Gastric outlet obstruction: Difference between revisions

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** [[Pancreas]]: [[Pancreatic cancer]]
** [[Pancreas]]: [[Pancreatic cancer]]
*** Most common [[Cancer|malignancy]] leading to extrinsic [[obstruction]] of the [[pylorus]]
*** Most common [[Cancer|malignancy]] leading to extrinsic [[obstruction]] of the [[pylorus]]
*** Occurence in one fifth of [[Patient|patients]]
*** Occurs in one fifth of patients
** [[Stomach]]: [[Stomach cancer|Gastric cancer]], [[Zollinger-Ellison syndrome|Zollinger-Ellison Syndrome]] <ref name="pmid11144036">{{cite journal |vauthors=Roy PK, Venzon DJ, Shojamanesh H, Abou-Saif A, Peghini P, Doppman JL, Gibril F, Jensen RT |title=Zollinger-Ellison syndrome. Clinical presentation in 261 patients |journal=Medicine (Baltimore) |volume=79 |issue=6 |pages=379–411 |year=2000 |pmid=11144036 |doi= |url=}}</ref>
** [[Stomach]]: [[Stomach cancer|Gastric cancer]], [[Zollinger-Ellison syndrome|Zollinger-Ellison Syndrome]] <ref name="pmid11144036">{{cite journal |vauthors=Roy PK, Venzon DJ, Shojamanesh H, Abou-Saif A, Peghini P, Doppman JL, Gibril F, Jensen RT |title=Zollinger-Ellison syndrome. Clinical presentation in 261 patients |journal=Medicine (Baltimore) |volume=79 |issue=6 |pages=379–411 |year=2000 |pmid=11144036 |doi= |url=}}</ref>
** [[Duodenum]]: [[Small intestine cancer|Duodenal cancer]], [[Small intestine cancer|ampullary cancer]]  
** [[Duodenum]]: [[Small intestine cancer|Duodenal cancer]], [[Small intestine cancer|ampullary cancer]]  
Line 48: Line 48:


