Gastric Outflow Obstruction Research Articles

990 A Rare Case of Adenomyoma in Gastric Pylorus of a Young Adult Female: A Case Report

Abstract Introduction Gastric adenomyoma is a rare benign tumour which occurs 85% in antrum and 15% in pylorus. Although adenomyomas are benign, diagnosis is difficult as they are commonly found alongside with adenocarcinomas. Case report A 20-year-old previously healthy female presented with epigastric pain, gastric outflow obstruction features and weight loss for 3 months. Initial USS was followed by a CECT which, showed intramural mass lesion with necrotic centre arising from the inferior wall of the pre pyloric area of the stomach with acute inflammatory changes of the adjacent omental fat, giving differential diagnosis of GIST or gastrinoma at pyloric region. Subsequent upper GI endoscopy revealed a protruding pyloric mass without mucosal lesions. Unfortunately, the unavailability of EUS and biopsy posed a diagnostic hurdle. Intraoperatively, a mass intricately adhered to the transverse colon and omentum was discovered, leading to a surgical intervention involving distal gastrectomy, gastrojejunostomy, and jejunojejunostomy. Unexpectedly, histological analysis unveiled adenomyoma at the prepyloric area, characterized by Brunner’s glands, dilated glands, and heterotrophic small intestinal tissue. Discussion This rare manifestation of adenomyoma in the gastric pylorus, particularly in a young adult, highlights the challenges in accurate preoperative diagnosis. The favourable postoperative outcome prompts reflection on the potential role of advanced diagnostic tools, emphasizing the significance of EUS and biopsy in steering clear of extensive surgeries. Conclusions This case report underscores the crucial role of personalized diagnostic methods, especially in cases like ours where a rare adenomyoma mimicking other tumours.

OGBN P13 Management of Bouveret Syndrome: an endoscopic approach

Abstract Background Bouveret syndrome is rare complication of gallstones with 600 reported cases since 1950. The syndrome occurs when adhesions develop between the gallbladder to surrounding hollow viscera leading to fistula formation. Large gallstones migrate into the enteric system and become impacted in the stomach or duodenum causing gastric outflow obstruction. Bouveret syndrome accounts for 1–4% of gallstone ileus cases. It is more common in co-morbid women in their 7th and 8th decades. Most common symptoms are vomiting and abdominal pain. Upper gastrointestinal bleeding is reported in 15% of cases. CT scan has the highest sensitivity at 79–93% to make the diagnosis. Of note 15–25% of gallstones are isoattenuating. Riglers triad is a diagnostic marker and consists of aerobilia, a gastric outflow obstruction or dilated bowel and the presence of a calculus outside of the biliary tree. The diagnosis was associated with mortality rates as high as 30% but with modern advances mortality has decreased to approximately 12%. Treatment options are surgical or endoscopic retrieval. Endoscopic management carries less risk especially in the frail elderly patient. This approach has low success rates. We present a case of successful endoscopic management of Bouveret syndrome and discuss surgical and endoscopic management strategies. Methods A frail 83 year old female attended ED with epigastric pain, vomiting and signs of sepsis. She had a recent diagnosis of severe cholecystitis that was managed conservatively. On examination she had tenderness in the right upper quadrant. Bloods revealed an AKI, a CRP 189 and normal liver function tests. Axial imaging showed aerobilia with a CBD dilated at 14mm and there was a 3.5cm calculus impacted in the duodenum with a cholecysto-duodenal fistula. Her medical history included diabetes mellitus, atrial fibrillation, hypertension, primary hyperparathyroidism, reflux and cauda equina (operated). On OGD there was a large stone which had eroded into the first part of the duodenum. A combination of mechanical lithotripsy and the Kudo snare were used to fragment the stone. 2 large fragments were retrieved using a bag to avoid gallstone ileus. Results The patient had an uneventful but slow recovery. She re-established oral intake on the second post-operative day. She was discharged 2 weeks later without complication. Conclusions The success of endoscopic management is reported as low as 10%. Endoscopic intervention is attempted in 61% of cases. Success is more likely with stones <4cm and if the site of impaction is the stomach or D1/D2. Surgical management is associated with a morbidity rate of 26% but was successful in 78%. Laparoscopic surgery is possible but less successful in stones >5cm. Endoscopic techniques have evolved and should be considered for extraction of stones in the first instance. If not feasible surgery can be considered. The literature shows that success is more likely when various endoscopic techniques are utilized including mechanical lithotripsy, nets and baskets, extracorporeal shock wave lithotripsy, electrohydraulic lithotripsy, laser lithotripsy and duodenal stenting. There is a risk of distal migration of stone fragments causing gallstone ileus in the more distal small bowel. Bouveret syndrome can be resolved with endoscopy in expert hands.

