S3713 Pre-Pyloric Gastric Ulcer Leading to Stenosed Pylorus, Obstruction of Gastric Outlet and Pseudo-Gastroparesis

Abstract

Introduction: Gastric outlet obstruction (GOO) is a syndrome manifested with combination of early satiety, abdominal pain, postprandial vomiting and weight loss. The usual etiology is either mechanical (benign or malignant) or motility related. Most common cause of benign obstruction is peptic ulcer disease. Here we discuss a case of pre-pyloric ulcer with significant stenosis that mimics gastroparesis causing acquired GOO. Case Description/Methods: 58 year old female with history of migraines, anxiety and chronic pain presented with generalized weakness and epigastric pain. She had been taking 2 pills of aspirin and Advil each every 3 hours for past 2 weeks for her toothache. She also reported melanotic stools. In the ER, she was vitally stable but had hemoglobin of 5.5. CTA of abdomen pelvis noted abnormal duodenum with diffuse mural thickening and mildly prominent lymph nodes. She was transfused 2 units of PRBC. EGD done revealed linear antral ulcer occupying two-thirds of pre-pyloric area measuring 4 cm extending into the pylorus with minimal oozing on contact. Pylorus was severely narrowed and ulcerated; it could not be traversed with adult scope. XP scope was then used which passed with ease through the pylorus into the duodenal bulb which appeared to be severely ulcerated. Rest of the duodenum was normal. Patient subsequently had Gastrografin follow through study to evaluate for gastric outlet obstruction which showed suspected mild stenosis &/or edema in pylorus secondary to ulcerative dislocation; however no bowel obstruction was noted since the contrast passed through the duodenum. Biopsy ruled out malignancy & H. pylori infection and was consistent with chemical gastropathy. Gastrin level was also noted to be normal. Patient was on placed on clear liquid diet initially and later transitioned to full liquids since she was unable to tolerate solid foods. She had a repeat EGD 4 weeks later while on Pantoprazole 2 times daily and eventually showed partial resolution of ulcerated lesions. Discussion: Pre-pyloric ulcers are the most common form of peptic ulcer disease leading to GOO. Most common site is the pyloric channel or duodenal bulb which was the case in our patient. Acute ulcers usually cause inflammation and edema that leads to tissue deformation and obstruction especially with solid food particles getting lodged into the ulcer. Despite these, obstruction usually occurs in 2% of the cases of peptic ulcer disease and is the least common complication contributing to gastroparesis like symptoms.Figure 1.: Figure 1). Pre-pyloric stomach ulcer 2). Pre-pyloric stomach ulcer 3). Pylorus with food residue/Bezoar stuck in the stenosed pylorus 4). Pre-pyloric stomach ulcer after 4 weeks of Protonix therapy 5). Ulcer at 11-1 o clock 6). Ulcer at 12 o clock.