==Differentiating {{PAGENAME}} from Other Diseases==
==Differentiating {{PAGENAME}} from Other Diseases==
* '''The table below differentiates gastric outlet obstruction from other conditions:'''<ref name="pmid6710074">{{cite journal| author=Sugimachi K, Inokuchi K, Kuwano H, Ooiwa T| title=Acute gastritis clinically classified in accordance with data from both upper GI series and endoscopy. | journal=Scand J Gastroenterol | year= 1984 | volume= 19 | issue= 1 | pages= 31-7 | pmid=6710074 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6710074  }} </ref><ref name="pmid25901896">{{cite journal| author=Sipponen P, Maaroos HI| title=Chronic gastritis. | journal=Scand J Gastroenterol | year= 2015 | volume= 50 | issue= 6 | pages= 657-67 | pmid=25901896 | doi=10.3109/00365521.2015.1019918 | pmc=4673514 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25901896  }} </ref><ref name="pmid16819502">{{cite journal| author=Sartor RB| title=Mechanisms of disease: pathogenesis of Crohn's disease and ulcerative colitis. | journal=Nat Clin Pract Gastroenterol Hepatol | year= 2006 | volume= 3 | issue= 7 | pages= 390-407 | pmid=16819502 | doi=10.1038/ncpgasthep0528 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16819502  }} </ref><ref name="pmid2789799">{{cite journal| author=Sipponen P| title=Atrophic gastritis as a premalignant condition. | journal=Ann Med | year= 1989 | volume= 21 | issue= 4 | pages= 287-90 | pmid=2789799 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2789799  }} </ref><ref name="pmid25133039">{{cite journal| author=Badillo R, Francis D| title=Diagnosis and treatment of gastroesophageal reflux disease. | journal=World J Gastrointest Pharmacol Ther | year= 2014 | volume= 5 | issue= 3 | pages= 105-12 | pmid=25133039 | doi=10.4292/wjgpt.v5.i3.105 | pmc=4133436 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25133039  }} </ref><ref name="pmid17956071">{{cite journal| author=Ramakrishnan K, Salinas RC| title=Peptic ulcer disease. | journal=Am Fam Physician | year= 2007 | volume= 76 | issue= 7 | pages= 1005-12 | pmid=17956071 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17956071  }} </ref><ref name="pmid17985090">{{cite journal| author=Banasch M, Schmitz F| title=Diagnosis and treatment of gastrinoma in the era of proton pump inhibitors. | journal=Wien Klin Wochenschr | year= 2007 | volume= 119 | issue= 19-20 | pages= 573-8 | pmid=17985090 | doi=10.1007/s00508-007-0884-2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17985090  }} </ref><ref name="pmid15621988">{{cite journal| author=Dicken BJ, Bigam DL, Cass C, Mackey JR, Joy AA, Hamilton SM| title=Gastric adenocarcinoma: review and considerations for future directions. | journal=Ann Surg | year= 2005 | volume= 241 | issue= 1 | pages= 27-39 | pmid=15621988 | doi= | pmc=1356843 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15621988  }} </ref><ref name="pmid21390139">{{cite journal| author=Ghimire P, Wu GY, Zhu L| title=Primary gastrointestinal lymphoma. | journal=World J Gastroenterol | year= 2011 | volume= 17 | issue= 6 | pages= 697-707 | pmid=21390139 | doi=10.3748/wjg.v17.i6.697 | pmc=3042647 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21390139  }} </ref>
* '''The table below differentiates gastric outlet obstruction from other conditions:'''<ref name="pmid6710074">{{cite journal| author=Sugimachi K, Inokuchi K, Kuwano H, Ooiwa T| title=Acute gastritis clinically classified in accordance with data from both upper GI series and endoscopy. | journal=Scand J Gastroenterol | year= 1984 | volume= 19 | issue= 1 | pages= 31-7 | pmid=6710074 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6710074  }} </ref><ref name="pmid25901896">{{cite journal| author=Sipponen P, Maaroos HI| title=Chronic gastritis. | journal=Scand J Gastroenterol | year= 2015 | volume= 50 | issue= 6 | pages= 657-67 | pmid=25901896 | doi=10.3109/00365521.2015.1019918 | pmc=4673514 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25901896  }} </ref><ref name="pmid16819502">{{cite journal| author=Sartor RB| title=Mechanisms of disease: pathogenesis of Crohn's disease and ulcerative colitis. | journal=Nat Clin Pract Gastroenterol Hepatol | year= 2006 | volume= 3 | issue= 7 | pages= 390-407 | pmid=16819502 | doi=10.1038/ncpgasthep0528 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16819502  }} </ref><ref name="pmid2789799">{{cite journal| author=Sipponen P| title=Atrophic gastritis as a premalignant condition. | journal=Ann Med | year= 1989 | volume= 21 | issue= 4 | pages= 287-90 | pmid=2789799 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2789799  }} </ref><ref name="pmid25133039">{{cite journal| author=Badillo R, Francis D| title=Diagnosis and treatment of gastroesophageal reflux disease. | journal=World J Gastrointest Pharmacol Ther | year= 2014 | volume= 5 | issue= 3 | pages= 105-12 | pmid=25133039 | doi=10.4292/wjgpt.v5.i3.105 | pmc=4133436 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25133039  }} </ref><ref name="pmid17956071">{{cite journal| author=Ramakrishnan K, Salinas RC| title=Peptic ulcer disease. | journal=Am Fam Physician | year= 2007 | volume= 76 | issue= 7 | pages= 1005-12 | pmid=17956071 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17956071  }} </ref><ref name="pmid17985090">{{cite journal| author=Banasch M, Schmitz F| title=Diagnosis and treatment of gastrinoma in the era of proton pump inhibitors. | journal=Wien Klin Wochenschr | year= 2007 | volume= 119 | issue= 19-20 | pages= 573-8 | pmid=17985090 | doi=10.1007/s00508-007-0884-2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17985090  }} </ref><ref name="pmid15621988">{{cite journal| author=Dicken BJ, Bigam DL, Cass C, Mackey JR, Joy AA, Hamilton SM| title=Gastric adenocarcinoma: review and considerations for future directions. | journal=Ann Surg | year= 2005 | volume= 241 | issue= 1 | pages= 27-39 | pmid=15621988 | doi= | pmc=1356843 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15621988  }} </ref><ref name="pmid21390139">{{cite journal| author=Ghimire P, Wu GY, Zhu L| title=Primary gastrointestinal lymphoma. | journal=World J Gastroenterol | year= 2011 | volume= 17 | issue= 6 | pages= 697-707 | pmid=21390139 | doi=10.3748/wjg.v17.i6.697 | pmc=3042647 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21390139  }} </ref><small> {| class="wikitable" style="border: 0px; font-size: 90%; margin: 3px;" align="center" | colspan="12" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|'''Differential Diagnosis'''}} |+ | rowspan="3" style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#FFF|'''Disease'''}} | colspan="9" style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#FFF|'''Symptoms'''}} | style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#FFF|'''Diagnosis'''}} | rowspan="3" style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#FFF|'''Other findings'''}} |- | colspan="3" style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#FFF|'''Pain'''}} | rowspan="2" style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#FFF|'''Nausea & Vomiting'''}} | rowspan="2" style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#FFF|'''Heartburn'''}} | rowspan="2" style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#FFF|'''Belching or Bloating'''}} | rowspan="2" style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#FFF|'''Weight loss'''}} | rowspan="2" style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#FFF|'''Loss of Appetite'''}} | rowspan="2" style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#FFF|'''Stools'''}} | rowspan="2" style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#FFF|'''Endoscopy findings'''}} |- | rowspan="1" style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#FFF|'''Location'''}} | rowspan="1" style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#FFF|'''Aggravating Factors'''}} | rowspan="1" style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#FFF|'''Alleviating Factors'''}} |- | style="padding: 5px 5px; background: #DCDCDC;" | Gastric outlet obstruction (GOO) |
<small>
* [[Abdominal pain|Epigastric pain]] |[[Food]] | - |✔ |✔ |✔ |✔ |✔ |[[Melena|Black stools]] in case of [[Peptic ulcer|Peptic Ulcer Disease(PUD)]] |
{| class="wikitable" style="border: 0px; font-size: 90%; margin: 3px;" align="center"
| colspan="12" style="background: #4479BA; text-align: center;" | {{fontcolor|#FFF|'''Differential Diagnosis'''}}
|+  
| rowspan="3" style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#FFF|'''Disease'''}}
| colspan="9" style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#FFF|'''Symptoms'''}}
| style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#FFF|'''Diagnosis'''}}
| rowspan="3" style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#FFF|'''Other findings'''}}
|-
| colspan="3" style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#FFF|'''Pain'''}}
| rowspan="2" style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#FFF|'''Nausea & Vomiting'''}}
| rowspan="2" style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#FFF|'''Heartburn'''}}
| rowspan="2" style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#FFF|'''Belching or Bloating'''}}
| rowspan="2" style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#FFF|'''Weight loss'''}}
| rowspan="2" style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#FFF|'''Loss of Appetite'''}}
| rowspan="2" style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#FFF|'''Stools'''}}
| rowspan="2" style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#FFF|'''Endoscopy findings'''}}
|-
| rowspan="1" style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#FFF|'''Location'''}}
| rowspan="1" style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#FFF|'''Aggravating Factors'''}}
| rowspan="1" style="background:#4479BA; padding: 5px 5px;" align="center" |{{fontcolor|#FFF|'''Alleviating Factors'''}}
|-
| style="padding: 5px 5px; background: #DCDCDC;" | Gastric outlet obstruction (GOO)
|
* [[Abdominal pain|Epigastric pain]]
|[[Food]]
| -
|✔
|✔
|✔
|✔
|✔
|[[Melena|Black stools]] in case of [[Peptic ulcer|Peptic Ulcer Disease(PUD)]]  
|
* Determines the site of [[obstruction]]
* Determines the site of [[obstruction]]
* Helps in the visualization of the [[Stomach|gastric]] silhouette
* Helps in the visualization of the [[Stomach|gastric]] silhouette
* Differentiation of GOO from [[gastroparesis]] where gastric [[dilation]] is not associated with the narrowing of the [[pylorus]]
* Differentiation of GOO from [[gastroparesis]] where gastric [[dilation]] is not associated with the narrowing of the [[pylorus]] | ==== Sodium chloride load test ====
|
* Presence of >400 mL NaCl solution in [[stomach]] after half an hour, is diagnostic of GOO. ==== Needle-guided biopsy ====
==== Sodium chloride load test ====
* Helps in the evaluation of [[Patient|patients]] for [[metastasis]] |- | style="padding: 5px 5px; background: #DCDCDC;" |[[Acute gastritis|'''Acute gastritis''']] |
* Presence of >400 mL NaCl solution in [[stomach]] after half an hour, is diagnostic of GOO.
* [[Epigastric pain]] |Food |[[Antacids]] |✔ |✔ |✔ |<nowiki>-</nowiki> |✔ |[[Melena|Black stools]] |
 
