Non-Malignant Gastric Outlet Obstruction: Therapy With Endoscopic Ultrasound Guided Gastrojejunonostomy

Abstract

We describe here an 82 year-old male with past medical history of coronary artery disease, sick sinus syndrome s/p permanent pacemaker insertion who presents with a three day history of nausea and vomiting. A CT scan was obtained in the emergency department that showed a markedly distended abdomen. Although no discrete mass was seen, findings were concerning for a gastric outlet obstruction (GOO) (Figure 1). The patient was made NPO and a nasogastric tube was placed for decompression. Of note, the patient was hospitalized at an outside facility 1 month prior due to a severe gastro-intestinal hemorrhage. An endoscopy performed at that time revealed that a ulcerated mucosa encompassing two-thirds of the second portion of the duodenum.2130_A Figure 1 No Caption available.A repeat EGD was performed at our facility revealing a benign appearing high grade stricture in the duodenal bulb at the base of a healing ulcer. Stone-like accretions were found in the pylorus and duodenal bulb which were noted to intermittently occlude the stricture (Figure 2). Biopsies were taken which were negative for malignancy.2130_B Figure 2 No Caption available.The decision was made to proceed with EUS-guided gastrojejunostomy (EUS-GJ). Sonographic examination of the stricture did not reveal an obvious mass. A stone-extraction balloon over a wire was advanced thorough the duodenal stricture into the jejunum. Sterile water was used to dilate the jejunal limb. The linear echoendoscope advanced to the stomach and the jejunal limb was identified. A 19G FNA needle was used to puncture into the jejunum and a second wire was advanced into this limb. Under endoscopic, fluoroscopic and sonographic guidance a 15mm lumen-apposing metal stent (LAMS) was successfully deployed, creating a gastrojejunostomy (Figure 3).2130_C Figure 3 No Caption available.Post-procedure day one patient tolerated a soft diet and was discharged after a 48 hour observation periord. At outpatient follow-up, six weeks after presentation, the patient has done well without significant complications. EUS-GJ are not common-place, however their utility in the treatment of malignant as well as benign gastric outlet obstruction has been demonstrated in international prospective trials. Here we demonstrate that EUS-GJ can be a reliable intervention in patients with GOO. In the future we hope for a comparison study between LAMS, enteral stents and surgical gastrojejunostomies.