Gastric outlet obstruction: Difference between revisions
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==Epidemiology and Demographics== | ==Epidemiology and Demographics== | ||
The epidemiology of GOO is as follows:<ref name="pmid21626606">{{cite journal |vauthors=Lin KJ, García Rodríguez LA, Hernández-Díaz S |title=Systematic review of peptic ulcer disease incidence rates: do studies without validation provide reliable estimates? |journal=Pharmacoepidemiol Drug Saf |volume=20 |issue=7 |pages=718–28 |year=2011 |pmid=21626606 |doi=10.1002/pds.2153 |url=}}</ref><ref name="pmid19220208">{{cite journal |vauthors=Sung JJ, Kuipers EJ, El-Serag HB |title=Systematic review: the global incidence and prevalence of peptic ulcer disease |journal=Aliment. Pharmacol. Ther. |volume=29 |issue=9 |pages=938–46 |year=2009 |pmid=19220208 |doi=10.1111/j.1365-2036.2009.03960.x |url=}}</ref> | |||
* The [[incidence]] of [[peptic ulcer]] disease (which is the most common benign cause of GOO) is approximately 10-19 per 100,000 individuals worldwide. | |||
* Five percent of all cases of [[Peptic ulcer|peptic ulcer disease]] worldwide, develop gastric outlet obstruction. | * Five percent of all cases of [[Peptic ulcer|peptic ulcer disease]] worldwide, develop gastric outlet obstruction. | ||
* The [[incidence]] of gastric outlet obstruction is less than 5 per 100,000 [[Patient|patients]] worldwide. | * The [[incidence]] of gastric outlet obstruction is less than 5 per 100,000 [[Patient|patients]] worldwide. | ||
Revision as of 21:18, 26 January 2018
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief:
Overview
GASTRIC OUTLET OBSTRUCTION: Pyloric obstruction
Historical Perspective
Classification
- Gastric outlet obstruction (GOO) is the result of any pathology that provides mechanical obstruction to emptying of gastric contents. GOO may be classified based on the underlying cause:
- Benign: 37 percent of cases, includes peptic ulcer disease
- Malignant: 53 percent of cases
Pathophysiology
Gastric Outlet Obstruction (GOO) may be caused by intrinsic or extrinsic pathologies that involve the antrum and the pylorus.
- Intrinsic obstruction:
- Infiltration, scar formation or inflammation of these structures leads to intrinsic obstruction, resulting in GOO.
- Extrinsic obstruction:
- Malignancy of any of these neighboring structures may lead to extrinsic obstruction of the gastric outlet:
Causes
Causes of GOO may be classified as benign and malignant.
Benign causes
Acquired causes of gastric outlet obstruction include:[1][2][3][4]
- Acute- edema and inflammation
- Chronic- due to intrinsic obstruction as a result of fibrosis and scar formation
- PUD: 5% cases (most commonly affecting pylorus and initial part of the duodenum)
- Gastric polyps[5][6]
- Caustic ingestion[7]
- Duodenal stricture [8]
- Systemic amyloidosis of the gastrointestinal tract [9][10]
- Eosinophillic gastroenteritis [11][12][13][14][15]
- Obstruction by gallstones (Bouveret syndrome)
- Complication of acute pancreatitis: pancreatic pseudocyst formation[16][17]
- Chronic pancreatitis [18][19]
- Sarcoidosis of the GIT [20][21][22][23]
- Bezoars[24][25][26][27][28]
- Crohn's disease involving the duodenum [29][30][31][32]
- Gastro-duodenal tuberculosis[33][34][35][36][37]
Congenital causes of gastric outlet obstruction include:[38][39]
- Pyloric stenosis:
- Most common cause in children
- More common in boys>girls
- Due to hypertrophy of pyloric circular smooth muscles
- Congenital duodenal webs[40]
- Annular pancreas[41]
Malignant causes
- Malignancies involving neighboring structures may lead to GOO:[42][43][44][45][46][47]
