Intermittent Gastric Outlet Obstruction Research Articles

A Case of Groove Pancreatitis Presenting with Intermittent Gastric Outlet Obstruction

A Case of Groove Pancreatitis Presenting with Intermittent Gastric Outlet Obstruction

S1887 A Case of PEG-Induced Pancreatitis

Introduction: PEG (percutaneous endoscopic gastrostomy) tube placement is a commonly performed procedure for patients in need of long-term enteral nutrition. It is a relatively safe procedure, with some complications including bleeding, infection, buried bumper syndrome, and dislodgement. Even rarer is the tube migration into the duodenum, obstructing the ampulla, causing biliary obstruction and pancreatitis. We present a case of pancreatitis secondary to migrated PEG tube bumper [1, 2]. Case Description/Methods: An 83-year-old male with a history of stroke and dysphagia, who one year prior had a PEG tube placed presenting with vomiting and epigastric pain and tenderness. Initial lipase was 1761 (reference 8-69 U/L), alkaline phosphatase was 145 (reference 36-112 IU/L), transaminases, bilirubin, and triglycerides were normal. Abdominal CT scan showed a migrated PEG tube balloon in second part of the duodenum at level of the ampulla (Figure). As it turned out patient was tolerating oral diet thus PEG was no longer needed. GI team deflated the balloon and removed the PEG without any further complications. With aggressive fluid resuscitation, patient's symptoms resolved after two days. Discussion: Pancreatitis due to migrated PEG tube obstructing the ampulla is a rare entity, with only a few case reports published. Patient's can present with nonspecific symptoms with significantly elevated hepatic and pancreatic enzymes. CT findings can show pancreatic inflammation and biliary/pancreatic duct dilation with PEG bumper at level of ampulla [1, 2]. Physical exam findings would show very little external tubing indicating distal internal migration of PEG bumper. Interestingly this can also cause intermittent gastric outlet obstruction. Treatment is PEG tube removal/replacement, and IV fluids. Marking the tube at the insertion site can help in diagnosis of migration, if it happens. Patients and care givers should be educated about tube care, regular follow-ups to ensure positioning and to ascertain the timing of removal.Figure 1.: Migration of percutaneous gastrostomy tube balloon to second portion of duodenum at level of ampulla.

Primary Endoscopic Treatments for Obesity

Endoscopic bariatric therapies (EBTs) are suitable alternatives since only a tiny portion of patients with definite indications undergo bariatric surgery. Several endoluminal modalities are currently available, but the level of evidence supporting each of them varies widely. This review aims to summarize the most relevant and novel evidence on EBTs. The intragastric balloon is the oldest EBT, and there is sound evidence supporting its use to address overweight and obesity; there is a novel space-occupying device that causes intermittent gastric outlet obstruction and has recently been approved by the FDA; gastric reduction methods (POSE and Endoscopic Sleeve Gastroplasty) have new and promising data showing its effectiveness and safety; the endoluminal duodenal bypass liner has been abandoned from clinical use due to high rates of serious adverse events. This article reviews the novel and traditional EBTs and their corresponding supportive data for the primary treatment of obesity. Also, we provide insightful personal perspectives on the future of endoluminal bariatric therapies.