Diabetic gastroparesis: clinical features, diagnosis and management.

Diabetic gastroparesis carries a heavy burden on people with diabetes and the healthcare system. It remains underdiagnosed and represents challenges to treat. This article reviews the epidemiology, pathophysiology, clinical features, diagnosis and treatment of diabetic gastroparesis. The disorder is characterized by delayed gastric emptying without evidence of mechanical gastric outflow obstruction. It presents with upper gastrointestinal (GI) symptoms such as nausea, vomiting, early satiety, postprandial fullness, upper abdominal discomfort and or bloating. As the prevalence of diabetes has been growing over the last few decades, we would expect an increased incidence of delayed gastric emptying in poorly controlled diabetes and perhaps in line with the increasing use of medications that act on the GI tract such as incretin-based therapy. The disease results from multiple reversible and irreversible mechanisms. Diagnosing diabetic gastroparesis requires careful history, examination and investigations to exclude other disorders that could mimic its clinical presentation. Treatment involves a wide variety of options starting with optimization of glycaemic control, stopping any offending medications and lifestyle modifications followed by the introduction of medical therapeutics such as prokinetics. Then, surgical interventions are considered in refractory cases.

543 Bouveret Syndrome: A Rare Presentation of Gastric Outlet Obstruction

Abstract A 76-year-old lady presented with a 5-day history of lower abdominal pain and vomiting. She had not opened her bowels for 3 days and 24 hours prior to admission had coffee ground vomitus. A CT abdomen and pelvis showed gastric outflow obstruction secondary to a large 3.5cm gallstone within the pylorus (Bouveret syndrome). She was initially treated conservatively for bowel obstruction and underwent an OGD where attempts to retrieve the stone were unsuccessful. A subsequent laparoscopic gastrotomy revealed a large stone in the duodenum and was successfully removed. This case highlights how this rare syndrome can present with non-specific symptoms, diagnosis can be challenging and relies on imaging, therefore patients should be worked up thoroughly to ensure a correct diagnosis. There are currently no standardised management guidelines for Bouveret syndrome, mainly due to its rare prevalence and this case demonstrates a variety of management options.

Heineke–Mikulicz pyloroplasty for the treatment of pyloric stenosis secondary to gastro‐duodenal ulcer disease in three foals

SummaryThe objective of the study was to describe a modified Heineke–Mikulicz pyloroplasty for the treatment of pyloric stenosis in foals due to gastric ulceration and assess the short‐ and long‐term outcome of foals receiving the pyloroplasty. Medical records of foals undergoing a modified Heineke–Mikulicz pyloroplasty due to gastric outflow obstruction secondary to a pyloric stenosis were included in this retrospective case series. The pyloroplasty consisted of an oral to aboral full thickness longitudinal incision on the ventral aspect of the pylorus and proximal duodenum, which was sutured closed with 0 polydioxanone in a transverse orientation, thereby, enlarging the pyloric lumen diameter. Long‐term outcome was obtained from medical and race records. The pyloroplasty was successfully performed in three foals with a surgical time of 95–121 min, with immediate return to nursing and hospital stay of 4–14 days. Complications included a small intestinal volvulus and intra‐abdominal adhesions in a foal that did not survive. Another foal had an incisional infection. Two of the three foals went on to race. It was concluded that the pyloroplasty procedure is an acceptable option for the treatment of pyloric stenosis and secondary gastric outflow obstruction due to gastric ulceration. The limited amount of bowel manipulation with no change in intestinal flow, along with the successful outcomes achieved, make this another surgical option available for the correction of pyloric stenosis in foals.

