Diagnosis Of Gastric Outlet Obstruction Research Articles

Prepyloric gastric antral muscular ring in an infant.

We present a unique case of a prepyloric gastric muscular ring, a pathology distinct from a gastric web. There is scarcity of literature on this topic, nearly all cases of prepyloric antral rings or webs published in literature are mucosal or submucosal in nature with no evidence of muscle hypertrophy. Given the prevalence of pyloric stenosis as the most common gastric outlet malformation in neonates, gastric rings and webs are not readily considered in the differential diagnosis of gastric outlet obstruction. While most cases of gastric outlet obstruction are diagnosed radiologically, less common pathologies will be confirmed with direct visual inspection during surgery. The term "congenital gastric outlet obstruction" has been used to encompass rare cases, making it appropriate to include a muscular ring in this category. We propose the term "gastric ring" be used with a semantic modifier of "muscular" versus "submucosal/mucosal" to avoid confusion.

A215 Gastric cancer after RYGB; work-up and diagnosis of gastric outlet obstruction

A215 Gastric cancer after RYGB; work-up and diagnosis of gastric outlet obstruction

Neuroendocrine carcinoma of stomach causing gastric outlet obstruction: a diagnostic dilemma

Gastric neuroendocrine tumour (GNET), also known as carcinoids, are a very rare cause of gastric outlet obstruction and arise from entero-chromaffin like cells of the mucosa. They account for 0.2/1000001 population and 8.7% of all Gastrointestinal carcinoids. They are four types based on the degree of differentiation, cell of origin and other pathologic features. Type 4 GNET are referred to as neuroendocrine carcinoma accounting for <1% of GNET. They are aggressive, poorly differentiated, locally invasive tumours with metastatic potential. Hence, they require an aggressive approach in terms of surgery and multimodality adjuvant treatment. Our patient is an elderly hypertensive who had complaints of projectile vomiting over ten days associated with weight loss over the last two years. A diagnosis of gastric outlet obstruction was made, and she underwent a contrast CT scan and endoscopy twice, both being suggestive of malignancy involving the antrum region however, the endoscopic biopsy showed unremarkable histology. Subsequently, she underwent emergency laparotomy in which there was a hard growth palpable in the antrum for which distal gastrectomy, D1 lymphadenectomy and gastrojejunostomy were done. Post-op HPE was suggestive of neuroendocrine carcinoma, thus, depicting our difficulty with diagnosis based on pre-op biopsy report given its rarity.

Gastric outlet obstruction as manifestation of eosinophilic gastroenteritis

Eosinophilic gastroenteritis (EG) is a rare entity. We report a 55-year-old man had no previous atopy or allergic history, who presented abdominal pain and vomiting. Abdominal computed tomography and endoscopy ultrasonography demostrated gastric wall thickening with wall thickening of the superior duodenum, without defined mass or fluid collection. Gastrointestinal endoscopy confirmed thickening of prepyloric folds and superior duodenum with luminal stenosis. Parcial gastrectomy was performed due to absence of definitive diagnosis and suspicion of possible malignancy and diagnosis of gastric outlet obstruction. Histopathology was compatible with EG, treated with an 8-week long howed clinical improvement, weight gain and normalization of eosinophil count on peripheral blood.

Pyloroduodenal duplication cyst presenting like hypertrophic pyloric stenosis

Gastrointestinal duplication cyst is a rare congenital anomaly. When it involves the pylorus or the first part of the duodenum, it may present with features of gastric outlet obstruction. We present a 4-month-old baby girl, second of a set of twins who presented with features of gastric outlet obstruction. A diagnosis of gastric outlet obstruction querying hypertrophic pyloric stenosis was made and she was resuscitated. The intraoperative finding was that of a huge non-communicating duplication cyst involving the pylorus and the first part of the duodenum. Excision and mucosal stripping of the cyst was done. Histology showed ectopic gastric mucosa. Pyloroduodenal duplication cyst is a rare congenital anomaly of the gastrointestinal tract and a close differential for patients who present too early or too late with features of Hypertrophic pyloric stenosis.

