Acute Gastric Outlet Obstruction Research Articles

Multidisciplinary treatment of massive trichobezoar caused an acute gastric outlet obstruction

Introduction. Trichobezoars presents a rare form of bezoar made of swallowed hair, with clinical manifestation of gastric or intestinal obstruction, gastric ulceration, bleeding, and perforation. It is predominantly found in emotionally disturbed or mentally retarded youngsters, who eating their own hair which is clinically known as trichophagia. Patients often deny eating their own hair which makes diagnosis difficult. Case report. We present a case of acute gastric outlet obstruction caused by a giant gastric trichobezoar made of a long thin hair, in a 20-year young female. Although patient had a long history of trichophagia, she did not think her behavior was unusual and she had not been treated before. Following the initial diagnostic procedures, exploratory laparotomy was indicated. After anterior gastrotomy was performed, a massive stomach-shaped trichobezoar was removed. Postoperatively, the patient had a psychiatric consult exam. She recovered well and was discharged without complications. She was referred for further psychiatric follow-up. Conclusion. Trichobezoars are non-digestible collections that usually accumulates in stomach and can extend to small bowel, causing mechanical injury such as hollow viscus obstruction. Patients with acute gastric obstruction caused by a giant trichobezoar require urgent removal of the trichobezoar, to preserve the stomach and avoid further, catastrophic consequences.

S3682 Vagal Nerve Injury Presenting as Acute Gastric Outlet Obstruction: A Rare Case Presentation

S3682 Vagal Nerve Injury Presenting as Acute Gastric Outlet Obstruction: A Rare Case Presentation

The Burden of Gastrointestinal, Hepatobiliary and Pancreas Related Diseases and Their Causes at Tertiary Care Hospital in Karachi

Objective: To determine the burden of gastrointestinal, hepatobiliary and pancreas-related disease, frequencies and their presentations.
 Study Design: Cross-sectional study.
 Place and Duration of Study: Gastroenterology Department, Liaquat National Hospital, Karachi from Oct 2020 to Jul 2021
 Methodology: Patients aged ≥18 years, having diagnosis related to gastrointestinal, hepatobiliary and pancreas were included in the study. Demographic features, reasons for admission, and length of stay were recorded.
 Results: A total of 2183 patients were enrolled. Nearly half of the patients were ≥60 years. 43% of patients were presented with abdominal pain. The most frequent diagnosis includes decompensated chronic liver disease followed by upper gastrointestinal bleed. The proportion of female patients was significantly higher for gastritis (p=0.009) and acute cholecystitis (p=0.036), while males with Hepatitis-B (p=0.019) and liver abscesses (p=0.018) were significant. Admissions through emergency were higher for gastrointestinal bleeding and decompensated chronic liver disease (p<0.001) in monitoring setup (p=0.034), ward admission via OPD were significant for upper gastrointestinal malignancy (p=0.011) and hepatocellular carcinoma (p=0.038). Extended length of stay and expiry was significant among acute liver failure (p=0.047) and gastric outlet obstruction (p=0.030).
 Conclusion: Notably, highly evitable diseases are still a foremost reason of clinical importance, lack of awareness and low cure rate, especially in rural areas progress to high fatality as most patients do not seek medical assistance until significant manifestation. This appeals to more effective measures, including eradicating the potentially life-threatening disease.

A JINXED VISITOR IN AN IRREDUCIBLE EPIGASTRIC HERNIA- A RARE CASE REPORT

Acute gastric outlet obstruction is a rare entity causing a nightmare to the treating surgeon and the patient. Etiologies include foreign body ingestion, opposing peptic ulcers, gastric volvulus, hiatus hernia. Causes for gastric outlet obstruction presenting with epigastric mass are epigastric hernia containing stomach pylorus, trichobezoar and carcinoma stomach. After an exhaustive literature review, only 6 cases of epigastric hernia with stomach as content could be found.