2695 Pedunculated Polyp at the Pyloric Channel Causing Intermittent Gastric Outlet Obstruction

INTRODUCTION: Gastric outlet obstruction (GOO) is the intrinsic or extrinsic obstruction of the pyloric channel or duodenum. The most common cause remains to be peptic ulcer disease which results in inflammation, edema or fibrosis. GOO typically presents with epigastric abdominal pain and postprandial vomiting. While the incidence of GOO is unclear, it has declined since the identification of Helicobacter pylori, H2-receptor antagonists and endoscopic therapy. We present a case of a benign polyp obstructing the pyloric channel. CASE DESCRIPTION/METHODS: 39 year-old female with a history of pulmonary embolism on Eliquis, Diabetes mellitus type 2 who presents for several months of epigastric pain, nausea and intractable vomiting. Prior to arrival, she had endoscopic evaluation at an outside hospital showing evidence of 1.5 cm gastric polyp in the pyloric channel. At the time, the polyp was not excised due to the patient being on anticoagulation. On admission, she underwent CT angiography showing no evidence of clot. She subsequently underwent repeat endoscopic evaluation demonstrating a 15 mm non-bleeding, pedunculated polyp at the pyloric channel obstructing the pyloric opening. The polyp was resected with hot snare. Biopsy showed a hyperplastic gastric polyp negative for malignancy. To prevent bleeding post-intervention, two hemostatic clips were placed. The patients abdominal pain, nausea and vomiting nearly resolved one day after her procedure. DISCUSSION: While the incidence of GOO has declined, it should continue to be considered in patient’s presenting with recurrent epigastric abdominal pain. Recent reviews estimate that, contrary to earlier years, 50 to 80% of cases have been attributable to malignancy such as pancreatic adenocarcinoma and distal gastric cancer. CT scan may show gastric distension or retained material within the gastric lumen. However, identifying the obstruction with upper endoscopy establishes the diagnosis. Treatment should be aimed at the underlying cause.

Submucosal Neuromuscular and Vascular Hamartoma of the Stomach: A Rare Cause of Abdominal Pain and Intermittent Partial Gastric Outlet Obstruction

Submucosal Neuromuscular and Vascular Hamartoma of the Stomach: A Rare Cause of Abdominal Pain and Intermittent Partial Gastric Outlet Obstruction

Duodeno-duodenal intussusception secondary to a Brunner's gland adenoma

Background: Duodenal intussusception is a rare complication of a Brunner’s gland adenoma with only 12 cases, including this report, reported to date. Symptoms are usually vague, diagnosis is often difficult and intussusception, due to its rarity, may mimic sinister tumours. Management usually involves a duodenotomy and excision of the adenoma. Methods: We present a 46-year-old female who presented with features of intermittent gastric outlet obstruction with associated anaemia. Results: A combination of fluoroscopy, endoscopy and computed tomography revealed a duodenal intussusception with a lead point from the 1st part of the duodenum intussuscepting into the 4th part of the duodenum. At laparotomy the Brunner’s adenoma was removed via an antrotomy. Conclusion: A Brunner’s gland adenoma must be suspected for tumours arising in the 1st part of the duodenum. Though rare, intussusception may mimic more sinister tumours and must be considered as an alternate diagnosis to prevent unnecessary major resections. Excision via an antrotomy rather than a duodenotomy should be considered.

An Unusual Etiology of Gastric Outlet Obstruction

Gastric polyps are often asymptomatic and an incidental finding on EGD. Hyperplastic polyps result from hyper-regeneration of the gut epithelium in conditions of chronic inflammation such as chronic gastritis, pernicious anemia and H. pylori. The patient is a 57 year-old woman with hypertension, hyperlipidemia and GERD who presented with 2 months of nausea, epigastric pain, early satiety, anorexia, 16 pound weight loss and feeling like she suffocates while she eats. Laboratories were unremarkable. CT scan of the abdomen and pelvis showed a 3.1 cm pedunculated polypoid mass along the posterior-inferior wall of the antrum proximal to the pylorus. EGD revealed a 4 cm pedunculated polyp at the incisura with a thick base that precluded endoscopic resection. Biopsies revealed a hyperplastic polyp and no signs of H. pylori infection. Given the size and endoscopic appearance of the polyp, repeat EGD was performed for biopsies to exclude dysplasia or malignancy. On repeat EGD, the multi-lobulated head of the polyp was found to have prolapsed into the duodenal bulb leading to gastric outlet obstruction (Figure 1). Using an open Roth net, the head of the polyp was delivered back into the stomach (Figure 2). Repeat biopsy revealed hyperplastic polyp and patient was referred to surgery. Exploratory laparotomy with gastric polypectomy and pyloroplasty was completed without complications. Pathology from surgical specimens confirmed hyperplastic polyp without dysplasia (Figure 3). At one year follow-up, symptoms had resolved and EGD showed pyloroplasty with no residual polyp.Figure 1Figure 2Figure 3We present an uncommon case of a symptomatic large gastric polyp in the pre-pyloric stomach leading to intermittent gastric outlet obstruction. Hyperplastic polyps are solitary in about two-thirds of cases. Small lesions are not considered pre-cancerous but a polyp's malignancy potential increases with larger polyp size. This case demonstrates how large gastric polyps can cause intermittently severe symptoms in contrast to the progressive presentations of stenosis or malignancy. Furthermore, we describe a rare etiology of gastric outlet obstruction and an endoscopic technique to reduce the prolapsed head of the polyp from the duodenum to the stomach with the Roth net.

