GASTRIC OUTLET OBSTRUCTION

GASTRIC OUTLET OBSTRUCTION (GOO)

..IS A CLINICAL SYNDROME CHARACTERIZED BY EPIGASTRIC
ABDOMINAL PAIN AND POSTPRANDIAL VOMITING DUE TO
MECHANICAL OBSTRUCTION.

EPIDEMIOLOGY
-The incidence of gastric outlet obstruction is not known precisely.
-It is likely to have declined in recent years because of the decline in peptic ulcer disease,
which has historically been an important cause of GOO.
-In 1990, as many as 2000 operations for GOO were performed annually in the
United States.
-Updated estimates are not available, but the need for surgery is thought to have declined
because of advancements in endoscopic methods to treat GOO
(such as dilation and stenting).

Etiology
-The term gastric outlet obstruction is a misnomer since many cases are not due to
isolated gastric pathology but rather involve duodenal or extraluminal disease.
-The predominant causes have changed substantively with the identification of
Helicobacter pylori and the use of proton pump inhibitors. Until the late 1970s,
benign disease was responsible for the majority of cases of GOO in adults, while
malignancy accounted for only 10 to 39 percent of cases
-By contrast, in recent decades, 50 to 80 percent cases have been attributable to
malignancy

Etiology
1.Malignancy

1.1 Pancreatic adenocarcinoma with extension to the duodenum or stomach

1.2 Distal gastric cancer
1.3 Other infrequent causes of malignant GOO include:
Gastric lymphoma
Large neoplasms of the proximal duodenum and ampulla
Local extension of advanced gallbladder carcinoma or
cholangiocarcinoma
Metastatic or primary malignancy in the duodenum
Gastric carcinoid

Etiology
2.Other (Benign cause)

2.1 Peptic ulcer disease Both acute phase and chronic phase
2.2 Crohns disease
2.3 Pancreatitis
2.4 Caustic injury
2.5 Large gastric polyps
2.6 Gastric tuberculosis
2.7 Gastric bezoars
2.8 Percutaneous endoscopic gastrostomy (PEG) tube migration
2.9 Gastric volvulus
2.10 Post-surgical complications

Clinical Manifestation
The most common clinical features of GOO include:
Nausea and/or vomiting
Epigastric pain
Early satiety
Abdominal distension
Weight loss
In one series of 49 patients, the most common clinical features were
epigastric pain (94 percent), vomiting (92 percent), and weight loss (63
percent.

Diagnosis

The diagnosis may be suspected based upon presenting clinical

features and physical examination described above and is confirmed
by radiologic evaluation and/or endoscopy.
Radiologic testing should precede endoscopic evaluation.

Laboratory finding
Laboratory tests may be normal or nonspecifically abnormal. Patients with
recurrent vomiting may have electrolyte abnormalities, including
hypokalemia or a hypochloremic metabolic alkalosis
Anemia may be seen in patients with peptic ulcer disease, primary
or metastatic malignant disease, or large gastric polyps.
Serum tumor markers, such as CA 19-9 and/or CEA, are often
elevated in patients with pancreatic cancer but are not specific for
pancreatic cancer.

Radiologic tests
Plain films enlarged gastric bubble and a dilated proximal duodenum. A paucity of
air in the small bowel is often noted.
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 An abdominal CT scan may reveal gastric distention along with retained
material within the gastric lumen and an associated air-fluid level .
CT will often also suggest the specific cause of GOO.

NORMAL ABDOMEN
ANATOMICAL STRUCTURE
GAS PATTERN
EXTRALUMINAL AIR
SOFTTISSUE MASS
CALCIFICATION

Abdominal radiograph
Dilatation of stomach
Mottling appearance of foods in the dilated stomach
Decreased distal bowel gas
Displaced transverse colon inferiorly

CT of the abdomen in a patient with gastric outlet obstruction

Abdominal CT in a patient with gastric outlet obstruction due to

peptic ulcer disease showing a distended and fluid filled stomach.

