Sp708 Endoscopic Therapy of a Gastric Antral Web Causing Gastric Outlet Obstruction

Abstract

Gastric antral web (GAW) is a rare cause of gastric-outlet obstruction in both children and adults. An 11 y/o boy referred to our institution for evaluation of nausea, abdominal pain and failure to thrive. He carried a diagnosis of “narrowed pylorus” by an outside facility and had undergone multiple EGDs with pyloric balloon dilation and pyloric botulinum toxin injections. This improved his symptoms for a few weeks, and then the nausea and pain returned. An upper GI series revealed a thin band-like deformity of the distal gastric antrum suggestive of an incomplete antral web. Surgical consultation recommended antrotomy and pyloroplasty. The patient came to our institutionfor an additional opinion regarding non-surgical therapy. An upper endoscopy was performed and confirmed the diagnosis of an antral web with 3 obstructing rings. A diagnostic upper endoscope could not be passed through the rings. Using a standard biliary needle-knife and electrocautery, multiple electroincisions were performed in a radial fashion through all points of obstruction in all 3 rings. A snare was used to resect some of the web as well after the electroincision. The endoscope was then passed to the second duodenum, and a 20-mm dilating balloon was passed through the channel of the endoscope. The endoscope was withdrawn and positioned with the balloon across the distal antrum and pylorus. The balloon was inflated to 20 mm. This exposed the more muscular part of the ring which was subsequently electroincised, and redilation with to 20 mm was performed. A therapeutic adult upper endoscope could be easily passed at the end of the procedure through the antrum and pylorus. The patient's symptoms resolved post endoscopic therapy and a follow-up upper GI was obtained after four weeks which showed a normal antrum. At 3 months, patient continued to have resolution of his symptoms, was eating well and gaining weight. This case illustrates the value of upper GI series and endoscopy establishing a correct diagnosis of gastric antral web. This case highlights that endoscopic therapy for a gastric antral web can be used as a first line treatment modality in selected patients. It also shows that endoscopic therapy can be used to avoid a potentially invasive surgical procedure and provide long-lasting resolution of symptoms in appropriate patients.