An observational study on benign/malignant gastric outlet obstruction in tertiary care centre of RIMS, Ranchi, India

Background: Gastric outlet obstruction is a group of clinico-patho physiological consequence of mechanical impediment of gastric emptying. Clinical entities that can result in gastric outlet obstruction are categorized into two well-defined groups of causes - benign and malignant. The proximal stomach is now the most common site for gastric carcinoma in the west but in Japan and developing countries like India the distal gastric cancer (antrum 13% and pylorus 7%) still predominates. Diagnosis of gastric outlet obstruction depends on different clinical features and certain investigations. The definitive treatment involves surgical relief of the gastric outlet obstruction. The correct surgical procedure to be adopted is planned according to the cause of obstruction and condition of the patients. This is an observational study aimed for characterization of gastric outlet obstruction in terms of benign and malignant and their relation to its causes, sites and other related factors in tertiary care centre (RIMS).Methods: This is an observational study comprises on 50 patients of gastric outlet obstruction admitted in the Department of Surgery R.I.M.S., Ranchi. The provisional diagnosis was based on detailed clinical history, thorough physical examinations, and some radiological investigations.Results: Majority of the patients of gastric outlet obstruction were malignant lesions of stomach and very few are benign. Antral carcinoma of stomach was found to be the commonest etiology of gastric outlet obstruction followed by pyloric stenosis secondary to acid peptic disorders. Most of the patient was in the age group of 40 to 60 years of age, males were affected more than Females.Conclusions: Gastric outlet obstruction in adults, a surgical problem of either sex, results commonly due to antral carcinoma or pyloric stenosis secondary to acid peptic disorder.

Food Allergy Mimicking Pylorus Hypertrophy

Food allergy (FA) is a disease with increasing prevalence and a wide spectrum of clinical manifestations. These include the eosinophilic disorders, which can involve any segment of the gastrointestinal tract (GIT), including the stomach. In this context, three patients with a confirmed diagnosis of food allergy, who were initially diagnosed with pyloric hypertrophy, are presented. All cases showed an adequate response to nutritional management. It is essential to consider food allergy, such as eosinophilic gastroenteritis, as part of the differential diagnosis of gastric outlet obstruction in those patients who present vomiting secondary to pyloric hypertrophy.

Demographic and Etiological Patterns of Gastric Outlet Obstruction in Kerala, South India.

Background:In the modern era, the major cause of gastric outlet obstruction (GOO) is known to be a malignancy, especially in the developed world. Many books and articles do suggest that the benign causes continue to be the major cause of GOO in the developing world however, there is growing evidence proving the contrary. Males were (more commonly) affected females and individuals in their fifth and sixth decade have been the predominant age group in the majority of studies. There is a minimal data of GOO from South India.Aims:A retrospective analysis of the endoscopic findings of patients presenting with features of GOO to determine the demographic and etiological patterns.Materials and Methods:A retrospective study of the endoscopic findings of patients with GOO from January 2005 to January 2014 was done. The diagnosis of GOO was based on clinical presentation, and an inability during the upper endoscopy to enter the second portion of the duodenum as documented in the endoscopy registers. Patients who have already been diagnosed with malignancy prior to the endoscopy were excluded from the study; so were the patients with gastroparesis.Results:A total of 342 patients with GOO underwent the endoscopy during the study period. The causes for benign obstruction were predominantly peptic ulcer disease. The major cause for malignant obstruction was carcinoma of stomach involving the distal stomach. The male to female ratio was 3.2:1. The patients with malignancy were older than patients with benign disorders. Most of the patients were in the sixth and seventh decade. The risk of malignancy was higher with increasing age, especially in women. A fourth of all carcinoma stomach presented with GOO.Conclusion:The study demonstrates that the cause for GOO in Kerala, South India is predominantly malignancy. The etiological and demographic patterns were similar to the studies conducted in the developed nations.

Delayed Diagnosis of Gastric Outlet Obstruction from Bouveret Syndrome in a Young Woman

Bouveret syndrome is a rare presentation of gastric outlet obstruction caused by a gallstone in the proximal duodenum via a bilioenteric fistula. This is an infrequent although clinically significant cause of abdominal pain, almost exclusively in the elderly. The clinical presentation is similar to that of a small bowel obstruction with abdominal pain, nausea and vomiting. Surgery or endoscopy is often required for definitive diagnosis and therapy. We describe the case of a young woman with this condition who had a delayed diagnosis in part because of her age and the rarity of the condition.

Gastric outlet obstruction at Bugando Medical Centre in Northwestern Tanzania: a prospective review of 184 cases

