Gastric Antral Web: A Case Series to Better Define a Rare Cause of Gastric Outlet Obstruction

Abstract

Listen

Translate article

Introduction: Gastric antral web (AW), or antral diaphragm, is a rare cause of gastric outlet obstruction (GOO). Etiology may be congenital or acquired from ulceration. We identified 33 patients with AW during 24,646 esophagogastroduodenoscopies (EGD) over a 7-year period (2006 to 2013). Only 4 cases (0.02%) presented with symptoms of GOO. Case 1: An 80-year-old female with dysphagia to solids and liquids and persistent vomiting underwent EGD with dilation of presumed pyloric stenosis without relief. Repeat EGD showed an obstructing AW. Sequential balloon dilation allowed passage of a 9.8 mm scope. Symptoms recurred in 2 weeks and the web was incised with needle-knife (NK). Case 2: A 72-year-old male with diabetes underwent EGD for a 10-year history of early satiety, intermittent regurgitation, and 100 lbs weight loss. Prior EGD with biopsy of antral “narrowing” was complicated by bleeding, but repeat showed an obstructing AW precluding passage of a 9-mm scope. Sequential balloon dilation from 8-15 mm was performed, allowing a 5 lbs weight gain in 2 weeks. Case 3: A 60-year-old female with dysphagia and nausea had an obstructing AW on EGD. Balloon dilation, 4-quadrant NK cuts, and steroid injection were performed without resolution of symptoms. Over a 5-year period, she underwent similar interventions with incremental improvement. Surgery was not offered. Case 4: A 74-year-old female with arthritis was admitted for 6 weeks of 10 loose, intermittently melenic, stools daily. Thickened antrum and pancolitis were noted on endoscopy. EGD performed after a 3-week steroid course showed an AW requiring a 6 mm scope to traverse. As per patient wishes, no intervention was performed. Cases 5 to 33: Twenty-nine patients were incidentally found to have a non-obstructing AW during EGD. Seventeen patients underwent EGD for gastroesophageal reflux not alleviated with long-term protonpump inhibitor use or presence of dysphagia, odynophagia, weight loss, or anemia. Twelve individuals were scoped for chronic abdominal pain, 2 of whom had melena of unclear etiology. Discussion: Non-obstructing AWs are incidental findings and frequently asymptomatic. Diagnosis is usually suspected during EGD, in which aperture size does not vary with peristalsis or ‘double bulb’ sign on upper GI series. Confirmation is made by demonstrating a normal pylorus distal to the AW. Symptoms of GOO are common with web aperture less than 1 cm. However, the association between GI bleeding when no other etiology is identified and reflux symptoms needs further study. Endoscopic balloon dilation is transiently effective. Endoscopic incision can be effective and safe in relieving symptoms, but repeat treatment may be needed. The role of surgery needs to be better defined.