Intrahepatic Pancreatic Pseudocysts: A Review of Recent Literature and Case Report

Intrahepatic pancreatic pseudocysts (IHPP) are a rare clinical entity which results from migration of amylase rich proteolytic pancreatic fluid along hepatogastric or hepatoduodenal ligaments into the hepatic parenchyma. There are no current management guidelines, and definitive management depends on varying features within each individual case. We report a rare case presenting with features of acute gastric outlet obstruction on a background of chronic pancreatitis. The rapid formation of this IHPP does not appear to have been previously reported in the literature.

A case report of duodenal carcinoid tumor causing gastric outlet obstruction

Carcinoids are tumours of neuroendocrine origin. Commonly found in gastrointestinal and respiratory tracts, however, duodenal carcinoids among them are comparatively rare. Duodenal carcinoids presenting as acute gastric outlet obstruction are even rarer. Clinically difficult to diagnose due to their non-specific presentation. Endoscopic ultrasound (EUS), computed tomography (CT) and immunohistochemistry (IHC) for markers like chromogranin A, neuron specific enolase (NSE), synaptophysin helps in making a definitive diagnosis. Management is influenced by multiple factors like size, site, metastases and regional lymph node involvement. Here is a case report of solitary duodenal carcinoid complicated with acute gastric outlet obstruction. A middle-aged female with chronic history of intractable dyspepsia, bloating and occasional vomiting, on thorough evaluation with upper GI endoscopy, EUS guided biopsy, CT scan and histopathological examination was diagnosed of a solitary 2.2×1.2×1.6 cm sized duodenal carcinoid tumour. Patient had no past, family or genetic history supporting the diagnosis. Patient presented with features of acute gastric outlet obstruction 1 week after the diagnosis which required a distal gastrectomy with resection of first part of duodenum followed by a Roux-en-Y gastrojejunostomy with an uneventful 6 month follow up. As the size in this case was more than 2 cm with AJCC staging of T2N0M0, distal gastrectomy with Roux-en-Y gastrojejunostomy was done to ensure an R0 resection and to relieve the gastric outlet obstruction. Duodenal carcinoids presenting as gastric outlet obstruction are not common. Early management is essential to prevent complications like gastric outlet obstruction despite of indolent course of the disease.

Acute gastric outlet obstruction due to an impacted gallstone: the Bouveret’s syndrome

A 59-year-old woman presented to the emergency department with a 3-day history of severe abdominal pain and recurrent vomiting. On admission, the patient reported that the pain was accompanied by...

Quality improvement of fluoroscopic guided nasojejunal tube insertionx in a large teaching hospital

Background: Post-pyloric feeding is an important method of providing nutrition in patients who are suffering from conditions such as acute pancreatitis and gastric outlet obstruction (due to malignancy or chronic peptic ulcer disease). It has been reported that enteral nutrition significantly reduces incidence of infection and organ failure and shortens hospital stays, as well as enabling early attainment of caloric/nutritional need in patients with gastric feeding intolerance.

Case report and literature review: patient with gastroduodenal intussusception due to the gastrointestinal stromal tumor of the lesser curvature of the gastric body

BackgroundIntussusception in adult patient is rare. Gastroduodenal intussusception due to the gastrointestinal stromal tumors is infrequently described in the literature. Authors present a case of gastroduodenal intussusception due to the low-risk gastrointestinal stromal tumor of the lesser curvature of the gastric body with literature review.Case presentationSixty-two-year-old male was admitted to our hospital with symptoms of acute gastric outlet obstruction. Imaging studies confirmed a lesion of the gastric wall producing gastroduodenal intussusception with pylorus obstruction. Upon laparotomy a tumor mass of the lesser curvature of the gastric body that invaginated through the pylorus into the duodenum was found. Desinvagination and resection of the tumor with the adequate resection margins were performed. Histology reveled a low-risk gastrointestinal stromal tumor. Due to favorable outcome only observation was suggested by the multidisciplinary team.ConclusionsGastroduodenal intussusception due to the gastrointestinal stromal tumor of the gastric wall is a rare event. Surgical resection is the treatment of choice. In selected cases laparosopic resection of the tumor can be performed.

