Case Of Gastric Outlet Obstruction Research Articles

True pylorus duplication: a case report

True pylorus duplication cysts are particularly rare, the literature describes only a small number of cases. They account for nearly 2.2% of all alimentary tract duplications. Most of the gastric duplications presents at an age younger than one year with one-third diagnosed in the neonatal period. However, they are not limited to that period. We report a case of a true pyloric duplication cyst in a 3-year-old girl who had been experiencing frequent vomiting with occasional abdominal pain for about 15 days prior to her presentation. The patient had an abdominal ultrasound that showed an epigastric cystic mass. CT of the abdomen demonstrated a 3.8×3.8 cm mass with a claw sign proximal to the first part duodenum. The diagnosis of pyloric duplication cyst was confirmed during the operation and with the histopathological examination following the resection. The patient is doing well with an appropriate weight gain at the follow-up appointments. The patient is doing well with an appropriate weight gain at the follow-up appointments. In summary, this is an an unusual case of gastric outlet obstruction that presented outside the usual age period caused by a pyloric duplication cyst. Imaging studies including US and CT are useful aids in the diagnoses of gastrointestinal duplication cysts.

Gastric outlet obstruction due to an intragastric balloon in a patient returning from the Caribbean

Key Clinical MessageGastric outlet obstruction can be a dangerous complication of intragastric balloons, as it can result in severe metabolic alkalosis. As weight loss procedures and medical tourism become more popular, physicians should have a high index of suspicion for complications of invasive procedures, particularly in returning travelers.AbstractIntragastric balloons for weight loss have decreased in frequency in the United States. However, they are still frequent in low‐ and middle‐income countries. Severe complications occur in less than 3% of patients who undergo this procedure. Herein, we present a case of gastric outlet obstruction, severe metabolic alkalosis, and refeeding syndrome in a patient returning from the Dominican Republic. She presented with 2 weeks of emesis and obstipation, followed by a pre‐syncope and altered mental status. An intragastric mass was observed on computerized tomography, which was characterized as an intragastric balloon and retrieved endoscopically. All metabolic derangements were corrected, and the patient improved without sequelae. As weight loss procedures and medical tourism become more popular, physicians should have a high index of suspicion for complications of invasive procedures, particularly in returning travelers.

Therapeutic Endoscopic Ultrasound for Complications of Pancreatic Cancer.

Progression of pancreatic adenocarcinoma can result in disease complications such as biliary obstruction and gastric outlet obstruction. The recent advances in endoscopic ultrasound (EUS) have transformed EUS from a purely diagnostic technology to a therapeutic modality, particularly with the development of lumen-apposing metal stents. In terms of biliary drainage, EUS-guided choledochoduodenostomy and EUS-guided hepaticogastrostomy offer safe and effective techniques when conventional transpapillary stent placement via ERCP fails or is not possible. If these modalities are not feasible, EUS-guided gallbladder drainage offers yet another salvage technique when the cystic duct is non-involved by the cancer. Lastly, EUS-guided gastroenterostomy allows for an effective bypass treatment for cases of gastric outlet obstruction that enables patients to resume eating within several days. Future randomized studies comparing these techniques to current standard-of-care options are warranted to firmly establish therapeutic EUS procedures within the treatment algorithm for this challenging disease.

An adult female case of autoimmune pancreatitis with gastric outlet obstruction complicated by annular pancreas.