Gastroparesis in carcinoma gallbladder: a scintigraphic study

Background: Gastroparesis is characterized by delayed gastric emptying in the absence of mechanical gastric outlet obstruction. There is strong association of gastroparesis with carcinoma gallbladder. The aim of the study was to find out the incidence of delayed gastric emptying in carcinoma gallbladder and its correlation with symptoms of stasis and stage of the disease.Methods: Patients diagnosed with carcinoma gallbladder and their matched controls were included in this study. Patients with mechanical gastric outlet obstruction were excluded. All patients underwent contrast enhanced computer tomography scan and radio labeled (Technitium 99) solid meal Scintigraphy study. Normal gastric emptying time was calculated from control group as Mean +2SD.Results: 30 patients were matched with 20 controls after obtaining informed consent. Upper limit of gastric emptying time is 55.09 minutes. Adenocarcinoma was the commonest histological subtype (50%), abdominal pain was the commonest symptom (86.7%) and hepatomegaly was the commonest sign (46.7%), GETt1/2 for patients was 66.72±26.52 minutes while it was 40.53±7.28 minutes in controls (p <0.05). Gastroparesis increased with advancing stage of carcinoma gallbladder (p <0.05). Symptoms of gastric stasis were seen only in 15.6% of patients.Conclusions: Patients with carcinoma gallbladder can have gastroparesis without obvious symptoms of delayed gastric emptying. This delay in gastric emptying can be documented reliably using solid meal scintigraphic study even in patients without symptoms of gastroparesis. The pathophysiology of gastroparesis needs further study. It may be prudent to remember that while performing palliative bypass surgery for gastric outflow obstruction, that in patients with carcinoma gallbladder, the gastrojejunostomy may not function as expected due to delayed gastric emptying.

Advances in the endoscopic management of gastric outflow disorders.

Disorders of gastric outflow and outlet obstruction include a variety of benign and malignant disorders such as peptic strictures, foreign bodies, gastroparesis, and cancers of the stomach, duodenum, and pancreas. Historically, a majority of patients presenting with gastric outlet obstruction (GOO) were to the result of peptic ulcers and surgical management of peptic ulcer complications was a mainstay of general surgical training. Invasive surgery is being performed less frequently today due to realization of the role of Helicobacter pylori in peptic ulcer disease and the introduction of novel endoscopic techniques for management of GOO. For malignant GOO, the introduction of lumen-apposing metal stents have opened the door for the development and performance of endoscopic ultrasound-guided gastric bypass procedures. For benign GOO, including gastroparesis and pyloric stenosis, endoscopic myotomy shows promise. Endoscopic ultrasound-guided gastric bypass, per-oral endoscopic myotomy, and other novel techniques in the endoscopic management of GOO, are discussed in this review.

Through the keyhole: Radiological management of malignant gastric outflow obstruction beyond the pylorus

Through the keyhole: Radiological management of malignant gastric outflow obstruction beyond the pylorus

YU Pyloroplasty for the Correction of Chronic Hypertrophic Pyloric Gastropathy in Canines

