Gastric Outflow Obstruction Research Articles

ULTRASONOGRAPHIC APPEARANCE OF CANINE GASTRIC POLYPS

Benign gastric polyps are uncommon in dogs and most are discovered incidentally. Polyps protruding into the pyloric antrum can cause gastric outflow obstruction. Clinical and ultrasonographic findings in seven dogs with histologically confirmed benign mucosal gastric polyps were reviewed. Sonographic findings such as shape, size, echogenicity, location, evidence of gastric wall thickening, wall layering, and size of regional lymph nodes were recorded. Five sessile and two pedunculated masses of different sizes (range 7-60 mm) and echogenicities were found. They primarily arose from the mucosal layer and protruded into the gastric lumen. Only one dog had a large inhomogeneous mass with a poorly visualized gastric wall layering. The polyps were all single, and were located in the pyloric antrum in six out of seven dogs. Although the ultrasonographic appearance allowed a presumptive diagnosis of mucosal gastric polyp, the final diagnosis was determined from histopathologic examination.

Electronic Clinical Challenges and Images in GI

Question: A 75-year-old woman presented with vomiting. She had a past history of right hip replacement and pyloric ulceration caused by the use of diclofenac, a nonsteroidal anti-inflammatory drug (NSAID) that she had been prescribed for many years. She was taking omeprazole 20 mg once daily and had avoided all NSAIDs for the previous 12 months. On examination, her abdomen was distended and exhibited a succussion splash. A clinical diagnosis of gastric outflow obstruction was made. Initial laboratory investigations showed evidence of iron deficiency anemia with hemoglobin 10.3 g/dL (normal range, 11.5–16.5), mean cell volume 70.3 fl (normal range, 76–96), and ferritin 8 μg/L (normal range, 10–210). Blood clotting was normal. Biochemistry investigations showed normal urea, electrolytes, and liver function except hypoalbuminemia 21 g/L (normal range, 35–50). Her admission plain abdominal radiograph is shown (Figure A). A gastroscopy was performed, which demonstrated large amounts of food residue within a grossly distended stomach. The pylorus was patent, leading into the first part of duodenum, which was dilated. A tight stricture with circumferential ulceration was identified at the junction of the first and second part of her duodenum, which was successfully balloon dilated. The endoscope was only just able to cross the stricture owing to the gastric distention. The next day, her symptoms and clinical examination findings persisted. What is the reason for the lack of clinical improvement despite successful dilatation of the stricture? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Owing to lack of resolution of the symptoms of gastric outflow obstruction, a repeat gastroscopy was undertaken using an enteroscope (Figure B). This showed that the index stricture remained patent, but a second discrete stricture was identified. This distal stricture was balloon dilated and the patient's clinical condition improved. Review of the abdominal radiograph shows evidence of 2 “diaphragm–like” strictures. The stomach is grossly distended, tapering to the pylorus. The first part of the duodenum is dilated owing to the proximal stricture and there is further dilated duodenum from the distal stricture. This demonstrates the usefulness of abdominal radiography in predicting endoscopic findings. This is a clinical example of the long-term sequelae of NSAID use, which is well known to cause bleeding and ulceration, as well as obstruction caused by luminal narrowing. Diaphragms are thin, septate narrowings, usually of the small intestinal mucosa and are thought to arise from circumferential ulcers.1Tibble J. Smale S. Bjarnason I. Adverse effects of drugs on the small bowel.Adv Drug React Bull. 1999; 198: 755-758Crossref Scopus (1) Google Scholar Multiple diaphragm strictures are rare and usually seen in the mid small bowel. They are pathognomonic of NSAID-induced intestinal damage.2Fortun P.J. Hawkey C.J. Nonsteroidal antiinflammatory drugs and the small intestine.Curr Opin Gastroenterol. 2007; 23: 134-141PubMed Google Scholar This patient also showed evidence of small bowel enteropathy (iron deficiency and hypoalbuminemia), which is thought to be due to increased small bowel permeability and microscopic blood loss from NSAID-induced small bowel inflammation, which can occur after as little as 6 months of treatment.2Fortun P.J. Hawkey C.J. Nonsteroidal antiinflammatory drugs and the small intestine.Curr Opin Gastroenterol. 2007; 23: 134-141PubMed Google Scholar Importantly, the deleterious effects of NSAIDs can last for up to 16 months after discontinuation.3Bjarnason I. Zanelli G. Smith T. et al.Nonsteroidal antiinflammatory drug-induced inflammation in humans.Gastroenterology. 1987; 93: 480-489PubMed Google Scholar

Can glucose make you faint?

