Dr Amiraj Singh

MBBS, MS, DNB

PDF (Upper GI surgery),
CMC Vellore
Swelling in stomach
• Part of stomach
• Whole stomach- Gastric Outlet Obstruction
• No swelling

•
(Picture )
Part of stomach
• Benign
o Leiomyoma
o Neuroma

• Malignant
o Adenocarcinoma
o GIST
o Carcinoid
o Leiomyosarcoma
Whole stomach- Gastric Outlet Obstruction
• Benign
o Pyloric stenosis/stricture
o CHPS
o Duodenal web
o Antral polyp

• Malignant
o Distal adenocarcinoma/ GIST/ Carcinoid tumor

• External Compression
o Lymph node
No swelling felt
• Benign
o Polyps
o Partial obstruction

• Malignant
o Small anterior proximal tumors
o Posterior tumors
o Intramural GIST
o Diffuse adenocarcinoma
o NET
o Lymphoma
Gastric outlet obstruction (Benign)
• Presentation
o CHPS- children
o Pyloric stricture- adults
• PUD
• Corrosives
• Duodenal Crohns

• Vomiting- Partially digested & Non billious

• Intermittent , 1 hr after meals
o Metabolic alkalosis
o Paradoxical aciduria
• Irritable/ Confused/ Convulsions/ Rapid Breathing

• Weight loss
• Early satiety, Dehydration
• H/o PUD, Corrosive intake, ?Hematemesis
Gastric outlet obstruction (Malignant)

• Presenting age
o Distal adenocarcinoma
o Lymphoma- NHL
o NET/ GIST

• Vomiting, Dehydration
• Significant weight loss
• Hematemesis/ Melena
• Loss of apetite
• Lymphadenopathy: Virchows node, Sister Mary Joseph, Blummers Shelf
• Trousseu sign
Virchows node/ Troisier sign
Sister Mary Joseph node
Blummers shelf
Trousseau Syndrome- Migratory
Thrombophlebitis
Systemic Metastatic Workup
• Respiratory- Cough/ Hemoptysis/ Brreathing difficulty
• CNS- Seizure/ Impairement
• Hepatobiliary- Jaundice
• Musculoskeletal- Fractures
Clinical Examination
• Performance status- ECOG
• Build/ BMI
• Tachycardia
• Palor
• Icterus?
• Lymphadenopathy
Per Abdomen
• Inspection
• Palpation
• Percussion
• Auscultation
Inspection
• Epigastric fullness
• Moves with Respiration
• Visible gastric peristalsis- Left to right
Palpation
• Epigastric swelling- Intrabdominal
o Head raising test
o Leg raising test
• Confirmation – moves with respiration
• Upper – not palpable
• Invaginate your fingers
• Pulsatile-

• Ascitis
Percussion
• Tympanic mass – Epigastric/ Left upper quadrant
Auscultation
Special tests
• VGP
• Succusion Splash
• Auscultopercussion
Visible Gastric Peristalsis
• To elicit drink 100 ml fluids
Succusion Splash
• To elicit 2hrs gap of last meal intake
Ausculto Percussion
• Stethoscope over Epigastrium- Skin is scratched
o From left downwards
o Line joined- Greater Curvature of stomach
▪ Lie Below Umbilicus
Gastric outlet Obstruction
Benign Malignant