Gastric outlet obstruction due to duodenal bezoar: A case report

INTRODUCTIONGastric outlet obstruction (GOO) is a clinical syndrome characterized by abdominal pain and postprandial vomiting. Causes of GOO include both benign and malignant disease. Bezoars, concretions of undigested or partially digested material in the gastrointestinal tract, are a rare entity and GOO due to duodenal bezoar is an uncommon presentation.PRESENTATION OF CASEWe report the case of a 56-year-old woman who presented to the emergency department acutely with a 3-day history of epigastric pain, weakness and postprandial nonbilious vomiting. Initially, an upper gastrointestinal endoscopy (UGE) was performed to evaluate the cause of the GOO. A solid impacted bezoar was detected in the first portion of the duodenum with complete obstruction of the pyloric canal. In spite of multiple attempts for fragmentation using different devices, the extraction attempts failed. We administered acetylcysteine and cola per os. Abdominal computerized tomography was obtained and showed a solid mass in the duodenum. UGE was performed once more however, the mass was not suitable for fragmentation and removal. Thus, surgical treatment was decided. The bezoar was extracted via gastrotomy. The postoperative period was uneventful.DISCUSSIONEven if a duodenal bezoar is small, because of its location it may cause GOO with abruptly clinical features. The diagnostic approach is similar to the other causes of the GOO. However, therapeutic options differ for each patient.CONCLUSIONWe should remember all the therapeutic and diagnostic options for a patient with upper gastrointestinal bezoars who present at the hospital whether or not there is a predisposing risk factor.     

Gastric outlet obstruction secondary to Morgagni hernia: a case report

An 89-year old female presented to us with symptoms of gastric outlet obstruction which appeared to be secondary to gastric volvulus on preoperative work-up. On laparoscopy the stomach was found to be incarcerated in a right-sided Morgagni hernia with surrounding adhesions. The hernia was reduced after dissecting the adhesions and the diaphragmatic defect was repaired using a biologic mesh onlay patch (Surgisis^® GOLD?, Cook Biotech Inc.). Her postoperative recovery was uneventful and she was doing well at three months follow-up.     

Gastric outlet and duodenal/ileal obstruction due to gastric phytobezoar

We herein present the case of an 83-year-old man, ASA status III, with a fragmented gastric phytobezoar causing obstruction in different parts of the gastrointestinal tract. The initial mass was obviously in the stomach, and due to continuing coughing and vomiting the bezoar was fragmented. The apex of the bezoar moved through the deformed pyloric channel, temporarily occluding first the duodenojejunal flexure and afterwards the ileus, while the larger remnants repeatedly sealed off causing gastric outlet obstruction. At emergent laparotomy, a gastrojejunostomy was created through which both bezoars were extracted, and the operation was completed with a vagotomy. The patient had an uneventful postoperative outcome and is doing well at 12-month follow-up. Complicated bezoars require emergent surgical removal.     

Gastric pneumatosis and concurrent aeroportia due to gastric outlet obstruction: A case report

Introduction and importanceGastric pneumatosis with concurrent hepatic portal vein gas is an extremely rare condition in the adult population. It can be idiopathic or associated with well-known etiologies. Gastric outlet obstruction can progressively inflate the stomach and cause pneumatosis. Regarding abdominal signs and the presence of acute abdomen, management varies from just conservative to emergent surgical interventions.Case presentationWe introduce an adult patient who presented to our hospital with weakness and dyspnea. After initial measures, unexpectedly we found intraabdominal free gas, concurrent gastric pneumatosis, and aeroportia. Due to the absence of positive abdominal signs, the patient was treated successfully without any surgical or endoscopic interventions.DiscussionGastric outlet obstruction is a well-known cause of gastric pneumatosis. Progressive dilation of the stomach due to pyloric stenosis is well-described both in infants and adult populations.ConclusionIn stable patients, gastric drainage and correction of electrolyte disturbance are the only required treatment. However endoscopic and surgical interventions should be considered in unstable patients or those developing acute abdomen.     

Gastric outlet and duodenal obstruction from inflammatory pancreatic disease

During a ten-year period, 16 patients with gastric outlet and duodenal obstruction due to inflammatory pancreatic disease were seen. The cause of obstruction was chronic pancreatitis in ten patients, pseudocysts with associated pancreatitis in five patients, and pancreatic abscess in one patient. All patients had nausea and vomiting, 14 had abdominal pain, and five had weight loss greater than 4.5 kg. Diagnosis was made by plain abdominal film in one case, upper gastrointestinal tract roentgenographic series in 15 cases, and endoscopy in 11 cases. Mobilization of the duodenum relieved the obstruction in two patients. Fixed obstruction remained in 14 patients. This was relieved by gastrojejunostomy in 12 patients. Gastrojejunostomy was combined with drainage of a pseudocyst in three patients, a dilated pancreatic duct in three patients, and a dilated common bile duct in four patients. Obstruction was relieved by pseudocyst drainage in two patients. Associated common duct and pancreatic duct obstruction must be identified preoperatively.     

