Gastric outlet obstruction

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

13. 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

14. 2) Late dumping: due to hypoglycaemia Mgt:small meals,less carbohydrates,antiperistaltic loop duodenal blow out:4-5 th post op day,life threatening, mgt;fluid and electrolyte correction,enteroentostomy

15. Thank you