Gastric outlet obstruction
Gastric outlet obstruction is a medical condition where there is an obstruction at the level of the pylorus, which is the outlet of the stomach. Individuals with gastric outlet obstruction will often have recurrent vomiting of food that has accumulated in the stomach, but which cannot pass into the small intestine due to the obstruction. The stomach often dilates to accommodate food intake and secretions. Causes of gastric outlet obstruction include both benign causes, such as peptic ulcer disease affecting the area around the pylorus, and malignant causes, such as gastric cancer.
Causation related to ulcers may involve severe pain which the patient may interpret as a heart condition or attack.
Treatment of the condition depends upon the underlying cause; it can involve antibiotic treatment when Helicobacter pylori is related to an ulcer, endoscopic therapies, other medical therapies, or surgery to resolve the obstruction.
Signs and symptoms
The main symptom is vomiting, which typically occurs after meals, of undigested food devoid of any bile. A history of previous peptic ulcers and loss of weight is not uncommon. In advanced cases, signs to look for on physical examination are wasting and dehydration. Visible peristalsis from left to right may be present. Succussion splash is a splash-like sound heard over the stomach in the left upper quadrant of the abdomen on shaking the patient, with or without the stethoscope. Bowel sound may be increased due to excessive peristaltic action of the stomach. Fullness in the left hypochondrium may also be present.Causes
The causes are divided into benign or malignant.- Benign
- * Peptic ulcer disease
- * Infections, such as tuberculosis; and infiltrative diseases, such as amyloidosis.
- * A rare cause of gastric outlet obstruction is blockage with a gallstone, also termed "Bouveret syndrome" or "Bouveret's syndrome".
- * In children, congenital pyloric stenosis / congenital hypertrophic pyloric stenosis may be a cause.
- * A pancreatic pseudocyst can cause gastric compression.
- * Pyloric mucosal diaphragm could be a rare cause.
- Malignant
- * Tumours of the stomach, including adenocarcinoma, lymphoma, and gastrointestinal stromal tumours
Pathophysiology
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.Diagnosis
The most confirmatory investigation is endoscopy of upper gastrointestinal tract.Laboratory often find hypochloremic, hypokalemic, and alkalotic due to loss of hydrogen chloride and potassium. High urea and creatinine levels may also be observed if the patient is dehydrated.
Abdominal X-ray may show a gastric fluid level which would support the diagnosis.
Barium meal and follow through may show an enlarged stomach and pyloroduodenal stenosis.
Gastroscopy may help with cause and can be used therapeutically.