Symptoms Of Gastric Outlet Obstruction Research Articles

Palliation of Gastric Outlet Obstruction in Case of Biliary Obstruction-A Retrospective, Multicenter Study: The B-GOOD Study.

EUS-guided gastroenterostomy (EUS-GE) is a novel and effective procedure for the management of malignant gastric outlet obstruction (GOO) with more durable results when compared to enteral stenting (ES). However, data comparing EUS-GE to ES in patients already treated with EUS-guided choledocoduodenostomy (EUS-CDS) for distal malignant biliary obstruction (DMBO) are lacking. We aimed to compare outcomes of EUS-GE and ES for the palliation of GOO in this specific population of patients. A multicenter, retrospective analysis of patients with DMBO treated by EUS-CDS and subsequent GOO treated by EUS-GE or ES from 2016 to 2021 was conducted. Primary outcomes were overall AEs rate and dysfunction of the EUS-CDS after GOO treatment. Secondary outcomes included clinical success, technical success, procedure duration, length of hospital stay and relapse of GOO symptoms. A total of 77 consecutive patients were included in the study: 25 patients underwent EUS-GE and 52 underwent ES. AEs rate and patency outcomes of the EUS-CDS after GOO treatment were comparable between the two groups (12.5% vs. 17.3%; p = 0.74). No recurrence of GOO symptoms was registered in the EUS-GE group while 11.5% of ES patients had symptoms recurrence, even if not statistically significant (p = 0.16), after a mean follow-up period of 63.5 days. EUS-GE and ES are both effective and safe for the palliation of GOO in patients already treated by EUS-CDS for DMBO with no difference in the biliary stent dysfunction rate and overall AEs. EUS-GE is associated with less recurrence of GOO symptoms.

Laparoscopic Gastrojejunostomy Versus Endoscopic Stenting as a Palliative Treatment for Gastric Outlet Obstruction.

Introduction: Gastric outlet obstruction (GOO) is a common complication in advanced stage upper gastrointestinal malignancies. The symptoms of severe nausea and protracted vomiting can lead to a decline in quality of life and cachexia. Symptoms of GOO can be effectively managed with either operative or nonoperative palliative interventions. In our article, we aim to compare laparoscopic gastrojejunostomy (GJ) to endoscopic stenting as palliative interventions for GOO. Methods: We retrospectively evaluated the charts of patients who underwent palliative procedure for gastric outlet obstruction. Group I included patients who underwent endoscopic stenting, and group II patients underwent Laparoscopic GJ. The groups' demographics (age, gender), length of procedure, length of stay, days to oral intake, overall survival, complications rate, and 30-day mortality rates were compared. Results: Overall, 38 patients were included in the study. Nineteen patients underwent endoscopic stenting and 19 underwent laparoscopic GJ. Comparing the groups, no significant differences were noted. Surgical time was significantly longer than the endoscopic procedures (83 minutes versus 25 minutes, P = .001). No significant differences were noted in days of oral intake initiation, overall survival and 30-day mortality rates. Five patients in the stenting group had complications (26.3%) versus none in the surgical group (P = .046). No postoperative complications were noted. Conclusion: Laparoscopic GJ is a safe and feasible treatment for GOO, demonstrating early resumption of oral intake. The relative short hospital stay, combined with an encouraging postoperative complications profile and low reintervention rate, should be kept in mind especially among patients with longer life expectancy.

Systematic review of long-term effectiveness of endoscopic gastrojejunostomy in patients presenting with gastric outlet obstruction from periampullary malignancies.

Recently, endoscopic ultrasound-guided (EUS) gastrojejunostomy (GJ) has emerged as an alternative option to surgical palliation and endoscopic duodenal stenting for malignant gastric outlet obstruction (GOO). Although early success rates are commonly reported with the technique, there is a paucity of data regarding the long-term efficacy of this approach. In this study, we investigated long-term outcomes in patients that underwent EUS-guided GJ for palliation of periampullary malignancies. From a total of 192 studies that were reviewed, 6 studies with a follow-up time frame of a minimum of 5months were analyzed, totaling 238 patients. Outcome variables included technical success rate, clinical success rate, adverse events, symptom recurrence, and re-intervention rates. The cohort of 238 patients had a technical success rate of 93.7% and a clinical success rate of 92.9%. A total of 25 patients (10.5%) experienced adverse events associated with EUS-GJ. A total of 14 patients (5.9%) experienced recurrence of GOO symptoms within 5months. A total of 14 patients (5.9%) underwent re-intervention with the first 5months. This systematic review shows that data are scarce regarding long-term effectiveness of EUS-guided GJ. Even though early success rates have been reported, further studies are needed to focus on long-term efficacy of this approach. Until such studies become available, surgical palliation should continue to be the treatment of choice for patients with malignant GOO with a prolonged life expectancy.

