Gastric outlet obstruction

1
Gastric outlet obstruction

• 50 due to underlying malignancy 40 due to
  duodenal or pyloric channel ulceration 5
  gastric ulceration
• Pathogenesis acute spasm, edema,
  inflammation, pyloric dymotility
• Chronic fibrosis, scarring
• Late gastric atony after prolonged obstruction

2
Gastric outlet obstruction

• Signs/symptoms vomiting (gt80 of cases),
  anorexia, bloating, early satiety, weight loss,
  midepigastric pain, recognizable food gt8hours
  post prandial
• Ddx malignancy, gastric motility disorder,
  hypergastrinemia, hiatal hernia with obstruction
  or strangulation
• W/U EGD with biopsies to r/o malignancy,
  gastric emptying study or saline load NG study,
  upper GI series

3
Gastric outlet obstruction

• Treatment place NG (note residual), correct
  electrolytes, IVF, IV H2 blocker. 1/2 will
  respond to this regimen.
• Refractory cases endoscopic balloon dilatation,
  surgical management (truncal vagotomy
  gastrojejunostomy).
• Identify and treat underlying cause.

4
Gastroparesis

• Diabetes mellitus (gt5 years, poor control),
  autonomic dysfunction of motor control
• Scleroderma infiltrative process must
  distinguish from esophageal dysmotility
• Medications alpha blockers, TCAs,
  anticholinergics, dopaminergics
• Prior gastric surgery with vagal denervation
• Neurologic disease multiple sclerosis, brain
  stem stroke/tumor, amyloid neuropathy, primary
  dysautonomias, HIV, Parkinsons

5
Gastroparesis

• Diagnosis EGD or upper GI series to exclude
  mechanical obstruction
• Gastric empyting study radiographic egg meal
  with two hour and four hour residuals
• Treatment dietary modification (small frequent
  meals that are low in fiber, low in fat)
  motility agents (metoclopramide, tegaserod)

6
Hiatal hernia

• Distal end of esophagus is anchored by the
  phrenoesophageal membrane
• Subject to wear and tear age related
  degeneration, and tonic contraction of
  surrounding esophageal smooth muscle due to acid
  reflux
• Herniation Type I sliding, 95 of cases. A
  portion of the gastric cardia herniates upward.
• The only complication is GERD (heartburn, chest
  pain, dyspnea, chest fullness, belching)

7
Hiatal hernia

• Type II, III, IV these are rare (5 of cases),
  also termed paraesophageal hernias
• Type II localized defect in the
  phrenoesophageal membrane but the GE junction
  remains fixed?herniation of the gastric fundus
• Type III type I II (sliding element)
• Type IV largest defect with other organs
  (spleen, colon, etc) in the hernia sac

8
Hiatal hernia

• The paraesophageal types can result in serious
  complicatoins gastric torsion, volvulus,
  respiratory compromise.
• Progressive enlargement is the rule.
• Surgical management is indicated even in smaller,
  asymptomatic paraesophageal hernias.