Background: One of the causes of delay gastric emptying is the chronic hypertrophic pyloric gastropathy, unusual disease that can occur in acquired or congenital form. It is characterized by hypertrophy of the antral mucosa, by thickening of the muscular layer, or by hyperplasia of the pylorus. The animals are presented with a history of chronic intermittent vomiting. Treatment is based on surgical correction through techniques such as pyloromyotomy or transverse or Y-U pyloroplasty. Thus, the aim was report three cases of pyloric stenosis by hypertrophy in dogs of the breeds, Fila Brasileiro, English Bull Terrier and American Pitbull Terrier, emphasizing the diagnosis and therapy instituted.Cases: All animals in this study reached the Veterinary Hospital of the Federal University of Mato Grosso with a history of chronic intermittent vomiting. The findings of physical and laboratory examinations in all animals were unspecific, with those important to rule out other causes of vomiting. Contrast radiographic evaluation revealed marked stomach distension and delayed gastric emptying, indicated gastric outflow obstruction. In one case, a video endoscopy was performed. The images reveal hyperemia of the gastric mucosa with small areas of bleeding around the stomach. It was observed intense production of gastric juice and the presence of the same reflux. In the pyloric antrum, a thick fold reddish gastric mucosa, which partially obstructed the pyloric ostium. There was very little motility during the examination. As therapeutic approach for all cases, we opted for performing the surgical technique of pyloroplasty in Y-U, consisting of enlarging the diameter of the antral pyloric region in an attempt to create a broader pylorus, what make possible an emptying a gastric rapidly. All the pacients remained in hospital in the postoperative period receiving medications intravenously. Postoperative fluid based on Ringer’s lactate solution and administration of ondansetron (0.2 mg/kg every 8 h), sucralfate (30 mg/ kg every 12 h), sulfadoxine to trimethoprim (20 mg/kg every 12 h) and meloxicam (0.2 mg/kg every 24 h). Twelve h of fasting after the surgical procedure without vomiting, the dog received light past food. An average of three to four days post-surgical discharged with recommendations to keep antibiotic therapy for ten days and light diet. The fifteenth day of surgery, the patients returned for removal of skin spots, with good general condition and satisfactory healing. No cases of vomiting were reported. As the case one returned to perform the monitoring gastograma. The dog was anesthetized and giving the contrast. On radiographs, there was a slight delay in gastric emptying, which can be explained by the anesthesia used for contrast administration, as described in the literature. The images showed stomach and intestines in size, shape and normal position. The technique was satisfactory in reducing clinical signs in all these cases, confirmed by the absence of vomiting in the post-operative period.Discussion: The surgical technique used, pyloroplasty Y-U consists of traspor a part of the antral wall to the pyloric region in an attempt to create a broader pylorus, and possibly a time soon gastric emptying. It was possible to demonstrate with only three cases the pyloroplasty Y-U proved to be a simple and effective technique for the treatment of hypertrophic pyloric stenosis with a favorable prognosis in all cases. Thus, disease should be considered in the differential diagnosis in cases of gastric outflow obstruction, regardless of patients age.Keywords: dog, hypertrophy, pylorus.

Pylorectomy and Gastroduodenostomy (Billroth I Procedure) for Obstructive Antrum Pyloric Leiomyoma in a Bitch

Background: Gastric neoplasms are uncommon in dogs, especially those affecting smooth muscle layers. Leiomyoma is a smooth muscle benign neoplasm, which requires surgical resection. Pylorectomy and gastroduodenostomy (Billroth I procedure) is the most indicated technique in cases not affecting the biliary and pancreatic tracts. Thus, the purpose of this study was to report a successful case of Billroth I procedure in a bitch presenting antrum pyloric obstructive leiomyoma. Case: A 12-year-old, non-spayed, Cocker Spaniel bitch was admitted presenting depression, hyporexia, postprandial vomiting and sparse episodes of hematemesis, for 30 days. Clinical suspicion on obstructive gastric outflow disease was established. Bloodwork (complete blood count, BUN, albumin, ALP and ALT), abdominal ultrasound and thoracic radiographs were assessed. The patient undergone upper gastrointestinal endoscopy. On endoscopic evaluation, small hemorrhagic mucosa ulcers were visualized on the gastric body, antrum and pylorus. Moreover, a sessile, ulcerated, round-shape and infiltrated antral-pyloric mass was seen. The mass was 1.5-2.0 cm in diameter and apparently involved the smooth muscle layer, causing severe pyloric obstruction. However, endoscopic evaluation of the duodenum was possible. Several biopsy samples were taken from the neoplasm and sent for histopathologic assessment. The result was not conclusive due to low quality samples. The patient had progressive worsening of obstruction episodes and required surgery. A wide-margin pylorectomy and gastroduodenostomy (Billroth I procedure) was carried out. The retrieved specimen was sent to histopathological and immunohistochemistry (IHC) assessment. Positive staining for actin and desmin confirmed smooth muscle origin of the mass and histopathological assessment confirmed leiomyoma. The patient underwent regular periodic postoperative assessments, revealing progressive clinical improvement and normal weight gain. Control upper gastrointestinal endoscopy was performed. Gastric ulcers were completely healed and gastroduodenal anastomosis was functional. The anastomotic scar tissue was sampled and revealed chronic and normal healing process. Complete healing was confirmed and the patient was discharged. Discussion: Gastric neoplasms are not common in dogs. However, severe obstruction of gastric outflow is a potential risk for complications in those cases. Upper gastrointestinal endoscopic assessment is important not only for diagnosis, but also for surgery decision making. In the current study, gastroscopy provided accurate preoperative evaluation of severity of pyloric obstruction and diagnosis of secondary gastric ulcers. Direct visualization of lesions and multiple biopsy sampling were performed. The presence of neoplasms over 2-cm in diameter indicates need for complete laparoscopic or conventional surgical resection. In this case report, open resection was carried out due to prohibitive cost of laparoscopic approach, mass dimensions and probable involvement of deeper tissue layers. In conclusion, pylorectomy and gastroduodenostomy (Billroth I procedure) was curative and provided good prognosis following resection of an antrum pyloric obstructive leiomyoma. Endoscopy was critical for both diagnosis and decision-making towards surgery for gastric outflow obstruction due to an antrum pyloric neoplasm. Histopathological and immunohistochemistry assessment confirmed neoplasm type and assured oncological safety of resection with wide margins. Keywords: gastric neoplasms, smooth muscle tumor, endoscopy, dog.