==== Needle-guided biopsy ====
* Helps in the evaluation of [[Patient|patients]] for [[metastasis]]
|-
| style="padding: 5px 5px; background: #DCDCDC;" |[[Acute gastritis|'''Acute gastritis''']]
|
* [[Epigastric pain]]
|Food
|[[Antacids]]
|✔
|✔
|✔
|<nowiki>-</nowiki>
|✔
|[[Melena|Black stools]]
|
* [[Pangastritis]] or antral [[gastritis]]
* [[Pangastritis]] or antral [[gastritis]]
* [[Gastric erosion|Erosive]] (Superficial, deep, hemorrhagic)
* [[Gastric erosion|Erosive]] (Superficial, deep, hemorrhagic)
* Nonerosive (''[[H. pylori]]'')
* Nonerosive (''[[H. pylori]]'') |<nowiki>-</nowiki> |- | style="padding: 5px 5px; background: #DCDCDC;" |[[Gastritis|'''Chronic gastritis''']] |
|<nowiki>-</nowiki>
* [[Epigastric pain]] |Food |[[Antacids]] |✔ |✔ |✔ |✔ |✔ |<nowiki>-</nowiki> |''[[H. pylori]] [[gastritis]]''
|-
| style="padding: 5px 5px; background: #DCDCDC;" |[[Gastritis|'''Chronic gastritis''']]
|
* [[Epigastric pain]]
|Food
|[[Antacids]]
|✔
|✔
|✔
|✔
|✔
|<nowiki>-</nowiki>
|''[[H. pylori]] [[gastritis]]''
* [[Atrophy]]
* [[Atrophy]]
* Intestinal [[metaplasia]]
* Intestinal [[metaplasia]] Lymphocytic gastritis
Lymphocytic gastritis
* Enlarged folds
* Enlarged folds
* Aphthoid erosions
* Aphthoid erosions |<nowiki>-</nowiki> |- | style="padding: 5px 5px; background: #DCDCDC;" |[[Atrophic gastritis|'''Atrophic gastritis''']] |
|<nowiki>-</nowiki>
*[[Epigastric pain]] |<nowiki>-</nowiki> |<nowiki>-</nowiki> |✔ |<nowiki>-</nowiki> | |✔ |✔ |<nowiki>-</nowiki> |''[[H. pylori]]''
|-
* Mucosal [[atrophy]] [[Autoimmune]]
| style="padding: 5px 5px; background: #DCDCDC;" |[[Atrophic gastritis|'''Atrophic gastritis''']]
* Mucosal [[atrophy]] |Diagnosed by:
|
*[[Epigastric pain]]
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|✔
|<nowiki>-</nowiki>
|
|✔
|✔
|<nowiki>-</nowiki>
|''[[H. pylori]]''
* Mucosal [[atrophy]]
[[Autoimmune]]
* Mucosal [[atrophy]]
|Diagnosed by:
*Antiparietal and anti-IF antibodies
*Antiparietal and anti-IF antibodies
*[[Achlorhydria]] and hypergastrinemia
*[[Achlorhydria]] and hypergastrinemia
*Low serum [[vitamin B12|cobalamine]]
*Low serum [[vitamin B12|cobalamine]] |- | style="padding: 5px 5px; background: #DCDCDC;" |[[Crohn's disease|'''Crohn's disease''']] |
|-
* [[Abdominal pain]] |<nowiki>-</nowiki> |<nowiki>-</nowiki> |<nowiki>-</nowiki> |<nowiki>-</nowiki> |<nowiki>-</nowiki> |✔ |✔ |
| style="padding: 5px 5px; background: #DCDCDC;" |[[Crohn's disease|'''Crohn's disease''']]
|
* [[Abdominal pain]]
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|✔
|✔
|
* Chronic [[diarrhea]] often bloody with [[pus]] or [[mucus]]
* Chronic [[diarrhea]] often bloody with [[pus]] or [[mucus]]
* [[Rectal bleeding]]
* [[Rectal bleeding]] |
|
* Thickened antral folds
* Thickened antral folds
* Antral narrowing
* Antral narrowing
* Hypoperistalsis
* Hypoperistalsis
* Duodenal strictures
* Duodenal strictures |
|
* [[Fever]]
* [[Fever]]
* [[Fatigue]]
* [[Fatigue]]
* [[Anemia]] ([[pernicious anemia]])
* [[Anemia]] ([[pernicious anemia]]) |- | style="padding: 5px 5px; background: #DCDCDC;" |[[GERD|'''GERD''']] |
|-
* [[Epigastric pain]] |
| style="padding: 5px 5px; background: #DCDCDC;" |[[GERD|'''GERD''']]
|
* [[Epigastric pain]]
|
* Spicy food
* Spicy food
* Tight fitting clothing
* Tight fitting clothing |
|
* [[Antacids]]
* [[Antacids]]
* Head elevation during sleep
* Head elevation during sleep |✔ (Suspect delayed gastric emptying) |✔ |<nowiki>-</nowiki> |<nowiki>-</nowiki> |<nowiki>-</nowiki> |<nowiki>-</nowiki> |
|✔
 