Gall bladder carcinoma masquerading as bouveret syndrome as the initial presentation

Introduction: Gallbladder Cancer (GBC) is a rare yet serious condition that often presents diagnostic challenges due to its nonspecific symptoms, which are similar to other biliary disorders. Advanced stages of GBC can lead to rare complications like Cholecystoenteric Fistulas (CEF) or Bouveret Syndrome, where a gallstone migrates and causes Gastric Outlet Obstruction (GOO). We present a case of a woman who presented with symptoms of GOO but later led to the unexpected discovery of GBC.

“Through-stent enterography”: first experience with a novel technique intended to improve safety in endosonography-guided gastroenterostomy

Background and AimsEndosonographic-guided gastroenterostomy (EUS-GE) is a novel technique to manage symptoms of gastric outlet obstruction. Major challenges are the high mobility of intestinal loops and the transient loss of endosonographic visibility during the puncture. This can lead to stent-misdeployment, which can be associated with potentially fatal adverse events. By injecting contrast medium through the guidewire-channel of the lumen apposing metal stent (LAMS) application system under fluoroscopic guidance, a positive enterogram can confirm the position of the stent inside the intestinal lumen before its deployment. The aim of this study was to describe this novel technique and to assess its feasibility. MethodsThe data of 39 consecutive patients undergoing EUS-GE with “through-stent-enterography” between July 2020 and March 2022 were retrospectively collected and analyzed. Primary endpoint was to assess the technical success. Secondary endpoints were to assess adverse events, rate of reinterventions and clinical success. ResultsTechnical success was achieved in all cases (n=39). In two cases a second puncture was required to place the stent successfully. In one case, misdeployment could be avoided after a negative enterogram. In the other case, misdeployment occurred despite a positive enterogram a reintervention was needed. Clinical success was achieved in 92.3% (n=36). No major adverse events or mortalities were encountered. Conclusions“Through-stent-enterography” after the puncture to confirm the correct position of the stent in the small bowel is a novel and simple technique, which can potentially reduce the risk of misdepolyment of the stent.

HPB P44 Case Report: Retrograde transhepatic duodenal and antegrade common bile duct stenting in malignant duodenal stricture

Abstract Background Duodenal adenocarcinoma is a rare and aggressive malignancy, that unfortunately often present late meaning diagnosis can be delayed and commonly have no curative surgical options available. Patients with non resectable disease typically have a life expectancy from 2-8 months. In these palliative patients, antegrade stenting of the malignant stricture can effectively relieve symptoms of gastric outlet obstruction. We present retrograde transhepatic duodenal stenting in a patient where antegrade stenting had failed. Methods A 68 year old woman presented with abdominal pain, vomiting and weight loss, was found to have gastric outlet obstruction on imaging and subsequently diagnosed with D1 duodenal adenocarcinoma. Multiple attempts at dilatation had failed and one failed attempt at antegrade stenting to relieve their symptoms. A novel technique of retrograde transhepatic stenting of duodenal stricture and antegrade common bile duct (CBD) was then successfully performed with no post procedure complications. Not only did this help alleviate the patients’ symptoms but allowed subsequent antegrade passage of a D3 stent from a subsequent obstruction. Results Retrograde transhepatic duodenal stenting was carried out under general anesthesia with a right percutaneous puncture to pass a guide wire into the intrahepatic ducts, then the CBD narrowing followed by the duodenal stricture. The duodenal stricture was then stented followed by the CBD stricture and a drain left in the common hepatic duct. Conclusions Although duodenal adenocarcinoma is rare, it should be considered in all patients with suspected gastric outlet obstruction. A multidisciplinary team approach is necessary in managing patients with duodenal strictures. Retrograde transhepatic duodenal should be considered in palliative patients when antegrade stenting fails.