A 65-year-old woman presented with epigastric pain persisting for more than 3months. She was diagnosed with autoimmune pancreatitis (AIP), based on high serum IgG4 levels (981mg/dL) and diffuse pancreatic enlargement with a capsule-like rim on computed tomography (CT). Additionally, the main pancreatic duct was indistinct on magnetic resonance cholangiopancreatography. CT, esophagogastroduodenoscopy, and upper gastrointestinal radiography revealed stenosis with gastric outlet obstruction (GOO) in the second part of the duodenum. Prednisolone administration was initiated as treatment; on day 3 of treatment, the patient's symptoms improved. After 2weeks, CT and endoscopic ultrasonography of the duodenal bulbs revealed improvement of the enlarged pancreas. The second part of the duodenum ran into the pancreatic head, and no malignant lesions were observed. Based on the above findings, we suspect that she developed AIP in the annular pancreas (AnnP), where duodenal stenosis worsened with diffuse pancreatic enlargement, resulting in GOO. She is currently under careful observation with tapering of prednisolone-without surgical treatment for AnnP. The pathogenesis of GOO caused by AIP without malignancy is rare. One case of GOO caused by AIP, wherein AIP developed in the AnnP (similar to the present case), has been reported, highlighting the novelty of our report.

S3711 A Mimic of Gastroparesis: An Atypical Case of Gastric Outlet Obstruction Caused by a Gastric Polyp

S3711 A Mimic of Gastroparesis: An Atypical Case of Gastric Outlet Obstruction Caused by a Gastric Polyp

S355 Presidential Poster Award Recurrent Obstruction After Surgical GJ in a Rare Case of Gastric Outlet Obstruction: EUS to the Rescue

Introduction: Eosinophilic enteritis is a rare cause of gastric outlet obstruction and if not recognized early can be very difficult to manage. Endoscopic ultrasound (EUS) guided gastrojejunostomy (GJ) is most often used for malignant disorders. However, it can act as a very effective temporary tool in benign disorders for effective medical therapy to take its course. Case Description/Methods: A 49-year-old man presented to us with features of recurrent vomiting and pain abdomen for 5 months. He had alcohol-related chronic calcific pancreatitis. Three years prior to current presentation he had features of gastric outlet obstruction for which he underwent oesophagogastroduodenoscopy (EGD) revealing a circumferential ulcer in antropyloric region with swelling. He underwent truncal vagotomy with antecolic gastrojejunostomy. Biopsy from the specimen had revealed eosinophilic gastroenteritis (EE). He again had some symptoms of obstruction 2 months after surgery which responded to proton pump inhibitors. He remained apparently well with regular follow up for chronic pancreatitis. Now he was symptomatic with progressive symptoms of gastric outlet obstruction since last 4 months. On endoscopy he was found to have both afferent and efferent loop strictures. He was also having a few geographic ulcers and psuedopolyps near stricture mouth. He underwent balloon dilatation twice upto 13.5 mm but symtoms did not improve. Repeat biopsies were taken from the ulcer and stricture site revealed EE with eosinophilic abscesses. Barium meal follow-through and Contrast enhanced CT was done for evaluation of stricture. A nasoduodenal (ND) tube of 10 french was negotiated over guidewire through the stricture using a cannula. It was used to continue enteral feeding. Surgical consultation was taken and poor surgical outcome was predicted in view of both loop involvement. He was started on oral budesonide and planned for an endoscopic bypass procedure. The ND tube was used to distend the normal jejunal loops beyond stricture and endoscopic ultrasound was used for gastrojejunostomy using a lumen apposing metal stent. Discussion: EUS-GJ is a viable option for gastric outlet obstruction even in benign cases for bridging for further surgical or medical therapy. Post-surgery complications may be difficult to manage and EUS-GJ appears more lucrative for the short time period. It requires a carefully selected patient with preset managment plan and a learning curve for successful implementation. Watch the video at https://tinyurl.com/ACGAbstractS355

Gastric outlet obstruction secondary to heterotopic pancreas being mistaken for gastric cancer: "Case report".

