Demographic and Etiological Patterns of Gastric Outlet Obstruction in Kerala, South India

Gastric outlet obstruction with benign endoscopic biopsies

BackgroundGastric outlet obstruction poses diagnostic and therapeutic challenges to general surgeons practicing in resource-limited countries. There is a paucity of published data on this subject in our setting. This study was undertaken to highlight the etiological spectrum and treatment outcome of gastric outlet obstruction in our setting and to identify prognostic factors for morbidity and mortality.MethodsThis was a descriptive prospective study which was conducted at Bugando Medical Centre between March 2009 and February 2013. All patients with a clinical diagnosis of gastric outlet obstruction were, after informed consent for the study, consecutively enrolled into the study. Statistical data analysis was done using SPSS computer software version 17.0.ResultsA total of 184 patients were studied. More than two-third of patients were males. Patients with malignant gastric outlet obstruction were older than those of benign type. This difference was statistically significant (p < 0.001). Gastric cancer was the commonest malignant cause of gastric outlet obstruction where as peptic ulcer disease was the commonest benign cause. In children, the commonest cause of gastric outlet obstruction was congenital pyloric stenosis (13.0%). Non-bilious vomiting (100%) and weight loss (93.5%) were the most frequent symptoms. Eighteen (9.8%) patients were HIV positive with the median CD 4+ count of 282 cells/μl. A total of 168 (91.3%) patients underwent surgery. Of these, gastro-jejunostomy (61.9%) was the most common surgical procedure performed. The complication rate was 32.1 % mainly surgical site infections (38.2%). The median hospital stay and mortality rate were 14 days and 18.5% respectively. The presence of postoperative complication was the main predictor of hospital stay (p = 0.002), whereas the age > 60 years, co-existing medical illness, malignant cause, HIV positivity, low CD 4 count (<200 cells/μl), high ASA class and presence of surgical site infection significantly predicted mortality ( p< 0.001). The follow up of patients was generally poor as more than 60% of patients were lost to follow up.ConclusionGastric outlet obstruction in our setting is more prevalent in males and the cause is mostly malignant. The majority of patients present late with poor general condition. Early recognition of the diagnosis, aggressive resuscitation and early institution of surgical management is of paramount importance if morbidity and mortality associated with gastric outlet obstruction are to be avoided.

To determine the relative incidence of malignant and nonmalignant pathology in patients presenting with gastric outlet obstruction in the era of H2 blockers and to determine whether clinical features can differentiate between the two causes. The charts of 33 consecutive patients with gastric outlet obstruction admitted to one institution between July 1990 and November 1993 were reviewed to determine etiology, management, and outcome. The diagnosis of gastric outlet obstruction was based on clinical presentation, an upper gastrointestinal barium study, and/or an inability during upper endoscopy to intubate the second portion of the duodenum. Patients with gastroparesis or a previously known cancer were excluded. Sixty-one percent (20 patients) had malignancy as the cause of their gastric outlet obstruction. Thirty-nine percent (13 patients) had benign disease. The patients with cancer tended to be older, and fewer had a history of peptic ulcer disease, although these factors were not statistically significant. The use of nonsteroidal anti-inflammatory drugs was not associated with gastric outlet obstruction. Four patients had malignancy that had not been suspected before operation despite numerous endoscopic and radiological studies. The incidence of malignancy in patients presenting with gastric outlet obstruction is greater than 50%. The etiology of gastric outlet obstruction cannot be predicted by age, history of peptic ulcer disease, or nonsteroidal anti-inflammatory drug use. The endoscopic treatment of gastric outlet obstruction should be approached with caution because malignancy cannot be reliably excluded by endoscopic or radiological studies.