- Pancreas: Pancreatic cancer
- Most common malignancy leading to extrinsic obstruction of the pylorus
- Occurence in one fifth of patients
- Stomach: Gastric cancer, Zollinger-Ellison Syndrome [48]
- Duodenum: Duodenal cancer, ampullary cancer
- Bile duct: Cholangiocarcinoma
- Secondary metastasis to the gastric outlet by other primaries
- Pancreas: Pancreatic cancer
Differentiating Gastric outlet obstruction from Other Diseases
- The table below differentiates gastric outlet obstruction from other conditions:[49][50][51][52][53][54][55][56][57]
| Differential Diagnosis | ||||||||||||
| 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 (GOO) |
|
Epigastric pain | Food | - | ✔ | ✔ | ✔ | ✔ | ✔ | Black stools in case of Peptic Ulcer Disease(PUD) |
|
Sodium chloride load test
Needle-guided biopsy
|
| Acute gastritis |
|
Food | Antacids | ✔ | ✔ | ✔ | - | ✔ | Black stools |
|
- | |
| Chronic gastritis |
|
Food | Antacids | ✔ | ✔ | ✔ | ✔ | ✔ | - | H. pylori gastritis
Lymphocytic gastritis
|
- | |
| Atrophic gastritis | - | - | ✔ | - | ✔ | ✔ | - | H. pylori
|
| |||
| Crohn's disease | - | - | - | - | - | ✔ | ✔ |
|
|
|||
| GERD |
|
|
|
✔
(Suspect delayed gastric emptying) |
✔ | - | - | - | - | Other symptoms:
Complications
| ||
| Peptic ulcer disease |
|
|
|
✔ | ✔ | - | - | - | Gastric ulcers
Duodenal ulcers
|
Other diagnostic tests | ||
| Gastrinoma |
|
- | - | ✔
(suspect gastric outlet obstruction) |
✔ | - | - | - | Useful in collecting the tissue for biopsy |
Diagnostic tests
| ||
| Gastric Adenocarcinoma |
|
- | - | ✔ | ✔ | ✔ | ✔ | ✔ |
|
Esophagogastroduodenoscopy
|
Other symptoms | |
| Primary gastric lymphoma |
|
- | - | - | - | - | ✔ | - | - | Useful in collecting the tissue for biopsy | Other symptoms
| |
Epidemiology and Demographics
The epidemiology of GOO is as follows:[58][59]
- The incidence of peptic ulcer disease (which is the most common benign cause of GOO) is approximately 10-19 per 100,000 individuals worldwide.
- Five percent of all cases of peptic ulcer disease worldwide, develop gastric outlet obstruction.
- The incidence of gastric outlet obstruction is less than 5 per 100,000 patients worldwide.
- In the United States, peptic ulcer disease requires 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% of all cases.
Risk Factors
- The various risk factors for Gastric Outlet Obstruction (GOO) include all those pathologies that lead to intrinsic or extrinsic obstruction of the gastric outlet:
- PUD: 5% cases (most commonly affecting pylorus and initial part of the duodenum)
- Gastric polyps[5][6]
- Caustic ingestion[7]
- Duodenal stricture [8]
- Systemic amyloidosis of the gastrointestinal tract [9][10]
- Eosinophillic gastroenteritis [11][12][13][14][15]
- Obstruction by gallstones (Bouveret syndrome)
- Complication of acute pancreatitis: pancreatic pseudocyst formation[16][17]
- Chronic pancreatitis [18][19]
- Sarcoidosis of the GIT [20][21][22][23]
- Bezoars[24][25][26][27][28]
- Crohn's disease involving the duodenum [29][30][31][32]
- Gastro-duodenal tuberculosis[33][34][35][36][37]
- Malignancies involving neighboring structures:[42][43][44][45][46][47]
- Pancreas: Pancreatic cancer
- Most common malignancy leading to extrinsic obstruction of the pylorus
- Occurence in one fifth of patients
- Stomach: Gastric cancer, Zollinger-Ellison Syndrome [48]
- Duodenum: Duodenal cancer, ampullary cancer
- Bile duct: Cholangiocarcinoma
- Secondary metastasis to the gastric outlet by other primaries
- Pancreas: Pancreatic cancer
Screening
There is no screening available for gastric outlet obstruction.
