Obstruction at the level of the pylorus.
Etiology
Benign:
- Peptic ulcer disease
- Infections (tuberculosis, infiltrative diseases such as amyloidosis)
- Bouveret syndrome (blockage with a gallstone) (rare)
- Congenital hypertrophic pyloric stenosis
- Pancreatic pseudocyst (can cause gastric compression)
- Pyloric mucosal diaphragm (rare)
Malignant:
- Adenocarcinoma stomach (and its linitis plastica variant)
- Lymphoma
- Gastrointestinal stromal tumours
Presentation
- Nonbilious projectile vomiting
- Later stages:
- Wasting & dehydration
Clinical signs:
- Visible peristalsis (right → left)
- Succusion splash (splash-like sound heard over the stomach in the left upper quadrant of the abdomen on shaking the patient, with or without the stethoscope)
- Borborygmi (stomach rumble) (due to excessive peristaltic action of the stomach)
Diagnosis
- Hypochloremic hypokalemic alkalosis (due to loss of hydrogen chloride and potassium)
- ↑ Urea & creatinine (if the patient is dehydrated)
- Gastroscopy/UGI-endoscopy (CONFIRMATORY)
Abdominal X-ray (gastric fluid level):
Barium meal & follow through (enlarged stomach and pyloroduodenal stenosis)
Differential diagnosis:
- Early gastric carcinoma
- Hiatal hernia
- Gastroesophageal reflux (GERD)
- Adrenal insufficiency
- Inborn errors of metabolism
Management
Medical management (peptic ulcer disease):
- Nasogastric suction
- Replacement of fluids & electrolytes
- Proton pump inhibitors
Surgical management (significant obstruction and in cases where medical therapy has failed):
- Endoscopic balloon therapy
- Antrectomy (removal of the antral portion of the stomach)
- Vagotomy (severing of the vagus nerve)
- Billroth I (anastomosing the duodenum to the distal stomach)
- Bilateral truncal vagotomy + gastrojejunostomy