Pyloric resection with Billroth 1 gastroduodenostomy versus bypass loop gastrojejunostomy for the management of post corrosive long segment pyloric stricture: a retrospective study

Background Accidental or suicidal ingestion of corrosive substances remains a major public health problem. Worldwide, the causative materials for corrosive injury are not the same. Surgery remains the mainstay of treatment with available different surgical options. The selected surgical technique should offer symptomatic treatment with less postoperative morbidity. Patients and methods Retrospective evaluation of 62 patients with long segment pyloric stricture postacid ingestion presenting with gastric outlet obstruction in the period between May 2017 and June 2022. They were divided into two groups, (group A (n=24), managed by Billroth 1 gastroduodenostomy; group B (n=38), managed by bypass loop gastrojejunostomy). Results In group A, the age ranged 3–59 years with a mean age of 25.7±22.62 years, while in group B, the age ranged 2.5–63 years with a mean age of 19.72±15.71 years. The type of ingested corrosive was hydrochloric acid in 60 patients (96.77%), while in two (3.23%) patients the exact acid was unknown. The interval between initial acid ingestion and symptoms of gastric outlet obstruction was 3 weeks to 18 months. In group A, the mean operative time was 64.125±7.023 min, while in group B, it was 61.763±7.837 min. Postoperative vomiting occurred in three (12.5%) patients in group A and in six (15.78%) patients in group B. In group A, the mean hospital stay was 5.5±0.932 days, while in group B, it was 4.921±1.806 days. Conclusion Billroth 1 gastroduodenostomy has the superiority of prophylaxis against long-term low risk of future malignancy. Bypass loop gastrojejunostomy is a safer alternative to Billroth 1 gastroduodenostomy, especially in the presence of severe perigastric adhesions and malnutrition. Future studies should include a large sample of patients with long periods of follow-up.

Endoscopic ultrasonography-guided gastroenterostomy versus surgical gastrojejunostomy for palliation of malignant gastric outlet obstruction (ENDURO): study protocol for a randomized controlled trial

BackgroundMalignant gastric outlet obstruction (GOO) is a debilitating condition that frequently occurs in patients with malignancies of the distal stomach and (peri)ampullary region. The standard palliative treatment for patients with a reasonable life expectancy and adequate performance status is a laparoscopic surgical gastrojejunostomy (SGJ). Recently, endoscopic ultrasound-guided gastroenterostomy (EUS-GE) emerged as a promising alternative to the surgical approach. The present study aims to compare these treatment modalities in terms of efficacy, safety, and costs.MethodsThe ENDURO-study is a multicentre, open-label, parallel-group randomized controlled trial. In total, ninety-six patients with gastric outlet obstruction caused by an irresectable or metastasized malignancy will be 1:1 randomized to either SGJ or EUS-GE. The primary endpoint is time to tolerate at least soft solids. The co-primary endpoint is the proportion of patients with persisting or recurring symptoms of gastric outlet obstruction for which a reintervention is required. Secondary endpoints are technical and clinical success, quality of life, gastroenterostomy dysfunction, reinterventions, time to reintervention, adverse events, quality of life, time to start chemotherapy, length of hospital stay, readmissions, weight, survival, and costs.DiscussionThe ENDURO-study assesses whether EUS-GE, as compared to SGJ, results in a faster resumption of solid oral intake and is non-inferior regarding reinterventions for persistent or recurrent obstructive symptoms in patients with malignant GOO. This trial aims to guide future treatment strategies and to improve quality of life in a palliative setting.Trial registrationInternational Clinical Trials Registry Platform (ICTRP): NL9592. Registered on 07 July 2021.

Extensive Pneumobilia Secondary to a Benign Cause

Pneumobilia is presence of air within biliary tree, there are several causes which can be iatrogenic or non-iatrogenic. We report a case of a 15- year-old boy presenting with typical symptoms of gastric outlet obstruction with finding of extensive pneumobilia on imaging, he underwent surgical exploration to relieve high grade obstruction and rule out ischemia. Spontaneous pneumobilia is rare but often present in a benign course. Conservative management is usually suitable after ruling out life threating conditions.

Early Gastric Outlet Obstruction Caused by the Free End of Barbed Sutures Following Laparoscopic Gastric Resection with Roux-en-Y Reconstruction.

