Gastric outlet obstruction

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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

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

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

Autoimmune

Crohn's disease - - - - - ✔ ✔
  • Mucosal nodularity with cobblestoning
  • Multiple aphthous ulcers
  • Linier or serpiginous ulcerations
  • Thickened antral folds
  • Antral narrowing
  • Hypoperistalsis
  • Duodenal strictures
GERD
  • 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:[58][59]

Clinical presentation:

Early stages:[5][41]

Late stages:[44][43][60][61]

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][90][91][92][93][94][95]

Contraindications to surgery

Complications of surgery

Complications arising after surgery include:[117][118]

Prevention

References

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  2. ↑ 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.
  3. ↑ 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.
  4. ↑ 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. ↑ 5.0 5.1 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. ↑ 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. ↑ 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.
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  9. ↑ 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.
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  11. ↑ Khan S, Orenstein SR (2000). "Eosinophilic gastroenteritis masquerading as pyloric stenosis". Clin Pediatr (Phila). 39 (1): 55–7. doi:10.1177/000992280003900109. PMID 10660821.
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  82. ↑ Kozarek RA (1993). "Dilation therapy for gastric outlet obstruction. Are balloons a bust?". J. Clin. Gastroenterol. 17 (1): 2–4. PMID 8409292.
  83. ↑ Cherian PT, Cherian S, Singh P (2007). "Long-term follow-up of patients with gastric outlet obstruction related to peptic ulcer disease treated with endoscopic balloon dilatation and drug therapy". Gastrointest. Endosc. 66 (3): 491–7. doi:10.1016/j.gie.2006.11.016. PMID 17640640.
  84. ↑ Benjamin SB, Cattau EL, Glass RL (1982). "Balloon dilation of the pylorus: therapy for gastric outlet obstruction". Gastrointest. Endosc. 28 (4): 253–4. PMID 7173580.
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  86. ↑ Boylan JJ, Gradzka MI (1999). "Long-term results of endoscopic balloon dilatation for gastric outlet obstruction". Dig. Dis. Sci. 44 (9): 1883–6. PMID 10505729.
  87. ↑ Solt J, Bajor J, Szabó M, Horváth OP (2003). "Long-term results of balloon catheter dilation for benign gastric outlet stenosis". Endoscopy. 35 (6): 490–5. doi:10.1055/s-2003-39664. PMID 12783346.
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