In April, 2008, a 27-year-old woman came to the emergency department of her local hospital, with a 3-week history of dizziness, low appetite, and occasional vomiting. 2 months before, she had undergone an uncomplicated laparoscopic proximal gastric bypass for obesity; on discharge, she was prescribed multivitamins and lansoprazole.

Prospective randomized trial of laparoscopic gastrojejunostomy versus duodenal stenting for malignant gastric outflow obstruction

We prospectively compared laparoscopic gastrojejunostomy with duodenal stenting as a means of palliating malignant gastric outflow obstruction. A total of 27 patients with malignant gastric outflow obstruction were randomized to either laparoscopic gastrojejunostomy (LGJ) or duodenal stenting (DS) over a 3-year period. Thirteen patients underwent successful LGJ and 10 had successful DS. Eight patients had complications after LGJ, but none had complications after DS. Patients who underwent LGJ had a significant increase in visual analog pain score at day 1 (p = 0.05), and also had a longer hospital stay compared to those who underwent DS (11.4 vs. 5.2 days, p = 0.02). After DS, patients experienced an improvement in physical health at 1 month as measured using the Short Form-36 (SF-36) questionnaire (p < 0.01). There was no change following LGJ. Duodenal stenting is a safe means of palliating malignant gastric outflow obstruction. It offers significant advantages for patients compared with minimal-access surgery.

An unusual case of massive gastric distension with catastrophic sequelae

We report a case of massive gastric distension presenting with abdominal pain, shock and lower limb ischaemia. At laparotomy, gastric distension was found to be secondary to gastric outflow obstruction compounded by gas formation from antacid ingestion. Both the aorta and inferior vena cava were directly compressed by the distended stomach. This mode of presentation and combined aetiologies remain unreported. Gastric decompression resulted in profound cardiovascular compromise, multiorgan failure and eventually death.

Enteral stenting in 21 patients with malignant gastroduodenal obstruction.

Placement of an enteral stent is emerging as an effective alternative to surgery for symptomatic relief in patients with malignant gastric outflow and duodenal obstruction. We report experience in a series of patients who had the Wallstent enteral prosthesis inserted. 21 consecutive patients with inoperable obstruction, median age 75 years, had twenty-three procedures for insertion of the Wallstent under fluoroscopic guidance. Stent implantation was successful in 18 patients (86%), all of whom gained relief from nausea and vomiting. There were no short-term complications. Median survival after the procedure was four months (longest ten months), and no deaths were related to insertion. The efficacy and lack of complications in this series support use of the endoscopically placed stent for palliative management of malignant upper gastrointestinal obstruction.

Enteral stenting in 21 patients with malignant gastroduodenal obstruction

Placement of an enteral stent is emerging as an effective alternative to surgery for symptomatic relief in patients with malignant gastric outflow and duodenal obstruction. We report experience in a series of patients who had the Wallstent enteral prosthesis inserted. 21 consecutive patients with inoperable obstruction, median age 75 years, had twenty-three procedures for insertion of the Wallstent under fluoroscopic guidance. Stent implantation was successful in 18 patients (86%), all of whom gained relief from nausea and vomiting. There were no short-term complications. Median survival after the procedure was four months (longest ten months), and no deaths were related to insertion. The efficacy and lack of complications in this series support use of the endoscopically placed stent for palliative management of malignant upper gastrointestinal obstruction.

Canine gastric adenocarcinoma and leiomyosarcoma: a retrospective study of 21 cases (1986-1999) and literature review.

