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Internal Medicine

Gastric outlet obstruction (GOO)

Obstruction at the level of the pylorus.

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):

396px-goo_axr
Decubitus abdominal x=ray of gastric outlet obstruction. Note the large gastric air bubble and the solid particulate matter in a dilated stomach | Samir – CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=38414269

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

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