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Gastric outlet obstruction (GOO) can be due to any underlying condition that results in mechanical [[obstruction]] to emptying of [[Stomach|gastric]] contents. GOO may be 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|peptic ulcer disease]] whereas malignant GOO comprises of 53 percent of cases.
Gastric outlet obstruction (GOO) can be due to any underlying condition that results in mechanical [[obstruction]] to emptying of [[Stomach|gastric]] contents. GOO may be 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|peptic ulcer disease]] whereas malignant GOO comprises of 53 percent of cases.


* [[Malignant]]: 53 Pathophysiology
==Pathophysiology==
Gastric Outlet Obstruction (GOO) may be caused by intrinsic or extrinsic pathologies that involve the [[antrum]] and the [[pylorus]].
Gastric Outlet Obstruction (GOO) may be caused by intrinsic or extrinsic pathologies that involve the [[antrum]] and the [[pylorus]].
* Intrinsic [[obstruction]]:  
* Intrinsic [[obstruction]]:  

Revision as of 18:36, 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) can be due to any underlying condition that results in mechanical obstruction to emptying of gastric contents. GOO may be 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 53 percent of cases.

Pathophysiology

Gastric Outlet Obstruction (GOO) may be caused by intrinsic or extrinsic pathologies that involve the antrum and the pylorus.

Causes

Causes of GOO may be classified as benign and malignant.

Benign causes

Acquired causes of gastric outlet obstruction include:[1][2][3][4]

Congenital causes of gastric outlet obstruction include:[38][39]

Malignant causes

Differentiating Gastric outlet obstruction from Other Diseases

Differential Diagnosis
Disease Cause Symptoms Diagnosis Other findings
Pain Nausea & Vomiting Heartburn Belching or Bloating Weight loss Loss of Appetite Stools Endoscopy findings
Location Aggravating Factors Alleviating Factors
Gastric outlet obstruction (GOO) Epigastric pain Food - ✔ ✔ ✔ ✔ ✔ Black stools in case of Peptic Ulcer Disease(PUD)

Sodium chloride load test

Needle-guided biopsy

Acute gastritis Food Antacids ✔ ✔ ✔ - ✔ Black stools -
Chronic gastritis Food Antacids ✔ ✔ ✔ ✔ ✔ - H. pylori gastritis

Lymphocytic gastritis

  • Enlarged folds
  • Aphthoid erosions
 -
Atrophic gastritis - - ✔ - ✔ ✔ - H. pylori

Autoimmune

Crohn's disease - - - - - ✔ ✔
  • Mucosal nodularity with cobblestoning
  • Multiple aphthous ulcers
  • Linier or serpiginous ulcerations
  • Thickened antral folds
  • Antral narrowing
  • Hypoperistalsis
  • Duodenal strictures
GERD
  • Spicy food
  • Tight fitting clothing
 ✔

(Suspect delayed gastric emptying)

✔ - - - - Other symptoms:

Complications

Peptic ulcer disease

Duodenal ulcer

  • Pain aggravates with empty stomach

Gastric ulcer

  • Pain aggravates with food
  • Pain alleviates with food
 ✔ ✔ - - - Gastric ulcers
  • Discrete mucosal lesions with a punched-out smooth ulcer base with whitish fibrinoid base
  • Most ulcers are at the junction of fundus and antrum
  • 0.5-2.5cm

Duodenal ulcers

Other diagnostic tests
Gastrinoma - - ✔

(suspect gastric outlet obstruction)

✔ - - - Useful in collecting the tissue for biopsy

Diagnostic tests

Gastric Adenocarcinoma - - ✔ ✔ ✔ ✔ ✔ Esophagogastroduodenoscopy
  • Multiple biopsies are taken to establish the diagnosis
 Other symptoms
Primary gastric lymphoma - - - - - ✔ - - Useful in collecting the tissue for biopsy Other symptoms

Epidemiology and Demographics

The epidemiology of GOO is as follows:[58][59]

Diagnosis

History and Symptoms

The following history is relevant in patients with GOO:[60][61]

The clinical presentation of GOO is as follows:

Early stages:[5][41]

Late stages:[44][43][62][63]

Physical Examination

In the late stages of GOO, patients may develop signs of malnutrition and incomplete obstruction.

