Case Of Gastric Outlet Obstruction Research Articles

A Rare Case of Gastric Outlet Obstruction in Stage IV Breast Cancer

A Rare Case of Gastric Outlet Obstruction in Stage IV Breast Cancer

Long-Term Palliative Effect of Stenting in Gastric Outlet Obstruction Due to Transarterial Chemoembolization with Yttrium-90 in a Patient with Metastatic Neuroendocrine Tumor.

Internal radioembolization with yttrium-90 is a promising treatment method, predominantly for liver tumors. However, the shifting of yttrium-90-loaded spherules into the arteries and veins that supply the duodenum and stomach, leading to ulceration, hemorrhage, perforation, and outlet obstruction of these organs, is one of the major undesirable consequences of this technique. We report a case of gastric outlet obstruction (GOO) due to antropyloric stenosis with ulceration, edema, and inflammation following transarterial yttrium-90 treatment for a metastatic neuroendocrine tumor in a 58-year-old man. Stenting was used for palliation in this case. GOO improved after stenting and recovery of oral intake was permanent after stent removal.

Retrograde pylorogastric intussusception – Case report and review

Abstract A case of gastric outlet obstruction in an infant due to retrograde intussusception of the pylorus into the stomach is presented. This anomaly is extremely rare, with almost no reports in the literature. The patient underwent formal Heineke-Mikulicz pyloroplasty with an uneventful recovery and resumed full enteral feeding.

An Unusual Case of Gastric Outlet Obstruction

Introduction: Embolization is an accepted treatment modality for selected cases of visceral artery aneurysms and pseudo aneurysms. Although safe, it can result in various post procedural complications. We report a rare case of gastric outlet obstruction after embolization of large posterior pancreatico duodenal artery (PPDA) and gastroduodenal (GDA) artery pseudo aneurysms. Case: 45 year old male with past medical history of GERD, recurrent alcohol induced pancreatitis and pseudocyst presented with upper abdominal pain, anorexia, hematemesis and coffee ground emesis. He had undergone coil embolization of large PPD A and GDA pseudo aneurysms 4 weeks prior to his presentation. He denied any NSAID use or uncontrolled GERD. CTA showed edema along posterior wall of stomach and medial wall of duodenum adjacent and surrounding pancreatic head. No evidence of flow was identified within prior embolized vessels. EGD revealed intense edema, inflammation, and friability in the duodenal bulb causing near obstruction. Mucosa in the second portion of duodenum appeared to be normal. Malignancy versus extrinsic compression were in the differential. Biopsies from the area were benign and showed no evidence of malignancy. Upper GI series showed compression of the gastric antrum, without evidence of obstruction. This was thought to be most likely from ischemia due to recent embolization. The patient was managed conservatively with liquid diet and PPI twice daily and improved slowly clinically and endoscopically in 6 months. Discussion: Visceral artery pseudo aneurysms occur in minority of patients with pancreatitis because of pancreatitis-induced periarterial inflammation. Endovascular therapy including embolization or stent graft deployment is considered the treatment of choice for hemodynamically stable patients. Several intra and post procedural complications have been reported, however, gastric outlet obstruction is an extremely uncommon finding. It most likely occurred due to ischemia of the duodenal bulb post procedure. It can mimic malignancy clinically and endoscopically. Therefore, when pertinent, it is important to keep this benign complication in differentail diagnosis. Conservative management with liquid diet and PPI may improve the condition over time with revascularization and formation of collateral vessels, otherwise surgical bypass needs to be considered.Figure 1Figure 2Figure 3

Gastric outlet obstruction: An unusual adverse event of percutaneous endoscopic gastrostomy

