Severe, Chronic Duodenitis as an Unusual Cause of Gastric Outlet Obstruction

Abstract

Gastric outlet obstruction (GOO) is classically associated with peptic ulcer disease, or less frequently associated with, pyloric or duodenal malignancy. A case of GOO caused by chronic duodenitis is reported. A 53-year-old woman who was administered flurbiprofen 100 mg twice daily to relieve dental pain for the prior two weeks, admits to tobacco and marijuana use, and underwent prior cesarean section, presented with nausea, vomiting, and acute on chronic, epigastric and left upper quadrant (LUQ) abdominal pain, and early satiety. Physical examination revealed a blood pressure of 173/101 mmHg and pulse of 95 beats/minute. Her abdomen was soft but distended, had hyperactive bowel sounds, and was diffusely tender to palpation, especially in the LUQ, without rebound tenderness. Laboratory examination revealed electrolyte disturbances compatible with moderate dehydration. Abdominal computer tomography with oral and intravenous (IV) contrast, revealed a markedly, diffusely, distended stomach and retention of oral contrast, indicative of GOO. There was no small intestinal or colonic dilatation. The patient was administered IV fluids and IV pantoprazole. A nasogastric tube was placed for gastric decompression. Esophagogastroduodenoscopy revealed severe focal inflammation, edema, erythema, and erosions in the duodenal bulb and descending duodenum, with duodenal narrowing, spasm, and tortuosity. There was mild gastric inflammation and edema. Careful examination of the duodenal bulb and descending duodenum revealed no duodenal ulcers. Biopsies of duodenal and gastric mucosa demonstrated no dysplasia and no Helicobacter pylori infection. The nasogastric tube was removed four days after admission and her diet was advanced. She was managed conservatively with proton pump inhibitors (PPIs) and bowel rest without endoscopic dilation or more invasive surgical procedures. She was discharged to receive oral PPI, twice daily, with the diagnosis of GOO secondary to nonsteroidal anti-inflammatory drug (NSAID)-induced chronic duodenitis. She was asymptomatic at one month follow-up while taking the prescribed PPI and discontinuing NSAID therapy. This case report appears to be novel. Review of the literature revealed no other reported cases of GOO from chronic duodenitis. NSAID-induced chronic duodenitis should be included in the differential of GOO.Figure 1