Gastric outlet obstruction

BACKGROUND/AIMS: To study causes of gastric outlet obstruction (GOO) in Saudi patients in a tertiary hospital. During one year (between March 2005 and April 2006), twelve patients were referred to the gastroenterology department as possible GOO. METHODOLOGY: All patients had gastroscopy, barium meal and CT scan of abdomen. All patients presented with history of repeated vomiting usually after food. Two of these patients were known to have chronic duodenal ulceration. Gastroscopy in all patients showed food and fluid residue (in spite of fasting more than 12 hours), different lesions were found and biopsied. In patients who had pyloric obstruction, endoscopic dilatation for pyloric canal was done. RESULTS: Four patients had neoplastic disorders (two with adenocarcinomas and one with neuroendocrine tumor and one had lymphoma) and they were referred for surgery. Three patients had chronic duo denal ulceration and two of them were managed by endoscopic pyloric dilatation and medical treatment. One patient had cytomegalovirus (CMV) gastritis together with vitamin B12 deficiency and he improved on medical treatment. One patient had eosinophilic gastroenteritis which improved with medical treatment. One patient had adult congenital pyloric stenosis and serial endoscopic dilatation failed and was referred for surgery. One patient had superior mesenteric artery syndrome and she improved with medical treatment and advises about food and postures and she did not require surgical intervention. Lastly, one patient had GOO secondary to pancreatic tumor and was managed surgically. CONCLUSIONS: There are various causes of GOO as shown in our patients, some of which are rare and interesting such as CMV gastritis, adult congenital pyloric stenosis, eosinophilic gastritis and superior mesenteric artery syndrome. Those patients with rare causes will be included in discussion.     

Marked hypergastrinemia in gastric outlet obstruction

We report a 45-year-old woman with chronic peptic ulcer disease and multiple episodes of bowel obstruction, who was admitted with gastric outlet obstruction. Because of gastric hypersecretion, a diagnosis of Zollinger-Ellison syndrome was suspected and an initial serum gastrin of 1,251 pg/ml supported this diagnosis. Subsequent evaluation failed to reveal a gastrinoma. A repeat serum gastrin level after 14 days of continuous nasogastric decompression was 43 pg/ml, suggesting that the initial hypergastrinemia was due to antral distention. It is important to consider the possibility of gastric outlet obstruction as a stimulus for serum gastrins in the range previously considered diagnostic for the Zollinger-Ellison syndrome.     

Constipation caused by functional outlet obstruction

Functional constipation is a very common problem in Western societies. Functional outlet obstruction, part of the spectrum of functional constipation, is suspected when patients present with select symptoms. Diagnosis is commonly made with anorectal manometry, electromyography, and rectal evacuation tests. Abnormal test patterns include poor relaxation and contraction of the anal sphincter in response to attempted defecation and difficult rectal evacuation. Several treatment approaches have been tested in these patients. Biofeedback training is considered the most specific therapeutic modality, and it is particularly attractive because of its safety. This review provides an assessment of the diagnostic tests for functional outlet obstruction and summarizes current options for therapy.     

Chronic idiopathic constipation with outlet obstruction

Defecatory difficulties may be a source of great distress to patients. Normal defecation requires the coordination of abdominal and pelvic muscles. Throughout the last decade, many studies have demonstrated various and often mixed abnormalities of these mechanisms. Pathophysiological studies are able to determine, in a specific patient, the most probable causes of the obstructive symptom. Progress in the management of such disorders can only be achieved by understanding their pathophysiology.     

Echocardiographic evaluation of fixed left ventricular outlet obstruction in children. Pre and postoperative outlet obstruction in children.

Rencently, several investigators have utilized the echographically determined magnitude of relative left ventricular posterior wall hypertrophy as a reflection of normalized systolic wall stress to estimate left ventricular systolic pressure noninvasively. In this study, relative wall thickness determined echographically was compared to peak systolic pressure measured at catheterization in 20 children without obstruction to left ventricular outflow and with normal left ventricular function. From these data a relationship, pressure = 225 X left ventricular systolic wall thickness/left ventricular end-systolic internal dimension, was derived. The relationship was then applied to 57 children with fixed aortic stenosis. Left ventricular pressure estimated echographically compared well with that demonstrated at cardiac catheterization (r = 0.89). Twenty-one patients had further echographic studies following surgical relief of outlet obstruction. Estimated left ventricular pressure fell to normal values within two months following surgery in over half the patients with good surgical relief of obstruction, and was normal at subsequent studies up to 22 months postoperatively in all but one patient with good surgical relief. In patients in whom outlet obstruction was not adequately relieved at surgery, echographically estimated left ventricular pressure remained persistently elevated.     

Gastric outlet obstruction in chronic granulomatous disease

We report the case of a three year old dystrophic boy who suffered from vomiting, loss of weight and fever. In the history there were several episodes of severe infections which had repeatedly lead to hospitalisation. The cause of the actual disorder was a gastric manifestation of chronic granulomatous disease, which led by an inflammatory thickening of the gastric wall to a gastric outlet obstruction. Treatment with prednisone and gamma interferon normalised the thickness of the gastric wall and gastric outlet function. A prophylactic treatment with antibiotic and antifungeal agents was started. During the following 13 months no further severe infections were observed. We discuss incidence, kinds of manifestation, diagnostics and therapeutical options of the disease and give an overview of the literature.     

Jejunogastric intussusception presenting with outlet obstruction.

A 77-year-old man presented with sudden-onset epigastric pain and bilious vomiting following a light breakfast. Vagotomy and gastrojejunostomy for bleeding duodenal ulcer had been done 22 years ago. Barium meal study suggested jejunogastric intussusception. At laparotomy, a retrograde type II jejunogastric intussusception was confirmed and managed by reduction of the intussusception, disconnection of gastrojejunostomy and resection of the jejunum. Postoperative recovery was uneventful.