BACKGROUND Recent developments in surgical suture material include the use of sutures with unidirectional barbs that facilitate laparoscopic suturing thanks to self-anchoring and tension-keeping properties. Complications deriving from the use of barbed sutures have been previously reported. In this report we present the case of a patient with gastric outlet obstruction by the free end of a V-Loc™ barbed suture (Medtronic, Dublin, Ireland) following Roux-en-Y gastric resection. CASE REPORT In February 2023, a 77-year-old man who underwent laparoscopic subtotal gastrectomy for cancer followed by Roux-en-Y reconstruction developed symptoms of gastric outlet obstruction a few days after discharge. The patient was readmitted to the hospital due to vomiting 4 days after being discharged after an uneventful postoperative course. Imaging confirmed the presence of an occlusion at the level of the jejunojejunal anastomosis, with a noticeable change in caliber. During laparoscopy, a loop of bowel was entrapped around the tail of the barbed suture used to close the common enterotomy of jejunojejunal anastomosis. Following laparoscopic division of the anchoring suture, the bowel regained its normal caliber. CONCLUSIONS Although complications from the use of unidirectional barbed surgical sutures are rare, this report highlights bowel obstruction as a recognized postoperative complication. The preferred treatment is laparoscopic division of the suture's tail. To prevent complications related to barbed sutures, it is essential to ensure that all barbs of the suture are properly unfolded.

Annular pancreas in elderly male: a case report

Annular pancreas (AP) is a rare congenital abnormality in which the ventral portion of the pancreas fails to rotate with the duodenum during embryological development, thus causing the ventral portion to remain partially or fully enveloped around the duodenum. The actual incidence of AP is unknown, as many cases are asymptomatic and undiagnosed. Adults with AP may present with a variety of symptoms suggestive of gastric outlet obstruction, or may present with gastrointestinal bleeding, pancreatitis, or biliary obstruction. Surgery continues to remain the diagnostic “gold standard” for AP, but imaging techniques such as CT, MRCP (Magnetic resonance cholangiopancreatography), ERCP (Endoscopic retrograde cholangiopancreatography) and EUS (Endoscopic ultrasound) can now be used to make the diagnosis. We report the case of a 65-year-old gentleman who presents with symptoms of gastric outlet obstruction who was diagnosed with AP by CECT (Contrast enhanced computed tomography) and MRCP.

PERIOPERATIVE MANAGEMENT OF A CARCINOMA OF STOMACH CASE PRESENTING WITH GASTRIC OUTLET SYNDROME AND RECENT MYOCARDIAL INFARCTION-ASSESSMENT, RISK STRATIFICATION, OPTIMISATION AND ANAESTHETIC MANAGEMENT

The patients with perioperative myocardial infarction (PMI) have increased risk of myocardial ischemia, myocardial infarction (MI), conduction disturbances, cardiac failure, morbidity and mortality. The risks of these events are even higher in patients with recent MI. Here, we report 53year old female diagnosed with carcinoma of stomach presenting with gastric outlet obstruction symptoms. The surgery planned was distal gastrectemy, lymhadenectomy and feeding jejunostomy. During preoperative assessment detailed history, physical examination was carried out. She gave a history of chest discomfort and breathlessness along with presenting complaints. Her ECG showed ST/T wave changes. Cardiologist opinion was obtained. The Troponin I was positive. A diagnosis of NSTMI was made. The Echocardiogram revealed Ejection Fraction of 45% and regional wall motion abnormality. She was started on blood thinners, unfractionated heparin, anti-angina drugs, anti diuretics, beta blockers and statins .The cardiologist gave moderate to high risk for surgery. The deranged coagulation parameters and electrolyte imbalance were corrected. The blood thinners were stopped ve days before surgery. Anaesthesiologist reviewed the patient and gave tness for surgery under ASA classication IV. A high risk written informed consent, repeat serum electrolytes, coagulation prole and 12 lead ECG on day of surgery were asked. Heparin was stopped 4-6 hours before surgery. Patient underwent a high risk procedure (calculated RCRI of ≥ 2) with an elevated risk of adverse perioperative cardiac outcome (MACE-moderate risk score). The perioperative management of this patient is reported

Nasojejunal tube-assisted endoscopic ultrasound-guided gastrojejunostomy for the management of gastric outlet obstruction is safe and effective.

Endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) is a therapeutic option for patients with gastric outlet obstruction (GOO), which provides long-term luminal patency without the risk of tumor ingrowth and/or overgrowth and avoids surgical morbidity. The goal of this study was to assess technical success, clinical success, and adverse events associated with a nasojejunal tube-assisted EUS- GJ technique. This was a retrospective study conducted at a single tertiary care center. The nasojejunal tube (14F) was used to perform the EUS-GJ (device-assisted method). During the study period, consecutive GOO patients who underwent EUS-GJ between August 2018 and December 2021 were included. Technical success was defined as adequate positioning and deployment of the stent. The patient's ability to tolerate a normal oral diet without vomiting was defined as clinical success. Thirty patients underwent EUS-GJ during this study period. Twenty-six patients had malignant GOO, while four had a benign obstruction. EUS-GJ was successfully performed in 29 patients, and technical success was 96.67% (29/30). Nasojejunal tube-assisted EUS-GJ technique was used in all patients. Clinical success was achieved in all patients who had technical success (29/29, 100%). The adverse events rate was 6.6%. During the procedure, the median procedure time was 25 min (interquartile range 15-42.5), and the average hospitalization was 4.4 days. Normal meals were tolerated by all patients. After 210 days of median follow-up (range 5-880 days), no recurrence of symptoms was observed. The nasojejunal tube-assisted EUS-GJ is a safe and effective technique to treat GOO symptoms.

Laparoscopic management of rare smoked dry pork bezoar in the stomach.

Medical literature recognise only 4 types of bezoar - phytobezoar, trichobezoar, lactobezoar and pharmacobezoar. Here, we discuss a new unique type of bezoar composed of undigested dry pork. A 58-year-old male patient from Nagaland, India, presented with intermittent symptoms of gastric outlet obstruction and pain abdomen. On clinical examination, he was found to have an epigastric lump. Upper gastrointestinal endoscopy showed an undigested ball of swallowed meat at the pylorus and later at the fundus on repeat endoscopy just before the surgical intervention. Endoscopic mechanical fragmentation was tried, but owing to the large size and hard sticky consistency of the bezoar, fragmentation was not feasible. Due to persistent pain abdomen and clinical gastric outlet obstruction, a decision for operative intervention was taken. He finally underwent laparoscopic anterior gastrotomy and evacuation of the bezoar. The post-operative course was uneventful, and the patient went home symptom free on the 5th post-operative day.

Temporary EUS-guided gastrojejunostomy for gastric outlet obstruction caused by severe acute pancreatitis (with videos).

Gastric outlet obstruction (GOO) due to duodenal stricture after acute pancreatitis occurs in 5.7%, with two peaks, during the early phase or after 4 weeks.[1] Patients may require enteral and parenteral nutrition or surgical therapy when conservative treatment fails.[1] EUS-guided gastrojejunostomy (EUS-GJ) has emerged as an alternative for malignant GOO and a bridge therapy for benign causes,[23] including after acute pancreatitis as an unusual indication.[24] We present the case of a 73-year-old male with a history of severe acute pancreatitis 8 weeks earlier, with percutaneous drainage of 70 mm × 50 mm pancreatic fluid collection. He complained of oral intolerance. A computed tomography scan revealed a large gastric retention with two small pancreatic fluid collections [Figure 1]. Gastroscopy confirmed impassable duodenal inflammatory stenosis leading to severe gastric outlet gastrointestinal edema (GOGE) [Figure 2]. A nasojejunal tube was inserted downstream the jejunum but failed to achieve enteral nutrition so parenteral nutrition was initiated. He was referred to our unit to address GOO. A 0.035 mm guidewire was inserted through the duodenal stenosis downstream the jejunum using a gastroscope. After exchange for linear echoendoscope and distension of jejunum with water and contrast, the gastric wall was punctured and free-hand deployment of a cautery-enhanced 15 mm × 10 mm lumen-apposing metal stent (LAMS) was performed [Video 1]. However, an unplanned procedure event occurred as free perforation due to distal flange misdeployment outside the jejunum [Figure 3]. The LAMS was removed using rat-tooth forceps [Figure 4] and the procedure was repeated without finding the previous puncture site. Hence, a 15 mm × 10 mm LAMS was inserted allowing the EUS-GJ [Video 2]. Oral feeding was tolerated the next day, and the patient was discharged 6 days after uneventfully. A barium-meal radiography performed 54 days after confirmed adequate gastric emptying [Figure 5]. The LAMS was removed 3 months later and the patient underwent cholecystectomy 9 months later. He remained with any GOO symptoms throughout a 12-month follow-up.Figure 1: A computed tomography scan showing a large gastric distension together with a small fluid collection in the pancreatic headFigure 2: Endoscopic view of impassable duodenal inflammatory stenosis due to severe acute pancreatitisFigure 3: Endoscopic view of the misdeployed distal lumen-apposing metal stent flange after the first EUS-guided gastrojejunostomy attempt. Notice that the peritoneum can be observed across the lumen-apposing stentFigure 4: Radiological view of lumen-apposing metal stent removal using a rat-tooth forceps after misdeployment of distal flangeFigure 5: Radiological view of barium meal. An adequate gastric emptying is observed as the first and second image are compared. (a) The arrow indicates the pylorus. Notice that only a small amount of contrast pass to the duodenum with a second and third portion stenosis. The asterisk refers to the EUS-guided gastro-jejunal anastomosis. (b) Also, the lumen-apposing metal stent can be observed in situ in the right imageThis case suggests that temporary EUS-GJ is feasible and safe in some patients with GOGE after acute pancreatitis[3] as an alternative to indefinite LAMS placement.[5] Distal flange misdeployement noted intraprocedurally was successfully managed by immediate LAMS removal and repeat LAMS insertion across a new puncture tract. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest Dr. Manuel Perez-Miranda is a consultant for Boston Scientific, Olympus, Medtronic and M.I.Tech. He is also an Editorial Board Member of the journal. This article was subject to the journal’s standard procedures, with peer review handled independently of this editor and his research group.