Peutz-Jeghers Hamartoma: The Cause of Intermittent Gastric Outlet Obstruction

Peutz-Jeghers Syndrome (PJS) is a rare, autosomal dominant inherited disease that manifests with gastrointestinal Hamartomatous polyps and mucocutaneous pigmentation. PJS can cause bleeding, anemia, and intussusception. We report the case of a 21 year old male patient who was diagnosed with Peutz-Jeghers syndrome at age 13 in Ukraine, and after immigration to the US, was referred to our institution for evaluation of intermittent episodes of abdominal pain, vomiting, and anemia. During endoscopic evaluation he was found to have multiple hamartomatous polyps throughout the gastrointestinal tract. One of the largest hamartomas located in the duodenal bulb was approximately 4 cm in diameter, and the culprit of intermittent gastric outlet obstruction. The patient's symptoms of episodic abdominal pain and vomiting resolved after polypectomy of this large duodenal bulb hamartomatous polyp. Peutz-Jeghers Syndrome is usually known to cause intussusception; gastric outlet obstruction, however, is a rare presentation of PJS. Treatment in PJS is geared mainly at removal of polyps, endoscopically, when possible, while minimizing surgical resections. Patients with PJS need close follow ups and monitoring due to increased riskst of gastrointesinal and extra-intestional malignancies during their lifetime.Figure 1Figure 2Figure 3

Gastro-Intestinal Stromal Tumour presenting as Gastroduodenal Intussusception

Gastrointestinal stromal tumours (GISTs), are relatively common tumours of the gastrointestinal tract, most commonly found in the stomach. Previously they were termed as leiomyomas and leiomyosarcomas. Clinically, they are asymptomatic but may cause abdominal pain or bleeding from ulceration of the overlying mucosa. We present a case of gastroduodenal intussusception secondary to large gastric stromal tumour in a 50 year old male, which presented with intermittent abdominal pain and gastric outlet obstruction. Pre-operative diagnosis was made on abdominal CT and confirmed at laparotomy. DOI: http://dx.doi.org/10.3126/njr.v4i1.11573 Nepalese Journal of Radiology, Vol.4(1) 2014: 71-75

Giant Gastric Polyp, A Rare Cause Of Gastric Outlet Obstruction

Gastric polyps are often an incidental finding on upper gastrointestinal endoscopy. Hyperplastic polyps are the most commonly encountered gastric polyps (75%). Most of gastric polyps are asymptomatic but they may present with occult bleed, obstruction or abdominal pain. We report a case of an 80-year-old woman who presented with a benign gastric polyp causing an intermittent gastric outlet obstruction, who was successfully treated with resection.

Giant antral inflammatory fibroid polyp causing intermittent gastric outlet obstruction and a wasting syndrome: Case report

Hyperplastic or inflammatory polyps of the gastric corpus and antrum typically develop in association with chronic gastritis and are very common benign and asymptomatic lesions of the stomach. Rarely, they cause gastric outlet by prolapsing through the pyloric channel. We report an 82-year-old woman who presented with abdominal pain, intermittent nausea, eructation, anorexia and important weight loss and iron deficiency anemia. The clinical presentation mimic malignancy. The CT scan showed the presence of large irregular and ulcerated pedunculated mass located in the duodenum conditioning delay in gastric emptying. The endoluminal caliber reduction of the antrum/pyloric transition was evident. Upper gastrointestinal endoscopy exposed a 50 mm eroded prepyloric sessile polyp, prolapsed through the duodenum. It was totally removed with a snare and diathermy technical. Microscopic examination revealed chronic gastric, intestinal metaplasia and the presence of polymorphic fusiform fibroblast cells arranged in fascicles and whom formation in an inflammatory background rich in eosinophils. Rapid urease test for Helicobacter pylori yielded a negative result. The patient recovered the wasting syndrome and has been symptom-free during nine months of follow-up. We highlight this case because of the unusual presentation of a clinical suspicion of malignant disease.

