Gastrci outlet obstruction

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1. Gastric outlet obstruction Sunil Kumar Daha

2. May be pre-pyloric, pyloric or duodenal Most commonly associated with Long standing peptic ulcer disease (Pyloric stenosis) Gastric cancer Nowadays, Crohn’s disease , external compression from a pancreatic carcinoma are being common causes Introduction

3. Causes Children Idiopathic hypertrophic Pyloric stenosis (IHPS) Gastric volvolus Hiatal hernia Antral web Gastric duplication Polyps Neoplasm Malrotation Adult Gastric carcinoma Pyloric stenosis secondary to Peptic ulcer disease Crohn’s disease Pancreatitis Large gastric polyps Gastric tuberculosis Gastric volvolus Pyloric mucosal diaphragm Trichobezoar / phytobezoar

4. Pyloric stenosis Narrowing occurs in the first part of the duodenum, seldom at pylorus Chronic duodenal ulcers after many years Scarring and cicatrisation Total obstruction of pylorus Enormous dilatation of the stomach Stomach full of ingested food , fluid and gastric juice vomiting

5. Clinical features History Long h/o peptic ulcer disease Pain persistent in epigastric region , radiates from above and left of umbilicus to the LIF often with feeling of fullness , within1/2 hr of food intake loss of periodicity

6. Contd … Vomiting – large quantity , foul smelling and frothy vomitus  partially digested or non-digested food , non-bilious Hematemesis or malaena may occur Loss of appetite and weight

7. Clinical features On examination Patient appear unwell and dehydrated Confused status d/t alkalosis and electrolyte changes Visible gastric peristalsis - from left  right , elicited by asking the pt. to drink a cup of water pathognnomonic Positive succussion splash – on shaking pt’s abdomen On auscultation and persussion – dilated stomach ( the greater curvature lies below the level of umbilicus here)

8. Metabolic Effects Vomiting of HCl → Hypochloraemic alkalosis → Progression of dehydration → Metabolic abnormalities related to the renal function HCO3 excreted along with Na + → Hyponatremia and profound dehydration → Na + retention with K+ and H+ excretion → Urine acidic → Metabolic Alkalosis and Hypokalaemia → Hypocalcaemia → Tetany

9. Investigation Laboratory: Sodium, Potassium, Urea, Creatinine CBC (TC, DC, Hematocrit) Abdominal X-ray USG/ CT scan Endoscopy and biopsy – to rule out gastric Ca and view stenosed area Barium meal study Endoscopic ultrasound ECG – for hypokalemia

10. Management Involves Correcting the metabolic abnormality Dealing with the mechanical problem Addressing the electrolyte abnormality Rehydration with IV isotonic saline with K supplementation NaCl and water replacement  to allow kidney to correct acid-base abnormality Ca ,K and Mg supplementation Blood transfusion if pt is anemic

11. Management contd ….. Stomach should be emptied using wide bore gastric tube and lavage the stomach till completely emptied This allows investigation of patient with endoscopy and contrast radiology Biopsy  around the pylorus to exclude malignancy . IV Proton pump inhibitor  decreases gastric secretion and improves inflammatory response and ensures absorption

12. Management contd …. Endoscopic treatment with balloon dilatation May be useful in early cases Has complications of perforation and dilatation may have to be performed several times may not be successful in long term

13. Surgery Highly Selective Vagotomy (HSV) with gastrojejunostomy technically difficult but better than truncal vagotomy Maintains the nerve supply of chronically obstructed antrum May reduce the chronic emptying problems Truncal vagotomy with gastrojejunostomy of Mayo  commonly advocated Vagotomy , antrectomy with Billroth I anastomosis with feeeding jejunostomy for nutrition

14. Gastric Carcinoma It is the most common cause of Gastric Outlet Obstruction in recent years Less metabolic abnormalities due to less acid–base disturbance 16

15. Risk Factors for Stomach Cancer H. pylori infection – Ca. distal stomach or body of stomach Pt. with peptic ulcer surgery Reflux gastritis Smoking or dust ingestion Obesity  Proximal gastric cancer (Higher socio-economic groups) 17

16. Distribution of Gastric Cancer 18

17. Clinical Features In early stage no specific sign and symptoms Late features include: Dyspepsia Vomiting Early satiety Bloating Distension Iron deficiency anemia Obstruction leads to dysphagia or E pigastric fullness Virchow’s node enlarged Thrombophlebitis: Trousseau’s sign positive Deep Vein Thrombosis

18. Trosier’s sign Trousseau’s sign of malignancy

19. Comparing….

20. Pathology Early Gastric Cancer Cancer limited to mucosa and submucosa With or without lymph node involvement Can be either protruding, superficial or excavated Late Gastric Cancer Involves muscularis externa

21. Spread of carcinoma of stomach Distant spread Unusual before disease spreads locally Uncommon in the absence of lymph node metastasis Routes of spread Direct spread: penetrates muscularis , serosa and untimately adjacent organs like pancreas, colon, liver

22. Lymphatic Spread : Antrum right gastric lymph nodes superiorly gastroepiploic and subpyloric lymph nodes inferiorly Pylorus- right gastric suprapyloric lymph nodes superiorly subpyloric lymph nodes inferiorly Suprapyloric→paraaortic Subpyloric → superior mesenteric lymph nodes Tumor can appear in supraclavicular lymph node ( Troisier’s sign) Nodal involvement does not imply systemic dissemination

23. Contd … Blood- borne metastasis First to liver than to other organs like lungs and bone Uncommon without nodal involvement Trans peritoneal Spread Common mode of spread once tumor reached serosa of stomach and indicates incurability Ovaries may also be involved sometimes ( Krukenberg’s tumors)

24. Management Total gastrectomy (Esophagojejunostomy) Proximal Tumor and Mid-body Tumor Subtotal Distally placed tumor Proximal stomach preserved Post -operative Complications Immediate : B leeding Early : Leakage, Secondary Hemorrhage Late : Fistula, Septic collection, nutritional deficiency

25. Management: Others Radiotherapy Radiosensitive tissue in gastric bed which limits the dose, so not much effective Role in palliative treatment Chemotherapy Respond well to combined cytotoxic chemotherapy and neo-adjuvant chemotherapy Palliative surgery In patient with significant symptoms of either obstruction or bleeding Remove the tumor and reconstruct the gastrointestinal tract

26. Palliative Surgery High gastroenterostomy Roux loop with a wide anastomosis between the stomach and jejunum Gastric exclusion and O esophagojejunostomy . Inoperable tumors situated in the cardia : palliative intubation, stenting or another form of recanalisation The end

27. References Bailey and Love’s Short Practice of Surgery; 26 th Edition SRB’s manual of surgery; 5 th edition