(Suspect delayed gastric emptying)
|✔
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|
* [[Esophagitis]]
* [[Esophagitis]]
* [[Barrette's esophagus]]
* [[Barrette's esophagus]]
* [[Strictures]]
* [[Strictures]] |Other symptoms:
|Other symptoms:
* [[Dysphagia]]
* [[Dysphagia]]
* [[Regurgitation]]
* [[Regurgitation]]
* [[Cough|Nocturnal cough]]
* [[Cough|Nocturnal cough]]
* [[Hoarseness]]
* [[Hoarseness]] |- | style="padding: 5px 5px; background: #DCDCDC;" |[[Peptic ulcer disease|'''Peptic ulcer disease''']] |
|-
| style="padding: 5px 5px; background: #DCDCDC;" |[[Peptic ulcer disease|'''Peptic ulcer disease''']]
|
* [[Epigastric pain]] sometimes extending to back
* [[Epigastric pain]] sometimes extending to back
* [[Right upper quadrant pain]]
* [[Right upper quadrant pain]] | '''[[Duodenal ulcer]]'''
|
*Pain aggravates with empty stomach '''[[Gastric ulcer]]'''
'''[[Duodenal ulcer]]'''
*Pain aggravates with food |
*Pain aggravates with empty stomach
'''[[Gastric ulcer]]'''
*Pain aggravates with food
|
* [[Antacids]]
* [[Antacids]]