Diagnosis and management of acute esophageal necrosis.

Acute esophageal necrosis is a rare syndrome classically characterized by a striking endoscopic image of diffuse and circumferential black mucosal discoloration of distal esophagus, with an abrupt transition at the gastroesophageal junction and variable proximal extension. The typical patient is an older male with general debilitation and multiple comorbidities presenting with hematemesis or melena. The pathophysiology usually involves a combination of esophageal ischemia, backflow injury from gastric chemical contents and impaired mucosal reparative mechanisms associated with debilitated physical states. It may arise in the setting of hemodynamic compromise, diabetic ketoacidosis, hypothermia, alcoholic intoxication, trauma, inflammatory diseases, esophageal local infection, solid organ transplantation, postoperative status, drugs or acute gastric outlet obstruction, usually in the background of a chronic debilitating process, where the concurrent presence of multiple risk factors, including diabetes mellitus, hypertension, malnutrition, malignancy or alcohol abuse, places a patient at higher risk. The characteristic endoscopic appearance establishes the diagnosis. Biopsy is supportive but not required. Management is mainly supportive and consists of correcting coexisting conditions, fluid therapy, bowel rest, intravenous proton pump inhibitor therapy and red blood cell transfusion as needed. Although this is a serious life-threatening condition, appropriate treatment may result in a favorable outcome in the majority of patients.

Initial Presentation of Gastric Cancer Among Various Racial/ethnic Groups at an Academic Center in New York City

Introduction: Due to its often asymptomatic presentation or nonspecific manifestations, over one-third of gastric cancers (GC) are diagnosed at an advanced stage with limited, if any, durable treatment options. The initial presentation of gastric cancer among various racial and ethnic minorities in the USA is not well-described. Methods: We performed a retrospective analysis of patients included in a pathology database with histologically confirmed GC between 2008 and 2016 at a single academic center in NYC, who also had confirmatory endoscopic data available. Patients with cancer of the gastroesophageal junction or cardia were excluded. Age at diagnosis, race/ethnicity, smoking status, and presenting signs and/or symptoms were recorded. Statistical analysis was performed in STATA. Results: 108 patients [67.6% men/32.4% women] were included. Median age at diagnosis was 71.5 (range 41-92) years. Racial/ethnic breakdown was as follows: Hispanic/Latino (n=27), Asian (n=19), African-American (AA) (n=18), European/Russian (n=21), non-European/Russian white (n=5), unknown (n=18). Indications for endoscopy were available in 103/108 patients, with only 3 listing “surveillance” as the indication. Abdominal pain/dyspepsia was the most common presenting symptom (n=53), followed by acute GI bleed (n=27), asymptomatic anemia (n=18), weight loss (n=18), and gastric outlet obstruction (n=9), or a combination of these. 29.3% were stage 3 or more advanced at presentation; less than 20%(n=22) had endoscopies prior to GC diagnosis. Asians (61.8+/-1.6 years), AA (70.4+/-2.6 years), Hispanic/Latinos (71.1+/-2.1 years), and Europeans/Russians (72.2+/- 2.4 years) presented at younger ages versus whites (80+/-0.2 years), but the number in the latter group was small (n=5). There was no difference in presenting symptoms between the groups. Although non-whites presented with higher-grade lesions, there was no difference in stage at presentation between the groups (p=0.216). Conclusion: Patients with higher GC risk based on race/ethnicity had similar stage and presenting symptoms compared to whites, with nearly a third of patients having at least stage 3 GC at diagnosis. Only a minority had endoscopies prior to their one at diagnosis. Further research is needed to clarify whether some races/ethnicities may benefit from GC screening.