Diagnosis
History and Symptoms
The following history is relevant in patients with GOO:[60][61]
- History of Peptic Ulcer Disease (PUD) or its complications
- Indigestion
- Anorexia
- Nausea, vomiting
- Epigastric pain
- History of abdominal pain and weight loss in cases of pancreatic cancer
Clinical presentation:
- Nausea
- Vomiting: characteristic feature
- Intermittent
- Occurs one hour after ingestion
- Non bilious
- Contains undigested particles of food
- Patient has intolerance to solids, followed by liquids
- Dehydration
- Electrolyte abnormalities
- Weight loss
- Malnutrition: more pronounced in patients with malignancy
- Abdominal distension
- Features of incomplete obstruction
- Gastric retention: presenting as early satiety
- Bloating
- Fullness of epigastrium
- Aspiration pneumonia: due to dilatation of stomach, loss of contractility and accumulation of undigested food contents
Physical Examination
In the late stages of GOO, patients may develop signs of malnutrition and incomplete obstruction.
- Weight loss
- Signs of chronic dehydration
- Malnutrition: more pronounced in patients with malignancy
- Abdominal distension
- Features of incomplete obstruction
- Aspiration pneumonia
- Abdominal examination:
- Abdominal mass may be present
- Location: Epigastrium, Left upper quadrant of the abdomen
- Palpation: Fullness of epigastrium
- Percussion: Tympanitic mass
Laboratory Findings
- Characteristic features due to vomiting:[64]
- Complete Blood Count (CBC): may show anemia
- Electrolyte panel
- Liver function tests: in case of malignancy
- Test for H pylori for diagnosis of PUD
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
- Obstruction series includes:
- This helps in the determination of the presence of gastric dilatation.
Contrast upper gastrointestinal (GI) studies (Gastrografin or barium)
- Barium upper GI studies:
- Helps in the determination of site of obstruction
- Helps in the visualization of the gastric silhouette:
- Helps note the following:
- Nuclear gastric emptying study:[65]
- Radionuclide is given orally and its passage is measured over a certain duration.
Computed tomography (CT) with oral contrast
- CT with oral contrast may also be of use in suspected cases with equivocal findings on X Ray and Barium Upper GI studies. CT-guided biopsy may be especially useful in cases of pancreatic cancer.
Other Diagnostic Studies
Endoscopy
- Upper endoscopy may help with:[66][67]
- Visualization of the gastric outlet
- Biopsy sampling in case of intraluminal pathology
- Endoscopic biopsy helps rule out the presence of malignancy in patients with symptoms of Peptic Ulcer Disease (PUD)
Sodium chloride load test
- Procedure: Patient is infused with 750 mL of sodium chloride solution into the stomach via a nasogastric tube (NGT).[68]
- In case > 400 mL is left in the stomach after half an hour, the diagnosis of GOO may be made.[68]
Needle-guided biopsy
- Helps in the evaluation of patients for metastasis
Treatment
Medical Therapy
- Medical therapy may be given to all patients prior to surgery in cases of Gastric Outlet Obstruction. This includes the following:[69][70]
- Hydration
- Gastric decompression
- Sodium chloride to correct low chloride levels
- Replacement of potassium
- Replacement of volume status
- Placement of a nasogastric tube (NG tube) for stomach decompression
- Jejunostomy tube may be placed during surgery
- Treatment of electrolyte imbalances
- Palliative therapy for cases of advanced cancer: Endoscopic stent placement[71][72][73][74][75][76][77][78][79]
- In patients with benign Gastric Outlet Obstruction due to Peptic Ulcer Disease (PUD), medical therapy is given in patients to treat acute inflammation and edema.[43][80][81][82][83]
- Histamine-2 (H2) blockers
- Proton pump inhibitors