PWE-026 Role of pyloric and duodenal self expandable metal stents (sems) for malignant gastric outflow obstruction in palliative patients

<h3>Introduction</h3> Stent placement for malignant gastric outflow obstruction (GOO) is recommended for palliative management for patients with unresectable disease. Gastrojejunostomy is an alternative but may not be appropriate due to poor performance status and prognosis. Endoscopic SEMS for GOO is less invasive and has been shown to be safe and effective method for relieving symptoms of GOO. Previously reported endoscopic success rate of GOO stenting is 92–100%.¹ Our aim was to assess the safety and efficacy of pyloric and duodenal stents (SEMS) for gastric outflow obstruction caused by malignancy. <h3>Method</h3> Retrospective audit between Jan 2012 to Dec 2014, reviewing medical notes and electronic patient records. All procedures were performed using Through the Scope (TTS) technique and fluoroscopic guidance. End-points were technical success (correct SEMS placement confirmed radiologically and endoscopically at time of procedure) and clinical success (resolution of obstructive symptoms, resumption of oral diet). <h3>Results</h3> 63 patients were identified (median age 71 years). 50 patients (79%) had malignant stricture due to primary cancers (gastric 33%, pancreatic 25%). 13 patients had GOO from metastases (20%). Median ASA grade was 3. <h3>Procedural Success</h3> 4 patients did not require stent placement when evaluated endoscopically. Of the remaining 59 patients 55 were stented successfully (93.2%). In 4 patients stents could not be deployed as stricture could not be traversed with wire or cannula. Of the 55 patients who were stented clinical success was 96% (2 patients needed repeat procedure within one week). 13 patients (25%) required further interventions due to stent blockage from tumour ingrowth or food debris and all successfully managed with restenting. The mean time for further intervention 98 day. 83 procedures were carried in total with an overall success rate of 95.2%. There were no major complications reported, no perforation or procedure related mortality. Two patient had stent migrated proximally into stomach and one patient needed repeat procedure due to lack of stent expansion, all managed with successful restenting. <h3>Survival</h3> 78% were alive at 30 days, 32% were alive at 6 month with 4 patients yet to reach 6 month end point, 33% alive at 1 year. <h3>Conclusion</h3> Stenting for GOO is a safe procedure and avoids the need for surgical gastroenterojejunostomy in over 93% of palliative patients. Stent dysfunction can happen due to tumour overgrowth, food debris or stent migration. In our study all 25% of patients needing reintervention within 4 months were successfully managed with restenting. <h3>Disclosure of interest</h3> None Declared. <h3>Reference</h3> Gaidos JKJ. Treatment of malignant gastric outlet obs truction with endoscopically placed self -expandable metal stents. World J Gastroenterol 2009;15(35):4365–4371

Inter- and intrarater reliability of the Chicago Classification in pediatric high-resolution esophageal manometry recordings.