Dear Editor, A 75-year-old woman living in a nursing home presented with a 24-hour history of abdominal cramping and vomiting. Medical history was remarkable for dementia and a percutaneous endoscopic gastrostomy (PEG) was performed 3 years earlier. The day before the admission the feeding tube was accidentally pulled out and a Foley catheter was placed in order to avoid stoma closure. On physical examination, there was extravasation of the gastric content through the stoma. The base of the "Y" of the Foley catheter was introduced in the gastric stoma and a pulling sensation was felt when it was mobilized. The remainder abdominal examination was unremarkable. On esophagogastroduodenoscopy the Foley catheter was identified passing the pylorus and pulling duodenal bulb towards the antrum (Figure 1). Advancing the scope through the duodenum, the Foley balloon impacted in the duodenal apex was identified. There was no mucosal injury so the balloon was deflated and the catheter removed. A 14 Fr. Bard PEG tube was latter placed to allow a reduction in the calibre of the stoma. Gastric outlet obstruction is an unusual adverse event of PEG tubes. In adults it is usually related to Foley catheters use as peristalsis can pull the balloon into the duodenum in the absence of an external bumper. A clinical picture of abdominal cramping, vomiting and resistance to the attempt of percutaneous reposition should raise the suspicion of gastrostomy tube migration through the pylorus. Foley catheters are easily available and some may use it to prevent gastrostomy closure after accidentally PEG tube extraction. We have performed more than 800 PEG and assisted several cases of gastric outlet obstruction and even stoma damage in this setting. This case emphasises the importance of receiving an early PEG tube with external bumper replacement to prevent this adverse event.

Unusual Case of Gastric Outlet Obstruction

Unusual Case of Gastric Outlet Obstruction

A case series of gastric outlet obstruction secondary to tuberculosis: New diagnostic and treatment paradigm

AbstractTuberculosis can involve any part of gastrointestinal tract. Gastro-duodenal involvement in tuberculosis is rare. We report four cases of gastric outlet obstruction due to tuberculosis. In all of these patients obstruction was due to extra-luminal compression from lymph-nodes. Clinical presentation was with epigastric pain and recurrent vomiting. Upper GI endoscopy revealed duodenal stricture without any active ulcer or mass. Computed tomography scan showed duodenal thickening along with abdominal lymph nodes. Diagnosis was confirmed with EUS guided FNAC. Antral dilatation using CRE can be used as first treatment option for obstruction in these patients. Patients non responsive to dilatation may require surgery.

Update of Aetiological Patterns of Adult Gastric Outlet Obstruction in Accra, Ghana

Background: The aetiology of gastric outlet obstruction globally has evolved from benign to malignant causes, but there seem to be no recent data on the trends in Ghana. The aim was, therefore, to identify the current patterns in the aetiology of gastric outlet obstruction in the adult population in Ghana. Methodology: This was a retrospective review of all confirmed cases of gastric outlet obstruction in the last decade, spanning from June 2004 to May 2014, that were managed at the Korle Bu Teaching Hospital. Results: A total of 107 patients were managed for gastric outlet obstruction with a male to female ratio of 2.15:1 and most of the patients making 71.3% of cases belonged to the age range of 40 to 60 years. The predominant aetiology for gastric outlet obstruction was found to be gastric cancer (55.140%), followed by peptic ulcer disease (27.103%). Conclusion: The aetiology of gastric outlet obstruction in Ghana has evolved from benign to malignant causes, following current global trends. Gastric cancer is now the most important cause of gastric outlet obstruction in Ghana, followed by peptic ulcer disease which predominates as the commonest benign cause.

A Rare Case of Gastric Outlet Obstruction: Pancreatitis-induced Intramural Duodenal Hematoma

A Rare Case of Gastric Outlet Obstruction: Pancreatitis-induced Intramural Duodenal Hematoma

Gastric outlet obstruction caused by focal nodular hyperplasia of the liver: A case report and literature review