- For the treatment of strictures in patients with GOO due to advanced stage cancer, endoscopic pneumatic balloon dilatation and use of self-expandable metallic stents are preferred techniques.[84][85][86][87][88][89][90][91]
- Metallic stents may be associated with complications such as :
- Perforation
- Bleeding
- Malposition
- Migration
- Tumor overgrowth or ingrowth
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
- Correct fluid and electrolyte abnormalities
- Nutritional evaluation: TPN
- Gastric decompression using NG tube
Guidelines for surgery
- Patient should be able to tolerate surgery
- Major resections of the tumor must be done in the absence of metastatic disease
- In case of metastatic disease, extent of surgery needs to be determined
Types of surgical procedures
The types of surgical procedures performed in cases of GOO are as follows:[29][92][93][94][95][96][97]
- Vagotomy and antrectomy
- Gastrojejunostomy (vagotomy and antrectomy with Billroth II reconstruction) is the surgery of choice for GOO secondary to malignancy.[98][99]
- Balloon dilatation[98][100][101][102][103]
- Side effects:
- High incidence of gastroparesis
- High rate of recurrence
- Side effects:
- Pylorotomy[104]
- Pyloroplasty
- Robotic-assisted pyloroplasty
- Side effect:
- Gastric outlet scarring
- Side effect:
- Vagotomy and pyloroplasty
- Truncal vagotomy and gastrojejunostomy[105][106][107]
- Laparoscopic truncal vagotomy[108]
- Laparoscopic gastrojejunostomy[109]
- Laparoscopic pyloromyotomy[110]
- Laparoscopic gastrojejunostomy: The advantages of this procedure are as follows:
- Fast GI transit recovery time
- Fewer blood transfusions
- Low mortality
- Brief hospital stay
- Endoscopic surgery (Endoscopic gastroenteric anastomosis) is preferred in cases of malignant obstruction. The advantages of this procedure include:[111][112][113] [114][115][116][117][118]
Contraindications to surgery
- Severe malnutrition
- Advanced cancer
Complications of surgery
Complications arising after surgery include:[119][120]
- Perforation: in patients undergoing endoscopic surgery and stenting
- Stent reocclusion
- Stent migration
- Edema of the gastric wall
- Dilation and dysmotility of stomach
- Anastomotic leak
- Postgastrectomy syndromes:
References
- ↑ Bradley EL, Clements JL (1981). "Idiopathic duodenal obstruction: an unappreciated complication of pancreatitis". Ann. Surg. 193 (5): 638–48. PMC 1345138. PMID 7235767.
- ↑ Zargar SA, Kochhar R, Nagi B, Mehta S, Mehta SK (1992). "Ingestion of strong corrosive alkalis: spectrum of injury to upper gastrointestinal tract and natural history". Am. J. Gastroenterol. 87 (3): 337–41. PMID 1539568.
- ↑ Poley JW, Steyerberg EW, Kuipers EJ, Dees J, Hartmans R, Tilanus HW, Siersema PD (2004). "Ingestion of acid and alkaline agents: outcome and prognostic value of early upper endoscopy". Gastrointest. Endosc. 60 (3): 372–7. PMID 15332026.
- ↑ Ciftci AO, Senocak ME, Büyükpamukçu N, Hiçsönmez A (1999). "Gastric outlet obstruction due to corrosive ingestion: incidence and outcome". Pediatr. Surg. Int. 15 (2): 88–91. doi:10.1007/s003830050523. PMID 10079337.
- ↑ 5.0 5.1 5.2 Miner PB, Harri JE, McPhee MS (1982). "Intermittent gastric outlet obstruction from a pedunculated gastric polyp". Gastrointest. Endosc. 28 (3): 219–20. PMID 7129059.
- ↑ 6.0 6.1 Gencosmanoglu R, Sen-Oran E, Kurtkaya-Yapicier O, Tozun N (2003). "Antral hyperplastic polyp causing intermittent gastric outlet obstruction: case report". BMC Gastroenterol. 3: 16. doi:10.1186/1471-230X-3-16. PMC 166166. PMID 12831404.
- ↑ 7.0 7.1 Zargar SA, Kochhar R, Nagi B, Mehta S, Mehta SK (1989). "Ingestion of corrosive acids. Spectrum of injury to upper gastrointestinal tract and natural history". Gastroenterology. 97 (3): 702–7. PMID 2753330.
- ↑ 8.0 8.1 Taylor SM, Adams DB, Anderson MC (1991). "Duodenal stricture: a complication of chronic fibrocalcific pancreatitis". South. Med. J. 84 (3): 338–41. PMID 2000520.