75-Year-Old Man With Abdominal Pain and Reflux

We report a case of a 20-month-old who presented with a 3-week history of non-bilious vomiting and metabolic alkalosis. Serology demonstrated a hypokalaemic, hypochloraemic metabolic alkalosis. Abdominal ultrasonography and barium studies confirmed the diagnosis of gastric outlet obstruction. Oesophago-gastro-duodenoscopy identified a hypertrophied closed pylorus with evidence of pyloric muscular hypertrophy. A laparoscopic pyloroplasty was performed. Hypertrophic pyloric stenosis is the most common cause of gastric outlet obstruction in children. It typically occurs between 2 and 12 weeks of age and is very rarely found in older children. Primary acquired gastric outlet obstruction in late infancy and childhood is a rare cause of gastric outlet obstruction. Few cases have been reported in the literature outside of northern India. We present this case to highlight the need to consider this diagnosis in the older child.

70-Year-Old Man With Chronic Nausea and Vomiting

We present an extremely rare case of gastric outlet obstruction (GOO) in a young male attributed to hydrops of the gallbladder resulting from recurrent episodes of acute acalculous cholecystitis. Remarkably, approximately one and half years prior to this presentation, the patient was diagnosed with confirmed acute acalculous cholecystitis and had tested positive for Covid 19, despite exhibiting no respiratory symptoms. While it is established that Patients with acute acalculous cholecystitis can develop gallbladder mucoceles due to the mechanism akin to mechanical cystic duct obstructions. This functional condition leads to a non-emptying, distended gallbladder where biliary mucus replaces bile salts (1). Conventionally, hydrops of the gallbladder is associated with prolonged blockage of the cystic duct, often caused by an impacted gallstone in neck / cystic duct or a stricture in cystic duct. Bouveret’s Syndrome, characterized by GOO results from the impaction of a large gallstone in the duodenum or pyloric channel, typically secondary to a cholecystoenteric fistula (2),is a recognized rare entity. However, our case stands apart as it elucidates an infrequently reported cause of GOO- hydrops of gall bladder inducing extrinsic compression of the duodenum / pylorus and this case also emphasizes the distinction from Bouveret’s syndrome. This case underscores the importance of considering unusual etiologies in the diagnosis of GOO and emphasizes the need for timely recognition and intervention in such rare instances to ensure optimal patient outcomes. Additionally, we provide a comprehensive review of existing literature, highlighting the scarcity of reported cases with such relevant presentations.

We read with interest the article of Shetty et al [1] on trichotillomania with gastric trichobezoar obstruction. Similarly, Zin et al [2] reported on okra phytobezoar-related gastrojejunostomy efferent limb obstruction. We report a case of a 76-year-old man with a medical history of ulcer disease referred to our hospital due to recurrent vomiting, nausea and inability of food intake for the previous 48 h. On admission, his vital signs were normal (temperature: 36.5°C, blood pressure: 125/80 mmHg, heart rate: 93 bpm). Physical examination revealed mild sensitivity, distension of abdomen with splashing and presence of normal bowel movements. Laboratory tests, compared to previous ones, showed a significant increase in the hematocrit (51.8% from 46.1%) and serum urea (71 mg/dL from 47 mg/dL) implying moderate dehydration. Chest and abdominal X-ray showed a marked gastric air bubble, air-fluid levels located on small intestine and a downward shift of transverse colon (Fig. 1). Abdominal ultrasound demonstrated a stomach full of liquid content. The patient received parenteral hydration and a nasogastric tube was placed. Twelve hours later, approximately 2,500 mL had been drained. Upper gastrointestinal endoscopy revealed a phytobezoar with a diameter of 4 cm, impacted in the pyloric canal. The phytobezoar was captured with a Dormia basket and was extracted (Fig. 2). After the extraction, the antrum was inspected revealing erythema and nodular appearance of the propyloric area. Biopsies were taken to exclude malignancy. Insertion of the endoscope through the pylorus was successful, without any further findings in the duodenum. After the procedure, the patient mentioned that a few days before admission he ate an orange without proper mastication (he did not have his dentures on). The patient started oral feeding with instructions of mindful chewing. Treatment with proton pump inhibitors q.d. for one month was given. To our knowledge, he remains asymptomatic. Histology was negative. Figure 1 Abdominal X-ray of the patient which showed a marked gastric air bubble (black arrows) and a downward shift of transverse colon (white arrows) Figure 2 The orange-phytobezoar after it was extracted Gastric outlet obstruction (GOO) is the clinical and pathophysiological consequence of any disease process that produces a mechanical impediment to gastric emptying. In the past, when peptic ulcer disease (PUD) was more prevalent, benign causes were the most common, however, one review shows that only 37% of patients with GOO have benign disease and the remaining patients have obstruction secondary to malignancy [3]. The leading causes of benign GOO are PUD and ingestion of corrosives [4]. Non-steroidal anti-inflammatory drugs and opium addiction are rare causes of GOO [5]. Other benign causes are gastric polyps, pyloric stenosis, congenital duodenal webs, gallstone obstruction (Bouveret syndrome), pancreatic pseudocysts and bezoars [4]. Among the various types of bezoars, the most common type is the phytobezoars, composed mainly of undigested vegetable materials [2]. In conclusion, proper mastication should always be recommended to people with dentition problems. Treatment of any underlying cause with adequate fluid intake and avoidance of a strictly fibrous diet could prevent recurrence.