Use of an endoscopic attachment device for duodenal stricture dilation

A 75-year-old man with stage IV non–small–cell lung cancer was incidentally found to have a duodenal stricture during EUS to evaluate biliary dilation. The stricture was unable to be traversed with the linear echoendoscope or an adult upper endoscope despite through-the-scope balloon dilation from 8 to 12 mm. The results of analysis of stricture biopsy specimens were negative for malignancy and of gastric biopsy specimens were negative for Helicobacter pylori infection. Four months later, the patient experienced symptoms of gastric outlet obstruction.

S355 Presidential Poster Award Recurrent Obstruction After Surgical GJ in a Rare Case of Gastric Outlet Obstruction: EUS to the Rescue

Introduction: Eosinophilic enteritis is a rare cause of gastric outlet obstruction and if not recognized early can be very difficult to manage. Endoscopic ultrasound (EUS) guided gastrojejunostomy (GJ) is most often used for malignant disorders. However, it can act as a very effective temporary tool in benign disorders for effective medical therapy to take its course. Case Description/Methods: A 49-year-old man presented to us with features of recurrent vomiting and pain abdomen for 5 months. He had alcohol-related chronic calcific pancreatitis. Three years prior to current presentation he had features of gastric outlet obstruction for which he underwent oesophagogastroduodenoscopy (EGD) revealing a circumferential ulcer in antropyloric region with swelling. He underwent truncal vagotomy with antecolic gastrojejunostomy. Biopsy from the specimen had revealed eosinophilic gastroenteritis (EE). He again had some symptoms of obstruction 2 months after surgery which responded to proton pump inhibitors. He remained apparently well with regular follow up for chronic pancreatitis. Now he was symptomatic with progressive symptoms of gastric outlet obstruction since last 4 months. On endoscopy he was found to have both afferent and efferent loop strictures. He was also having a few geographic ulcers and psuedopolyps near stricture mouth. He underwent balloon dilatation twice upto 13.5 mm but symtoms did not improve. Repeat biopsies were taken from the ulcer and stricture site revealed EE with eosinophilic abscesses. Barium meal follow-through and Contrast enhanced CT was done for evaluation of stricture. A nasoduodenal (ND) tube of 10 french was negotiated over guidewire through the stricture using a cannula. It was used to continue enteral feeding. Surgical consultation was taken and poor surgical outcome was predicted in view of both loop involvement. He was started on oral budesonide and planned for an endoscopic bypass procedure. The ND tube was used to distend the normal jejunal loops beyond stricture and endoscopic ultrasound was used for gastrojejunostomy using a lumen apposing metal stent. Discussion: EUS-GJ is a viable option for gastric outlet obstruction even in benign cases for bridging for further surgical or medical therapy. Post-surgery complications may be difficult to manage and EUS-GJ appears more lucrative for the short time period. It requires a carefully selected patient with preset managment plan and a learning curve for successful implementation. Watch the video at https://tinyurl.com/ACGAbstractS355