- ↑ 9.0 9.1 Menke DM, Kyle RA, Fleming CR, Wolfe JT, Kurtin PJ, Oldenburg WA (1993). "Symptomatic gastric amyloidosis in patients with primary systemic amyloidosis". Mayo Clin. Proc. 68 (8): 763–7. PMID 8331978.
- ↑ 10.0 10.1 Friedman S, Janowitz HD (1998). "Systemic amyloidosis and the gastrointestinal tract". Gastroenterol. Clin. North Am. 27 (3): 595–614, vi. PMID 9891699.
- ↑ 11.0 11.1 Khan S, Orenstein SR (2000). "Eosinophilic gastroenteritis masquerading as pyloric stenosis". Clin Pediatr (Phila). 39 (1): 55–7. doi:10.1177/000992280003900109. PMID 10660821.
- ↑ 12.0 12.1 Chaudhary R, Shrivastava RK, Mukhopadhyay HG, Diwan RN, Das AK (2001). "Eosinophilic gastritis--an unusual cause of gastric outlet obstruction". Indian J Gastroenterol. 20 (3): 110. PMID 11400803.
- ↑ 13.0 13.1 Tursi A, Rella G, Inchingolo CD, Maiorano M (2007). "Gastric outlet obstruction due to gastroduodenal eosinophilic gastroenteritis". Endoscopy. 39 Suppl 1: E184. doi:10.1055/s-2006-945125. PMID 17614041.
- ↑ 14.0 14.1 Chen MJ, Chu CH, Lin SC, Shih SC, Wang TE (2003). "Eosinophilic gastroenteritis: clinical experience with 15 patients". World J. Gastroenterol. 9 (12): 2813–6. PMC 4612059. PMID 14669340.
- ↑ 15.0 15.1 Lee CM, Changchien CS, Chen PC, Lin DY, Sheen IS, Wang CS, Tai DI, Sheen-Chen SM, Chen WJ, Wu CS (1993). "Eosinophilic gastroenteritis: 10 years experience". Am. J. Gastroenterol. 88 (1): 70–4. PMID 8420276.
- ↑ 16.0 16.1 Aranha GV, Prinz RA, Greenlee HB, Freeark RJ (1984). "Gastric outlet and duodenal obstruction from inflammatory pancreatic disease". Arch Surg. 119 (7): 833–5. PMID 6732492.
- ↑ 17.0 17.1 Agrawal NM, Gyr N, McDowell W, Font RG (1974). "Intestinal obstruction due to acute pancreatitis. Case report and review of literature". Am J Dig Dis. 19 (2): 179–85. PMID 4811173.
- ↑ 18.0 18.1 Bradley EL (1989). "Complications of chronic pancreatitis". Surg. Clin. North Am. 69 (3): 481–97. PMID 2658160.
- ↑ 19.0 19.1 Levenick JM, Gordon SR, Sutton JE, Suriawinata A, Gardner TB (2009). "A comprehensive, case-based review of groove pancreatitis". Pancreas. 38 (6): e169–75. doi:10.1097/MPA.0b013e3181ac73f1. PMID 19629001.
- ↑ 20.0 20.1 Stampfl DA, Grimm IS, Barbot DJ, Rosato FE, Gordon SJ (1990). "Sarcoidosis causing duodenal obstruction. Case report and review of gastrointestinal manifestations". Dig. Dis. Sci. 35 (4): 526–32. PMID 2180656.
- ↑ 21.0 21.1 Johnson FE, Humbert JR, Kuzela DC, Todd JK, Lilly JR (1975). "Gastric outlet obstruction due to X-linked chronic granulomatous disease". Surgery. 78 (2): 217–23. PMID 807981.
- ↑ 22.0 22.1 Mulholland MW, Delaney JP, Simmons RL (1983). "Gastrointestinal complications of chronic granulomatous disease: surgical implications". Surgery. 94 (4): 569–75. PMID 6623357.
- ↑ 23.0 23.1 Huang A, Abbasakoor F, Vaizey CJ (2006). "Gastrointestinal manifestations of chronic granulomatous disease". Colorectal Dis. 8 (8): 637–44. doi:10.1111/j.1463-1318.2006.01030.x. PMID 16970572.