Gastric Bezoar Causing Massive Gastric Distention and Functional Outlet Obstruction in a Patient With Bulimia Nervosa

Gastric bezoar is an uncommon cause of gastric outlet obstruction, as well as a rare complication of bulimia nervosa (BN). The authors report a case of a young female with a history of BN presenting with acute gastric outlet obstruction. Radiologic imaging revealed a markedly dilated stomach and a retained gastric bezoar was identified during endoscopy. She was treated conservatively with nasogastric intubation and fluid resuscitation, followed by the consumption of Coca-Cola ® to promote fragmentation of the bezoar. The patient’s symptoms improved and she was transferred to a skilled eating disorder facility for further treatment of her underlying condition. J Med Cases. 2016;7(7):312-314 doi: http://dx.doi.org/10.14740/jmc2560w

Medication Bezoar Causing acute Gastric Outlet Obstruction: A Case Report

Medication bezoars are rare and are composed of medications and/or medication vehicles. Rarely, medication bezoars can cause serious problems due to complications such as perforation, obstruction, haemorrhage. A 60 years old woman presented with 10 days history of epigastric pain, weakness and postprandial non-bilious vomiting. Her abdominal ultrasonography showed strong post acoustic shadow noted within 1st part of duodenum possibly foreign body. Upper gastrointestinal endoscopy was performed and a bezoar of tablet of aluminum hydroxide was extracted. The patient had uneventful recovery. Acute gastric outlet obstruction is relatively uncommon and mostly due to foreign bodies related to food impaction, with meat being the most frequent culprit. The diagnostic approach to acute gastric outlet obstruction is similar to other cause of GOO. However, therapeutic options differ for each patient. The diagnosis should be made in prompt time to prevent life threatening complications due obstruction and/or effect of medication forming bezoar.J Bangladesh Coll Phys Surg 2015; 33(3): 177-180

Acute Gastric Volvulus

Gastric volvulus is characterized by abnormal rotation of the stomach along either its long or short axis, giving rise to acute or chronic gastric outlet obstruction. Rotation beyond 180 degrees can potentially lead to strangulation and ischemia of the stomach, resulting in necrosis and perforation. Thus, it is important to consider it as a differential diagnosis as the outcomes may be deleterious (1). A 75 year old Malay woman with significant past medical history of ischemic heart disease, diabetes mellitus, hypertension and hiatus hernia presented to our unit for acute onset of epigastric pain associated with vomiting. A year prior, she had been diagnosed with a large hiatus hernia on esophagogastroduodenoscopy done for gastro-intestinal evaluation of anemia. Vital signs were stable and cardiac evaluation for an acute myocardial event was unremarkable. A chest x-ray was subsequent performed, revealing air-fluid level in the intra-thoracic portion of the stomach (Figure 1). A computed tomography of the thorax and abdomen was obtained, which demonstrated the same hernia, measuring 14cm at its largest intra-thoracic diameter, compressing on the left lower lobe bronchus and thus leading to left lower lobe partial collapse (Figure 2). A nasogastric (NG) tube was then inserted to decompress the stomach but this was unsuccessful, with the distal tip of the NG tube being restricted only to the intra-thoracic portion of the stomach (Figure 3). The patient underwent laparoscopic repair of the paraoesophageal hernia with anterior 180 degrees partial fundoplication and was discharged well 2 weeks later. Borchardt's triad of pain, vomiting and inability to pass the NG tube is seen in up to 70% of patients with acute gastric volvulus (2). This can be complicated by pancreatic, omental or splenic ischemia secondary to traction, haematemesis due to vomiting or perforation as a result of ischemia. Signs of volume depletion and metabolic disturbances due to vomiting may also be present. Adequate resuscitation and decompression should be followed by surgery in fit candidates, with reduction of the stomach and repair of anatomical defects of the diaphragm (3).

