Severe Gastric Outlet Obstruction Research Articles

S4049 Duodenal Neoplasm Causing Severe Gastric Outlet Obstruction Treated with Unique Endoscopic Stenting

S4049 Duodenal Neoplasm Causing Severe Gastric Outlet Obstruction Treated with Unique Endoscopic Stenting

PYLORIC STENOSIS DUE TO BRUNNEROMA MASQUERADING AS PEPTIC ULCER COMPLICATION

A 42-year-male presented to the surgical emergency with features of severe gastric outlet obstruction. On investigation, upper gastrointestinal series showed features suggestive of a near complete gastric outlet obstruction. Endoscopy revealed multiple antral ulcers with near complete pyloric stenosis, features suggestive of complications arising out of antral ulcers. Biopsy report revealed Brunner’s gland hyperplasia. A unique aspect about the case is the finding of antral ulcers associated with Brunner’s gland hyperplasia. The patient underwent laparoscopic distal gastrectomy with gastrojejunostomy. A high index of suspicion of Brunner cell hyperplasia in case of the patient presenting with features suggestive of pyloric stenosis is the crux of diagnosis in view of the malignant potential of Brunner cell hyperplasia.

Gastric Outlet Obstruction Caused by a Triple Lesion: Eosinophilic Gastroenteritis, Brunner’s Gland Hyperplasia and Pancreatic Heterotopia in Unison

Gastric outlet obstruction is a common entity described with numerous benign and malignant causes. Historically, benign causes include Peptic Ulcer disease (PUD); however recent cases have reported other causes including Eosinophilic Gastroenteritis (EGE), Brunner’s Gland Hyperplasia (BGH) and Pancreatic Heterotopia (PH). We present an unusual case of a 31 year old male patient with severe gastric outlet obstruction requiring surgical intervention caused by all three pathologies in unison – EGE, BGH and PH. The patient underwent surgical resection with distal gastrectomy and Billroth II reconstruction. Histology confirmed the three pathologies and post-operative recovery of the patient was uneventful.

Clinical Vignettes/Case Reports - Biliary/Pancreas.

Groove pancreatitis is a rare type of segmental pancreatitis that can mimic the effects of a mass leading to gastric outlet obstruction. The clinical manifestations as well as the radiographic appearance make this entity a diagnostic challenge. A 61 year old male with a history of heavy alcohol use and multiple admissions for chronic pancreatitis presented with a four day history of nausea and vomiting. Nine months earlier he had been evaluated by his primary care doctor for a one month history of progressive jaundice. Initial workup was notable for a cholestatic elevation in liver enzymes and a direct bilirubinemia. MRCP suggested distal common bile duct stricture. ERCP confirmed this finding and suggested possible cholangiocarcinoma or pancreatic adenocarcinoma. Tumor markers including CA 19-9 and CEA were normal. A biliary stent was placed and jaundice resolved. Subsequent ERCP to exchange the stent revealed chronic calcified pancreatitis and adenopathy in the peripancreatic and porta-hepatis areas with persistent distal common bile duct stricture. Biopsies were taken from the pancreatic head which were suggestive of chronic pancreatitis but were negative for malignant cells. On admission, lab values were consistent with a severe metabolic alkalosis and a cholestatic pattern of hepatic enzyme elevations. Abdominal CT with oral contrast revealed partial gastric outlet obstruction. A nasogastric tube was placed to decompress the stomach. Repeat MRCP was notable for gastric outlet obstruction and a pancreatic head mass involving the second portion of the duodenum. Repeat ERCP showed partial obstruction in the duodenal cap with edematous folds. Biopsies were again taken from the pancreatic head, which were negative for malignancy. The patient underwent PEJ placement for nutrition and placement of a venting PEG tube for oral liquid intake. The patient was started on prednisone 40mg daily to reduce pancreatic inflammation and discharged. He was readmitted five days later with biliary sepsis, and severe gastric outlet obstruction. He was medically managed with antibiotics and hydration and subsequently transferred to the surgical service where he underwent gastrojejunostomy. At three month follow up he reported feeling well, resolved nasuea, and weight gain. A rare condition in the US, groove pancreatitis is associated with male gender and alcohol abuse. Pathogenesis likely involves increased viscocity of pancreatic secretions from alcohol use in susceptible patients, leading to stasis. inflammation, and obstruction of the minor papilla. Case series describing this condition suggest that definitive treatment is pancreatoduodenectomy, however this case demonstrates that pancreatic sparing surgical approaches may be feasible.Figure 1Figure 2Figure 2

Brunner’s Gland Hyperplasia: A Rare Cause Of Gastric Outlet Obstruction and a Review of Treatment Strategies

Brunner’s gland hyperplasia, sometimes referred to as Brunneroma or Brunner’s hamartoma, is a benign lesion arising from the duodenum. We report an unusual case of Brunner’s gland hyperplasia leading to severe gastric outlet obstruction requiring surgical intervention. A literature review of previous Brunnner’s gland hyperplasia cases leading to gastric outlet obstruction and the treatment strategies pursued in such cases suggest that size and pedunculation were important characteristics in determining amenability for endoscopic treatment.

