cm
'''Duodenal ulcers'''
* Well-demarcated break in the [[mucosa]] that may extend into the [[muscularis propria]] of the [[duodenum]]
* Found in the first part of [[duodenum]]
* <1cm
|'''Other diagnostic tests'''
* Serum [[gastrin]] levels
* [[Secretin]] stimulation test
* [[Biopsy]]
|-
![[Gastrinoma]]
|
* Associated with [[MEN type 1]]
|
* [[Abdominal pain]]
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|✔
(suspect [[gastric outlet obstruction]])
|✔
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|
* [[Melena|Black stools]]
|Useful in collecting the tissue for [[biopsy]]
|
* May present with symptoms of [[GERD]] or [[peptic ulcer disease]]
* Associated with [[MEN type 1]]
'''Diagnostic tests'''
* Serum [[gastrin]] levels
* [[Somatostatin]] receptor [[scintigraphy]]
* [[CT]] and [[MRI]]
|-
![[Gastric Cancer|Gastric Adenocarcinoma]]
|
* ''[[H. pylori]]'' infection
* Smoked and salted food
|
* [[Abdominal pain]]
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|✔
|✔
|✔
|✔
|✔
|
* [[Melena|Black stools]], or blood in stools
|'''Esophagogastroduodenoscopy'''
* Multiple biopsies are taken to establish the diagnosis
|'''Other symptoms'''
* [[Dysphagia]]
* Early [[satiety]]
* Frequent [[burping]]
|-
![[Gastric lymphoma|Primary gastric lymphoma]]
|
* ''[[H. pylori]]'' infection
|
* [[Abdominal pain]]
* [[Chest pain]]
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|✔
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|Useful in collecting the tissue for [[biopsy]]
|'''Other symptoms'''
* Painless swollen [[lymph nodes]] in neck and armpit
* Night sweats
* [[Fatigue]]
* [[Fever]]
* [[Cough]] or trouble breathing
|}


==Epidemiology and Demographics==
==Epidemiology and Demographics==

Revision as of 17:20, 25 January 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief:

Overview

GASTRIC OUTLET OBSTRUCTION: Pyloric obstruction

Gastric outlet obstruction (GOO,) is the result of any pathology that provides mechanical obstruction to emptying of gastric contents. Two important causes of GOO include: Benign: 37 percent of cases, includes peptic disease Malignant: 53 percent of cases

Location of the stomach: Left upper quadrant of the abdomen Parts of the stomach: Cardia Body Antrum Pylorus

Historical Perspective

Classification

Pathophysiology

Gastric Outlet Obstruction (GOO) may be caused by intrinsic or extrinsic pathologies that involve the antrum and the pylorus.

Causes

Benign causes

Acquired:[1][2][3][4]

Congenital:[38][39]

Malignant causes

Differentiating Gastric outlet obstruction from Other Diseases

Table

Disease Cause Symptoms Diagnosis Other findings
Pain Nausea

&

Vomiting

Heartburn Belching or

Bloating

Weight loss Loss of

Appetite

Stools Endoscopy findings
Location Aggravating Factors Alleviating Factors
Gastric outlet obstruction

Late stages:[44][43][49][50]

Food
✔ ✔ ✔ may be present in case of GOO due to malignancy ✔ Black stools in case of GOO due to PUD -
Acute gastritis Food Antacids ✔ ✔ ✔ - ✔ Black stools -
Chronic gastritis Food Antacids ✔ ✔ ✔ ✔ ✔ - H. pylori gastritis

Lymphocytic gastritis

  • Enlarged folds
  • Aphthoid erosions
 -
Atrophic gastritis Epigastric pain - - ✔ - ✔ ✔ - H. pylori

Autoimmune

Autoimmune gastritis diagnosis include:

Crohn's disease - - - - - ✔ ✔
  • Mucosal nodularity with cobblestoning
  • Multiple aphthous ulcers
  • Linier or serpiginous ulcerations
  • Thickened antral folds
  • Antral narrowing
  • Hypoperistalsis
  • Duodenal strictures
GERD
  • Lower esophageal sphincter abnormalities
  • Spicy food
  • Tight fitting clothing
 ✔

(Suspect delayed gastric emptying)

✔ - - - - Other symptoms:

Complications

Peptic ulcer disease

Duodenal ulcer

  • Pain aggravates with empty stomach

Gastric ulcer

  • Pain aggravates with food
  • Pain alleviates with food
 ✔ ✔ - - - Gastric ulcers
  • Discrete mucosal lesions with a punched-out smooth ulcer base with whitish fibrinoid base
  • Most ulcers are at the junction of fundus and antrum
  • 0.5-2.5cm

Duodenal ulcers

Other diagnostic tests
Gastrinoma - - ✔

(suspect gastric outlet obstruction)

✔ - - - Useful in collecting the tissue for biopsy

Diagnostic tests

Gastric Adenocarcinoma - - ✔ ✔ ✔ ✔ ✔ Esophagogastroduodenoscopy
  • Multiple biopsies are taken to establish the diagnosis
 Other symptoms
Primary gastric lymphoma - - - - - ✔ - - Useful in collecting the tissue for biopsy Other symptoms

Epidemiology and Demographics

  • Incidence: less than 5% in patients with PUD.
  • PUD is the most common benign cause of GOO.
  • In the US, five percent PUD cases require an average of 2000 surgeries annually.
  • Pancreatic cancer is the most common malignant cause of GOO.
  • The incidence of GOO in cases with pancreatic cancer is approximately 20%.

Risk Factors

Screening

Natural History, Complications, and Prognosis

Natural History

Complications

Prognosis

Diagnosis

History and Symptoms

The following history is relevant in patients with GOO:[51][52]

Clinical presentation:

Early stages:[5][41]

Late stages:[44][43][49][50]

Physical Examination

In the late stages of GOO, patients may develop signs of malnutrition and incomplete obstruction.

Laboratory Findings

Imaging Findings

Imaging studies such as plain radiographs, contrast upper gastrointestinal (GI) studies and Computed Tomography (CT) with oral contrast may be used for evaluating patients with symptoms of GOO.

Plain radiographs

Contrast upper gastrointestinal (GI) studies (Gastrografin or barium)

Computed tomography (CT) with oral contrast

Other Diagnostic Studies

Endoscopy

Sodium chloride load test

Needle-guided biopsy

Treatment

Medical Therapy

Surgery

Surgery is the primary modality of treatment for patients with GOO. It is required for more than 75 percent of patients, with scarring, fibrosis and tumors. The aims of surgery in case of GOO include:

  • Relief of obstruction
  • Relief in patients with failure to respond to medical therapy or failure to improve even after 72 hours of therapy
  • Correction of PUD symptoms

Preoperative evaluation

Guidelines for surgery

Types of surgical procedures

The types of surgical procedures performed in cases of GOO are as follows:[29][81][82][83][84][85][86]

Contraindications to surgery

Complications of surgery

Complications arising after surgery include:[108][109]

Prevention

References

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  99. ↑ Hall NJ, Pacilli M, Eaton S, Reblock K, Gaines BA, Pastor A, Langer JC, Koivusalo AI, Pakarinen MP, Stroedter L, Beyerlein S, Haddad M, Clarke S, Ford H, Pierro A (2009). "Recovery after open versus laparoscopic pyloromyotomy for pyloric stenosis: a double-blind multicentre randomised controlled trial". Lancet. 373 (9661): 390–8. doi:10.1016/S0140-6736(09)60006-4. PMID 19155060.
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