Endoscopic Treatment of Intermittent Gastric Outlet Obstruction Caused by a Prolapsing Gastric Antral Polyp

Purpose: Gastric outlet obstruction often presents with nausea and vomiting and usually develops over weeks to months. The most common causes of gastric outlet obstruction are peptic ulcers, malignancy, bezoars, foreign bodies, and pyloric stenosis. Methods: We report a case of intermittent gastric obstruction caused by a prolapsing hyperplastic gastric antral polyp. Results: A healthy 44-year-old female presented with 3 months of intermittent dull mid abdominal pain, nausea and intermittent non-bloody, non-bilious vomiting. She also described early satiety and a weight loss of 8 pounds over the 3 months. She was otherwise healthy and took no medications. On physical exam she had normal bowel sounds, and mild tenderness over the epigastric region. She had a negative Murphy's sign, and the spleen and liver were normal. Her complete blood count was normal, with no anemia. Upper endoscopy was recommended to further investigate the patient's pain, nausea, vomiting and weight loss. On upper endoscopy, a 3 cm pedunculated, prolapsing, polyp was found arising in the gastric antrum and causing ball-valve effect within the pylorus and near complete obstruction of the pyloric channel. The polyp was observed to cause intermittent gastric outlet obstruction. The polyp was completely resected by a monopolar polypectomy using a large snare and sent for pathology. Pathology showed a hyperplastic polyp without evidence of metaplasia, dysplasia or malignancy. Random gastric biopsies showed chronic inactive gastritis and no evidence of Helicobacter pylori. At the follow-up 12 months after the polypectomy, the patient remained symptom free. Conclusion: We report the case of a patient with intermittent symptomatic gastric outlet obstruction caused by a benign prolapsing gastric polyp treated by endoscopic snare resection. There are 39 previously reported cases of gastric polyps leading to gastric outlet obstruction. Gastric polyps causing gastric outlet obstruction are more common in females (23 cases) with median age of onset of 72 years in females. Previously reported polyps arise from the antrum and have a median size of 5 cm (1.5-8 cm). They can be managed surgically with excision, or endoscopically with snare polypectomy or endoscopic mucosal resection (EMR) of sessile polyps. The median size of endoscopically removed polyps is 3 cm, with largest reported in the literature being 8 cm. Complications of endoscopic management include bleeding and perforation. Gastric polyps should be considered in the differential diagnosis of a patient who present with intermittent gastric outlet obstruction. Endoscopic management with snare resection is a good option if technically feasible and can result in a long term response.

A quarter causing intermittent gastric outlet obstruction

M e c A 45-year-old man presented with 8 weeks of episodic postprandial nausea, vomiting, and abdominal distention lasting 2 to 3 hours and occurring every 3 to 4 days. The episodes resolved with no specific treatment but continued to occur every 3 to 4 days. Between episodes, the patient felt fine and had no abdominal pain, weight loss, altered bowel habits, or change in appetite. Abdominal examination showed normal results. Complete blood count, urinalysis, liver biochemical tests, serum amylase, and lipase results were all normal. A CT scan showed a 2.4-cm metal disk in the gastric antrum (A), and an upper endoscopy was ordered to follow-up the abnormal CT result. EGD confirmed a heavily corroded quarter (B), which was retrieved by using a Roth net. After the quarter

Benign intermittent gastric outlet obstruction in an elderly: Endoscopic management and brief review

We describe the clinical scenario in an 80 year old female who presented with history of epigastric discomfort and postprandial fullness of three weeks duration without any alarming symptoms. On upper GI endoscopy she was found to have gastric polyp with a long stalk which was partially obstructing her pyloric ring giving rise to features of intermittent gastric outlet obstruction. Polypectomy was done with complete relief of symptoms. She is following our clinic for last 6 months now. Although possibility of malignant etiology in gastric outlet obstruction ranks high in the elderly some patients are lucky to have a benign cause as the index case. Report of the case and brief review is presented.