* [[Duodenal ulcer]]
* [[Duodenal ulcer]]
:*Pain alleviates with food
:*Pain alleviates with food |✔ |✔ |<nowiki>-</nowiki> |<nowiki>-</nowiki> |<nowiki>-</nowiki> |
|✔
* [[Melena|Black stools]] |'''Gastric ulcers'''
|✔
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|
* [[Melena|Black stools]]
|'''Gastric ulcers'''
* Most [[ulcers]] are at the junction of [[fundus]] and antrum
* Most [[ulcers]] are at the junction of [[fundus]] and antrum
* 0.5-2.5cm
* 0.5-2.5cm '''Duodenal ulcers'''
'''Duodenal ulcers'''
* Found in the first part of [[duodenum]]
* Found in the first part of [[duodenum]]
* <1cm
* <1cm |'''Other diagnostic tests'''
|'''Other diagnostic tests'''
* Serum [[gastrin]] levels
* Serum [[gastrin]] levels
* [[Secretin]] stimulation test
* [[Secretin]] stimulation test
* [[Biopsy]]
* [[Biopsy]] |- | style="padding: 5px 5px; background: #DCDCDC;" |[[Gastrinoma|'''Gastrinoma''']] |
|-
* [[Abdominal pain]] |<nowiki>-</nowiki> |<nowiki>-</nowiki> |✔ (suspect [[gastric outlet obstruction]]) |✔ |<nowiki>-</nowiki> |<nowiki>-</nowiki> |<nowiki>-</nowiki> |
| style="padding: 5px 5px; background: #DCDCDC;" |[[Gastrinoma|'''Gastrinoma''']]
* [[Melena|Black stools]] |Useful in collecting the tissue for [[biopsy]] | '''Diagnostic tests'''
|
* [[Abdominal pain]]
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|✔
 
(suspect [[gastric outlet obstruction]])
|✔
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|
* [[Melena|Black stools]]
|Useful in collecting the tissue for [[biopsy]]
|
'''Diagnostic tests'''
* Serum [[gastrin]] levels
* Serum [[gastrin]] levels
* [[Somatostatin]] receptor [[scintigraphy]]
* [[Somatostatin]] receptor [[scintigraphy]]
* [[CT]] and [[MRI]]
* [[CT]] and [[MRI]] |- | style="padding: 5px 5px; background: #DCDCDC;" |[[Gastric Cancer|'''Gastric Adenocarcinoma''']] |
|-
* [[Abdominal pain]] |<nowiki>-</nowiki> |<nowiki>-</nowiki> |✔ |✔ |✔ |✔ |✔ |
| style="padding: 5px 5px; background: #DCDCDC;" |[[Gastric Cancer|'''Gastric Adenocarcinoma''']]
* [[Melena|Black stools]], or blood in stools |'''Esophagogastroduodenoscopy'''
|
* Multiple biopsies are taken to establish the diagnosis and determine histological variant. |'''Other symptoms'''
* [[Abdominal pain]]
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|✔
|✔
|✔
|✔
|✔
|
* [[Melena|Black stools]], or blood in stools
|'''Esophagogastroduodenoscopy'''
* Multiple biopsies are taken to establish the diagnosis and determine histological variant.
|'''Other symptoms'''
* [[Dysphagia]]
* [[Dysphagia]]
* Early [[satiety]]
* Early [[satiety]]
* Frequent [[burping]]
* Frequent [[burping]] |- | style="padding: 5px 5px; background: #DCDCDC;" |[[Gastric lymphoma|'''Primary gastric lymphoma''']] |
|-
| style="padding: 5px 5px; background: #DCDCDC;" |[[Gastric lymphoma|'''Primary gastric lymphoma''']]
|
* [[Abdominal pain]]
* [[Abdominal pain]]
* [[Chest pain]]
* [[Chest pain]] |<nowiki>-</nowiki> |<nowiki>-</nowiki> |<nowiki>-</nowiki> |<nowiki>-</nowiki> |<nowiki>-</nowiki> |✔ |<nowiki>-</nowiki> |<nowiki>-</nowiki> |Useful in collecting the tissue for [[biopsy]] |'''Other symptoms'''
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|✔
|<nowiki>-</nowiki>
|<nowiki>-</nowiki>
|Useful in collecting the tissue for [[biopsy]]
|'''Other symptoms'''
* Painless swollen [[lymph nodes]] in neck and armpit
* Painless swollen [[lymph nodes]] in neck and armpit
* Night sweats
* Night sweats |}</small>
|}
</small>
 