IntroductionHeterotopic pancreas (HP) is an uncommon and often incidental finding in clinical practice. It is the presence of pancreatic tissue distinct from the normal pancreas and with its own ductal and vascular supply. Distal stomach is the most common location of heterotopic pancreas followed by duodenum and jejunum. Most patients with heterotopic pancreas are asymptomatic. Gastric outlet obstruction is a rare presentation of heterotopic pancreas that can follow chronic inflammation and fibrosis of the pylorus from pancreatic secretion, pancreatitis, or malignant transformation. Heterotopic pancreas can be confused for gastric carcinomas on CECT and endoscopy. The aim of this paper is to present a rare case of gastric outlet obstruction due to heterotopic pancreas, mistaken for gastric cancer on endoscopy and CT scan, and its management.Presentation of the caseA 45 years old male from Adama, Ethiopia presented with vomiting of 8 months, which worsened since the last one month. He has no history of smoking and diabetes. He occasionally drinks alcohol. Physical examination was normal. CECT scan and endoscopy suggested distal gastric cancer. Radical subtotal gastrectomy done as gastric cancer couldn't be ruled out with excellent outcome. Histopathology revealed obstructing prepyloric chronic fibrosis and heterotopic pancreas.DiscussionHeterotopic pancreas is a rare pathological entity, clinical diagnosis is difficult preoperatively and frequently an incidental finding at laparotomy.ConclusionThough rare, heterotopic pancreas can present with gastric outlet obstruction and cause diagnostic confusion with gastric cancer. Definitive diagnosis is by histology that can also guide limited resection intraoperatively.

Gastric Outlet Obstructions and its Management in a Tertiary Care Hospital

Background: Gastric Outlet Obstruction may be caused by a heterogeneous group of diseases that include both benign and malignant conditions. In adults, mechanical obstruction due to ulcers, tumors or gastric polyps are common causes of gastric outlet obstruction. Until introduction of effective ulcer therapy duodenal ulcer was the commonest cause of gastric outlet obstruction and malignancy was attributed to only 20% of the cases. Objectives: To study the modes and presentation of presentation of gastric outlet obstruction among patients suffering from Duodenal ulcer diseases. Materials and Methods: A Hospital based Prospective study was conducted at Tertiary Care Centrefrom October 2017 to September 2019. A total of 100 cases of Gastric outlet obstruction were diagnosed during the study period. An elaborate study of these cases with regard to the history, clinical features, routine and special investigations, pre-operative treatment, operative findings, postoperative management and complications in post-operative period is done. Results: A total of 100 cases with gastric outlet obstruction were analyzed in our study. Out of the 100 cases with gastric outlet obstruction, 28 (28%) were diagnosed with cicatrizes duodenal ulcer and 72 (72%) of them had carcinoma antrum. Majority of the study subjects presented with pain, vomiting and anorexia on admission. Pallor was seen in nearly 68% of the study subjects followed by 56% of the cases with VGP and 54% with succession Splash. Only 28% of the subjects had palpable mass on palpation. Conclusion: Upper Gastro intestinal endoscopy should be mandatory in all suspected cases of gastric outlet obstruction. It can diagnose the cause of obstruction very effectively than any other investigative modality. Effective treatment in carcinoma stomach depends on early diagnosis.

A rare case of gastric outlet obstruction in a patient with multiple myeloma

Gastric amyloidosis is a very rare cause of gastric outlet obstruction. Therefore, general treatment recommendations are missing. A 61-year-old man with multiple myeloma and cast-nephropathy with suspected manifestation of amyloidosis was admitted for gastroscopy because of nausea and emesis. Video fluoroscopy demonstrated a gastric outlet obstruction with subtotal stenosis of the pylorus. Gastric amyloidosis (AL-amyloid) was confirmed histologically by deroofingbiopsies which was consistent with the clonotype of the patient’s myeloma. Botox injection was ineffective for control of symptoms. Therefore, endoscopic balloon-dilatation (15 mm to 20 mm) was performed with a long-lasting clinical response of 3 to 6 months.

Duodenal Ulcer-Induced Gastric Outlet Obstruction Showing Pyloric Wall Thickening and Abnormal FDG Uptake Mimicking Malignancy

Peptic ulcer disease is the most common benign cause of gastric outlet obstruction, in which mechanical obstruction occurs in the distal stomach, pylorus, or duodenum. We describe a case of gastric outlet obstruction induced by duodenal ulcer showing irregular pyloric wall thickening with marked enhancement on contras-enhanced CT and increased FDG uptake of the pyloric wall on FDG PET/CT mimicking malignancy.

