An unusual case of gastric outlet obstruction

An unusual case of gastric outlet obstruction due to hypertrophic pyloric stenosis associated with prepyloric ulceration is described. An upper gastrointestinal series showed a tumorous filling defect at the pylorus. Hypertrophy of the muscle layer and tumorous, elevated mucosa were found in the pylorus, and an ulceration was present in the elevated mucosa at surgery. The clinical course was uneventful after selective vagotomy and gastric antrectomy.Offprint requests to: N. Komi     

Spontaneous biliary perforation presenting as gastric outlet obstruction

Spontaneous biliary perforation (SBP) is a rare, surgically correctable cause of jaundice in neonates. The presenting feature is usually biliary ascites, and in rare cases, biliary peritonitis. This article reports a case of SBP, which presented with features of gastric outlet obstruction, leading to an erroneous preoperative diagnosis. Most probably this is the first report of such an unusual presentation of SBP. The child underwent exploratory laparotomy and a bilio-enteric bypass with drainage of the right subhepatic space, which led to a prompt resolution of the symptoms     

Gastric duplication cyst causing gastric outlet obstruction

We report a rare case of gastric outlet obstruction in a newborn infant caused by a gastric duplication cyst. Ultrasound provided a non-invasive and conclusive diagnostic technique, which should be used as a baseline investigation for cases of suspected gastric outlet obstruction.     

Pyloric duplication presenting with gastric outlet obstruction in the newborn period

Pyloric duplication is rare condition. A case of neonatal gastric outlet obstruction caused by a duplication of the pylorus is presented. This case, successfully treated surgically, illustrates that pyloric duplication should be considered in the differential diagnosis of neonatal gastric outlet obstruction. Offprint requests to: R. A. Superina, at the Department of Surgery     

Rare causes of gastric outlet obstruction in children

Gastric outlet obstruction (GOO) presenting beyond the newborn period is a relatively rare condition, when infantile hypertrophic pyloric stenosis (IHPS) is excluded. This report describes the clinical features, evaluation and management of 18 patients with GOO which was not caused by IHPS. The sex, age, and main presenting features were recorded on admission. Hemoglobin estimation, serum chemistry and blood gas analysis were also assessed in these patients. The diagnosis was confirmed with gastrointestinal barium, B ultrasound, gastroscopy, or at surgery. Some of them underwent gastroscopy with biopsy sampling for rapid urease test or histologic examination with Giemsa stains for Helicobacter pylori. Thirteen patients had peptic ulcer disease, of which six were successfully treated with medications. While the other seven needed operative management which included Heineke-Mikulicz pyloroplasty, gastroduodenostomy or gastrojejunostomy, respectively. All the patients who had Heineke-Mikulicz pyloroplasty or gastrojejunostomy developed bile reflux gastritis that could be alleviated with omeprazol. None of the patients developed dumping syndrome, failing to thrive, or anemia. Three children with antral diaphragm recovered without any complications by diaphragm excision with Heineke-Mikulicz pyloroplasty. The pylorus was compressed by fibrotic band in one 30-month boy, and he recovered uneventfully with Heineke-Mikulicz pyloroplasty during 10-year follow-up. Gastric outlet obstruction secondary to ingestion of sulfuric acid was noted in one patient, and he was successfully treated with gastroduodenostomy. Our data suggests that the satisfactory results could be expected in children with GOO with different therapeutic modalities based on the specific cause and degree of obstruction.     

Gastric phytobezoar presenting as gastric outlet obstruction in a child after Sugiura operation for bleeding esophageal varices

A case of gastric outlet obstruction caused by persimmon phytobezoars in a 14-year-old boy who had undergone a Sugiura operation for bleeding esophageal varices 5 years before admission is reported. Although most gastric bezoars represent a complication of previous gastric surgery, the occurrence in childhood after a Sugiura operation has not been previously reported. Offprint requests to: Soon-Ok Choi     

Gastric outlet obstruction caused by ectopic pancreas in newborns and infants

Gastric outlet obstruction caused by ectopic pancreas in infants is very uncommon; there are few reported cases in the literature and in these cases the diagnostic and operative procedures were notably dissimilar. In our patient the diagnosis was established by sonography, which appears not to have been previously reported.Total excision of the tumor was possible despite the extensive inflammatory response surrounding the ectopic pancreatic tissue.     