S3552 Herpes Gastritis: A Rare Cause of Gastric Outlet Obstruction

Introduction: Gastrointestinal tract involvement from herpes simplex virus is commonly associated with esophagitis. However, herpes simplex infection of the stomach is very rare with only a handful of cases being reported in immunocompromised patients. We present a case of herpes gastritis causing gastric outlet obstruction in an otherwise healthy, immunocompetent individual. Case Description/Methods: A 37-year-old male with a recent past medical history of COVID-19 infection, presented to the hospital with intractable nausea, vomiting, bloating, and early satiety for two days. Upon evaluation, CBC and CMP were remarkable for a WBC of 12.5 k/mm3 and ALT and AST of 124 U/L and 129 U/L, respectively. Lipase was 373 U/L. A CT abdomen/pelvis w/contrast showed circumferential wall thickening with edematous changes in the antrum consistent with localized inflammatory response. There was suspicion for gastric lymphoma and patient was admitted for further workup. An EGD was performed which showed exudative esophagitis and antral wall edema with luminal narrowing of gastric antrum. Endoscopic ultrasound (EUS) showed a 2.5 × 3 cm antral wall lesion worrisome for linitis plastica. Esophageal biopsies showed focal cytologic changes consistent with herpes esophagitis. The FNA of the gastric antral wall showed multinucleation of the basal cell layer with classic ground glass nuclei, consistent with herpes infection. No dysplasia or malignancy was seen. Both HSV1 and HSV2 IgG were elevated. HSV IgM was normal. A HSV PCR was ordered but never resulted. Patient was started on Valacyclovir 1 g PO BID for 10 days. He underwent a follow-up EGD 3 months later which showed complete resolution of the gastric antral changes (Figure). Discussion: Herpes gastritis is extremely rare. Literature review has revealed only 3 case reports of herpes gastritis; and all involved immunocompromised patients. To the best of our knowledge, this is the first case of herpes gastritis in an immunocompetent patient. Our patient presented with symptoms of gastric outlet obstruction which was caused by local inflammation from herpes simplex. It is unclear if having a COVID 19 infection altered patient’s immunity and lead to herpes gastritis. This may need further investigation. No established guideline exists for treatment duration. Our patient received 10-day course of Valacyclovir, and his symptoms improved. Furthermore, patient had complete resolution of the herpes infection on follow-up EGD, indicating adequate treatment response.Figure 1.: Panel A: EGD showing circumferential antral erosive gastropathy Panel B: Histology showing multinucleated cells with classic ground glass nuclei Panel C: Post-treatment EGD showing complete resolution of gastric antral erosive gastropathy.

S3646 Double Pylorus: A Case of Chronic Peptic Ulcer Disease Leading to Formation of a Gastroduodenal Fistula

Introduction: Double pylorus is a rare condition, either congenital or acquired, that results in a gastroduodenal fistula, forming an additional connection between the antrum of the stomach and the duodenal bulb. Case Description/Methods: A 75-year-old female with past medical history of cervical cancer (in remission), hypertension, tobacco use, chronic constipation, and peptic ulcer disease (PUD) presented to the emergency department (ED) with diffuse abdominal pain and blood in her stool. Patient reported intermittent black stools with occasional rectal bleeding. She was using non-steroidal anti-inflammatory drugs (NSAIDs) for headaches. In the ED, patient was hypertensive to 170/75, but other vital signs were stable. Her labs showed a hemoglobin of 12.6 g/dL (normal 12-16 g/dL) without evidence of coagulopathy. Imaging of the abdomen and pelvis did not show any acute findings. Esophagogastroduodenoscopy (EGD) showed two openings to the duodenal bulb, a functional pylorus inferiorly and an accessory channel superiorly (Figure). The two lumens of the duodenum appeared normal without evidence of acute ulceration. Colonoscopy showed a non-bleeding arteriovenous malformation in the proximal ascending colon and internal hemorrhoids, which were likely the cause of her bleeding. Discussion: Acquired double pylorus (ADP) is usually an incidental finding with a prevalence of approximately 0.001-0.4%, affecting males and females in a 2:1 ratio, respectively. Most cases of ADP are secondary to PUD, often an ulcer in the antrum of the stomach or duodenum penetrating directly into the duodenal bulb. Patients can be asymptomatic with ADP, but some may experience vomiting, epigastric pain, or dyspepsia. Melena may also be present with active ulceration. Initial diagnostic approach to ADP should include EGD, assessing NSAID or corticosteroid use, and H. pylori testing. Treatment involves proton-pump inhibitor administration or other mucosal protective agents, avoidance of NSAIDs and steroids, and eradication of H. pylori. Endoscopic division of the tissue bridge with a sphincterome should be considered if severe symptoms of gastric outlet obstruction persist. In severe cases where perforation, refractory bleeding and/or obstruction occurs, a surgical consultation should be pursued. The accessory pathway will typically remain patent for life, but rarely, the channel will close completely or merge to form a single connection to the duodenal bulb.Figure 1.: Double pylorus on EGD. The accessory channel is observed superiorly, revealing a gastroduodenal fistula.