A Rare Case of Gastric Outlet Obstruction Due to a Large Osteoclast-like Giant Cell Tumor of the Pancreatic Head - A Case Report

Background: Osteoclast-like Giant Cell Tumors (OGCT) of the pancreas are extremely rare, highly aggressive tumors which are still poorly understood. To date, multiple cases have been reported which characterize these tumors as variants of pancreatic giant cell tumors and provide evidence supporting a duct epithelium origin. The current prognostic factors and outcomes of various treatment protocols have not been established however, with very few reports discussing chemotherapy regimens and outcomes.

Superior mesenteric artery syndrome causing gastric outlet obstruction: A myth in acute abdomen

Objective: We aim to report a case of gastric outlet obstruction in adolescence that was diagnosed as a superior mesenteric artery syndrome and treated successfully by gastrojejunostomy. Case report: A 17-year-old female presented to emergency department with acute abdomen. She was also complaint of significant weight loss past 2 months. On clinical examination she was underweight with fullness of upper abdomen down to umbilicus. Oesophagogastroduodenoscopy (OGDS) was performed showed grossly dilated stomach with unable to go beyond D3 region. Contrast Enhanced Computed Tomography (CECT) abdomen suggestive of Superior Mesentery Artery (SMA) syndrome. She was subjected to gastrojejunostomy and recovered well postoperatively. Conclusion: An acute onset of gastric outlet obstruction in adolescence can be a diagnostic and treatment challenging. Our case patient was diagnosed as a SMA syndrome based on the history taking and CT findings. We would like to advocate a high index of suspicious SMA syndrome should be included in an acute abdomen in adolescence besides volvulus and malrotation. The treatment options should be individualized. In this case we opted for a gastrojejunostomy compared to duodenojejunostomy. The decision was made based on the patient nutritional status as patient was low Body Mass Index (BMI) was 16 kg/m2 which carries a high risk of anastomotic leak. Keywords: superior mesenteric artery syndrome; cast syndrome; wilkie’s syndrome; arteriomesenteric duodenal compression; duodenal vascular compression.

A rare case of gastric outlet obstruction due to a large osteoclast-like giant cell tumor of the pancreatic head - A case report

A rare case of gastric outlet obstruction due to a large osteoclast-like giant cell tumor of the pancreatic head - A case report

An unusual case of phytobezoar causing gastric outlet obstruction

A bezoar is defined as the accumulation of certain indigestible or poorly digestible substances in the gastrointestinal tract in the form of a mass, and when the bezoars consist of fruits and vegetables fibers, they are labeled as “phytobezoar.” Bezoars in the stomach are a rare condition and are often associated with episodes of gastric dysmotility and prior gastric surgery, though sometimes they can present without any significant history. Phytobezoars are difficult to diagnose due to its overlapping signs and episodic nature. however, in medical literature, the information about phytobezoars is insufficient due to the limited amount of documented cases, as well as the lack of research about this topic. in this case report, we present a rare case of gastric outlet obstruction with signs and symptoms overlapping with gastric carcinoma. On further investigation, the obstruction was found to be due to ingestion of unidentified type of vegetable fibers causing food impaction and phytobezoar formation for a 72-year-old patient with no former history of any type of surgeries.

Late-onset Cytomegalovirus Infection Associated With Gastric Outlet Obstruction in a Preterm Twin

The infant was born at a gestational age of 28 + 2 weeks as second twin to a 26-year-old woman, G1/P0, due to eclampsia. The patient developed well and was on full oral feeds when he started to develop nonbilious vomiting at 5 weeks. He was diagnosed with pyloric hypertrophy and underwent pylorotomy, but the condition did not improve and the patient was referred to our hospital. Here, esophagogastroduodenoscopy showed severely inflamed esophageal and gastric mucosa which was found to be due to cytomegaly virus (CMV) infection and a nonpassable pylorus. The patient underwent pyloroplasty revealing a fibrous pyloric ring. Histology showed giant cells suggestive of CMV infection which was confirmed by polymerase chain reaction. He was started on valganciclovir and discharged 4 weeks later on full enteral feeds. To our knowledge, this is the first case of gastric outlet obstruction due to CMV infection in a premature infant.