- ↑ 24.0 24.1 Bakken DA, Abramo TJ (1997). "Gastric lactobezoar: a rare cause of gastric outlet obstruction". Pediatr Emerg Care. 13 (4): 264–7. PMID 9291515.
- ↑ 25.0 25.1 De Backer A, Van Nooten V, Vandenplas Y (1999). "Huge gastric trichobezoar in a 10-year-old girl: case report with emphasis on endoscopy in diagnosis and therapy". J. Pediatr. Gastroenterol. Nutr. 28 (5): 513–5. PMID 10328129.
- ↑ 26.0 26.1 Phillips MR, Zaheer S, Drugas GT (1998). "Gastric trichobezoar: case report and literature review". Mayo Clin. Proc. 73 (7): 653–6. doi:10.1016/S0025-6196(11)64889-1. PMID 9663194.
- ↑ 27.0 27.1 White NB, Gibbs KE, Goodwin A, Teixeira J (2003). "Gastric bezoar complicating laparoscopic adjustable gastric banding, and review of literature". Obes Surg. 13 (6): 948–50. doi:10.1381/096089203322618849. PMID 14738689.
- ↑ 28.0 28.1 Zapata R, Castillo F, Córdova A (2006). "[Gastric food bezoar as a complication of bariatric surgery. Case report and review of the literature]". Gastroenterol Hepatol (in Spanish; Castilian). 29 (2): 77–80. PMID 16448609.
- ↑ 29.0 29.1 29.2 Nugent FW, Roy MA (1989). "Duodenal Crohn's disease: an analysis of 89 cases". Am. J. Gastroenterol. 84 (3): 249–54. PMID 2919581.
- ↑ 30.0 30.1 Kefalas CH (2003). "Gastroduodenal Crohn's disease". Proc (Bayl Univ Med Cent). 16 (2): 147–51. PMC 1201000. PMID 16278730.
- ↑ 31.0 31.1 Matsui T, Hatakeyama S, Ikeda K, Yao T, Takenaka K, Sakurai T (1997). "Long-term outcome of endoscopic balloon dilation in obstructive gastroduodenal Crohn's disease". Endoscopy. 29 (7): 640–5. doi:10.1055/s-2007-1004271. PMID 9360875.
- ↑ 32.0 32.1 Fitzgibbons TJ, Green G, Silberman H, Eliasoph J, Halls JM, Yellin AE (1980). "Management of Crohn's disease involving the duodenum, including duodenal cutaneous fistula". Arch Surg. 115 (9): 1022–8. PMID 6106466.
- ↑ 33.0 33.1 Amarapurkar DN, Patel ND, Amarapurkar AD (2003). "Primary gastric tuberculosis--report of 5 cases". BMC Gastroenterol. 3: 6. PMC 155648. PMID 12703983.
- ↑ 34.0 34.1 Rao YG, Pande GK, Sahni P, Chattopadhyay TK (2004). "Gastroduodenal tuberculosis management guidelines, based on a large experience and a review of the literature". Can J Surg. 47 (5): 364–8. PMC 3211943. PMID 15540690.
- ↑ 35.0 35.1 Padussis J, Loffredo B, McAneny D (2005). "Minimally invasive management of obstructive gastroduodenal tuberculosis". Am Surg. 71 (8): 698–700. PMID 16217956.
- ↑ 36.0 36.1 Di Placido R, Pietroletti R, Leardi S, Simi M (1996). "Primary gastroduodenal tuberculous infection presenting as pyloric outlet obstruction". Am. J. Gastroenterol. 91 (4): 807–8. PMID 8677960.
- ↑ 37.0 37.1 Subei I, Attar B, Schmitt G, Levendoglu H (1987). "Primary gastric tuberculosis: a case report and literature review". Am. J. Gastroenterol. 82 (8): 769–72. PMID 3605037.
- ↑ Kreel L, Ellis H (1965). "Pyloric stenosis in adults: A clinical and radiological study of 100 consecutive patients". Gut. 6 (3): 253–61. PMC 1552275. PMID 18668780.
- ↑ Gheorghe L, Băncilă I, Gheorghe C, Herlea V, Vasilescu C, Aposteanu G (2002). "Antro-duodenal tuberculosis causing gastric outlet obstruction--a rare presentation of a protean disease". Rom J Gastroenterol. 11 (2): 149–52. PMID 12145672.