This retrospective study describes the clinical course, treatment, and outcome of 21 dogs with gastric adenocarcinomas (n=19) and leiomyosarcomas (n=2). Medical records from 1986 to 1999 were reviewed for signalment, weight, diagnosis, tumor location, clinical signs, radiographic imaging procedures, surgical procedures, chemotherapy, duration of follow-up monitoring, outcome, cause of death, metastatic rate, metastatic sites, and method of detection of metastasis. Fourteen of 19 (74%) dogs with gastric adenocarcinomas had metastasis. Metastatic sites included gastric lymph nodes, omentum, liver, duodenum, pancreas, spleen, esophagus, adrenal glands, and lungs. Both cases of a gastric leiomyosarcoma had metastatic disease involving the liver (n=2) and duodenum (n=1). Surgery, consisting of either a Billroth I or a gastrojejunostomy, provided immediate relief of the gastric outflow obstruction and clinical improvement in the early postoperative period. The beneficial effects of chemotherapy alone or adjuvant chemotherapy are still unknown. Recurrence of clinical signs 3 days to 10 months after surgery caused all owners to elect euthanasia. The long-term prognosis for most cases of gastric adenocarcinomas and leiomyosarcomas is poor because of the presence of advanced disease. Surgical resection, however, does alleviate gastric outflow obstruction in the immediate postoperative period.

Esophageal and upper GI stenting

Self-expanding metallic stents are now well established in the palliative management of inoperable esophageal carcinoma. Dysphagia is successfully palliated in more than 90% of patients treated, with a low incidence of procedural complications. Use of covered stents minimizes recurrent dysphagia due to tumor ingrowth, and also provides palliation for the vast majority of malignant esophageal perforations and fistulae to the airways. However, these stents cannot be used at the esophagogastric junction because there is a high incidence of stent migration when they are used at this site. Use of stents in benign disease of the esophagus is limited by the high incidence of epithelial hyperplasia that occurs over follow-up. Stents may also be used in the relief of inoperable gastric outflow obstruction caused either by gastric or pancreatic carcinoma. The numbers of cases published in the literature are relatively small, but results indicate successful palliation with no reported complications at this time. Self-expanding metallic stents are now well established in the palliative management of inoperable esophageal carcinoma. Dysphagia is successfully palliated in more than 90% of patients treated, with a low incidence of procedural complications. Use of covered stents minimizes recurrent dysphagia due to tumor ingrowth, and also provides palliation for the vast majority of malignant esophageal perforations and fistulae to the airways. However, these stents cannot be used at the esophagogastric junction because there is a high incidence of stent migration when they are used at this site. Use of stents in benign disease of the esophagus is limited by the high incidence of epithelial hyperplasia that occurs over follow-up. Stents may also be used in the relief of inoperable gastric outflow obstruction caused either by gastric or pancreatic carcinoma. The numbers of cases published in the literature are relatively small, but results indicate successful palliation with no reported complications at this time.

Gastric outflow obstruction caused by gall stones and leading to death by complex metabolic derangement.

A 67 year old woman was admitted with a three week history of vomiting, having become increasingly confused for three days. Investigations revealed deranged serum biochemistry consistent with a combination...

Pyrexia of undetermined origin in advanced HIV disease.

Pyrexia of undetermined origin in advanced HIV disease.

The successful medical management of gastric outflow obstruction associated with the use of non-steroidal anti-inflammatory drugs in the elderly

One hundred and nineteen consecutive elderly patients with endoscopically diagnosed peptic ulceration were reviewed. Associated gastric outflow obstruction was present in 10.1%. The presenting clinical features differed significantly from typical younger patients and most (11/12) were taking non-steroidal anti-inflammatory drugs, suggesting a possible role for these agents in the pathogenesis of gastric outflow obstruction. These elderly patients have been successfully managed by medical therapy alone.

