Introduction
Gastric outlet obstruction (GOO) is a clinical condition presenting symptoms like abdominal pain, post-prandial (after food intake) vomiting, and feeling of fullness. Due to the symptoms, food intake and absorption get impaired and may gradually lead to weight loss. GOO is also known as pyloric obstruction. The chances of GOO increase with age due to many factors.
What Is Gastric Outlet Obstruction?
The part of the stomach that continues and joins the intestine is called the pylorus. GOO is a surgical condition in which the pyloric channel or duodenum (the part of the intestine connecting the stomach) becomes obstructed due to extrinsic or intrinsic causes. As a result, there will be abdominal pain and gastric dilation due to the accumulation of the contents. In addition, there will be recurrent vomiting after food intake, nausea, and early satiety.
What Are the Symptoms of Gastric Outlet Obstruction?
Due to the blockage of the outward movement of gastric contents in GOO, the primary symptoms will be related to content retention. Some of them are
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Early satiety.
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Bloating or epigastric fullness.
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Nausea.
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Vomiting.
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Epigastric pain.
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Weight loss and malnutrition.
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Dehydration.
What Causes Gastric Outlet Obstruction?
A variety of factors may cause GOO. The causes can be benign or malignant or related to the motion of the digestive tract.
Benign Causes - The leading benign causes of GOO are
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Peptic Ulcer Disease (PUD) - PUD refers to sores or ulcerations developed on the inner lining of the stomach or small intestine.
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Infections - Recurrent infections caused by microorganisms can cause GOO. It includes gastric tuberculosis, Helicobacter pylori inflammation, and amyloidosis.
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Bouveret's Syndrome - Impacted gallstone in the pylorus channel or duodenum causes a rare condition called Bouveret's syndrome.
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Pancreatitis - Pancreatitis is the inflammation or swelling of the pancreas.
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Pancreatic Pseudocysts - These are false cysts growing within the pancreas.
Malignant Causes - This includes the tumors related to the gastrointestinal tract, like pancreatic cancer, duodenal cancer, and gastric cancer.
How Does Peptic Ulcer Cause Gastric Outlet Obstruction?
Peptic ulcers are open sores or ulcerations in the stomach or the duodenum, a part of the small intestine that continues from the stomach. The stomach lining is protected by a thick layer, which gets disrupted for many reasons, causing the stomach lining to be vulnerable to acid attacks. People with regular drinking and smoking habits, those taking non-steroidal anti-inflammatory drugs (NSAID), and those with H. pylori infection are more prone to this condition. In acute peptic ulcers, tissues may get edematous and inflamed, which causes obstruction in the flow of gastric contents and may lead to GOO. In chronic peptic ulcers, scarring and fibrosis of the tissues occur, leading to a block. Medications like proton pump inhibitors (PPI) and Histamine receptor blockers (H2 blockers) have shown a considerable decrease in the complications of peptic ulcer these days.
How to Prevent Gastric Outlet Obstruction Caused by Peptic Ulcer?
Untreated or recurring forms of peptic ulcers can cause GOO. Here are some tips to be considered during this condition.
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Consult your doctor to discuss alternative drugs for NSAIDs.
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Quit smoking and control or quit alcohol intake.
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Follow a balanced diet and stay hygienic.
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Seek medical help to treat the underlying infections causing peptic ulcers.
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Improve physical activity.
How Will Crohn’s Disease Cause Gastric Outlet Obstruction?
Crohn's disease is the swelling of the digestive tract tissues, causing abdominal pain, diarrhea, weight loss, and malnutrition. It is an inflammatory bowel disease (IBD). It is either caused due to hereditary causes or due to an immune response to certain infections caused by viruses or bacteria. GOO is one of the local complications of Crohn's disease, which occurs through the inflammation of the tissues and the formation of scar tissue. The tissue changes can lead to the thickening of the gastric wall, gradually narrowing the lumen and creating an obstruction.
What Is the Gastric Complication of Tuberculosis?
Tuberculosis is an infectious condition that primarily affects the respiratory tract and may secondarily spread to the digestive tract, rarely affecting the stomach and intestine. The rare spread to the gastric area is mainly due to the highly acidic secretions and ingested organisms. Epigastric pain, upper gastrointestinal bleeding, nausea, and vomiting are common symptoms of this condition. The occurrence of ulcerations manifests on the inner lining, which may become inflamed or scarred, obstructing the area.