- ↑ Adebamowo CA, Oduntan O (1999). "Duodenal web causing gastric outlet obstruction in an adult". West Afr J Med. 18 (1): 73–4. PMID 10876738.
- ↑ 41.0 41.1 Urayama S, Kozarek R, Ball T, Brandabur J, Traverso L, Ryan J, Wechter D (1995). "Presentation and treatment of annular pancreas in an adult population". Am. J. Gastroenterol. 90 (6): 995–9. PMID 7771437.
- ↑ 42.0 42.1 Johnson CD (1995). "Gastric outlet obstruction malignant until proved otherwise". Am. J. Gastroenterol. 90 (10): 1740. PMID 7572886.
- ↑ 43.0 43.1 43.2 43.3 Shone DN, Nikoomanesh P, Smith-Meek MM, Bender JS (1995). "Malignancy is the most common cause of gastric outlet obstruction in the era of H2 blockers". Am. J. Gastroenterol. 90 (10): 1769–70. PMID 7572891.
- ↑ 44.0 44.1 44.2 Johnson CD, Ellis H (1990). "Gastric outlet obstruction now predicts malignancy". Br J Surg. 77 (9): 1023–4. PMID 2207566.
- ↑ 45.0 45.1 Tendler DA (2002). "Malignant gastric outlet obstruction: bridging another divide". Am. J. Gastroenterol. 97 (1): 4–6. doi:10.1111/j.1572-0241.2002.05391.x. PMID 11808968.
- ↑ 46.0 46.1 Jeong HY, Yang HW, Seo SW, Seong JK, Na BK, Lee BS, Song GS, Park HS, Lee HY (2002). "Adenocarcinoma arising from an ectopic pancreas in the stomach". Endoscopy. 34 (12): 1014–7. doi:10.1055/s-2002-35836. PMID 12471549.
- ↑ 47.0 47.1 Emerson L, Layfield LJ, Rohr LR, Dayton MT (2004). "Adenocarcinoma arising in association with gastric heterotopic pancreas: A case report and review of the literature". J Surg Oncol. 87 (1): 53–7. doi:10.1002/jso.20087. PMID 15221920.
- ↑ 48.0 48.1 Roy PK, Venzon DJ, Shojamanesh H, Abou-Saif A, Peghini P, Doppman JL, Gibril F, Jensen RT (2000). "Zollinger-Ellison syndrome. Clinical presentation in 261 patients". Medicine (Baltimore). 79 (6): 379–411. PMID 11144036.
- ↑ Sugimachi K, Inokuchi K, Kuwano H, Ooiwa T (1984). "Acute gastritis clinically classified in accordance with data from both upper GI series and endoscopy". Scand J Gastroenterol. 19 (1): 31–7. PMID 6710074.
- ↑ Sipponen P, Maaroos HI (2015). "Chronic gastritis". Scand J Gastroenterol. 50 (6): 657–67. doi:10.3109/00365521.2015.1019918. PMC 4673514. PMID 25901896.
- ↑ Sartor RB (2006). "Mechanisms of disease: pathogenesis of Crohn's disease and ulcerative colitis". Nat Clin Pract Gastroenterol Hepatol. 3 (7): 390–407. doi:10.1038/ncpgasthep0528. PMID 16819502.
- ↑ Sipponen P (1989). "Atrophic gastritis as a premalignant condition". Ann Med. 21 (4): 287–90. PMID 2789799.
- ↑ Badillo R, Francis D (2014). "Diagnosis and treatment of gastroesophageal reflux disease". World J Gastrointest Pharmacol Ther. 5 (3): 105–12. doi:10.4292/wjgpt.v5.i3.105. PMC 4133436. PMID 25133039.
- ↑ Ramakrishnan K, Salinas RC (2007). "Peptic ulcer disease". Am Fam Physician. 76 (7): 1005–12. PMID 17956071.
- ↑ Banasch M, Schmitz F (2007). "Diagnosis and treatment of gastrinoma in the era of proton pump inhibitors". Wien Klin Wochenschr. 119 (19–20): 573–8. doi:10.1007/s00508-007-0884-2. PMID 17985090.
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