Surgical management of acute esophageal necrosis

I read with great interest the article by Drs. M.H. Wu and H.Y. Wu [1] on acute esophageal necrosis (AEN). The authors described two patients with AEN and emphasized the role of esophagectomy in the treatment of this rare syndrome. While I welcome reports of new cases of ‘‘black esophagus’’ that stir scientific discussion about the condition, I disagree with the proposed, rather aggressive, surgical approach to manage AEN. In my original paper, I introduced a staging system that describes the progression of AEN based on the endoscopic and pathologic findings [2]. It should be noted that black esophagus is a striking medical condition that may present with acute gastrointestinal hemorrhage in patients with hemodynamic compromise, debilitated health, sepsis, multiorgan failure, acute gastric outlet obstruction and diabetic ketoacidosis. The mainstay of treatment of AEN is supportive medical therapy with acid suppression, nil-per-os restriction, red blood cell transfusion, and importantly, correction of the underlying medical condition that has led to the development of the AEN. The overall mortality rate in patients with black esophagus is high at 31 %, but the mortality specific to the esophageal disease is only 6 %. To date, surgical resection has been reserved only for cases of esophageal perforation, an event typically caused by external compression by a ruptured thoracic aorta, gastric volvulus or severe thromboembolic disease [3]. It may also be considered in situations with rapid clinical decompensation in the absence of any other explanation. I absolutely disagree with the authors that esophagectomy is indicated for a wide group of stage 1 AEN cases. I further disagree that surgical intervention is necessary for stages 2 and 3 of AEN to prevent the development of esophageal strictures. A subgroup of patients with diabetes mellitus has a low chance of developing stricture or stenotic complications, and all patients generally do well with endoscopic balloon dilatation [2]. In conclusion, the surgical management of AEN should be performed only in select cases of perforation/mediastinitis. The passage of a nasogastric tube, and especially a Sengstaken–Blakemore tube, in AEN patients should be prohibited, as the friability of the esophagus will lead to tragic perforation and death, as was seen in the second patient. In their description of their two cases of AEN, the authors failed to explain the need for rapid surgical treatment of patients with black esophagus, without first attempting conventional medical management.

Management of acute upside-down stomach

BackgroundUpside-down stomach (UDS) is characterized by herniation of the entire stomach or most gastric portions into the posterior mediastinum. Symptoms may vary heavily as they are related to reflux and mechanically impaired gastric emptying. UDS is associated with a risk of incarceration and volvulus development which both might be complicated by acute gastric outlet obstruction, advanced ischemia, gastric bleeding and perforation.Case presentationA 32-year-old male presented with acute intolerant epigastralgia and anterior chest pain associated with acute onset of nausea and vomiting. He reported on a previous surgical intervention due to a hiatal hernia. Chest radiography and computer tomography showed an incarcerated UDS. After immediate esophago-gastroscopy, urgent laparoscopic reduction, repair with a 360° floppy Nissen fundoplication and insertion of a gradually absorbable GORE® BIO-A®-mesh was performed.ConclusionGiven the high risk of life-threatening complications of an incarcerated UDS as ischemia, gastric perforation or severe bleeding, emergent surgery is indicated. In stable patients with acute presentation of large paraesophageal hernia or UDS exhibiting acute mechanical gastric outlet obstruction, after esophago-gastroscopy laparoscopic reduction and hernia repair followed by an anti-reflux procedure is suggested. However, in cases of unstable patients open repair is the surgical method of choice. Here, we present an exceptionally challenging case of a young patient with a giant recurrent hiatal hernia becoming clinically manifest in an incarcerated UDS.