Ectopic pancreas is a rare cause of gastric outlet obstruction, perhaps rarer still among Africans. Although the entity is known, the diagnostic challenges are enormous, especially in the poor-resource environment. Gastric outlet obstruction resulting from ectopic pancreas in an adult is the first of its kind in our center; we, therefore, present this case to describe the challenges faced with diagnosis, treatment, and the lesson learned. Ectopic pancreas should be considered in the differential diagnosis of gastric outlet obstruction.

Introduction: Gastrointestinal (GI) malignancies are a common cause of gastric outlet obstruction (GOO). However, the etiologic contribution of non-GI malignancies to GOO is rarely described in literature. Herein, we present a case of urothelial carcinoma of the right ureter causing GOO. Case Description/Methods: An 84-year-old woman presented with 2 months of nausea, vomiting, bloating, and abdominal pain. She had a history of urothelial carcinoma of the bladder 12 years ago, for which she underwent transurethral bladder resection and was thought to be in remission. CT with IV contrast showed GOO, severe right-sided hydronephrosis, and thickening of the mid right ureter. Upper GI series demonstrated 20 X 7 mm duodenal stenosis in the second portion of the duodenum. EGD and EUS showed duodenal deformity causing GOO, without evidence of luminal or pancreatobiliary malignancy. Duodenal biopsies were normal. In the absence of an intrinsic GI cause for GOO, urologic evaluation was then conducted. A nephrostomy tube was placed to relieve right sided hydronephrosis. This did not translate into clinical improvement of GOO and temporal parenteral nutrition was required. Cytologic evaluations of urine samples were negative for malignancy. Ureteroscopy then revealed a sessile tumor at the right mid ureter and final biopsies were consistent with high-grade invasive urothelial carcinoma. The patient underwent palliative surgical gastrojejunostomy to relieve GOO. The right ureteral cancer was invading the duodenum, causing GOO. No GI malignancy was found at the time of surgery. Discussion: GOO is rarely caused by urologic malignancies, and urologic malignancies uncommonly present with GOO. To our knowledge, this is the fourth case reporting ureteral cancer as a cause of GOO. Although rare, urothelial cancer should be recognized as a cause of GOO. This should be suspected when images reveal severe hydronephrosis and when EGD/EUS do not find GI-related etiology. Ureteral cancer can cause GOO due to severe hydronephrosis or direct duodenal invasion. Since the right ureter passes behind the second part of the duodenum in the retroperitoneum, GOO more often occurs when the right urothelial system is involved. When severe hydronephrosis is present, a nephrostomy tube may suffice to relieve GOO. When a nephrostomy tube is ineffective, direct duodenal invasion should be suspected, and palliative interventions are then necessary to relieve GOO.Figure 1.: a. Axial CT image of the upper abdomen. The two open (blue) arrows indicate visualized portions of the distended stomach. The solid (yellow) arrow shows severe hydronephrosis. b. Upper GI image. The solid yellow arrow shows the obstructed proximal duodenum. Note that contrast flows freely from the stomach into the anastomosed limb (solid white arrow) status post diverting jejunostomy c. Microscopic examination of the right ureter biopsy reveals invasive urothelial carcinoma with high grade nuclei.