INTRODUCTIONHere, we present a case of gastric outlet obstruction due to focal nodular hyperplasia of the liver. PRESENTATION OF CASEA 23-year-old female presented to our emergency clinic with nausea, vomiting, and abdominal pain. Endoscopy showed that the prepyloric region of the stomach was externally compressed by a lesion. Computed tomography and magnetic resonance imaging revealed a 70mm solid mass originating from the liver, extending caudally in an exophytic manner, and compressing the stomach. Laparotomy revealed an irregular and exophytic mass originating from the liver, which caused gastric outlet obstruction. The mass was resected with a 10mm safety margin. The histopathology report of the mass returned as focal nodular hyperplasia. DISCUSSIONGastric outlet obstruction is a clinical syndrome characterized by abdominal pain, nausea, and postprandial vomiting. This clinical condition frequently develops as a result of peptic ulcer disease, pyloric stenosis, and obstruction of pylorus by foreign bodies including phytobezoars, congenital duodenal webs, malignant disorders, and various lesions externally compressing the stomach. Gastric outlet obstruction due to hepatic lesions is extremely rare; few cases have been reported. CONCLUSIONThis is the first reported case of gastric outlet obstruction that developed due to focal nodular hyperplasia of the liver.

Primary duodenal tuberculosis mimicking malignancy

Gastrointestinal tuberculosis is the commonest form of extraintestinal tuberculosis. Primary gastrointestinal tuberculosis is not common, even in an endemic region like India. Upper gastrointestinal tuberculosis is even rarer and presents with a myriad of symptoms. A preoperative workup usually fails to conclude the diagnosis. The authors present a case of gastric outlet obstruction with weight loss and anorexia. Imaging and intraoperative findings raised the suspicion of advanced malignancy; however, histologic examination revealed tuberculosis. The patient responded well to treatment with antitubercular drugs.

Endoscopic ultrasound-guided double stenting for biliary and duodenal obstruction

Endoscopic biliary stenting for malignant biliary obstruction is currently the gold standard for biliary drainage. Biliary cancer treatment is crucial. Cases of gastric outlet obstruction that includes the duodenum because of cancer invasion and biliary obstruction are seldom observed. The required treatment for such cases is simple biliary stenting and a different treatment for duodenal obstruction. Hence, double stenting for bile duct and duodenal obstruction has drawn attention. In the present review, we state different treatment strategies for malignant duodenal obstruction and then describe double stenting in biliary obstruction that also includes non-biliary cancer malignant lesions and duodenal obstruction.

Endoscopic ultrasound-guided double stenting for biliary and duodenal obstruction.

Endoscopic biliary stenting for malignant biliary obstruction is currently the gold standard for biliary drainage. Biliary cancer treatment is crucial. Cases of gastric outlet obstruction that includes the duodenum because of cancer invasion and biliary obstruction are seldom observed. The required treatment for such cases is simple biliary stenting and a different treatment for duodenal obstruction. Hence, double stenting for bile duct and duodenal obstruction has drawn attention. In the present review, we state different treatment strategies for malignant duodenal obstruction and then describe double stenting in biliary obstruction that also includes non-biliary cancer malignant lesions and duodenal obstruction.

Efferent limb of gastrojejunostomy obstruction by a whole okra phytobezoar: Case report and brief review

A phytobezoar is one of the intraluminal causes of gastric outlet obstruction, especially in patients with previous gastric surgery and/or gastric motility disorders. Before the proton pump inhibitor era, vagotomy, pyloroplasty, gastrectomy and gastrojejunostomy were commonly performed procedures in peptic ulcer patients. One of the sequelae of gastrojejunostomy is phytobezoar formation. However, a bezoar causing gastric outlet obstruction is rare even with giant gastric bezoars. We report a rare case of gastric outlet obstruction due to a phytobezoar obstructing the efferent limb of the gastrojejunostomy site. This phytobezoar which consisted of a whole piece of okra (lady finger vegetable) was successfully removed by endoscopic snare. To the best of our knowledge, this is the first case of okra bezoar-related gastrojejunostomy efferent limb obstruction reported in the literature.

