Gastric outlet obstruction

GASTRIC OUTLET OBSTRUCTION

DR.EDWINA VASANTHA,M.S.,D.G.O

• GOO is the clinical and pathophysiological consequence of any symptom complex that produces a mechanical impediment to gastric emptying.

HISTORY• AGE :20-45 years with peak 30-35 years• Abdominal pain site:epigastric and left hypochondrial pain relationship to food: food - pain -relief=du food – pain =gu

relieved by alkali,milk association with time of the day h/o radiation to the back(? Pancreas penetration) generalised pain(perforation)• Anorexia,nausea• Early satiety• Vomiting- characteristic unpleasant -copious -projectile -non bilous,food taken several hours to days ago

• Feeling of unwell• Weight loss• Abdominal swelling

EXAMINATION• Chronically ill looking• Wasted,dehydrated• Pale• May be in shock• Epigastric /left or right hypochondrial

tenderness

• Distended abdomen• Visible gastric peristalsis• hepatosplenomegaly• Succussion splash• Auscultopercussion test-to look for stomach

dialatation• Internal pelvic,per rectal examination• Vitals• Lymph nodal enlargement- left supraclavicular

INVESTIGATIONS• To stabilise patient -complete haemogram -serum electrolytes, -arterial blood gases -urinalysis• To confirm diagnosis -plain x-ray abdomen erect -gastric function tests:>400ml resting juice aspirated shows presumptive diagnosis of GOO -endoscopy and biopsy

-barium meal:findings markedly dialated stomach with a lot of residue gastritis,stasis chronic cicatrised ulcer,diverticula trifoliate deformity of duodenal cap pyloric opening narrowed or total obstruction• Detection of H.pylori -Non invasive serology

carbon labelled urea breath test -invasive rapid ureasetest histology and culture

• Differential diagnosis PUD Gastric polyps Ingestion of caustics Pyloric stenosis; mostly fisrt borne male child Congenital duodenal webs Gallstone obstruction (Bouveret syndrome) Pancreatic pseudocysts bezoars Cast syndrome(superior mesentric artery

Malignancy pancreatic cancer ampullary cancer duodenal cancer cholangiocarcinoma gastric cancer metastases to gastric outlet from other primary

• TREATMENTGeneral measures resuscitation : IVF urethral catheter nasogastric tube correction of electrolyte imbalance ideally under ECG monitoring anaemia correctionAntisecretory therapy Non operative : warm saline lavage H.pylori eradication

Invasive :endoscopic balloon dialatationOperative measures highly selective vagotomy+GJ+H.pylori eradication truncal/selective vagotomy +Billroth II +kocherisation +HP Eradication TV/SV+ Antrectomy+GJ/GD+Kocherisation+HP eradication OBSTRUCTING TYPES-distal gastrectomy+TV+GJ+HPE

• POST OP COMPLICATIONS immediate:primary haemorrhage injury to contiguous strictures aneasthetic complications early: postgastrecrtomy syn i)early dumping: 20-30 mins after ingestion ofmeal both GI and cardiovascular symptoms Mgt-pt.informed preop dietary modification,long acting somatostatin analogue,jejunal 20cm isoperistaltic loop interposition,jejunal 10cm antiperistaltic loop interposition

2) Late dumping: due to hypoglycaemia Mgt:small meals,less carbohydrates,antiperistaltic loop

• duodenal blow out:4-5th post op day,life threatening, mgt;fluid and electrolyte correction,enteroentostomy

Thank you