S1127 EUS-Guided Gastroenterostomy vs. Enteral Stenting for Palliation of Benign and Malignant Gastric Outlet Obstruction

Introduction: Gastric outlet obstruction (GOO) can occur due to benign or malignant etiologies. Enteral stenting (ES) using self-expanding metal stents has been around for decades and remains a widely used technique in the palliation of GOO. With the advancement of interventional endoscopic ultrasound (EUS) techniques and the advent of lumen-apposing metal stents, EUS-guided gastroenterostomy (EUS-GE) has been adopted as a novel technique for treating symptomatic GOO in benign and malignant etiologies. We conducted a retrospective study to evaluate the outcomes of technical and clinical success and safety in patients with GOO undergoing EUS-GE versus ES. Methods: Patients who underwent EUS-GE or ES for GOO between September 2015 and December 2021 were included in the study. Primary outcomes included technical success defined as successful deployment of the stent and clinical success defined as relief of symptoms and tolerance of oral intake. Secondary outcomes were timing of unplanned re-intervention based on etiology and serious adverse events. Results: A total of 107 procedures among 103 patients met inclusion criteria, 63 (58.9%) underwent ES, and 44 (41.2%) underwent EUS-GE (Table). A higher percentage of malignant etiologies were in the enteral stenting group versus the EUS-GE group (88.9% vs 59.1%, p = 0.0003). Technical success among EUS-GE and ES patients was 100%. Clinical success was achieved by 90.5% of EUS-GE patients compared to 97.7% of ES patients, which was similar in both groups (p = 0.24). There was no significant difference in serious adverse events between EUS-GE and ES patients (3.2% vs 6.8%, p = 0.4). Thirteen ES patients required unplanned re-intervention compared to four EUS-GE patients (20.6% vs 9.1%) but the cumulative incidence functions were not significantly different (p = 0.11). The median time for reintervention in EUS-GE patients was 154 (50,425) days and 94 (43,112) days for ES patients. EUS-GE was associated with a significantly reduced need for unplanned reintervention in an adjusted model for etiology (benign or malignant) (HR: 0.264; 95% CI: 0.086, 0.813; p = 0.02). Conclusion: Technical success, clinical success, and rate of serious adverse events did not significantly differ among EUS-GE and ES patients. However, the rate of unplanned reintervention was significantly lower in the EUS-GE group when adjusted for the etiology of GOO, thus EUS-GE can be considered as a first line therapy for these patients. Table 1. - Summary of Patient Characteristics and Clinical Outcomes Procedures N = 107 Patients N = 103 Enteral Stenting N = 63 EUS-GE N = 44 P-value Age 0.19 Mean (SD) 69.5 (13.2) 65.9 (14.8) Range 38, 95 34, 91 Sex, n (%) 0.64 Male 33 (52.4%) 21 (47.7%) Female 30 (47.6%) 23 (52.3%) Etiology, n (%) 0.0003 Benign 7 (11.1%) 18 (40.9%) Malignant 56 (88.9%) 26 (59.1%) Technical success, n (%) N/A Yes 63 (100.0%) 44 (100.0%) Clinical success, n (%) 0.24 Yes 57 (90.5%) 42 (97.7%) Missing/Unknown 0 1 Serious Adverse event, n (%) 0.4 Yes 2 (3.2%) 3 (6.8%) Unplanned reintervention, n (%) 0.11 Yes 13 (20.6%) 4 (9.1%)