Radiologic tests
Endoscopy Upper endoscopy is often needed to establish the diagnosis and identify
a specific cause .It can also permit therapeutic procedures. Nasogastric tube suction is
recommended before endoscopy to minimize retained fluid that may increase the risk
of aspiration during endoscopy
Endoscopic biopsies often allow confirmation or exclusion of a malignant cause of
GOO. However, routine biopsy techniques can have poor sensitivity, particularly if the
tumor is extraluminal or does not involve the mucosa

Radiologic tests

Gastric outlet obstruction due to peptic ulcer disease

PANCREATIC CANCER

Pancreatic cancer
Pancreatic adenocarcinoma with extension to the duodenum or stomach
is a common cause of malignant GOO.
Fifteen to 25 percent of patients with pancreatic cancer present with GOO.
Such patients also commonly have biliary obstruction.

GASTRIC CANCER

Gastric cancer
Distal gastric cancer remains a relatively common cause of malignant GOO,
accounting for up to 35 percent of GOO.
However, the absolute number of cases has probably declined because of the
decreased incidence of gastric cancer in developed nations and the increase in the
proportion of gastric cancers arising from a proximal location

Gastric cancer

Gastric carcinoma on barium study. There

are a number
of large filling defects in the antrum and
body of the stomach

LINITIS
CAUSE PLASTICA

LYE (SODIUM HYDROXIDE) INGESTION

METASTATIC OF CA (BREAST AND LUNG
CARCINOMA)

SYMPTOM
DIARRHEA MAY BE A PRESENTING SYMPTOM
CLINICAL FINDING
DIFFUSE STOMACH CANCER
THE PRESENCE OF POORLY DIFFERENTIATED
TUMOR CELLS

MICROSCOPIC : SIGNET RING CARCINOMA

GROSS : LEATHER BOTTLE-LIKE APPEARANCE

LINITIS PLASTICA

ABDOMINAL FILM
CONCENTRIC ANNULAR LUMINAL
NARROWING OF THE GASTRIC
ANTRUM EXTENDING INTO THE
PYLORIC CHANNEL.

LINITIS PLASTICA

GASTRIC GASTROINTESTINAL STROMAL

TUMOR
CAUSE
MESENCHYMAL TUMOR OF GI TRACT
MUTATION OF KIT GENE

SIGN & SYMPTOM

TROUBLE SWALLOWING
GASTROINTESTINAL HEMORRHAGE
METASTASES

INVESTIGATION

ENDOSCOPY BIOPSY

IMAGE FINDING

UPPER GI IMAGE OBTAINED DURING THE SINGLE CONTRAST

ENHANCEMENT PORTION SHOWS AN INCIDENTALLY FOUND
MASS. THE SMOOTH BORDERS SUGGEST A SUBMUCOSAL
PROCESS.

GASTRIC GASTROINTESTINAL STROMAL TUMOR

Gastrointestinal stromal tumour on CT. There is a

smooth ovoid mass arising from the anterior wall of the stomach
(arrow). This causes an indentation of the stomach. L, liver; P,
pancreas; St, stomach.

GASTRIC LYMPHOMA

GASTRIC LYMPHOMA

THE CLINICAL FEATURES OF GASTRIC LYMPHOMA ARE

NONSPECIFIC AND FREQUENTLY INCLUDE ABDOMINAL
DISCOMFORT, ANOREXIA, EARLY SATIETY, AND WEIGHT LOSS AS
WELL AS GASTRIC OUTLET COMPLAINTS DUE TO OBSTRUCTION OR
IMPAIRMENT OF GASTRIC MOTILITY AND ANEMIA DUE TO BLOOD
LOSS FROM ULCERATION

Gastric lymphoma in the antrum, demonstrated on CT

(white arrows). Lymphadenopathy surrounds the inferior vena
cava (black arrow). St, stomach; Sp, spleen.