BackgroundGastric outlet obstruction poses diagnostic and therapeutic challenges to general surgeons practicing in resource-limited countries. There is a paucity of published data on this subject in our setting. This study was undertaken to highlight the etiological spectrum and treatment outcome of gastric outlet obstruction in our setting and to identify prognostic factors for morbidity and mortality.MethodsThis was a descriptive prospective study which was conducted at Bugando Medical Centre between March 2009 and February 2013. All patients with a clinical diagnosis of gastric outlet obstruction were, after informed consent for the study, consecutively enrolled into the study. Statistical data analysis was done using SPSS computer software version 17.0.ResultsA total of 184 patients were studied. More than two-third of patients were males. Patients with malignant gastric outlet obstruction were older than those of benign type. This difference was statistically significant (p < 0.001). Gastric cancer was the commonest malignant cause of gastric outlet obstruction where as peptic ulcer disease was the commonest benign cause. In children, the commonest cause of gastric outlet obstruction was congenital pyloric stenosis (13.0%). Non-bilious vomiting (100%) and weight loss (93.5%) were the most frequent symptoms. Eighteen (9.8%) patients were HIV positive with the median CD 4+ count of 282 cells/μl. A total of 168 (91.3%) patients underwent surgery. Of these, gastro-jejunostomy (61.9%) was the most common surgical procedure performed. The complication rate was 32.1 % mainly surgical site infections (38.2%). The median hospital stay and mortality rate were 14 days and 18.5% respectively. The presence of postoperative complication was the main predictor of hospital stay (p = 0.002), whereas the age > 60 years, co-existing medical illness, malignant cause, HIV positivity, low CD 4 count (<200 cells/μl), high ASA class and presence of surgical site infection significantly predicted mortality ( p< 0.001). The follow up of patients was generally poor as more than 60% of patients were lost to follow up.ConclusionGastric outlet obstruction in our setting is more prevalent in males and the cause is mostly malignant. The majority of patients present late with poor general condition. Early recognition of the diagnosis, aggressive resuscitation and early institution of surgical management is of paramount importance if morbidity and mortality associated with gastric outlet obstruction are to be avoided.

Gastric outlet obstruction in a patient with Bouveret’s syndrome: a case report

BackgroundGallstone ileus accounts for 1% to 4% of cases of mechanical bowel obstruction, but may be responsible for up to 25% of cases in older age groups. In non-iatrogenic cases, gallstone migration occurs after formation of a biliary-enteric fistula. In fewer than 10% of patients with gallstone ileus, the impacted gallstones are located in the pylorus or duodenum, resulting in gastric outlet obstruction, known as Bouveret’s syndrome.Case presentationWe report an 86-year-old female who was admitted to hospital with a 10-day history of persistent vomiting and prostration. She was in hypovolemic shock at the time of arrival in the emergency department. Investigations revealed a gallstone in the duodenal bulb and a cholecystoduodenal fistula. She underwent surgical gastrolithotomy. Unfortunately, she died of aspiration pneumonia on the fourth postoperative day.ConclusionThis case shows the importance of considering Bouveret’s syndrome in the differential diagnosis of gastric outlet obstruction, especially in the elderly, even in patients with no previous history of gallbladder disease.

Tuberculous pyloric stenosis; successful medical therapy may obviate surgery

Gastroduodenal involvement occurs in only 0.3 to 2.3% of patients with tuberculosis (TB). Clinically, it may resemble peptic ulcer disease or malignancy. We present a 36 year old man with gastric outlet obstruction proven to be pyloric stricture due to primary pyloric tuberculosis. Diagnosis was established endoscopically and patient was successfully managed by standard anti-tuberculous therapy. Although rare, tuberculous involvement of the stomach should be considered in the differential diagnosis of gastric outlet obstruction especially in regions where tuberculosis is endemic. This case also emphasizes that medical management with anti-TB medications can be tried solely as the first line therapy for strictured pyloric stenosis. However, surgical intervention is required more often than none in cases where gastrointestinal obstruction is the main clinical problem.

Duodenal intussusception due to a giant neuroendocrine carcinoma in a patient with Peutz–Jeghers syndrome

Duodenal intussusception is a rare entity. To date, only a few cases have been reported in the literature. In this report, a case of duodenal intussusception due to an unusual tumor was presented and the clinical features of this entity were discussed. A 42-year-old man with Peutz-Jeghers syndrome presented with epigastric pain, vomiting, and severe anemia. Computed tomography scan revealed synchronous duodenojejunal and jejunojejunal intussusceptions. An emergency laparotomy revealed a polypoid mass originating from the lateral wall of the descending duodenum with intussusception of the distal duodenum. Histological examination demonstrated a poorly differentiated neuroendocrine carcinoma with muscularis infiltration, vascular invasion, and a Ki-67 index of 20%. A comprehensive literature search revealed 44 English reports that provided adequate descriptions of an additional 47 such cases. Clinical presentation was usually chronic and nonspecific. Diagnostic modalities included ultrasonography, upper gastrointestinal series, computed tomography, and endoscopy. Five patients were due to a non-neoplastic lesion; however, the other 43 patients were secondary to a tumor, benign in 35 cases and malignant in eight cases. Only one patient was treated by endoscopic polypectomy, whereas the remaining underwent open surgeries. Duodenal intussusception is a challenging condition due to its rarity and nonspecific presentation. It should be considered in the differential diagnosis of gastric outlet obstruction, upper gastrointestinal bleeding, pancreatitis, and obstructive jaundice.