Perforated gastric ulcer v associated with pyloroplasty for chronic hypertrophic pyloric gastropathy in a dog

ABSTRACTA six‐year‐old male silkie terrier presented with a history of chronic vomiting. A diagnosis of gastric outflow obstruction was made using contrast radiography of the upper gastrointestinal tract. Surgical examination of the stomach revealed thickened pyloric antral mucosa. A Heineke‐Mikulicz pyloroplasty combined with resection of the hypertrophic pyloric mucosa were performed to increase the patency of the pyloric lumen. The dog recovered well from surgery and his condition remained stable until the sixth day postoperatively when his condition deteriorated rapidly resulting in his death that night. At autopsy a perforated gastric ulcer was found in the cardiac region of the pylorus with evidence for a generalised peritonitis. An association between gastric outflow obstruction and gastric ulceration has been reported in human clinical literature and in canine experimental models. No such association has been previously documented in the veterinary clinical literature.

Gastric outflow obstruction: an unusual complication of cholelithiasis

Gastric outflow obstruction: an unusual complication of cholelithiasis

Upper Gastrointestinal Surgery for Ulcer Disease in Foals

The goals of surgical therapy in foal gastroduodenal ulcer disease are the elimination of abdominal pain, healing of mucosal ulcerations, and prevention of complications. Gastrojejunostomy has been used with success in both pyloric and duodenal ulcerations that have progressed to gastric outflow obstruction. Gastrojejunostomy has resulted in rapid healing of gastritis and esophagitis and resolution of aspiration pneumonia and biliary stasis without recurrence of duodenal ulceration.

The objectives of palliative surgery in pancreas cancer: a retrospective study of 73 cases.

In 73 cases of pancreas cancer, histological diagnosis was not obtained in 43 (59%). Relief of obstructive jaundice was not satisfactorilly achieved in 14 of 39 patients at risk (36%), while gastric outflow obstruction developed subsequent to surgery in eight of 31 patients at risk (26%). Fine needle aspiration cytology is advocated to improve the rate of positive peroperative tissue diagnosis. To relieve bile duct obstruction, cholecystojejunostomy is advocated only in patients with pancreas cancer who have a very short life expectancy, and only when the cystic duct is patent. Choledochojejunostomy and gastrojejunostomy "double bypass" is advocated for cancers which are macroscopically localized to the pancreatic area. The selective use of this double bypass will improve surgical palliation and minimize reoperations in cancer of the pancreas.

SURGERY FOR RECURRENT PEPTIC ULCERATION

Sixty-six patients having surgery for recurrent peptic ulcers over a 10-year period are reviewed. The majority of the patients were male and developed their initial ulcers at an early age. Bleeding was the most common presenting symptom. Seventy-one percent of the recurrences occurred within three years. Barium meal X-ray examination plus endoscopy gave the correct diagnosis in 96% of cases. The causes of the recurrent peptic ulcers were: (1) incomplete vagotomy; (2) inadequate gastric resection; (3) inappropriate surgery; (4) Zollinger-Ellison syndrome; (5) gastric outflow obstruction; and (6) bile reflux. Other factors such as alcohol, analgesic abuse and psychiatric disorders were found to be common associations. Resection plus vagotomy was the summation of primary and secondary surgery in 85%. The operative mortality was 3%. Eighty-five percent of patients had a Visick grading of I or II. Only one patient had a further recurrent ulcer and this healed on medical treatment.

Surgical Treatment of Reflux Esophagitis

Reflux esophagitis has been established as a clinical entity 2,3 which in all probability is related to the action of acid-pepsin digestion of the esophageal mucosa. 4,14,20 In the majority of instances it is associated with the presence of a hiatus hernia, 6,11 gastric outflow obstruction, 7 or other abnormalities of the cardioesophageal junction. 27 In general, the results have been good when the cardioesophageal junction has been restored by surgical means to normal function. However, the presence of cicatricial stenosis of the lower end of the esophagus which may result from ulceration of the terminal esophagus has posed a far more complicated problem. Attempts to correct this by repair of hiatus hernia, plastic operations upon the cardia, and resection of the stenotic segment with esophageal-gastric anastomosis have frequently resulted in failure and severe recurrent esophagitis accompanied by stenosis. 10,23 A review of the experience during the past 10 years