PEPTICULCER DISEASE

PEPTIC ULCER DISEASE

peptic ulcer disease was once the most common cause of GOO, accounting for
up to 90 percent of cases , but the incidence has declined with the discovery of
Helicobacter pylori and the introduction of proton pump inhibitors
Obstruction is now the least common complication of peptic ulcer disease,
occurring in approximately 2 percent of cases .

PEPTIC ULCER DISEASE

Both acute and chronic peptic ulcer disease can lead to GOO. The principal sites
of involvement in cases of obstruction are the pyloric channel and the duodenal
bulb.

Acute peptic ulcers can cause obstruction via inflammation-induced edema and
tissue deformation.
By contrast, chronic peptic ulcer disease leads to scarring and tissue remodeling
as part of the healing process.

PEPTIC ULCER DISEASE

PEPTIC ULCER

PEPTIC ULCER

A SMALL 'PIT' OF
BARIUM
CONTAINED WITHIN
AN ULCER CAVITY
IN THE BODY OF
THE STOMACH

CROHN'S DISEASE

CROHNS DISEASE
Crohn's disease Clinically significant gastroduodenal Crohn's disease is
uncommon, occurring in fewer than 5 percent of patients.
When present, about 60 percent of patients have continuous disease that involves
the antrum
pylorus
proximal duodenum .
The majority have concomitant disease in the distal gastrointestinal tract

CROHNS DISEASE
Most patients with gastroduodenal Crohn's disease do not have symptoms
attributable to the gastroduodenal involvement .
On the other hand, obstruction due to Crohn's-related strictures is the most
common complication of gastroduodenal disease.
In a series of 215 patients hospitalized for Crohn's disease, 3 percent were
being treated for symptomatic Crohn's disease due to pyloric strictures .In
another study of 89 patients with gastroduodenal Crohn's disease, 33 patients
required surgery, most often for duodenal obstruction.

 TAPERED NARROWING OF THE DISTAL ANTRUM IS CAUSED BY CROHN

DISEASE INVOLVING THE STOMACH.

PANCRETITS

PANCREATITS
POTENTIALLY REVERSIBLE GASTRIC OUTLET OBSTRUCTION CAN
OCCUR DURING AN ACUTE FLARE OF PANCREATITIS SECONDARY
TO PERIPANCREATIC INFLAMMATION INVOLVING THE
GASTRODUODENAL REGION.
NASOJEJUNAL FEEDING MAY BE REQUIRED TO MAINTAIN
NUTRITION DURING THIS PERIOD. PATIENTS WITH A FI BROTIC
PROCESS INVOLVING THE DUODENUM REQUIRE SURGICAL BYPASS
OF THE GASTRIC OUTLET OBSTRUCTION

PANCREATITS
Patients with severe acute pancreatitis can develop narrowing of the duodenum due to
inflammation and edema in the pancreas.
However, obstruction of the duodenum is rare ,except in cases of walled-off
pancreatic necrosis (WOPN) after severe acute pancreatitis and large pseudocysts that
can occur as a result of both acute and chronic pancreatitis

PANCREATIC
PSEUDOCYSTS
MASS EFFECT

BILIARY OBSTRUCTION
GASTRIC OUTLET OBSTRUCTION

SECONDARY INFECTION
GROIN
MEDIASTINUM NECK

RETROPERITONEUM VIA
THE DIAPHRAGMATIC HIATUSES INTO
THE MEDIASTINUM

PANCREATIC PSEUDOCYSTS

PANCREATIC PSEUDOCYSTS

GALLSTONE COMPLICATIONS

GALLSTONE COMPLICATION

OBSTRUCTION AT THE LEVEL OF THE GASTRIC OUTLET BY A

GALLSTONE IS DEFINED AS BOUVERETS SYNDROME .

