Endoscopic Balloon Dilatation Should Be the Initial Therapy of Choice in Benign Ulcer Related Gastric Outlet Obstruction

Abstract

Background: Gastric outlet obstruction (GOO) is seen in 2%-20% of cases of peptic ulcer disease. GOO was managed surgically before the era of proton pump inhibitor(PPI) therapy. Aim: The present study was conducted to evaluate the effectiveness and safety of endoscopic balloon dilatation and PPI/ H.pylori eradication therapy in benign GOO. Methods: GOO was defined by presence of non bilious stale food vomitus and inability to pass a 9 mm diameter endoscope into second part of duodenum(D2). Patients in whom the endoscope could be negotiated into D2 with difficulty were not included. The treatment included eradication of H. pylori infection/PPI therapy and dilatation of the narrowed segment to a diameter of 12 mm using controlled radial expansion (CRE) balloon. Clinical and endoscopic response was classified as none, partial or complete. Endoscopically, no response was inability to pass a endoscope into D2, partial response was ability to negotiate the endoscope into D2 with difficulty, complete response was easy endoscope passage into D2. Persistence of vomiting with severe dietary curtailment was defined as no clinical response; partial response was ability to tolerate a diet modified in amount or consistency, with occasional vomiting; complete response was ability to tolerate a regular diet without vomiting. Results : From April 1997 to June 2003, 63 patients with benign GOO outlet obstruction attended the Ulcer Clinic. The mean age was 38.3 (13.6) years (range 16-63) with 39 (81.3%) males. The mean duration of symptoms was 69.4 (67.6) months (range 1-240 mths). H. pylori infection was present in 40 (83.3%) and eradication rate was 47.8% (per protocol). 20 CRE balloon dilatation sessions were carried out in 15 patients(once in 10 patients, twice in 2 patients and thrice in 2 patients). No complication related to the procedure was observed. The mean duration of follow up after balloon dilatation was 21.4 + 21.4 weeks (range 1-80 weeks). 1 month after dilatation clinical response was complete in 40%, partial in 50%, none in 10%; endoscopic response was complete 42.8%, partial in 28.5%, none in 28.7%. Clinical and endoscopic response at the end of follow up was complete in 54.5%, partial in 18.1% and none in 27.2%. Conclusions: Conservative management with endoscopic balloon dilatation and PPI/H.pylori eradication therapy was effective in three fourths of patients with ulcer related benign gastric outlet obstruction and should be the initial therapy of choice in this group of patients.