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What is Gastric outlet obstruction?
Gastric outlet obstruction (GOO) is a clinical syndrome characterized by epigastric abdominal pain and postprandial vomiting due to mechanical obstruction.
Describe pathophysiology of GOO. [TU 2072/6]
- Patients present with intermittent symptoms that progress until obstruction is complete.
- Vomiting is the cardinal symptom.
- Initially, patients may demonstrate better tolerance to liquids than solid food.
- In a later stage, patients may develop significant weight loss due to poor caloric intake.
- Malnutrition is a late sign, but it may be very profound in patients with concomitant malignancy.
- In the acute or chronic phase of obstruction, continuous vomiting may lead to dehydration and electrolyte abnormalities.
- When obstruction persists, patients may develop significant and progressive gastric dilatation. The stomach eventually loses its contractility.
- Undigested food accumulates and may represent a constant risk for aspiration pneumonia.
In a peptic ulcer it is believed to be a result of edema and scarring of the ulcer, followed by healing and fibrosis, which leads to obstruction of the gastroduodenal junction (usually an ulcer in the first part of the duodenum)
Etiology of GOO?
Describe treatment of GOO according to etiology. TU 2072/6]
- Malignancy – Gastric cancer, Pancreatic cancer with extension to duodenum, Gastric lymphoma, large neoplasm of proximal duodenum and ampulla, Local extension of advanced gall bladder carcinoma,
- Peptic ulcer disease
- Chronic pancreatitis with involvement of duodenum
- Pseudocyst of pancreas
- Secondary to caustic ingestion
- Large gastric polyps
- Gastric tuberculosis
- Gastric bezoars
- Gastric volvulus
- Annular pancreas
In children - congenital hypertrophic pyloric stenosis
Features of GOO?
- Projectile vomiting
- Food taken 1-2 days before in vomitus
- Non bilious
- Epigastric fullness
- Pain relieves after vomiting
- Evening time vomiting
- Associated with left to right visible movements in abdomen
- Sour taste in mouth
- Physical examination – Succession splash
Taste of vomitus
- Bitter : Bilious
- Sour : Non Bilious
Laboratory finding in GOO?
- Hypokalemia or a hypochloremic metabolic alkalosis
- CA 19-9 and/or CEA are often elevated in pancreatic cancer
Metabolic abnormality in GOO
- Hypochloremic, Hypokalemic, metabolic alkalosis with paradoxical aciduria
- Paradoxical aciduria due to exchange of Na for H+
- Dehydration : decrease Na leads to increase aldosterone →increase Na and H2O absorption for H+ and K+ loss - Paradoxical aciduria
Investigations in GOO?
- Plain films
- Contrast studies - Water-soluble contrast or barium studies can be useful if a partial obstruction is expected. Failure of any contrast to pass into the small bowel suggests complete GOO.
- CT scan
Saline loading test
- load 750ml of saline in Stomach, wait for 30 mins
- Aspirate NG : if >400ml: GOO, if 300-400ml : Probably GOO, If <200ml : No GOO
Role of barium follow through in GOO?
If you cannot negotiate beyond the growth in endoscopy, you can find the extent of lesion in Barium follow through
Treatment of pyloric stenosis due to chronic duodenal ulcer?
- Lifetime acid suppression also have good long-term results with endoscopic dilation.
- Patients with refractory obstruction are best managed with primary antrectomy and reconstruction along with vagotomy.