IT IS AN UNCOMMON FORM OF GALLSTONE ILEUS. A SINGLE

GALLSTONE AT LEAST 2.5 CM IN DIAMET

GALLSTONE COMPLICATION
Bouveret's syndrome is a rare but well documented cause of GOO. It is
characterized by the impaction of a large gallstone (a single stone in >90 percent)
within the pyloric channel or, more commonly, the duodenum.
It occurs most commonly in elderly women, with a mean age of 70 years The
offending stone travels from the biliary tree via a cholecystoduodenal fistula,
formed in the setting of cholecystitis and pericholecystic inflammation.

BOUVERET'S SYNDROME

IMPACTION OF A GALLSTONE IN THE

PYLORUS OR PROXIMAL DUODENUM

MOST COMMONLY IN ELDERLY WOMEN

CLINICAL PRESENTING :NAUSEA,
VOMITING, AND EPIGASTRIC PAIN

BOUVERET'S SYNDROME

GASTRIC VOLVULUS

defined as an abnormal rotation of the stomach, is a rare entity that is seen most
commonly in adults over the age of fifty .
Two etiologic factors predominate: diaphragmatic defects, such as a paraesophageal
hernia or diaphragmatic hernia of traumatic origin, and poor fixation of the stomach
due to laxity or absence of the gastrosplenic or gastrocolic ligaments .
Adhesive disease from previous surgery may serve as an axis for gastric rotation
The rotation can occur around the long axis of the stomach, called organoaxial, or
around the perpendicular axis, called mesenteroaxial. Obstruction and ischemia are
more likely in mesenteroaxial twisting.
Both acute and chronic gastric volvulus can cause GOO.

GASTRIC VOLVULUS

INTRA-THORACIC STOMACH WITH TWO AIR FLUID LEVELS

HYPERTROPHIC PYLORIC STENOSIS

 PROGRESSIVE GASTRIC OUTLET OBSTRUCTION DUE TO IDIOPATHIC

HYPERTROPHY OF THE CIRCULAR MUSCLE FIBRES OF THE PYLORUS

US is the investigation of choice

Thickened pylorus seen as a rim of hypoechoic thickened muscle with a hyper

echoic centre producing a target appearance

US measurements indicating hypertrophic pyloric stenosis

Total pyloric diameter >13 mm
Pyloric muscle thickness >3 mm
Pyloric length >16 mm

Distended stomach
Lack of passage of gastric contents through the thickened pylorus on real-time
scanning.

GASTRIC BEZOAR

GASTRIC BEZOAR
A bezoar is a concretion formed by the gradual accumulation of ingested
material, both inorganic and organic, most often in the gastric lumen.
While GOO from bezoars has been documented in adults, the majority of
cases of obstruction have been reported in children .
GOO secondary to bezoars in adults may become more common as a
complication of bariatric surgery

CT of a bezoar. The stomach is distended by a large

mass of hair mixed with oral contrast (white arrows). The
antrum is also distended by the ingested material (black arrow

POST-SURGICAL COMPLICATION

Post-surgical complications
can result in GOO, but only in the setting of a preserved or partially-preserved
stomach, such as
-Sleeve gastrectomy
-Pylorus preserving Whipple procedures
-Gastrojejunostomies
In a study of 186 patients receiving pylorus-preserving pancreaticoduodenectomy at
our institution, 4 percent developed efferent obstruction causing GOO due to edema
and enteric anastomotic strictures (unpublished data).

Transendoscopic extraesophageal stent placement for benign gastric outlet

obstruction. Afferent limb gastrojejunal anastomotic stricture
(cannulated with a wire) as seen on endoscopy just above the efferent limb
anastomosis, in which a Wallfl ex (Microvasive, Natick, MA) stent was placed
previously

A second Wallfl ex stent was deployed through the endoscope

across the afferent limb anastomosis.

Postplacement endoscopic view of both deployed Wallflex stents

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