Gastric outlet obstruction (GOO) is a medical condition where there is an obstruction at the level of the pylorus, which is the outlet of the

stomach The stomach is a muscular, hollow organ in the upper gastrointestinal tract of Human, humans and many other animals, including several invertebrates. The Ancient Greek name for the stomach is ''gaster'' which is used as ''gastric'' in medical t ...

. Individuals with gastric outlet obstruction will often have recurrent vomiting of food that has accumulated in the stomach, but which cannot pass into the

small intestine The small intestine or small bowel is an organ (anatomy), organ in the human gastrointestinal tract, gastrointestinal tract where most of the #Absorption, absorption of nutrients from food takes place. It lies between the stomach and large intes ...

due to the obstruction. The stomach often dilates to accommodate food intake and secretions. Causes of gastric outlet obstruction include both benign causes, such as peptic ulcer disease affecting the area around the pylorus, and malignant causes, such as gastric cancer. Causation related to ulcers may involve severe pain which the patient may interpret as a heart condition or attack. Treatment of the condition depends upon the underlying cause; it can involve antibiotic treatment when ''

Helicobacter pylori ''Helicobacter pylori'', previously known as ''Campylobacter pylori'', is a gram-negative, Flagellum#bacterial, flagellated, Bacterial cellular morphologies#Helical, helical bacterium. Mutants can have a rod or curved rod shape that exhibits l ...

'' is related to an ulcer, endoscopic therapies (such as dilation of the obstruction with balloons or the placement of self-expandable metallic stents), other medical therapies, or surgery to resolve the obstruction.

Signs and symptoms

The main symptom is vomiting, which typically occurs after meals, of undigested food devoid of any bile. A history of previous peptic ulcers and loss of weight is not uncommon. In advanced cases, signs to look for on physical examination are

wasting In medicine, wasting, also known as wasting syndrome, refers to the process by which a debilitating disease causes muscle and fat tissue to "waste" away. Wasting is sometimes referred to as "acute malnutrition" because it is believed that epis ...

and

dehydration In physiology, dehydration is a lack of total body water that disrupts metabolic processes. It occurs when free water loss exceeds intake, often resulting from excessive sweating, health conditions, or inadequate consumption of water. Mild deh ...

. Visible peristalsis from left to right may be present. Succussion splash is a splash-like sound heard over the stomach in the left upper quadrant of the abdomen on shaking the patient, with or without the

stethoscope The stethoscope is a medicine, medical device for auscultation, or listening to internal sounds of an animal or human body. It typically has a small disc-shaped resonator that is placed against the skin, with either one or two tubes connected t ...

. Bowel sound may be increased ( borborygmi) due to excessive peristaltic action of the stomach. Fullness in the left

hypochondrium In anatomy, the division of the abdomen into regions can employ a nine-region scheme. The hypochondrium refers to the two hypochondriac regions in the upper third of the abdomen; the left hypochondrium and right hypochondrium. They are located ...

may also be present.

Causes

The causes are divided into benign or malignant. * Benign ** Peptic ulcer disease ** Infections, such as

tuberculosis Tuberculosis (TB), also known colloquially as the "white death", or historically as consumption, is a contagious disease usually caused by ''Mycobacterium tuberculosis'' (MTB) bacteria. Tuberculosis generally affects the lungs, but it can al ...

; and infiltrative diseases, such as amyloidosis. ** A rare cause of gastric outlet obstruction is blockage with a gallstone, also termed "Bouveret syndrome" or "Bouveret's syndrome". ** In children, congenital pyloric stenosis / congenital hypertrophic pyloric stenosis may be a cause. ** A pancreatic pseudocyst can cause gastric compression. ** Pyloric mucosal diaphragm could be a rare cause. * Malignant ** Tumours of the stomach, including adenocarcinoma (and its linitis plastica variant), lymphoma, and gastrointestinal stromal tumours

Pathophysiology

In a peptic ulcer it is believed to be a result of edema and scarring of the ulcer, followed by healing and fibrosis, which leads to obstruction of the gastroduodenal junction (usually an ulcer in the first part of the duodenum).

Diagnosis

The most confirmatory investigation is endoscopy of upper gastrointestinal tract. Laboratory often find hypochloremic, hypokalemic, and alkalotic due to loss of

hydrogen chloride The Chemical compound, compound hydrogen chloride has the chemical formula and as such is a hydrogen halide. At room temperature, it is a colorless gas, which forms white fumes of hydrochloric acid upon contact with atmospheric water vapor. Hyd ...

and

potassium Potassium is a chemical element; it has Symbol (chemistry), symbol K (from Neo-Latin ) and atomic number19. It is a silvery white metal that is soft enough to easily cut with a knife. Potassium metal reacts rapidly with atmospheric oxygen to ...

. High

urea Urea, also called carbamide (because it is a diamide of carbonic acid), is an organic compound with chemical formula . This amide has two Amine, amino groups (–) joined by a carbonyl functional group (–C(=O)–). It is thus the simplest am ...

and

creatinine Creatinine (; ) is a breakdown product of creatine phosphate from muscle and protein metabolism. It is released at a constant rate by the body (depending on muscle mass). Biological relevance Serum creatinine (a blood measurement) is an impor ...

levels may also be observed if the patient is dehydrated. Abdominal X-ray may show a gastric fluid level which would support the diagnosis. Barium meal and follow through may show an enlarged stomach and pyloroduodenal stenosis. Gastroscopy may help with cause and can be used therapeutically.

Differential diagnosis

The differential diagnosis of gastric outlet obstruction may include: early gastric carcinoma, hiatal hernia, gastroesophageal reflux, adrenal insufficiency, and inborn errors of metabolism.

Treatment

Treatment of gastric outlet obstruction depends on the cause, but is usually either surgical or

medical Medicine is the science and Praxis (process), practice of caring for patients, managing the Medical diagnosis, diagnosis, prognosis, Preventive medicine, prevention, therapy, treatment, Palliative care, palliation of their injury or disease, ...

Medication

In most people with peptic ulcer disease, the oedema will usually settle with conservative management with nasogastric suction, replacement of fluids and electrolytes and

proton pump inhibitors Proton-pump inhibitors (PPIs) are a class of medications that cause a profound and prolonged reduction of gastric acid, stomach acid production. They do so by irreversibly inhibiting the stomach's H+/K+ ATPase, H+/K+ ATPase proton pump. The body ...

Surgery

Surgery is indicated in cases of gastric outlet obstruction in which there is significant obstruction and in cases where medical therapy has failed. Endoscopic balloon therapy may be attempted as an alternative to surgery, with balloon dilation reporting success rates of 76% after repeat dilatons.Lam YH, Lau JY, Fung TM, et al. Endoscopic balloon dilation for benign gastric outlet obstruction with or without Helicobacter pylori infection. Gastrointest Endosc. Aug 2004;60(2):229-33 The operation usually performed is an antrectomy, the removal of the antral portion of the stomach. Other surgical approaches include: vagotomy, the severing of the

vagus nerve The vagus nerve, also known as the tenth cranial nerve (CN X), plays a crucial role in the autonomic nervous system, which is responsible for regulating involuntary functions within the human body. This nerve carries both sensory and motor fibe ...

, the Billroth I, a procedure which involves anastomosing the duodenum to the distal stomach, or a bilateral truncal vagotomy with gastrojejunostomy.

References

External links

{{Digestive system diseases Stomach disorders Syndromes affecting the gastrointestinal tract
Gastric outlet obstruction due to duodenal tuberculosis