The Chicago Classification (CC) facilitates interpretation of high-resolution manometry (HRM) recordings. Application of this adult based algorithm to the pediatric population is unknown. We therefore assessed intra and interrater reliability of software-based CC diagnosis in a pediatric cohort. Thirty pediatric solid state HRM recordings (13M; mean age 12.1 ± 5.1 years) assessing 10 liquid swallows per patient were analyzed twice by 11 raters (six experts, five non-experts). Software-placed anatomical landmarks required manual adjustment or removal. Integrated relaxation pressure (IRP4s), distal contractile integral (DCI), contractile front velocity (CFV), distal latency (DL) and break size (BS), and an overall CC diagnosis were software-generated. In addition, raters provided their subjective CC diagnosis. Reliability was calculated with Cohen's and Fleiss' kappa (κ) and intraclass correlation coefficient (ICC). Intra- and interrater reliability of software-generated CC diagnosis after manual adjustment of landmarks was substantial (mean κ = 0.69 and 0.77 respectively) and moderate-substantial for subjective CC diagnosis (mean κ = 0.70 and 0.58 respectively). Reliability of both software-generated and subjective diagnosis of normal motility was high (κ = 0.81 and κ = 0.79). Intra- and interrater reliability were excellent for IRP4s, DCI, and BS. Experts had higher interrater reliability than non-experts for DL (ICC = 0.65 vs ICC = 0.36 respectively) and the software-generated diagnosis diffuse esophageal spasm (DES, κ = 0.64 vs κ = 0.30). Among experts, the reliability for the subjective diagnosis of achalasia and esophageal gastric junction outflow obstruction was moderate-substantial (κ = 0.45-0.82). Inter- and intrarater reliability of software-based CC diagnosis of pediatric HRM recordings was high overall. However, experience was a factor influencing the diagnosis of some motility disorders, particularly DES and achalasia.

Endoscopic stenting versus operative gastrojejunostomy for malignant gastric outlet obstruction-a systematic review and meta-analysis of randomized and non-randomized trials.

Open surgical gastrojejunostomy (GJ) has been the treatment of choice, but it has high morbidity and mortality rates. During the last decade, endoscopic self-expandable metal stents (SEMS) have been used. This meta-analysis aimed to compare surgical GJ and endoscopic stenting in palliation of malignant gastric outlet obstruction (GOO). A systematic search was conducted using MEDLINE, PubMed, EMBASE, Current Contents Connect, Cochrane library, Google Scholar, Science Direct, and Web of Science. The search identified 3 randomized controlled trials (RCTs) and 14 non-RCTs reporting on patients who underwent surgical GJ or endoscopic stenting for malignant gastroduodenal outflow obstruction. THE RESULTS OF THE THREE RCTS DEMONSTRATED THAT SEMS RESULTED IN COMPARABLE MAJOR [ODDS RATIO (OR): 0.62, 95% confidence intervals (CI): 0.021-18.371] and minor (OR: 0.32, 95% CI: 0.049-2.089) complications in a shorter time to tolerating an oral intake (SEMS: 3.55 days and GJ: 7.15 days) and shorter hospital stay (SEMS: 5.1 days and GJ: 12.13 days, however, statistical insignificant P value =0.11). Among the non RCTs: SEMS resulted in a shorter time to tolerating an oral intake (SEMS: 1.48 days and GJ: 8.07 days, P value <0.01), similar rate of complications (OR: 0.33, 95% CI: 0.1-1.08), lower mortality (OR: 0.5, 95% CI: 0.21-1.20, P value <0.01) and a shorter hospital stay (SEMS: 7.61 days and GJ: 19.04 days, P value <0.0001). There was no significant difference between median survival times among RCTs and non RCTs. These findings suggest that stent placement is associated with better short-term outcomes and hence, duodenal stenting is a safe means of palliating malignant gastric outflow obstruction. However, a large RCT is needed to systematically compare stent placement with GJ with regard to medical effects, quality of life and costs.