Gastric outlet obstruction due to corrosive ingestion: incidence and outcome

A retrospective clinical study was performed to determine the incidence, management, and outcome of gastric outlet obstruction (GOO) caused by caustic ingestion in children. Of 220 patients who sustained caustic substance ingestion and were treated at our unit between 1976 and 1996, 168 ingested alkaline substances; of these, 9 children (5.3%) developed GOO in addition to esophageal strictures. The remaining 52 patients ingested acid agents, and 2 of them (3.8%) presented with GOO without esophageal strictures. The overall incidence of corrosive GOO was 5% (n = 11). The mean age of the patients with GOO was 5.7 ± 2.8 years (range 2–14) with a female:male ratio of 6:5. Sodium hydroxide (n = 6), potassium hydroxide (n = 3), and hydrochloric acid (n = 2) were the ingested caustic agents. The patients were subdivided into two groups according to serial endoscopic and radiologic findings: group I: moderate (dense superficial and spotty ulcerations with intact mucosa) mucosal injury with partial pyloric obstruction; and group II: severe (deep ulcerations, extreme hemorrhagic erosions, eschar formation with white plaques) mucosal injury with complete pyloric obstruction. Group I consisted of 5 patients who ingested alkali agents while group II included 6 who presented with ingestion of alkaline (n = 4) and acid (n = 2) agents. Surgical treatment included Billroth I (n = 6) operations performed in group II and Finney (n = 3) and Heineke-Mikulicz (n = 2) pyloroplasty procedures done in group I. All patients are alive without any complaints. Fiberoptic endoscopy should be the preferred method of evaluating a patient with ingestion of a corrosive agent. It determines the presence of injury and assesses the extent of damage, establishing the diagnosis and allowing therapy to be instituted immediately. Our experience revealed that substantial damage has occurred early after ingestion, and early surgical intervention has decreased the morbidity and mortality. The extent of the mucosal injury and status of the pylorus and antrum determined the type of surgical treatment. A Billroth I procedure recommended for severely injured mucosa with complete pyloric obstruction, and pyloroplasty for moderate mucosal injury associated with partially obstructed but still viable pylorus. In contrast to the current belief, alkali ingestion also has a high risk of corrosive gastric injury causing GOO, which should be considered during assessment of the injury. We emphasize that a detailed evaluation of radiologic and especially endoscopic findings is very important for determining the timing, necessity, and type of appropriate surgical treatment. Accepted: 17 June 1998     

Infantile myofibromatosis: a most unusual cause of gastric outlet obstruction

Non-bilious vomiting in the newborn is common. Etiologies include both surgical and medical conditions. Gastroesophageal reflux, soy or milk protein allergy, and prostaglandin-induced foveolar hyperplasia are among the medical causes. Surgical entities include gastric antral webs, pre-ampullary duodenal and pyloric atresia, and hypertrophic pyloric stenosis. We report the unique case of an 8-day-old girl who presented with gastric outlet obstruction secondary to infantile myofibromatosis.     

Gastric outlet obstruction caused by prepyloric mucosal diaphragm mimicking duodenal ulcer: a case report

An 11-year-old child was evaluated for chronic gastric obstruction with intermittent symptoms from the age of 11 months. An upper gastrointestinal series performed at the age of 11 months was interpreted as compatible with severe pyloric stenosis due to a duodenal ulcer, but no surgery was recommended. Several other UGIT series, and at least four endoscopies performed during the following years by experienced gastroenterologists in Israel and in the United States, failed to reveal the true nature of the gastric outlet obstruction. The patient was operated upon shortly after referral to our institute. Upon celiotomy, a congenital antral web was found, the excision of which resulted in long-term relief of all symptoms. The differential diagnoses of childhood gastric outlet obstruction and the possible pitfalls in the diagnostic workup are discussed.     

Transient gastric outlet obstruction and tetralogy of Fallot: a true association or a coincidental finding?

Infants suffering from congenital heart anomalies who are receiving intravenous prostaglandins may present with gastric outlet obstruction. We describe a newborn with tetralogy of Fallot who was not being treated with prostaglandins and presented with gastric outlet obstruction. The typical clinical and radiological signs of infantile hypertrophic pyloric stenosis resolved spontaneously within several days. We suggest that there may be an association between cyanotic heart disease and gastric outlet obstruction unrelated to the use of prostaglandins.     