==Epidemiology and Demographics==
==Epidemiology and Demographics==
The epidemiology of GOO is as follows:<ref name="pmid21626606">{{cite journal |vauthors=Lin KJ, García Rodríguez LA, Hernández-Díaz S |title=Systematic review of peptic ulcer disease incidence rates: do studies without validation provide reliable estimates? |journal=Pharmacoepidemiol Drug Saf |volume=20 |issue=7 |pages=718–28 |year=2011 |pmid=21626606 |doi=10.1002/pds.2153 |url=}}</ref><ref name="pmid19220208">{{cite journal |vauthors=Sung JJ, Kuipers EJ, El-Serag HB |title=Systematic review: the global incidence and prevalence of peptic ulcer disease |journal=Aliment. Pharmacol. Ther. |volume=29 |issue=9 |pages=938–46 |year=2009 |pmid=19220208 |doi=10.1111/j.1365-2036.2009.03960.x |url=}}</ref>
The epidemiology of GOO is as follows:<ref name="pmid21626606">{{cite journal |vauthors=Lin KJ, García Rodríguez LA, Hernández-Díaz S |title=Systematic review of peptic ulcer disease incidence rates: do studies without validation provide reliable estimates? |journal=Pharmacoepidemiol Drug Saf |volume=20 |issue=7 |pages=718–28 |year=2011 |pmid=21626606 |doi=10.1002/pds.2153 |url=}}</ref><ref name="pmid19220208">{{cite journal |vauthors=Sung JJ, Kuipers EJ, El-Serag HB |title=Systematic review: the global incidence and prevalence of peptic ulcer disease |journal=Aliment. Pharmacol. Ther. |volume=29 |issue=9 |pages=938–46 |year=2009 |pmid=19220208 |doi=10.1111/j.1365-2036.2009.03960.x |url=}}</ref>
* The [[incidence]] of gastric outlet obstruction is less than 5 per 100,000 [[Patient|patients]] worldwide.
* The [[incidence]] of [[peptic ulcer]] disease (which is the most common benign cause of GOO) is approximately 10-19 per 100,000 individuals worldwide.
* The [[incidence]] of [[peptic ulcer]] disease (which is the most common benign cause of GOO) is approximately 10-19 per 100,000 individuals worldwide.
* Five percent of all cases of [[Peptic ulcer|peptic ulcer disease]] worldwide, develop gastric outlet obstruction.
* Five percent of all cases of [[Peptic ulcer|peptic ulcer disease]] worldwide, develop gastric outlet obstruction.
* The [[incidence]] of gastric outlet obstruction is less than 5 per 100,000 [[Patient|patients]] worldwide.
* In the United States, [[Peptic ulcer|peptic ulcer disease]] requires an average of 2000 [[Surgery|surgeries]] annually.
* In the United States, [[Peptic ulcer|peptic ulcer disease]] requires an average of 2000 [[Surgery|surgeries]] annually.
* [[Pancreatic cancer]] is the most common malignant cause of GOO.
* [[Pancreatic cancer]] is the most common malignant cause of GOO.

Revision as of 20:28, 2 February 2018

Gastric outlet obstruction Microchapters

Home

Overview

Classification

Pathophysiology

Causes

Differentiating Gastric outlet obstruction from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Diagnosis

Treatment

Medical Therapy
Surgery

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Sudarshana Datta, MD [2]

Synonyms and keywords: GOO

Overview

Gastric outlet obstruction occurs due to pathologies that cause intrinsic or extrinsic obstruction of the pylorus and antrum. Infiltration, scar formation or inflammation of the gastric outlet leads to intrinsic obstruction, while malignancy of neighboring structures such as the pancreas, gallbladder, liver and duodenum may lead to extrinsic obstruction of the gastric outlet. Common causes of GOO include PUD, gastric polyps, caustic ingestion, duodenal stricture, systemic amyloidosis of the gastrointestinal tract, eosinophillic gastroenteritis and obstruction by gallstones. Five percent of all cases of peptic ulcer disease (which is the most common benign cause of GOO) worldwide, develop gastric outlet obstruction. GOO presents as nausea, vomiting, dehydration, electrolyte abnormalities, weight loss, malnutrition, fullness of epigastrium, early satiety and bloating. Laboratory studies of patients may show hypokalemic hypochloremic metabolic alkalosis which is a characteristic feature due to vomiting. In case of of GOO due to suspected PUD, tests for H pylori should also be performed in patients. Barium upper GI studies help in the determination of site of obstruction, visualization of the gastric silhouette, presence of gastric dilation, pylorus narrowing, presence of ulcers, tumors and differentiation from gastroparesis. Upper endoscopy performed in patients may help with visualization of the gastric outlet, biopsy sampling in case of intraluminal pathology and thereby helps rule out the presence of malignancy in patients with symptoms of Peptic Ulcer Disease (PUD). Surgery is the primary modality of treatment for patients with GOO. It is required for more than 75 percent of patients, with scarring, fibrosis and tumors. The aims of surgery in case of GOO include relief of obstruction, relief in patients with failure to respond to medical therapy or failure to improve even after 72 hours of therapy and correction of PUD symptoms. Various types of surgical procedures performed in cases of GOO are vagotomy and antrectomy, gastrojejunostomy (vagotomy and antrectomy with Billroth II reconstruction), balloon dilatation, pylorotomy, pyloroplasty and laparoscopic techniques. Care must be taken to look out for various complications arising after surgery such as perforation, anastomotic leak, dilation and dysmotility of stomach, edema of the gastric wall and postgastrectomy syndromes.