Inflammatory Myofibroblastic Tumor of the Stomach in an Adult Woman: A Rare Intermittent Cause of Gastric Outlet Obstruction

Inflammatory myofibroblastic tumor is a neoplasm of intermediate biological potential that frequently recurs and rarely metastasizes. We report a rare case of intermittent gastric outlet obstruction by an inflammatory myofibroblastic tumor of the cardia. A 56-year-old woman presented at the gastroenterology department with a two-day history of hematemesis and melena. She had intermittent nausea and vomiting complaints, which had manifested periodically for about five months. Upper gastrointestinal endoscopy demonstrated a mass of 6 cm in diameter, which was resected. Histological examination revealed ulcerated mucosal granulation-like tissue with myofibroblastic spindle cell proliferation in a storiform pattern. In order to avoid unnecessary aggressive therapy, gastric IMT should be taken into account when a gastric mass accompanied by the various clinical manifestations of IMT is found in an adult.

Intermittent gastric outlet obstruction caused by a prolapsing antral gastric polyp

Most gastric polyps have an asymptomatic presentation and are an incidental finding on upper endoscopy. Symptomatic presentations can range from an ulcerated polyp leading to anemia and occult bleed to complete gastric outlet obstruction. We report a case of an 89-year-old woman who presented with postprandial nausea and early satiety. Her upper endoscopy revealed a 2 cm pedunculated hyperplastic polyp arising from the antrum of the stomach which was seen prolapsing into the pylorus causing intermittent gastric outlet obstruction. In the present report, we statistically analyzed 39 prolapsing gastric polyps previously reported in the English literature and demonstrate the current utility of monopolar snare polypectomy in establishing a histological diagnosis while offering simultaneous treatment. Additionally, we review the literature for the management of all hyperplastic gastric polyps in relation to advancements in digestive endoscopy.

Intermittent gastric outlet obstruction due to a gallstone migrated through a cholecysto-gastric fistula: A new variant of “Bouveret’s syndrome”

Bouveret's syndrome, defined as gastric outlet obstruction due to a large gallstone, is still one of the most dramatic biliary gallstone complications. Although new radiological and endoscopic techniques have made pre-surgical diagnosis possible in most cases and the death rate has dropped dramatically, "one-stage surgery" (biliary surgery carried out at the same time as the removal of the gut obstruction) should be still considered as the gold standard for the treatment of gallstone ileus.In this case, partial gastric outlet obstruction resulted in an atypical and insidious clinical presentation that allowed us to perform the conventional one-stage laparatomic procedure that completely solved the problem, thus avoiding any further complications.

Gastric Polyps Causing Intermittent Gastric Outlet Obstruction

Purpose: A 40-year-old Caucasian male with a history of GERD and Osgood-Schlatter disease presented with acute-onset of abdominal bloating, nausea and vomiting for one month. His daily symptoms were worse at night, usually resolving by the next morning. He denied any worsening heartburn, weight loss, appetite changes, dietary changes or modification of bowel habits. He had been on long-term proton-pump inhibitor therapy for GERD and was taking NSAIDs for osteochondritis. Elective gastroscopy showed multiple large gastric polyps occupying the gastric fundus and body. Two of these polyps were pedunculated and were prolapsing into the pyloric channel, presumably causing intermittent gastric outlet obstruction. We endoscopically removed two 3.5 cm hyperplastic polyps by snare technique. The patient's symptoms completely resolved following this intervention. Proton-pump inhibitors are widely used in clinical practice and are associated with an increased incidence of hyperplastic gastric polyps via stimulation of enterochromaffin-like cells. Gastric polyps causing gastric outlet obstruction should be considered in the differential diagnoses of abdominal distention.[figure1][figure2]FigureFigure

A gastric inflammatory polyp causing both bleeding and intermittent gastric outlet obstruction

A gastric inflammatory polyp causing both bleeding and intermittent gastric outlet obstruction

Endoscopic hemoclip application for the treatment of a large gastric polyp causing intermittent outlet obstruction

Gastric polyps are usually incidental findings at endoscopy and of little clinical significance. They are seen in about 2% of endoscopies and are even less frequent, approximately 0.15%, in autopsy series.1 Hyperplastic polyps account for 80% to 85% of gastric polyps and constitute the most common variety.2 They are usually located in the antrum or at the junction of the antrum and body. Most are small; only about 10% to 15% are 2 cm or larger. It is these large polyps that are clinically significant because of chronic occult bleeding and anemia or intermittent gastric outlet obstruction.3