A rare case of esophageal atresia with gastric outlet obstruction

Although the combination of gastric outlet obstruction and esophageal atresia is rarely seen in neonates, it has been well described. We report the case of a 5-day-old newborn with esophageal atresia and tracheoesophageal fistula associated with complete gastric outlet obstruction due to a mucous plug. As the patient had intense gastric distention, severe respiratory distress requiring ventilatory therapy and complete pyloric obstruction in radiograms, emergency gastrostomy was performed before definitive operation. Definitive treatment consisted of tracheoesophageal fistula ligation and primary esophageal anastomosis. Exploratory laparotomy during the same session revealed a normal pyloric canal, completely obstructed by a firm mucous plug. The plug was removed by pylorotomy, and a pyloroplasty was performed to ease gastric evacuation. Postoperative feeding problems suggested gastric dysmotility as the possible cause for the mucous plug obstruction.     

Successful management of an acquired gastric outlet obstruction with endoscopy guided balloon dilatation

Antral-pyloric strictures and gastric outlet obstruction are known complications of caustic ingestions. These lesions can develop even in the absence of overt signs of potentially serious upper gastrointestinal tract pathology such as oropharyngeal burns, dysphagia, vomiting, or abdominal pain at the time of ingestion. The development of radial balloon catheters, which can be endoscopically guided into narrow strictures and inflated, offers an alternative therapy to surgical resection of obstructing lesions. We report the successful management of a pyloric stricture secondary to a caustic ingestion by sequential endoscopically guided balloon dilatations and offer guidelines for the use of this procedure.     

Congenital bladder diverticulum causing bladder outlet obstruction: case report and review of the literature

Reports of acute urinary retention caused by obstruction from a congenital bladder diverticulum are rarely found in the literature: to date, only ten such cases have been reported. We describe a 3-month-old boy whose urinary retention could be traced to such a cause and describe a minimally traumatic reconstructive technique. Correspondence to: C. A. Sheldon     

Rapid deterioration of primary fourth ventricular outlet obstruction resulting in syndrome of inappropriate antidiuretic hormone secretion

Fourth ventricular outlet obstruction (FVOO) is a rare cause of obstructive hydrocephalus. Although FVOO accompanied by malformative syndrome and secondary causes of obstruction are common, there are few reports of primary FVOO (PFVOO). The syndrome of inappropriate antidiuretic hormone secretion (SIADH) is a rare presenting feature of hydrocephalus. A 1‐year, 8‐month‐old boy with a normal head circumference developed SIADH accompanied by rapid deterioration of symptoms of intracranial hypertension. PFVOO was diagnosed because magnetic resonance imaging revealed an enlarged ventricular system with a barely visible membranous obstacle at the foramen of Magendie. All symptoms were resolved by endoscopic third ventriculostomy. PFVOO should be considered as a rare form of congenital obstructive hydrocephalus, especially in patients with tetraventricular hydrocephalus. To the best of our knowledge, this is the first case of an infant with SIADH, resulting from acute deterioration of non‐tumoral raised pressure hydrocephalus.     

An unusual case of small bowel obstruction: heterotopic gastric mucosa

We report a case of heterotopic gastric mucosa (HGM) causing small-bowel obstruction by occlusion of the jejunal lumen, confirmed at laparotomy. The clinical presentation, radiographic features, and pathological findings are described and a brief review of the literature is cited. It is very rate for HGM to present in this way and the surgical significance is described. Offprint requests to: J. P. A. Lodge     

Chronic granulomatous disease of childhood

Diffuse gastric infiltration in a child with CGD is described as a cause for gastric outlet obstruction.     

Pseudoweb of the gastric antrum in infants

Two infant boys, one 3 months of age and the other 8 weeks of age, with symptoms suggesting gastric outlet obstruction had upper gastrointestinal fluororadiographic examinations which showed typical signs for gastric antral webs (diaphragms or membranes), but neither had actual webs as proven by surgery in one and by endoscopy in the other. The report emphasizes the possibility of falsely positive radiographic findings, which can be tested by potentially corroborative fiberoptic endoscopy, thus avoiding unnecessary surgery.     

A sticky case of intestinal obstruction

The cause of intestinal obstruction in children can occasionally be obscure although history and examination usually directs the clinician to the correct diagnosis. Pica, the ingestion of non-nutrient material, however can be surreptitious and escape detection. A case report is presented of a 9-year-old child with an extensive and complicated surgical history. Following lengthy investigation and progression of sub-acute to acute intestinal obstruction over a long period, the cause was finally found to be due to persistent ingestion of Blu-Tack—a common household putty-like adhesive.