A challenging case of gastric outlet obstruction (Bouveret's syndrome): a case report

IntroductionBouveret's syndrome is a clinically distinct form of gallstone ileus caused by the formation of a fistula between the biliary tract and duodenum. This case reinforces the need for early recognition and treatment of Bouveret's syndrome, as it is associated with high morbidity and mortality rates.Case presentationAn 82-year-old Caucasian woman presented with signs and symptoms of small bowel obstruction. Her laboratory workup showed elevated alkaline phosphatase and amylase levels. Computed tomography of her abdomen revealed pneumobilia, a choledochoduodenal fistula and a gallstone obstructing her distal duodenum. The impacted gallstone could not be extracted endoscopically, so our patient underwent open enterolithotomy successfully. However, the postoperative course was complicated by myocardial infarction, respiratory failure and disseminated intravascular coagulation. She died 22 days after surgery, secondary to cardiopulmonary arrest.ConclusionThis case clearly highlights the considerable morbidity and mortality associated with Bouveret's syndrome.

Duodenal tuberculosis presenting as gastric outlet obstruction: A case report

Gastric outlet obstruction is commonly associated with malignancies and peptic ulcer disease. However, when no malignancy is seen and the patient is non-responsive to conventional peptic ulcer treatment, other etiologies need to be explored. We report a case of gastric outlet obstruction due to duodenal tuberculosis. The patient is a 31 year old male who presented with 1 year history of recurrent epigastric pain and an acute episode of vomiting. Endoscopy revealed duodenal stricture. Computed tomography scan showed pyloroantral thickening. The patient was referred to the surgery service and underwent an exploratory laparotomy and gastrojejunostomy. A duodenal mass and calcified lymph nodes were noted on exploration and biopsy revealed a tuberculous origin. The patient was started on anti-tuberculosis medications and had improved on discharge. Gastroduodenal tuberculosis is rare and pyloric stenosis resulting from tuberculosis is even rarer. This, however, should be considered in patients who come from areas where the disease is endemic.

Partial gastric outlet obstruction caused by a huge submucosal tumor originating in the heterotopic pancreas

A 21-year-old woman presented gastrointestinal manifestation showing intermittent abdominal pain, nausea, and vomiting. An upper endoscopic examination showed round, elevated mucosa at the antrum of the stomach anterior wall. After CT scanning, a huge degenerated gastrointestinal stromal tumor was suspected. Subtotal gastrectomy with Billroth II anastomosis was performed. Histologically, pseudocystic degeneration of the heterotopic pancreas was confirmed. The patient showed eventful postoperative course except temporary dilated gastric emptying. The patient is doing well without any abnormal symptom at 8-month follow-up. This report is a rare case of gastric outlet obstruction caused by a pseudocyst originating from a heterotopic pancreas in the gastric antrum.

Malignant transformation of ectopic pancreatic cells in the duodenal wall

Ectopic pancreas (EP) is the relatively uncommon presence of pancreatic tissue outside the normal location of the pancreas. This condition is usually asymptomatic and rarely complicated by pancreatitis and malignant transformation. A few cases of neoplastic phenomena that developed from EP into the duodenal wall are described in the literature. Herein we report a case of gastric outlet obstruction due to adenocarcinoma arising from EP of the duodenal wall. The patient underwent a Whipple's procedure and had an uneventful post-operative recovery. Traditional imaging studies are often inconclusive in the definitive diagnosis, whilst endoscopic ultrasonography and guided biopsy may aid accurate pre-operative diagnosis. Diagnostic uncertainty warrants surgical exploration and if necessary extended resection is indicated.

Gastric Outlet Obstruction and Pancreatitis Caused By Migrated Gastrostomy Tube: A Rare Scenario