Classification

Gastric outlet obstruction (GOO) may be due to any underlying condition that results in mechanical obstruction to emptying of gastric contents. GOO is classified based on the underlying cause into benign GOO and malignant GOO. Statistically, benign GOO comprises of 37 percent of cases and includes peptic ulcer disease whereas malignant GOO comprises of the remaining 53 percent of cases.

Pathophysiology

It is understood that GOO is the result of multiple intrinsic (lumen & wall) or extrinsic (involving neighbouring structures) pathologies that involve the antrum and the pylorus.

  • Intrinsic obstruction: Conditions involving infiltration, scar formation or inflammation of antrum and the pylorus may lead to intrinsic obstruction and GOO.
  • Extrinsic obstruction: Any malignancy of neighboring structures such as duodenum, liver, gallbladder and pancreas may lead to extrinsic obstruction of gastric outlet.

Causes

Causes of GOO may be classified as benign and malignant.

Benign causes

Benign causes of GOO can either be congenital or acquired. The acquired causes of GOO may further be categorized into acute or chronic. The acquired acute causes of GOO results from edema and inflammation of antrum and the pylorus. The acquired chronic causes of GOO results from intrinsic obstruction due to fibrosis and scar formation. In general, benign causes of GOO include: [1][2][3][4]

Congenital causes of gastric outlet obstruction include:[23][24]

Malignant causes

Differentiating Gastric outlet obstruction from Other Diseases

  • The table below differentiates gastric outlet obstruction from other conditions:[34][35][36][37][38][39][40][41][42] {| class="wikitable" style="border: 0px; font-size: 90%; margin: 3px;" align="center" | colspan="12" style="background: #4479BA; text-align: center;" | Differential Diagnosis |+ | rowspan="3" style="background:#4479BA; padding: 5px 5px;" align="center" |Disease | colspan="9" style="background:#4479BA; padding: 5px 5px;" align="center" |Symptoms | style="background:#4479BA; padding: 5px 5px;" align="center" |Diagnosis | rowspan="3" style="background:#4479BA; padding: 5px 5px;" align="center" |Other findings |- | colspan="3" style="background:#4479BA; padding: 5px 5px;" align="center" |Pain | rowspan="2" style="background:#4479BA; padding: 5px 5px;" align="center" |Nausea & Vomiting | rowspan="2" style="background:#4479BA; padding: 5px 5px;" align="center" |Heartburn | rowspan="2" style="background:#4479BA; padding: 5px 5px;" align="center" |Belching or Bloating | rowspan="2" style="background:#4479BA; padding: 5px 5px;" align="center" |Weight loss | rowspan="2" style="background:#4479BA; padding: 5px 5px;" align="center" |Loss of Appetite | rowspan="2" style="background:#4479BA; padding: 5px 5px;" align="center" |Stools | rowspan="2" style="background:#4479BA; padding: 5px 5px;" align="center" |Endoscopy findings |- | rowspan="1" style="background:#4479BA; padding: 5px 5px;" align="center" |Location | rowspan="1" style="background:#4479BA; padding: 5px 5px;" align="center" |Aggravating Factors | rowspan="1" style="background:#4479BA; padding: 5px 5px;" align="center" |Alleviating Factors |- | style="padding: 5px 5px; background: #DCDCDC;" | Gastric outlet obstruction (GOO) |
  • Epigastric pain |Food | - |✔ |✔ |✔ |✔ |✔ |Black stools in case of Peptic Ulcer Disease(PUD) |
  • Determines the site of obstruction
  • Helps in the visualization of the gastric silhouette
  • Differentiation of GOO from gastroparesis where gastric dilation is not associated with the narrowing of the pylorus | ==== Sodium chloride load test ====
  • Presence of >400 mL NaCl solution in stomach after half an hour, is diagnostic of GOO. ==== Needle-guided biopsy ====
  • Helps in the evaluation of patients for metastasis |- | style="padding: 5px 5px; background: #DCDCDC;" |Acute gastritis |
  • Epigastric pain |Food |Antacids |✔ |✔ |✔ |- |✔ |Black stools |
  • Pangastritis or antral gastritis
  • Erosive (Superficial, deep, hemorrhagic)
  • Nonerosive (H. pylori) |- |- | style="padding: 5px 5px; background: #DCDCDC;" |Chronic gastritis |
  • Epigastric pain |Food |Antacids |✔ |✔ |✔ |✔ |✔ |- |H. pylori gastritis
  • Atrophy
  • Intestinal metaplasia Lymphocytic gastritis
  • Enlarged folds
  • Aphthoid erosions |- |- | style="padding: 5px 5px; background: #DCDCDC;" |Atrophic gastritis |
  • Epigastric pain |- |- |✔ |- | |✔ |✔ |- |H. pylori
  • Mucosal atrophy Autoimmune
  • Mucosal atrophy |Diagnosed by:
  • Antiparietal and anti-IF antibodies
  • Achlorhydria and hypergastrinemia
  • Low serum cobalamine |- | style="padding: 5px 5px; background: #DCDCDC;" |Crohn's disease |
  • Abdominal pain |- |- |- |- |- |✔ |✔ |
  • Chronic diarrhea often bloody with pus or mucus
  • Rectal bleeding |
  • Thickened antral folds
  • Antral narrowing
  • Hypoperistalsis
  • Duodenal strictures |
  • Fever
  • Fatigue
  • Anemia (pernicious anemia) |- | style="padding: 5px 5px; background: #DCDCDC;" |GERD |
  • Epigastric pain |
  • Spicy food
  • Tight fitting clothing |
  • Antacids
  • Head elevation during sleep |✔ (Suspect delayed gastric emptying) |✔ |- |- |- |- |
  • Esophagitis
  • Barrette's esophagus
  • Strictures |Other symptoms:
  • Dysphagia
  • Regurgitation
  • Nocturnal cough
  • Hoarseness |- | style="padding: 5px 5px; background: #DCDCDC;" |Peptic ulcer disease |
  • Epigastric pain sometimes extending to back
  • Right upper quadrant pain | Duodenal ulcer
  • Pain aggravates with empty stomach Gastric ulcer
  • Pain aggravates with food |
  • Antacids
  • Pain alleviates with food |✔ |✔ |- |- |- |