S2993 A Case of Gastric Outlet Obstruction Due to Metastatic Breast Cancer

S2993 A Case of Gastric Outlet Obstruction Due to Metastatic Breast Cancer

Bouveret’s syndrome: A challenging case of gastric outlet obstruction.

Bouveret’s syndrome causes gastric outlet obstruction when a gallstone is impacted in the duodenum or stomach via a bilioenteric fistula. We present case of a 40-year-old female presented with epigastric pain and intractable vomiting for 2 days. Her physical examination and laboratory workup including blood analysis, amylase test and lipase test were normal. Plain abdominal X-ray did not show any signs of small bowel obstruction. A nasogastric tube was placed and drained 2.5 L of gastric contents immediately. Esophagogastroduodenoscopy showed a dilated stomach with excessive secretions and a large blackish-brown hard stone in the duodenal bulb. After failed attempt at endoscopic extraction, patient underwent laparotomy and removal of stone via duodenal incision. Subsequently, the patient exhibited a good postoperative recovery. The condition of the patient has remained stable after being followed up for one year.

The safety and efficacy of a new 20-mm lumen apposing metal stent (lams) for the endoscopic treatment of pancreatic and peripancreatic fluid collections: a large international, multicenter study.

Lumen apposing metal stent (LAMS) allows an easy access to peripancreatic fluid collections (PPFCs) and the possibility of performing direct endoscopic necrosectomy (DEN). The aim of our study was to evaluate the safety and efficacy of a new 20-mm LAMS in the management of PPFCs. This novel stent represents the largest diameter LAMS available on the market to date. This is an international, multicenter retrospective study involving 20 centers. Consecutive patients who underwent EUS-guided PPFC drainage using a 20-mm LAMS were included. Primary outcomes were technical and clinical success. Secondary outcomes were rate and the severity of adverse events. A total 105 patients underwent PPFC drainage using the new 20-mm LAMS and 106 LAMS were placed. Technical success was 100% (106/106). 7/105 patients died due to causes not related to the stent. Clinical success was achieved in 92/98 patients (93.9%). Significant adverse events occurred in 8/98 patients (8.16%): 4 cases (4.08%) of bleeding, 3 cases (3.06%) of suprainfection, 1 case of gastric outlet obstruction. This multicenter study demonstrated acceptable rates of technical and clinical success using a new 20-mm LAMS for PPFC, including walled-off pancreatic necrosis (WOPN). The results of our study suggest that a new 20-mm LAMS is non-inferior in terms of safety, efficacy, and adverse events as compared to smaller diameter LAMS in the management of PPFCs, including pancreatic psuedocysts (PP) and WOPN. Randomized controlled studies will be needed to determine the ideal size of LAMS needto achieve the greatest clinical benefit with the minimized risk exposure for this high-risk patient population.