Canine Giant Hypertrophic Gastritis Treated Successfully with Partial Gastrectomy

A 4 yr old castrated male Jack Russell terrier was presented with a 2 mo history of vomiting, anorexia, and weight loss. Abdominal radiographs and ultrasound supported the diagnosis of gastric outflow obstruction. Celiotomy and gastrotomy revealed a large, narrowly based mass originating from the mucosa of the dorsal gastric body, occupying the lumen of the stomach and protruding through the pylorus into the duodenum. A partial gastrectomy was performed to excise the mass along with a 1 cm margin of grossly normal tissue. Giant hypertrophic gastritis was diagnosed via histopathology of the excised tissue. Giant hypertrophic gastritis is a rarely diagnosed disease of canines, characterized by giant gastric folds, hypoalbuminemia, and mucosal hypertrophy. Long-term treatment success has not been previously reported. In the case described herein, surgical excision of the affected gastric tissue provided complete resolution of clinical signs. Twelve mo following surgery, no recurrence of either vomiting or weight loss had been noted and the dog was clinically normal.

Polyurethane Adhesive Ingestion

Polyurethane adhesives are found in a large number of household products in the United States and are used for a variety of purposes. Several brands of these expanding wood glues (those containing diphenylmethane diisocyanate [MDI]) have the potential to form gastrointestinal (GI) foreign bodies if ingested. The ingested adhesive forms an expanding ball of glue in the esophagus and gastric lumen. This expansion is caused by a polymerization reaction using the heat, water, and gastric acids of the stomach. A firm mass is created that can be 4-8 times its original volume. As little as 2oz of glue have been reported to develop gastric foreign bodies. The obstructive mass is reported to form within minutes of ingestion of the adhesive. The foreign body can lead to esophageal impaction and obstruction, airway obstruction, gastric outflow obstruction, mucosal hemorrhage, ulceration, laceration, perforation of the esophageal and gastric linings, and death. Clinical signs following ingestion include anorexia, lethargy, vomiting, tachypnea, and abdominal distention and pain, and typically develop within 12 hours. Clinical signs may depend upon the size of the mass. If left untreated, perforation and rupture of the esophagus or stomach can occur. The glue mass does not stick to the GI mucosa and is not always detectable on abdominal palpation. Radiographs are recommended to confirm the presence of the “glue-ball” foreign body, and radiographic evidence of the obstruction may be seen as early as 4-6 hours following ingestion. Emesis is contraindicated owing to the risk of aspiration of the glue into the respiratory tree or the subsequent lodging of the expanding glue mass in the esophagus. Likewise, efforts to dilute the glue and prevent the formation of the foreign body through administration of liquids, activated charcoal, or bulk-forming products to push the foreign body through the GI tract have proven ineffective. Even endoscopy performed to remove the foreign body has been shown to be unreliable. The safest, most effective, and successful therapy is surgical intervention to remove the GI foreign body. If performed early enough, complete recovery of the animal can be expected. Differential diagnoses for polyurethane adhesive ingestion include any potential cause of GI obstruction. The public is largely unaware of the hazards that ingestion of this product may produce. Public education efforts are needed to inform pet owners about the hazards of these glues and the overall importance of providing our companion animals with safe, poison-free environments.

Congenital pyloric mucosal fold resulting in an antral valve outflow obstruction in a bull terrier

An under-sized three-month-old female bull terrier was referred with a history of regurgitation since three days of age. Thoracic radiographs were unremarkable, while abdominal radiographs showed a distended stomach, despite a 12 hour fast. Abdominal ultrasonography revealed gastric outflow obstruction of unclear aetiology. Coeliotomy was performed, during which an excessive mucosal fold at the pyloric antrum was excised. Histopathology of the pyloric fold revealed mild oedema and fibrosis of the mucosal tissue. The dog made a complete recovery, with resolution of regurgitation and grew to within the expected breed size. In the authors' opinion, this is the first canine report of congenital antral mucosal valve resulting in gastric outflow obstruction, and only the second report in any species.