Background: Gastric Outlet Obstruction implies complete or incomplete obstruction of the distal stomach, pylorus or proximal duodenum. Gastric outlet obstruction is not a single entity; it is the clinical and pathophysiological consequence of any disease process that produces a mechanical impediment to gastric emptying. Now in the era of H2 blockers and proton pump inhibitors, incidence of duodenal ulcer producing gastric outlet obstruction has been decreasing as symptomatic ulcer begin to respond to medical treatment, and at the same time the incidence of antral carcinoma of stomach producing gastric outlet obstruction has comparatively increased, which may be due to increased early diagnosis of the condition with the help of flexible fibre optic endoscope.Methods: An elaborate study of these cases with regard to the history, clinical features, routine and special investigations, pre-operative treatment, operative findings, post-operative management and complications in post-operative period is done.Results: Of the 50 cases of gastric outlet obstruction 26 had carcinoma antrum (52%), 23 had cicatrized duodenal ulcer (46%) and 1 had gastric outlet obstruction secondary to corrosive ingestion. The age incidence of the patients in this study ranged from 22 – 84 years with a mean of 53.62 years. In case of obstruction secondary to duodenal ulcer the maximum age incidence is between 31-40 years. The maximum age incidence of gastric outlet obstruction due to carcinoma antrum is 61-70 years.In this series, 42 patients (84%) were males and 8 patients (16%) were female. Male to female ratio (M:F) is 5.25:1. M: F ratio in cicatrized duodenal ulcer is 10.5:1 and in carcinoma antrum is 3.33:1. 52% of the patients were manual labourers who gave a history of irregular diet habits. 68% of patients had history of smoking and 66% had history of alcohol intake. Post – prandial vomiting and epigastria pain are the main symptoms (96%) in this series. Other symptoms included anorexia (84%), weight loss (72%), post prandial Epigastric fullness (68%), haematemesis (24%), melena (64%) and constipation (48%). Pallor was present in 56% and dehydration in 62%. Blood group ‘O’ was common in cicatrized duodenal ulcer patients (52.18%) whereas blood group ‘A’ was common in malignant cases (50%).Conclusions: Number of cases with cicatrized duodenal ulcer as the chief etiological factor for gastric outlet obstruction is diminishing and the number of cases of antral carcinoma of stomach as the cause of gastric outlet obstruction is increasing. Upper Gastro intestinal endoscopy should be mandatory in all suspected cases of gastric outlet obstruction. It can diagnose the cause of obstruction very effectively than any other investigative modality. Effective treatment in carcinoma stomach depends on early diagnosis.

Background: The aetiology of gastric outlet obstruction globally has evolved from benign to malignant causes, but there seem to be no recent data on the trends in Ghana. The aim was, therefore, to identify the current patterns in the aetiology of gastric outlet obstruction in the adult population in Ghana. Methodology: This was a retrospective review of all confirmed cases of gastric outlet obstruction in the last decade, spanning from June 2004 to May 2014, that were managed at the Korle Bu Teaching Hospital. Results: A total of 107 patients were managed for gastric outlet obstruction with a male to female ratio of 2.15:1 and most of the patients making 71.3% of cases belonged to the age range of 40 to 60 years. The predominant aetiology for gastric outlet obstruction was found to be gastric cancer (55.140%), followed by peptic ulcer disease (27.103%). Conclusion: The aetiology of gastric outlet obstruction in Ghana has evolved from benign to malignant causes, following current global trends. Gastric cancer is now the most important cause of gastric outlet obstruction in Ghana, followed by peptic ulcer disease which predominates as the commonest benign cause.