Adhesions due to peritoneal carcinomatosis caused by a renal carcinoma leading to mechanical gastric outlet obstruction: a case report

IntroductionGastric outlet obstruction is a clinical syndrome caused by a variety of mechanical obstructions. Peptic ulcer disease used to be responsible for most gastric outlet obstruction, but in the last 40 years the prevalence of malignant tumors has risen significantly. Adhesive disease is an infrequent and insidious cause of mechanical gastric outlet obstruction.Case presentationWe report the case of a 78-year-old Caucasian man who had a clinical history of a right nephrectomy for malignancy three years earlier and who was admitted for a severe gastric outlet obstruction (score of 1) confirmed both by an upper endoscopy and by a fluoroscopic view after contrast injection. A computed tomography scan and a laparotomy, with omental biopsies, showed a peritoneal carcinomatosis with the development of abdominal adhesions that prompted an abnormal gastric rotation around the perpendicular axis of his antrum with a dislocation in the empty space of his right kidney. Symptoms disappeared after surgical bypass through a gastrojejunostomy.ConclusionsOur patient experienced a very rare complication characterized by the development of adhesions due to peritoneal carcinomatosis caused by a renal carcinoma treated with nephrectomy. These adhesions prompted an abnormal dislocation of his antrum, as an internal hernia, in the empty space of his right kidney.

Surgical treatment of gastric outlet obstruction due to gastroduodenal tuberculosis

Gastroduodenal tuberculosis is a very rare location of abdominal tuberculosis; it is usually secondary to pulmonary tuberculosis and is often associated with HIV infection. We report a case of a 45-year-old woman with no HIV infection and no evidence of pulmonary tuberculosis, with a history of duodenal ulcer treated for several months, who presented at the emergency department with severe gastric outlet obstruction of recent onset caused by ulcerohypertrophic antroduodenal tuberculosis. The lesion was misdiagnosed at endoscopy as a malignancy, although histological examination of biopsies showed only chronic inflammation. The diagnosis was established at surgery, when a frozen section of an enlarged lymph node showed the presence of giant cells and caseating granuloma. The treatment was gastric resection with Roux-en-Y gastrojejunal anastomosis. In this patient the rare gastroduodenal location of tuberculosis occurred as primary disease in the absence of other organ involvement.

Severe Gastric Outlet Obstruction in a Child with Ectopic Pancreas

Alagille syndrome (AGS) is an autosomal dominant, multisystem disorder defined by developmental abnormalities of the liver, heart, eye and skeleton. Although visual problems are recognised, the severity of visual loss and its link with idiopathic intracranial hypertension (IIH) has not been reported.To review the incidence of visual loss and IIH in children with AGS managed at a National Paediatric Liver Unit between 1989 and 2004.Retrospective case note review of children who fulfilled criteria for diagnosis of AGS and had an ophthalmic examination by a paediatric ophthalmologist.Fifty-five children with AGS were evaluated. Of these, 41 children fulfilled diagnostic criteria and had a documented ophthalmic examination. Six children had undergone liver transplantation. Three children had a definite diagnosis of IIH, 2 of whom developed postliver transplant. All 3 were treated medically, but 1 child with IIH required lumboperitoneal shunting. All 3 children with definite IIH have normal vision after treatment. Another child with probable undiagnosed IIH has bilateral optic atrophy and is registered blind. Two children with AGS are registered partially sighted, one with rod cone dystrophy and the other with pigmentary retinopathy and right disc atrophy.Although visual abnormalities are well described in children with AGS, a minority of children have significant progressive visual loss. Idiopathic intracranial hypertension has been identified as a potentially treatable precipitating factor.We recommend annual fundoscopy in the follow-up of children with AGS to facilitate early detection and appropriate management of IIH to prevent visual loss.

Intrathoracic Gastrojejunostomy for Gastric Outlet Obstruction After Ivor Lewis Esophagogastrectomy

Gastric outlet obstruction after esophagogastrectomy with a drainage procedure is unusual, but when encountered, its management can be formidable. A Rous-en-Y intrathoracic gastrojejunostomy was created in a 74-year-old woman 2 years after Ivor Lewis esophagogastrectomy for benign disease to treat severe gastric outlet obstruction at the native pylorus.

Gastric outlet obstruction caused by prepyloric web in a case of Down's syndrome

The authors describe an infant with Down's syndrome who had a prepyloric web complicated by severe gastric outlet obstruction. The delay in diagnosis was responsible for malnutrition and the early postoperative complications of hypothermia and hypoglycemia. Awareness of the association of gastrointestinal abnormalities with Down's syndrome will enable appropriate evaluation for early diagnosis of this surgically correctable malformation.