Gastric outlet

obstruction
(case presentation)

DONE BY: SULTAN AIMAN NEAZY

37-1-1-2-0117
overview of the lecture
Case presentation.
Epidemiology of gastric outlet obstruction.
Etiology and clinical presentation of gastric outlet obstruction.
Diagnosis and management of gastric outlet obstruction.(that caused the
gastric outlet obstruction).
Management of small intestine cancer.
case presentation
(history of presenting illness )

A 52 years old male present with dizziness and nausea without loss of
consciousness and associated with hypotension.
History of yellowish odorless projectile vomiting (small amount) for 3 times/day
for 3 days.
Symptoms appeared following a gastrojejunal bypass surgery before 11 days.
He denies any cough, weight loss and contact with Covid-19 case .
case presentation
Vital signs:

respiratory rate: 18 Heart rate: 71 ( tachycardic )

Blood pressure :90/42 (hypotensive) O2 saturation: 100
Past Medical/ Medication history: ( no allergy )
-HTN controlled - DM controlled
-Dyslipidemia controlled (Atorvastatin) - AKI
-Subclinical hypothyroidism - Bilateral renal cyst
 Past surgical history:
- Surgery on the foot 20 years ago

- Gastrojejunal bypass 11 days ago (converted from wipple ) why?

- Endoscopy 2 months ago showed tubulvillous adenoma between d2 and d3

Past family history:

- No family history of any malignancy
case presentation
( why from wipple’s to gastric bypass )
case presentation
The physical examination reveals a well-nourished man.

Examination of the abdomen reveals and distended abdomen without

tenderness or Palpable masses.

The rectal examination reveals no masses, a smooth enlarged prostate

(Bestcare)
case presentation
(physical examination)
Inspection:
- well nourished man but pale (No cyanosis or jaundice)
- generalized abdominal distention (no ascites finding)
- No stoma/inguinal swelling
- gastric bypass scar (No stria or spider nevi)

Auscultation:
- Distal bowel sound audible (borborygmi)
- No renal bruit/friction rub/ aortic rub
case presentation
(physical examination)
Percussion:
- generalized hyper resonance
- liver span normal (10 cm)
- Negative Castell’s sign and tympanic Traube’s space
- No sign of kidneys enlargement
- No shifting dullness or fluid thrill
case presentation
(physical examination)
Palpitation:
- difficult to assess ( due to abdominal distention )
- No superficial mass/tenderness/ hernia (even when coughing )
- No gardening or rigidity on deep palpitation
-Organomegaly not found
-
Special maneuvers:
All ( what I did )negative
case presentation
(management at presentation)
Medication and fluids:
IV bolus ( normal saline ) over 1 hr
IV Dextrose 5% in NaCl 0.45% ( for 4 days when NPO )
IV metoclopramide + enoxaparin + esomeprazole
Insulin injection + atorvastatin + acetaminophen injection
Lab orders: CBC / chemistry / glucose
Imaging: x-ray / ultrasound / CT cap / bone scan
case presentation
(Lab orders)
Chest x ray
abdominal
x ray
(before 2
months)
abdominal x ray
(at the presentation)
minal x ray
(before 2 months)
abdominal x ray
(1 week after management )
al x ray (before 2 months)
CT scan of
Abdomen
and Pelvis
Bilateral
renal cyst
 Prostate
and Bladder
ultrasound
Bone scan
Bone scan
DEFINITION
Gastric Outlet Obstruction is clinical or pathophysiological
consequence of any disease process that produces mechanical
impediment to gastric emptying
Gastric
Outlet
Obstruction
Etiology
BENIGN
• Peptic Ulcer disease
• Ingestion of Caustics
• Trichobezoars ( Hairballs)
• Adult hypertrophic Pyloric stenosis
• Pyloric mucosal diaphragm
• Pancreatic Pseudocysts
• BARIATRIC PROCEDURES ( such as Roux-en-Y gastric bypass)
Epidemiology
• Precise estimates on the incidence of GoO are lacking.

• starting from the 21st century, the incidence have declined.

• This may be due to decline in peptic ulcer disease ( important

cause of GOO)
Etiology
MALIGNANT
• Carcinoma of Stomach
• Periampullary carcinomas
• Carcinoma Head of pancreas
• ampullary carcinoma
• Carcinoma of second part of duodenum
• cholangiocarcinomas
CLINICAL FEATURES
METABOLIC EFFECTS
• Vomiting of Hydochloric acid ( HCL) leads to hypochloremic
metabolic alkalosis
• Kidneys respond by excreting Bicarbonate and conserving chloride
• This bicarbonate is excreted with sodium
• So with time patient becomes more profoundly dehydrated and
hyponatremic
Metabolic effects
• Because of dehydration body responds to preserve intravascular volume by
sodium retention
• Now potassium and hydrogen are excreted in preference to preserve sodium
• This leads to paradoxical aciduria (acidic urine despite metabolic alkalosis)
• Hypokalemia ensues
• Alkalosis leads to lowering of circulating ionized calcium
• This can lead to tetany
Radiology
• Plane Xray Erect Abdomen:

• Large Gastric shadow and Large amount of Gastric fluid

Plane Xray
Abdomen
Barium Meal
• 6 hour period of fasting is observed prior to study
• Barium sulphate is ingested by the patient
• Xray images are taken at 20 to 30 minutes interval in
supine position
Barium
meal
Gastric
outlet
obstruction
Management
Two Aims
1.Correct metabolic abnormality
2.Deal with mechanical obstruction
Correcting Metabolic Abnormalities
• Pass double large Bore IV line
• Pass wide bore nasogastric tube to empty the stomach
• Sometimes an orogastric tube is required to lavage and empty
the stomach as nasogastric tube may not be sufficiently large
to deal with contents of the stomach
Correcting Metabolic Abnormalities
• Intravenous Normal Saline (0.9% NaCI) with Potassium
Supplementation
• Correct anemia
management
• Early cases may settle with conservative management
• NPO
• ANTACIDS
• PPI
• as the edema around the ulcer diminishes as the ulcer is healed
Surgery for benign GOO
Pyloroplasty
with vagotomy
Truncal Vagotomy
and Antrectomy
and Billroth
Reconstructions
PYLOROPLASTY
• FINEY
• JABOULEYS
• Heineke-Mikulicz
PYLOROPLAST
Y
GASTROJEJUNOSTOMY
BALLOON DIALATATION
• ENDOSCOPIC DALATION
• Repeated dilatations needed
• May cause perforation
Endoscopic
stenting for
unresectable
tumor
Pyloric
stenting
Management of Duodenal Adenoma
Resectable cancers: mainly surgical
• duodenum: Whipple procedure is typically done.
• other parts of the small intestine: segmental resection.
• near the end of the small intestine: part of the large intestine resection.
• lymph node metastasis: chemotherapy and sometimes radiotherapy
 Management of Duodenal Adenoma
unresectable cancers: mainly chemotherapy and radiotherapy
• organ metastasis: palliative surgery + chemotherapy and radiotherapy
• other options: immunotherapy ( MMR or MSI ) e.g: pembrolizumab
References
1- Bailey & Love's Short Practice of Surgery 27th

2- BMJ best practice

3- Up to date