Epidemiology and Demographics

The epidemiology of GOO is as follows:[43][44]

Diagnosis

History and Symptoms

The following history is relevant in patients with GOO:[45][46]

The clinical presentation of GOO is as follows:

Early stages:[5][26]

Late stages:[29][28][47][48]

Physical Examination

In the late stages of GOO, patients may develop signs of malnutrition and incomplete obstruction. Signs of malnutrition include weight loss and signs of dehydration. Signs of incomplete obstruction include findings such as abdominal mass, visible gastric peristalsis, fullness of epigastrium and a tympanitic mass on percussion. {{#ev:youtube|UVJYQlUm2A8}}

Laboratory Findings

Laboratory investigations suggestive of GOO include Hypokalemic hypochloremic metabolic alkalosis (due to vomiting). In order to assess the severity and etiology of GOO, other investigations such as CBC, electrolyte panel, tests for H Pylori and liver function tests may be done.[49]

Imaging Findings

Imaging studies such as plain radiographs, contrast upper gastrointestinal (GI) studies and Computed Tomography (CT) with oral contrast may be used for evaluating patients with symptoms of GOO.

X ray

An x-ray (obstruction series or barium study) may be helpful in the diagnosis of GOO. Findings on an x-ray suggestive of GOO include gastric dilatation. Findings on barium or Gastrografin study help in the determination of site of obstruction, visualization of the gastric silhouette, Gastric dilation, narrowed pylorus, presence of ulcers and tumors. GOO may also be differentiated from gastroparesis in which gastric dilation is not associated with the narrowing of the pylorus.

Computed tomography (CT) with oral contrast

CT with oral contrast or CT-guided biopsy may be done in suspected cases with equivocal findings on X Ray and Barium Upper GI studies. Findings of CT are variable and include those of the underlying condition.

Other Diagnostic Studies

Endoscopy

Upper endoscopy may be helpful in the diagnosis of GOO. An upper endoscopy aids in visualization of the gastric outlet, Biopsy sampling in case of intraluminal pathology. In addition, Endoscopic biopsy helps rule out the presence of malignancy in patients with symptoms of Peptic Ulcer Disease (PUD) :[51][52]

Sodium chloride load test

In sodium chloride test, the patient is infused with 750 mL of sodium chloride solution into the stomach via a nasogastric tube (NGT). After half an hour if > 400 mL is left in the stomach, the diagnosis of GOO is made.[53]

Needle-guided biopsy

Needle guided biopsy is used to evaluate patients for metastasis, in order to detect the primary tumor on histology.

Treatment

Medical Therapy

Surgery

Surgery is the primary modality of treatment for patients with GOO. It is required for more than 75 percent of patients, with scarring, fibrosis and tumors. The aims of surgery in case of GOO include:

  • Relief of obstruction
  • Relief in patients with failure to respond to medical therapy or failure to improve even after 72 hours of therapy
  • Correction of PUD symptoms

Preoperative evaluation

Preoperative evaluation of patients include:

Guidelines for surgery

The following points need to be considered by surgeons:

Types of surgical procedures

The types of surgical procedures performed in cases of GOO are as follows:[20][77][78][79][80][81][82]

Contraindications to surgery

Contraindications to surgery include the following conditions:

Complications of surgery

Complications arising after surgery include:[105][106]

References

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