A Rare Cause of Duodenal Obstruction

Purpose: Aortoduodenal syndrome is described as compression of the duodenum by a AAA presenting as gastric outlet obstruction. Described by Osler in 1905, it is modestly reported in the literature. Symptoms include vomiting, abdominal pain, distention, weight loss, electrolyte imbalance, and a pulsatile abdominal mass. It is associated with aspiration pneumonia, renal failure, and aortic rupture. Diagnosis is made by CT or UGIS. EGD is useful to rule out other causes of obstruction, to visualize compression by a pulsatile mass, to obtain tissue, and for possible intervention. Treatment includes fluid and electrolyte replacement, NGT decompression, nutritional support, and surgical intervention. We describe a case of an 80 yo man who presented with intractable vomiting. He complained of epigastric pain, weight loss, and a nonproductive cough. On admission, he had a leukocytosis and was started on antibiotics for pneumonia. CT revealed gastric and duodenal distention with a transition zone in the distal duodenum along a 4.6 cm aortic aneurysm. NGT drained 3 liters of dark fluid. EGD was recommended, but the family declined. He was started on TPN and underwent a Roux-en-Y gastric bypass. No mass or anatomic abnormality was identified during the surgery, which confirmed the diagnosis. The patient was able to tolerate PO intake and was discharged. Aortoduodenal syndrome remains a rare entity of unknown etiology. Similar to cases described in the literature, the patient's AAA was described as an infrarenal, non-inflammatory aneurysm. The aneursymal sac measured 4.6 cm, while most previously described sacs were typically 8-10 cm. The patient also suffered from the classically associated comorbidities of aortoduodenal syndrome. His case was unique because it was associated with significant weight loss likely secondary to compression of the duodenum by an existing AAA, rather than the more commonly reported SMA syndrome. We report this case to review the presentation, diagnosis, and treatment of aortoduodenal syndrome. Aortoduodenal syndrome should be included in the differential diagnosis of gastric outlet obstruction, particularly in patients at risk for AAA.Figure

Imaging diagnosis of two unusual forms of gallstone ileus

ileus caused by gallstone has become more and more common recently due to popular usage of computed tomography (CT) and magnetic resonance imaging (MRI). In the past, imaging diagnosis relied primarily on conventional radiography and contrast-enhanced fluoroscopy. 1 CT has subsequently been shown to be quite useful for this diagnosis. 2,3 Recently, MR cholangiopancreatography (MRCP) has emerged as a valuable noninvasive technique for evaluation of biliary disease. Here we described the CT, MRCP and gastroenterography findings in two patients with unusual form of gallstone ileus (GI), one is Bouveret's syndrome and the other is negative gallstone-induced ileus. Few reports about GI with angiografin and MRCP findings of Bouveret's syndrome has been published. 3-8

Gastric outlet obstruction secondary to wandering spleen

Surgery 2000; 128:480–1.

Gastric lymphoma causing gastric outlet obstruction

An unusual presentation of abdominal lymphoma causing gastric outlet obstruction is reported. Gastric lymphoma should be considered in the differential diagnosis of gastric outlet obstruction during childhood. The possibility of gastric malignancy should not be excluded only on the basis of the patient's age. Complete resection of the tumor, with postoperative radiation and/or chemotherapy, is the best method of treatment for high-grade lymphomas.

Malignancy is the most common cause of gastric outlet obstruction in the era of H2 blockers.

To determine the relative incidence of malignant and nonmalignant pathology in patients presenting with gastric outlet obstruction in the era of H2 blockers and to determine whether clinical features can differentiate between the two causes. The charts of 33 consecutive patients with gastric outlet obstruction admitted to one institution between July 1990 and November 1993 were reviewed to determine etiology, management, and outcome. The diagnosis of gastric outlet obstruction was based on clinical presentation, an upper gastrointestinal barium study, and/or an inability during upper endoscopy to intubate the second portion of the duodenum. Patients with gastroparesis or a previously known cancer were excluded. Sixty-one percent (20 patients) had malignancy as the cause of their gastric outlet obstruction. Thirty-nine percent (13 patients) had benign disease. The patients with cancer tended to be older, and fewer had a history of peptic ulcer disease, although these factors were not statistically significant. The use of nonsteroidal anti-inflammatory drugs was not associated with gastric outlet obstruction. Four patients had malignancy that had not been suspected before operation despite numerous endoscopic and radiological studies. The incidence of malignancy in patients presenting with gastric outlet obstruction is greater than 50%. The etiology of gastric outlet obstruction cannot be predicted by age, history of peptic ulcer disease, or nonsteroidal anti-inflammatory drug use. The endoscopic treatment of gastric outlet obstruction should be approached with caution because malignancy cannot be reliably excluded by endoscopic or radiological studies.