2626 A Curious Case of Gastric Outlet Obstruction!

INTRODUCTION: The average lifetime risk of a woman developing breast cancer is 12%. Invasive lobular carcinoma (ILC), the second most common histologic type attributes to 10–15% of breast cancer diagnoses. Compared to invasive ductal carcinoma, ILC has a higher chance to metastasize liver, ovaries and even the gastrointestinal tract. We present a unique case of gastric outlet obstruction (GOO) as the initial presentation of metastatic ILC. Histologically, it can be challenging to delineate ILC from primary gastric adenocarcinoma. This was a rare case where the diagnosis was made via the comparison of the endoscopic biopsy with the patient’s previous lymph node pathology. CASE DESCRIPTION/METHODS: 75-year-old female with history of type 2 diabetes mellitus, and lobular carcinoma treated with a bilateral mastectomy and Anastrozole hormone therapy for 8 years presented with confusion and non-bilious, non-bloody vomiting for two weeks. Vitals indicated orthostatic hypotension and abdominal exam revealed a tender epigastrium without rigidity or guarding. Laboratory findings demonstrated severe contraction alkalosis. Abdominal CT with contrast depicted wall thickening in the second and third portion of the duodenum. Endoscopy revealed an infiltrative circumferential mass that stemmed from the antrum extending through to the proximal duodenum causing GOO. The morphological features of the duodenal mass were consistent with biopsy findings of the patient’s previous sentinel lymph node and mastectomy specimen. The diagnosis was further confirmed with immunostains, which were positive for estrogen receptor and mammoglobin, and negative for progesterone receptor and E-cadherin. Patient received robotic gastrojejunostomy tube placement. Her nutritional status improved and was started on chemotherapy. She had a complete metastatic workup which was unrevealing. DISCUSSION: ILC can metastasize later in life to the brain, ovaries and gastrointestinal tract. Isolated duodenal metastasis is limited to only a few case reports. It is theorized in the literature that lack of expression of the adhesion molecule, E-cadherin, may facilitate ILC’s permeation into tissues. This may contribute to metastasis of ILC with a predilection to gastrointestinal and gynecological sites, which generally occurs after a mean duration of 7 years. Our case is rare in that, the patient presented with GOO as the only initial manifestation of duodenal metastasis within 8 years of treatment of ILC without any other evidence metastatic spread.

2595 Metastatic Urothelial Carcinoma to the Duodenum: An Unusual Cause of Duodenal Stenosis

INTRODUCTION: Bladder cancer typically presents within the confines of the bladder wall with less than 4% of cases spreading to distant lymph nodes and organs. We present a unique case of gastric outlet obstruction with early satiety and weight loss secondary to usual mass effect from metastatic bladder cancer in the duodenum. CASE DESCRIPTION/METHODS: An 81-year-old male presented with two weeks of bilious vomiting, early satiety, and 20 lb weight loss. Medical history significant for prostate cancer status post prostatectomy with biochemical recurrence and bladder cancer status post radical cystectomy. On physical exam, he had mild epigastric tenderness. Labs were significant for metabolic alkalosis, acute kidney injury, and normal liver function tests. MRI of the abdomen showed diffuse thickening of the duodenal wall. He subsequently underwent an esophagogastroduodenoscopy (EGD), which revealed gastric outlet obstruction at the second portion of the duodenum. An endoscopic ultrasound (EUS) was performed which revealed no pancreatic head mass. However, a two centimeter hypoechoic thickening of the second portion of the duodenum with resultant peri-duodenal biopsies via fine needle aspiration revealed metastatic urothelial carcinoma. Patient was managed conservatively with nasogastric tube placement. With gradual improvement to a soft diet, he was discharged home with plans for outpatient palliative chemotherapy. However, he was readmitted two weeks later with similar complaints and underwent an exploratory laparotomy and palliative gastrojejunostomy. The patient was discharged on a soft diet and plans for platinum chemotherapy. DISCUSSION: Bladder cancer ranks as the ninth most frequently-diagnosed cancer worldwide. It typically spreads via the lymphatic and hematogenous routes with the most common sites involving: regional lymph nodes, liver, lung, and bone. Metastasis to the duodenum is extremely rare and to the best of our knowledge is only reported in 4 cases in the literature to date. Three of these cases presented as duodenal obstruction and one case presented as a massive upper GI bleeding. We describe an uncommon presentation of gastric outlet obstruction from bladder metastasis to the duodenum in a patient whose cancer was in remission. Tumor metastasis should be considered in a patient with a history of cancer and presenting with gastric outlet obstruction despite a normal EGD. We also highlight the utility of EUS as a safe and minimally invasive procedure to establish the diagnosis.