Acute abdomen due to J-pouch outlet obstruction: A case report and review of literature

IntroductionIleal pouch–anal anastomosis is the procedure of choice for re-establishing intestinal continuity for patients undergoing total proctocolectomy. Despite growing experience with this procedure, it is still associated with considerable morbidity rates.Presentation of caseHerein, we report the case of a 14-year-old boy with familial adenomatous polyposis who underwent total proctocolectomy, ileal pouch–anal anastomosis, and diverting ileostomy. The patient developed early postoperative complications; on postoperative day 1, he developed bleeding from the pouch staple line, which was managed endoscopically. On postoperative day 15, he developed intestinal obstruction due to adhesions. One year after proctocolectomy, ileostomy closure was performed uneventfully. From postoperative day 3, the patient presented with obstructive signs such as abdominal distention, bloating, abdominal pain, and fever. Computed tomography identified diffuse intense intestinal distension with pouch dilatation. Digital rectal examination identified the pouch filled with liquid stool and no signs of anal canal anastomosis stenosis. The patient was considered to have pouch outlet obstruction and was successfully managed using bedside evacuation anoscopy. After 3 days, oral nutrition was re-established, and appropriate stool evacuation and fecal continence were achieved.DiscussionProctocolectomy with ileal pouch–anal anastomosis still carries a considerable complication rate. Proper identification of causative factors is mandatory for appropriate treatment. Pouch outlet obstruction can present as acute abdomen after diverting ileostomy closure. In this case, outlet obstruction was identified and treated by pouch evacuation, avoiding morbidity of a new surgical procedure.ConclusionWe presented an unusual case of acute intestinal obstruction due to pouch outlet obstruction that was managed nonoperatively with bedside pouch evacuation.     

Portomesenteric gas due to intestinal obstruction: a case report

A case of mesenteric vein gas as a nonfatal complication of intestinal obstruction is reported. A 48-year-old woman presented postoperatively signs and symptoms of acute abdomen on the eighth day following a gastric pull-up surgery due to an oesophageal carcinoma. The abdominal tomography findings revealed dilated jejunal segments and free gas in the superior mesenteric vein and end branches of the portal vein in the left hepatic lobe. The patient underwent a second laparotomy with a provisional diagnosis of intestinal ischaemia. Intraoperative gross appearance of the intestines revealed no ischaemic finding, the pathology was the dense adhesions between the jejunal segments and previous incision site. On the basis of these findings, the operation was ended with adhesiolysis. One month after the operation, the patient was well, there were no complications. As the authors, we think that the main reason for portomesenteric gas is mucosal destruction and that these case may be followed conservatively as long as intestinal ischaemia is excluded.     

Intestinal perforation due to phytobezoar obstruction: a case report

Phytobezoars are uncommon causes of acute abdomen. We report a patient who presented with acute abdomen and who was intra-operatively diagnosed as having a small intestinal perforation due to an intestinal phytobezoar.     

Gastric outlet obstruction by a lost gallstone: Case report and literature review

IntroductionSpilled gallstones from a laparoscopic cholecystectomy can be a source of significant morbidity, most commonly causing abscesses and fistulae. Preventative measures for loss, careful removal during the initial surgery, and good documentation of any concern for remaining intraperitoneal stones needs to be performed with the initial surgery.Case reportAn 80-year-old male with a history of complicated biliary disease resulting in a cholecystectomy presented to general surgery clinic with increasing symptoms of gastric outlet obstruction. CT imaging was concerning for a malignant process despite negative biopsies. A distal gastrectomy and Billroth II reconstruction was performed and final pathology showed dense inflammation with a single calcified stone incarcerated within the gastric wall of the inflamed pylorus and no malignancy.DiscussionStones lost during laparoscopic cholecystectomy are not innocuous and preventative measures for loss, careful removal during the initial surgery, and good documentation of any concern for remaining intraperitoneal stones.ConclusionThis is the first case of gastric outlet obstruction caused by an intramural obstruction of the pylorus from a spilled gallstone during a laparoscopic cholecystectomy and subsequent inflammation. This is an etiology that must be considered in new cases of gastric outlet obstruction and can mimic malignancy.     