Multiple Surgical Clips Found in Duodenum after Balloon Dilation

Purpose: Laparoscopic cholecystectomy with use of metallic surgical clips is a safe procedure with a less than 3% overall complication rate. We are reporting a rare case of migrated cholecystectomy clips into the duodenum associated with postbulbar stricture and ulcer. 68 year old female with history of cholecystectomy, metastatic colon cancer treated with right hemicolectomy, chemotherapy, and radiofrequency ablation of liver lesions. She was disease free for 5 years until a new right hepatic lobe lesion was discovered and treated with stereotactic radiation therapy with incomplete success. A year later, she presented with obstructive jaundice from malignant biliary stricture which was treated with a metal stent. Recently, she presented with acute cholangitis and gastric outlet obstruction. EGD showed an intrinsic postbulbar duodenal stricture requiring balloon dilation to 15 mm. There were no complications post dilation and cholangitis was treated with stenting. Progressive duodenal stricture lead to repeat endoscopic evaluation showing the postbulbar stricture and a deep ulcer with metallic clips seen at the ulcer base. Simultaneous fluoroscopic imaging confirmed that these were cystic duct clips eroding into the duodenum. This was also confirmed with CT scan. Many clip-associated complications, such as biliary leaks, clip migration into the common bile duct, and clip embolism have been reported. Migration of endo-surgical clips into the duodenum is a rare complication, previously reported in only five cases. In all the reported cases, an ulcer was present as in our case. Additionally, the ulcer was large and bleeding, and endoscopic or surgical treatment was required. Our case is the first report of migrated cholecystectomy clips into the duodenum to be associated with stricture and previous radiation. Proposed mechnisms: 1. the base of the cystic duct and artery lie immediately adjacent to the first part of the duodenum and through direct contact clips can erode in bowel wall; 2.) a pre-existing ulcer may have perforated and healed immediately, capturing the clips in the process; 3.) previous endoscopic stenting/radiation can lead ulcer formation. Though exact mechanism is unknown the associated deep ulceration and known complications of bleeding require careful management.Figure: Cholecystectomy clip in duodenum.

Gastric Volvulus Through Morgagni Hernia: An Easily Overlooked Emergency

BackgroundIntractable vomiting in an elderly patient is an emergency condition requiring prompt diagnosis and intervention. Acute gastric outlet obstruction due to gastric volvulus through Morgagni-type diaphragmatic hernia is an exceedingly rare cause of this nonspecific complaint. ObjectiveOur aim was to highlight that Morgagni hernia, although rare in adults, should be suspected in the appropriate clinical setting, and that a clue toward diagnosis often comes from routine chest and abdominal x-ray studies. In addition, we emphasize the atypical radiological findings and importance of emergency surgical intervention in such a case. Case ReportWe describe the case of a 78-year-old woman who presented to the Emergency Department with a 4-day history of intractable vomiting, and with no definitive clue to the diagnosis on examination. Her routine chest and abdomen x-ray studies suggested abnormal air-fluid level at right hemithorax, which prompted a computed tomography (CT) scan of the abdomen and an upper gastrointestinal contrast study. Gastric volvulus through a foramen of Morgagni was diagnosed and transthoracic reduction of the contents was performed, along with repair of the defect. ConclusionsA symptomatic Morgagni hernia in adults, although rare, can present with a variety of symptoms ranging from nonspecific complaints of bloating and indigestion to the more severe complaint of intestinal obstruction. Gastric volvulus and obstructive features are less frequently reported as acute complications of these hernias, which need early identification and intervention.

Gastroduodenal Intussusception of a Gastrointestinal Stromal Tumor (GIST)

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors in adults. They frequently occur in the stomach. Gastric GISTs typically present as a gastrointestinal bleed but can sometimes cause obstructive symptoms such as nausea and vomiting. We present a patient with a gastric GIST and liver metastases who during treatment with iminitab therapy presented with an acute gastric outlet obstruction. A computed tomography scan revealed a gastroduodenal intussusception of the gastric GIST. The patient underwent a laparoscopic exploration and resection of the GIST. We reviewed the English language literature of GISTs that presented as a gastroduodenal intussusception and put our case in the context of the previously reported cases. We discuss the diagnostic and therapeutic challenges that arise when treating these patients.

Gastric outlet obstruction secondary to paraesophageal herniation of gastric antrum after laparoscopic fundoplication

The most common causes of acute gastric outlet obstruction (GOO) are duodenal and type 3 gastric ulcers. However, mechanical or functional causes may also lead to this pathology. Acute GOO is characterized by delayed gastric emptying, anorexia, or nausea accompanied by vomiting. Herein we report a 56-year-old man diagnosed with GOO secondary to paraesophageal hiatal herniation of gastric antrum after laparoscopic fundoplication. Because of the rarity of this disease, common gastrointestinal complaints may mislead the emergency physician to diagnose a nonsurgical gastrointestinal disease if a detailed history and physical examinations are not obtained.