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Gastric Outlet Obstruction
Gastric Outlet Obstruction
OBSTRUCTION
Dr Harshraj Choudhary
Department of Surgery
RNT Medical College, Udaipur
Introduction
Gastric outlet obstruction (GOO) is a condition where the
opening between the stomach and small intestine is
blocked either partially or completely.
It is not a single entity or disease, but rather a clinical and
pathophysiological consequence of any disease process
that produces a mechanical or non-mechanical impediment
to gastric emptying.
This portion of the stomach where the blockage is located
is known as the pylorus, hence the alternative term for
gastric outlet obstruction – pyloric obstruction.
Normal movement of food through the
stomach
Food and fluid enters the stomach from the esophagus through the
top of the stomach known as the cardia. It is then mixed with
stomach acid and digestive enzymes.
Strong muscular contractions of the stomach churns the food with
these enzymes. This assists with chemical digestion but also helps
break down the food into smaller pieces as part of mechanical
digestion.
Eventually it is transformed into semi-solid mixture which is then
pumped out of the stomach through the pylorus. Larger solids
remain behind in the stomach until it is broken down further.
The two common causes of gastric outlet obstruction are
(i) Gastric cancer and
(ii) Pyloric stenosis secondary to peptic ulceration.
Previously, the latter was more common.
Now, with the decrease in the incidence of peptic ulceration and
the advent of potent medical treatments, gastric outlet obstruction
should be considered malignant until proven otherwise, at least in
resource-rich countries.
The term ‘pyloric stenosis’ is normally a misnomer.
The stenosis is seldom at the pylorus.
Commonly, when the condition is due to underlying peptic ulcer
disease, the stenosis is found in the first part of the duodenum,
the most common site for a peptic ulcer.
True pyloric stenosis can occur due to fibrosis around a
pyloric channel ulcer.
However, in recent years the most common cause of gastric
outlet obstruction has been gastric cancer.
In this circumstance the metabolic consequences may be
somewhat different from those of benign pyloric stenosis
because of the relative hypochlorhydria found in patients
with gastric cancer.
EPIDEMIOLOGY
The
incidence of gastric outlet obstruction (GOO) is not precisely known, though it is likely
lower in recent years due to the decrease in peptic ulcer disease (PUD).
The clinical entities that cause GOO are generally categorized into two well-defined groups—
benign and malignant. Before the identification of Helicobacter pylori (H. pylori) and the
advent of H2-receptor antagonists, when PUD was more prevalent, benign causes of GOO
were more common than malignant causes.
Today, this ratio is reversed, with recent reviews reporting that 50% to 80% of all cases are
attributable to an underlying malignancy. The leading benign cause of GOO remains PUD,
although the incidence is very low, with GOO occurring in only approximately 2% of patients
with PUD.
In contrast, the incidence of GOO complicating primary pancreatic, gastric, or duodenal
malignancy is reported to be as high as 15% to 25%.
Etiology
BENIGN
BARIATRIC PROCEDURES
Vertical banded gastroplasty
Roux-en-Y gastric bypass
Etiology
MALIGNANT
Carcinoma of Stomach
Periampullary carcinomas
Carcinoma Head of pancreas
Ampullary carcinoma
Carcinoma of second part of duodenum
Cholangiocarcinomas
Other causes of gastric outlet obstruction