Background: Gastric Outlet Obstruction may be caused by a heterogeneous group of diseases that include both benign and malignant conditions. In adults, mechanical obstruction due to ulcers, tumors or gastric polyps are common causes of gastric outlet obstruction. Until introduction of effective ulcer therapy duodenal ulcer was the commonest cause of gastric outlet obstruction and malignancy was attributed to only 20% of the cases. Objectives: To study the modes and presentation of presentation of gastric outlet obstruction among patients suffering from Duodenal ulcer diseases. Materials and Methods: A Hospital based Prospective study was conducted at Tertiary Care Centrefrom October 2017 to September 2019. A total of 100 cases of Gastric outlet obstruction were diagnosed during the study period. An elaborate study of these cases with regard to the history, clinical features, routine and special investigations, pre-operative treatment, operative findings, postoperative management and complications in post-operative period is done. Results: A total of 100 cases with gastric outlet obstruction were analyzed in our study. Out of the 100 cases with gastric outlet obstruction, 28 (28%) were diagnosed with cicatrizes duodenal ulcer and 72 (72%) of them had carcinoma antrum. Majority of the study subjects presented with pain, vomiting and anorexia on admission. Pallor was seen in nearly 68% of the study subjects followed by 56% of the cases with VGP and 54% with succession Splash. Only 28% of the subjects had palpable mass on palpation. Conclusion: Upper Gastro intestinal endoscopy should be mandatory in all suspected cases of gastric outlet obstruction. It can diagnose the cause of obstruction very effectively than any other investigative modality. Effective treatment in carcinoma stomach depends on early diagnosis.

Gastric outlet obstruction (GOO) includes obstruction in the antropyloric area or in the bulbar or post bulbar duodenal segments. Though malignancy remains the most common cause of GOO in adults, a significant number of patients have benign disease. The latter include peptic ulcer disease, caustic ingestion, post-operative anastomotic state and inflammatory causes like Crohn's disease and tuberculosis. Peptic ulcer remains the most common benign cause of GOO. Management of benign GOO revolves around confirmation of the etiology, removing the offending agent Helicobacter pylori (H. pylori), non-steroidal anti-inflammatory drugs, etc. and definitive therapy. Traditionally, surgery has been the standard mode of treatment for benign GOO. However, after the advent of through-the-scope balloon dilators, endoscopic balloon dilation (EBD) has emerged as an effective alternative to surgery in selected groups of patients. So far, this form of therapy has been shown to be effective in caustic-induced GOO with short segment cicatrization and ulcer related GOO. In the latter, EBD must be combined with eradication of H. pylori. Dilation is preferably done with wire-guided balloon catheters of incremental diameter with the aim to reach the end-point of 15 mm. While it is recommended that fluoroscopic control be used for EBD, this is not used by most endoscopists. Frequency of dilation has varied from once a week to once in three weeks. Complications are uncommon with perforation occurring more often with balloons larger than 15 mm. Attempts to augment efficacy of EBD include intralesional steroids and endoscopic incision.

Gastric neuroendocrine tumour (GNET), also known as carcinoids, are a very rare cause of gastric outlet obstruction and arise from entero-chromaffin like cells of the mucosa. They account for 0.2/1000001 population and 8.7% of all Gastrointestinal carcinoids. They are four types based on the degree of differentiation, cell of origin and other pathologic features. Type 4 GNET are referred to as neuroendocrine carcinoma accounting for &lt;1% of GNET. They are aggressive, poorly differentiated, locally invasive tumours with metastatic potential. Hence, they require an aggressive approach in terms of surgery and multimodality adjuvant treatment. Our patient is an elderly hypertensive who had complaints of projectile vomiting over ten days associated with weight loss over the last two years. A diagnosis of gastric outlet obstruction was made, and she underwent a contrast CT scan and endoscopy twice, both being suggestive of malignancy involving the antrum region however, the endoscopic biopsy showed unremarkable histology. Subsequently, she underwent emergency laparotomy in which there was a hard growth palpable in the antrum for which distal gastrectomy, D1 lymphadenectomy and gastrojejunostomy were done. Post-op HPE was suggestive of neuroendocrine carcinoma, thus, depicting our difficulty with diagnosis based on pre-op biopsy report given its rarity.