Palliative Enteric Bypass for Malignant Gastric Outflow Obstruction after Pancreaticoduodenectomy in Early Recurrent Pancreatic Cancer

Recurrent pancreatic cancer has a poor prognosis and there are no established therapeutic strategies. We retrospectively studied patients who underwent palliative surgery for recurrent disease with gastric outlet obstruction (GOO) after an initial pancreaticoduodenectomy (PD) for pancreatic cancer. We retrospectively studied 4 patients who had undergone a bypass operation, including a modified Devine gastrojejunostomy with vertical stomach reconstruction (MDVSR) for GOO to ensure a direct dietary route to the jejunum, thereby, enabling the gastric contents to easily reach the jejunum. MDVSR was performed in 4 patients, and in addition to the bypass, 1 patient underwent a jejunojejunostomy, and 1 patient an ileocolostomy. The median operative time and blood loss were 123min (range, 95-150 min) and 164mL (range, 115-235 mL). After the second surgery, 2 of 4 patients received chemotherapy (1 patient: gemcitabine + S1, 1 patient: gemcitabine alone). The remaining 2 patients did not receive chemotherapy. The mean survival after the second operation was 145 days (range, 34-386 days). Palliative surgery including MDVSR is useful to improve a patient's nutritional state and it is more effective than chemotherapy for treating recurrent disease with GOO after a PD for pancreatic cancer.

Transmural eosinophilic gastritis with gastric outlet obstruction: case report and review of the literature

Eosinophil-associated gastrointestinal disorders (EGIDs) are uncommon conditions whose aetiologies are unclear, but which are characterised by eosinophilic infiltration and inflammation of the gastrointestinal tract in the absence of other causes of eosinophilia. We report the case of a 65-year-old woman with eosinophilic gastritis who underwent a Polya gastrectomy for a suspected gastric tumour with gastric outflow obstruction. Subsequent histological examination showed a non-malignant transmural eosinophilic infiltration of the stomach wall, a rare pathological entity. We present a review of the literature and discuss the management of such cases.

Long‐term prognosis of gastrojejunostomy in foals with gastric outflow obstruction: 16 cases (2001–2006)

It has been suggested that the success of gastric bypass surgery in foals for the treatment of gastric outflow obstruction is poor. However, few reports exist evaluating the long-term prognosis of these cases. To determine the long-term success of foals, including racing records, surgically treated for gastric outflow obstruction secondary to gastroduodenal ulceration. Medical records of foals undergoing surgical treatment of gastric outflow obstruction secondary to gastroduodenal ulceration were evaluated for clinical information. Owners, trainers and race records were evaluated regarding long-term survival and racing success. Sixteen foals were included in the study, all treated with a gastrojejunostomy. All foals survived to immediate discharge from the hospital; 8 survived to racing age, with 7 of those entering training and 3 actually racing. Foals that did not survive to racing age had various post operative complications. The success rate for these foals appears somewhat better than that previously reported. Gastrojejunostomy for the treatment of gastric outflow obstruction, secondary to gastric ulceration, is a valid treatment option for foals.

Surgical Treatment of Gastric Outflow Obstruction in 40 Foals

To report short- and long-term survival and factors affecting outcome of foals after surgical correction of gastric outflow obstruction. Case series. Foals (n=40) aged 5-180 days. Clinical signs, laboratory data, diagnostic imaging, surgical findings, surgical procedures, medical treatment, and necropsy findings were retrieved from medical records. Outcome was obtained by reviewing performance, sales, and produce records or by telephone conversations with the owners. Gastric outflow obstruction was treated by gastroduodenostomy or by gastrojejunostomy with or without jejunojejunostomy. Long-term follow-up was available for 36 of 39 foals that survived to hospital discharge; 25 (69%) survived >2 years. All 8 foals with pyloric obstruction survived >2 years, whereas only 11 of 21 (52%) foals with duodenal obstruction survived >2 years. Six of 8 foals with obstruction of the duodenum and pylorus survived >2 years. Obstruction of the duodenum, adhesions to the duodenum, and postoperative ileus were significantly associated with decreased long-term survival. Long-term outcome after gastric bypass procedures was substantially improved compared with previous reports. Factors that may have contributed to improved survival include better case selection and performing the gastrojejunostomy with the jejunum aligned from left to right. The prognosis for long-term survival after surgical bypass of pyloric obstruction is excellent. The overall prognosis for long-term survival after surgical bypass of duodenal obstruction is fair but should be considered guarded in those with pre-existing duodenal adhesions.