Trichobezoar presenting as a gastric outlet obstruction: A case report

IntroductionRapunzel syndrome is a rare intestinal condition that starts with the ingestion of a trichobezoar. The condition is predominately found in females and can be associated with trichotillomania, or the compulsive urge to pull one’s own hair out. There are less than 40 cases described in the literature with the prevention of recurrence aimed at psychological treatment.Presentation of caseThe patient is a 7 year-old girl with a history of trichotillomania with trichophagia as a young child who presented with abdominal pain, nausea, and vomiting, consistent with a gastric outlet obstruction. She had an exploratory laparotomy with gastrostomy performed revealing a 18 cm by 18 cm trichobezoar with extension into the small bowel.DiscussionBezoars, an already rare entity, can occasionally lead to gastric and small bowel obstructions. Small collections of ingested hair build up in the intestinal tract causing significant symptoms. These obstructions can sometimes be treated through minimally invasive techniques but, in our case described, it is unlikely to have been treated any other way due to the substantial size of the trichobezoar.ConclusionEarly consideration of Rapunzel syndrome is important in young females presenting with a gastric outlet obstruction.     

Gastric teratoma presented as gastric outlet obstruction and melena; report of rare case

Gastric teratoma is a very rare tumor, accounting for less than 1 % of all teratomas in infants and children. Melena or upper gastrointestinal tract bleeding in newborns and infants is a rare event and is usually caused by a benign lesion. Gastric teratoma has been reported as a cause of gastrointestinal bleeding on a few occasions. As gastric teratomas generally present as a palpable abdominal mass, more aggressive solid masses of childhood must be excluded. We present intramural extension of gastric teratoma presented as symptom of gastric outlet obstruction and melena.     

Gastric outlet obstruction secondary to pancreatic cancer

Background: Gastric outlet obstruction in patients with pancreatic cancer has a grim prognosis. Open surgical bypass is associated with high morbidity, whereas endoscopic duodenal stenting appears to provide better palliation. Methods: We reviewed the medical records of patients with gastric outlet obstruction secondary to pancreatic carcinoma who were admitted to our clinic between 1 October 1988, and 30 September 1998. The data included stage of disease, American Society of Anesthesiologists (ASA) class, surgical interventions, complications, and survival. Results: A total of 250 patients with pancreatic cancer were identified. Twenty-five of them (10%) had gastric outlet obstruction. Of these 25, 17 were treated with gastrojejunostomy, six had duodenal stenting (Wallstent), and two were resectable. There was no significant difference between the gastrojejunostomy group and the duodenal stenting group in ASA class or stage of disease. For the gastrojejunostomy group, median survival was 64 days (range, 15-167) and postoperative stay in hospital was 15 days (range, 8-39). For the duodenal stenting group, median survival was 110.5 days (range, 42-212) and postoperative stay was 4 days (range, 2-6). Ten patients (58.8%) in the gastrojejunostomy group had delayed gastric emptying. All of the patients in the duodenal stenting group were able to tolerate a soft diet the day after stent placement. Thirty-day mortality in the gastrojejunostomy group was 17.64%; in the duodenal stenting group, it was 0. Conclusion: In pancreatic carcinoma patients with gastric outlet obstruction, duodenal stenting results in an earlier discharge from hospital and possibly improved survival.     

Gastric outlet obstruction as a consequence of a duodenal web masquerading as gastrinoma in an adult

We present the case of a 24-year-old man with recurrent peptic ulcers and hypergastrinemia, in whom a multidisciplinary investigation for gastrinoma revealed a duodenal web. The affected duodenal segment was excised, and a gastroduodenostomy with highly selective vagotomy was performed. Postoperative serum gastrin levels returned to the normal range over the next 6 weeks. Congenital duodenal anomalies are unusual causes of gastric outlet obstruction in adults. Chronic gastric outlet obstruction secondary to an adult duodenal web can induce neurohumoral changes in gastric function, which enhance both acid output and gastrin secretion. This case reminds clinicians to consider congenital anomalies in adults presenting with recurrent peptic ulcers and hypergastrinemia.     

Common bile duct perforation due to tuberculosis: a case report

A young man with HIV presented with biliary peritonitis secondary to spontaneous common bile duct perforation. Investigation revealed that the perforation was due to Mycobacterium tuberculosis. Tuberculosis of the bile duct is uncommon and usually presents with obstructive jaundice due to stricture. Bile duct perforation due to tuberculosis is extremely rare. Its management is discussed.     

Intestinal obstruction due to phytobezoars of banana seeds: a case report

Phytobezoars are a well-known, though rare, cause of mechanical alimentary tract obstruction. They occur mainly in patients who have undergone abdominal surgery, where most literature reports describe the causes as persimmons and oranges. We report four cases, seen within a period of 19 months in Laos, with intestinal obstruction caused by phytobezoars from jungle banana seeds. They had no history of previous gastrointestinal surgery. The recommended therapy in total obstruction is laparotomy, "milking" through the ileocaecal junction, or enterotomy and direct extraction. As recurrence and presentation at multiple sites are possible, all of the gastrointestinal tract should be thoroughly examined intraoperatively.