gastric outlet obstruction an overview

1. GASTRIC OUTLET OBSTRUCTION
DR.EDWINA VASANTHA,M.S.,D.G.O

2. • 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

3. 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

4. • Feeling of unwell
• Weight loss
• Abdominal swelling
EXAMINATION
• Chronically ill looking
• Wasted,dehydrated
• Pale
• May be in shock
• Epigastric /left or right hypochondrial
tenderness

5. • 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

6. 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

7. -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

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

9. • 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

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

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

12. Invasive :endoscopic balloon dialatation
Operative 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

15. • 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

16. 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

25. Thank you