Can Pancreatitis Lead To Gastric Outlet Obstruction?
Pancreatitis is the swelling of the pancreas due to infection, injury, surgery, cancer, gastrointestinal causes, or problematic lifestyle. The symptoms include abdominal pain radiating to the back, fever, nausea, and vomiting. In some cases of pancreatitis, pancreatic pseudocyst or false cysts grows in the pancreas. The pseudocyst, on enlarging, exerts an external compression to the gastric areas and can cause pyloric obstruction.
How Is Bouveret’s Syndrome Associated With Gastric Outlet Obstruction?
Bouveret's syndrome is the gastric outlet obstruction caused by a large gallstone that reaches the duodenum of the intestine and obstructs the lumen. After lodging within the lumen, the size of the gallstone may increase, causing the increased intensity of obstruction. Due to gastric outlet obstruction, gastric dilation is a prominent symptom of this condition. Therefore, the primary aim in managing Bouveret's syndrome is to remove this obstruction. The treatment plans may be done surgically (laparoscopy) or nonsurgically (endoscopy).
What Is Malignant Gastric Outlet Obstruction?
Malignant gastric outlet obstruction is a clinical symptom due to pancreatic and gastric malignancies. The malignant form is caused by pancreatic, duodenal, and gastric cancer. In the initial stage, intermittent symptoms may arise, gradually progressing to decreased caloric intake, weight loss, and severe malnutrition. Due to continuous vomiting, there are chances of dehydration and electrolyte loss.
How Can Gastric Outlet Obstruction Be Treated?
Initial management steps include reduction of pain and vomiting. Approaches will be taken to manage fluid and electrolyte levels and to regulate acid-base balance. Medications like proton pump inhibitors may decrease gastric secretions. The healthcare provider may undertake the first steps to relieve the symptoms.
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Endoscopic Balloon Dilation (EBD)
Pyloric balloon dilators are used to examine the area. It is an endoscopic procedure to visualize the narrowed lumen and to detect the presence of ulceration. The procedure is done using a wire-guided balloon. EBD is a treatment option for benign or mild cases alone, and if the condition is due to an underlying infection, additional treatments should be taken to cure the disease. In case of active peptic ulcers, proton pump inhibitors will be given to relieve the ulcerations before the procedure. Then, the gastroenterologist will inflate the balloon under predetermined pressure and conditions. The doctor will provide post-procedure review appointments to check for the recurrence of any symptoms.
Since the likelihood of GOO symptoms is moderate to high, proper nutrient intake is necessary during the procedure. The most effective method is by providing parenteral nutrition. After a successful treatment, the doctor will provide a liquid diet orally. Once the obstruction is reviewed and opens up, semisolid, and gradually regular food may be allowed.
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Surgical Treatment:
The only treatment option for GOO, if non-operative treatment fails, is to conduct the surgery. Some of the conventional surgical procedures are
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Antrectomy with a vagotomy.
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Pyloroplasty with a vagotomy.
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Gastrojejunoplasty with a truncal vagotomy.
Gastrojejunoplasty is the surgical procedure connecting the part of the stomach to the jejunum, the middle part of the small intestine. The surgeon may perform this procedure during malignant GOO to remove the part of the stomach with an obstruction to the small intestine. Recently, laparoscopic gastrojejunostomy became the most favorable form of surgical approach. Laparoscopy, called keyhole surgery, is a minimally invasive procedure with benefits like quick post-surgical recovery time and decreased hospitalization duration.
What Is the Difference Between Gastric Outlet Obstruction and Gastroparesis?
Gastroparesis is delayed gastric emptying without any mechanical obstruction. Gastroparesis is a neuromuscular (related to nerves and muscles) disorder, and the leading causes are surgery, diabetes, viral infection, radiation, neurological disorders, idiopathy (hidden cause), and others. Both these conditions share similar symptoms like nausea, vomiting, early satiety, and abdominal pain, but the latter is less in gastroparesis.
Conclusion
GOO can be due to benign or malignant causes. Some lifestyle changes may prevent the occurrence of pyloric obstruction. Adapting to a modified lifestyle, including following a well-balanced nutrient-rich diet, staying active, and quitting smoking and alcohol consumption, may help prevent GOO. If a symptom arises, always consult the doctor.