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Laboratory Findings

Laboratory investigations in patients may reveal the following findings:

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.

Plain radiographs

Contrast upper gastrointestinal (GI) studies (Gastrografin or barium)

Computed tomography (CT) with oral contrast

Other Diagnostic Studies

Endoscopy

Sodium chloride load test

Needle-guided biopsy

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:[29][92][93][94][95][96][97]

Contraindications to surgery

Contraindications to surgery include the following conditions:

Complications of surgery

Complications arising after surgery include:[120][121]

References

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  71. ↑ Holt AP, Patel M, Ahmed MM (2004). "Palliation of patients with malignant gastroduodenal obstruction with self-expanding metallic stents: the treatment of choice?". Gastrointest. Endosc. 60 (6): 1010–7. PMID 15605026.
  72. ↑ Adler DG, Merwat SN (2006). "Endoscopic approaches for palliation of luminal gastrointestinal obstruction". Gastroenterol. Clin. North Am. 35 (1): 65–82, viii. doi:10.1016/j.gtc.2005.12.004. PMID 16530111.
  73. ↑ Baron TH (2004). "Surgical versus endoscopic palliation of malignant gastric outlet obstruction: big incision, little incision, or no incision?". Gastroenterology. 127 (4): 1268–9. PMID 15481009.
  74. ↑ Telford JJ, Carr-Locke DL, Baron TH, Tringali A, Parsons WG, Gabbrielli A, Costamagna G (2004). "Palliation of patients with malignant gastric outlet obstruction with the enteral Wallstent: outcomes from a multicenter study". Gastrointest. Endosc. 60 (6): 916–20. PMID 15605006.
  75. ↑ Song GA, Kang DH, Kim TO, Heo J, Kim GH, Cho M, Heo JH, Kim JY, Lee JS, Jeoung YJ, Jeon TY, Kim DH, Sim MS (2007). "Endoscopic stenting in patients with recurrent malignant obstruction after gastric surgery: uncovered versus simultaneously deployed uncovered and covered (double) self-expandable metal stents". Gastrointest. Endosc. 65 (6): 782–7. doi:10.1016/j.gie.2006.08.030. PMID 17324410.
  76. ↑ Maetani I, Mizumoto Y, Shigoka H, Omuta S, Saito M, Tokuhisa J, Morizane T (2014). "Placement of a triple-layered covered versus uncovered metallic stent for palliation of malignant gastric outlet obstruction: a multicenter randomized trial". Dig Endosc. 26 (2): 192–9. doi:10.1111/den.12117. PMID 23621572.
  77. ↑ Yim HB, Jacobson BC, Saltzman JR, Johannes RS, Bounds BC, Lee JH, Shields SJ, Ruymann FW, Van Dam J, Carr-Locke DL (2001). "Clinical outcome of the use of enteral stents for palliation of patients with malignant upper GI obstruction". Gastrointest. Endosc. 53 (3): 329–32. PMID 11231392.
  78. ↑ van Hooft JE, van Montfoort ML, Jeurnink SM, Bruno MJ, Dijkgraaf MG, Siersema PD, Fockens P (2011). "Safety and efficacy of a new non-foreshortening nitinol stent in malignant gastric outlet obstruction (DUONITI study): a prospective, multicenter study". Endoscopy. 43 (8): 671–5. doi:10.1055/s-0030-1256383. PMID 21656455.
  79. ↑ Ly J, O'Grady G, Mittal A, Plank L, Windsor JA (2010). "A systematic review of methods to palliate malignant gastric outlet obstruction". Surg Endosc. 24 (2): 290–7. doi:10.1007/s00464-009-0577-1. PMID 19551436.
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