Purpose: Percutaneous Endoscopic Gastrostomy (PEG) is a very common method of enteral nutritional support. The most common indication for PEG tube placement is oropharyngeal dysphagia secondary to cerebrovascular accident, advanced dementia, and benign and malignant oropharyngeal and esophageal obstruction. Use of PEG tube feeding has increased exponentially since its introduction in 1980. Major complications of PEG include aspiration, hemorrhage, peritonitis and rarely necrotizing fasciitis and tumor implantation. Minor complications include ileus, peri-stomal infection, stomal leakage, buried bumper, gastric ulcer, fistulous tracts and inadvertent removal. We report a case of gastric outlet obstruction and pancreatitis induced by migrated PEG tube. The migrated inner balloon of the PEG-tube blocked the duodenum causing gastric outlet obstruction and obstructed Ampulla of Vater leading to acute pancreatitis. The presenting symptoms rapidly resolved after prompt diagnosis and PEG tube repositioning. Case Report: An 83-year-old female nursing home resident with PEG tube feeding presented with two episodes of projectile vomiting. On physical examination at the time of admission, her vital signs were within normal limit and abdominal exam was benign. Admission labs showed Amylase - 460 U/L, Lipase - 291 IU/L, Total Bilirubin - 0.3 mg/dl, Direct Bilirubin - 0.1 mg/dl, ALP - 109 IU/L, AST - 102 U/L and ALT - 80 U/L. Abdominal sonogram excluded cholelithiasis or cholecystitis. However, CT abdomen revealed gastrostomy tube's balloon migrated in the duodenal bulb. The balloon was repositioned by deflating and then reinflating. Vomiting resolved and LFTs, amylase and lipase dramatically improved. Two days after admission, labs showed Amylase - 162, Lipase - 78, ALP - 80, AST - 25 and ALT - 42. Repositioning of the external bumper at mark 3-4 as needed will prevent PEG tube migration and related complications.

Gastric Outlet Obstruction Due to Secreting Heterotopic Pancreas

Purpose: Introduction: Heterotopic pancreas (also termed as pancreatic rests) is a rare congenital anomaly of the gastrointestinal tract. Presence of heterotopic pancreatic tissue within the stomach is a rare cause of gastric outlet obstruction. We report an interesting case of gastric outlet obstruction as a complication of heterotopic pancreas presenting as a submucosal cyst in the gastric antrum diagnosed with endoscopic ultrasound (EUS). Case report: A 22 year old female with history of gastroesophageal reflux disease presented with 6 week history of progressively worsening nausea, emesis, heartburn and early satiety with weight loss. Esophagogastroduodenoscopy to the descending duodenum revealed a large, submucosal antral gastric lesion with partial gastric outlet obstruction. Abdominal computer tomography showed a 4 cm×2.7 cm low-density mass in the distal stomach. Subsequent EUS demonstrated a large 5 cm submucosal cystic lesion in the gastric antrum in layer three. EUS guided fine needle aspiration of the cyst revealed amorphous material. Biochemical studies of the fluid showed elevated amylase level with a value of 4,878 U/L and a CEA level of 96.6 ng/ml. Due to persistent symptoms, patient subsequently underwent distal gastrectomy with Roux-En-Y anastomosis. Final histological diagnosis showed gastric heterotopic pancreas. Discussion: Heterotopic pancreas is defined as the presence of pancreatic tissue outside normal pancreas that lacks anatomic or vascular continuity with main pancreas itself. Most common sites for heterotopic pancreas are stomach (25-38%), duodenum and jejunum. Complications include mechanical obstruction like gastric outlet obstruction in our patient, cyst formation, acute or chronic pancreatitis, bleeding due to ulceration and malignant transformation. Differential diagnosis of gastric submucosal lesions includes gastrointestinal stromal tumors, duplication cyst, lymphoma and gastric carcinoma. On endoscopy, heterotopic pancreas appears as a broad based submucosal lesion that may have umblication on the mucosal surface indicating the site of draining duct. EUS has proven to be very useful in diagnostic evaluation. Fine needle aspiration via EUS allows cytological evaluation of submucosal lesions which can usually confirm the diagnosis. Definite diagnosis of pancreatic heterotopia is by histology of the lesion. Symptomatic lesions are treated surgically. Submucosal lesions of gastrointestinal tract present a diagnostic challenge for gastroenterologists. Heterotopic pancreas, albeit a rare entity, should be considered in cystic lesions of gastric wall causing gastric outlet obstruction.