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BENIGN GASTRIC OUTLETBENIGN GASTRIC OUTLET
OBSTRUCTIONOBSTRUCTION
By
Dr E.Aravind
Under Guidance of
Dr DSVL Narasimham MS
...
Gastric outlet
obstruction (GOO)
represents a clinical
and pathophysiological
consequence of any
disease process which
pr...
EpidemiologyEpidemiology
Until the late 1970s benign disease was
responsible for a majority of cases
Recent decades 50 t...
ETIOLOGYETIOLOGY
PEPTIC ULCER DISEASEPEPTIC ULCER DISEASE
Most common cause previously
Decline after discovery of Helicobacter pylori and
proton pump inhibitors
Occurs both in a...
GOO associated with Chronic PUD
It includes pathologic entities such as:
-Chronic PUD with active edematous
ulcer;
-Chron...
Corrosive injuryCorrosive injury
Ingestion of both
acid and alkali
Antral or pyloric
scarring
DrugsDrugs
 Mostly NSAIDs and
Opium products
 NSAIDs cause GOO by
diminishing the levels of
prostaglandin E2 causing
pyl...
Inflammatory causesInflammatory causes
Crohn’s disease
Tuberculosis
Chronic pancreatitis
Annular pancreas
Duodenal ob...
Rare causesRare causes
Gastric bezoars
Large gastric polyps
Gastric vovlulus
Bouveret’s syndrome
Amyloidosis
PathogenesisPathogenesis
Intrinsic or extrinsic obstruction of the
pyloric channel or duodenum
Depends upon the underlyi...
Obstruction of the stomach
Hypertrophy of the stomach
Dilatation
Gastritis & depressed acid secretion
Complications /EffectsComplications /Effects
Malnourishment – weight loss
Iron deficiency anaemia
Vomiting of gastric c...
Clinical PresentationClinical Presentation
HistoryHistory
AGE:20-45 years with peak 30-35 years
Known or suspected case of chronic PUD
Epigastric and Lt hypochond...
Anorexia, nausea.
Easy satiety
Vomiting: -characteristic unpleasant
-copious
-projectile
-Non bilious
-Food taken sever...
Feeling of unwell
Appetite is maintained but fear of pain
often prevent patient from eating
Weight loss.
Abdominal swe...
General examinationGeneral examination
Wasted
Dehydrated
Pallor
Shock
Epigastric / Rt
hypochondrial
tenderness
Distended abdomen
Visible gastric
peristalsis
Succussion splash
Goldstein sa...
Investigationsnvestigations
Hemoglobin
Serum Electrolytes
ECG
Blood Gases
Urine analysis
Serum Gastrin levels
Detection of H.pylori
Non invasive:
serology
carbon labelled urea breath test
Invasive:
◦ Rapid urease test,histology an...
Plain x-ray of
abdomen - shows
marked gastric air
bubble (black
arrows) and a
downward shift of
transverse colon
(white a...
Barium meal:
-markedly dilated
stomach with a lot of
residue
-presence of an
ulcer crater
-filling defect at
the duodenal...
CT Abdomen –
shows dilated
stomach, any other
extrinsic pathology
EndoscopyEndoscopy
To establish the
diagnosis
Identify a specific
cause
Therapeutic benefit
Endoscopic biopsies
to ide...
ManagementManagement
Symptomatic GOO needs hospitalization.
Fluid resuscitation
Management of Metabolic alkalosis
Nasogastric decompression...
Endoscopic balloon dilatation (EBD)
 Safe and effective
alternative in the
management in surgically
unfit patients.
 A t...
Complications of EBD
- Self limiting pain
- Bleeding
- Perforation
Eradication of H. pylori
Proton pump Inhibitors
Tub...
Intralesional steroids like Triamcinolone
and endoscopic incision along with
Endoscopic balloon dilatation increase the
e...
Surgery for Benign GOOSurgery for Benign GOO
Surgery forms the final option for
patients presenting with refractory GOO
...
Goal of surgery for ulcer
- Reduce gastric acid secretions
Achieved by
- Vagotomy – decrease stimulus
- Anterectomy – de...
Vagotomy, antrectomy and
gastrojejunostomy
Gastrojejunostomy can be Billroths I or II
some times Rouxen- Y Gastrojejunos...
Vagotomy
Truncal Vagotomy –
need a drainage
procedure Finneys
pyloroplasty or
Heineke-Mikulicz
pyloroplasty
Selective Va...
Highly Selective
Vagotomy
Billroth I
Gastrojejuostomy
Billroth II
Gastrojejunostomy
Rouxen- Y
Gastrojejunostomy
High Selective Vagotomy with
Gastrojejunostomy is the recommended
procedure
Truncal Vagotomy and gastrojejunostomy
most ...
Post Vagotomy testsPost Vagotomy tests
i)Pentagastrin test -Peak acid output
reduction of >/50% is indicative of
completen...
ComplicationsComplications
Early complications
- Haemorahage
- Injury to surrounding organs like spleen,
liver, pancreas,...
Post Gasterectomy SyndromesPost Gasterectomy Syndromes
Dumping Syndrome
- Rapid passage of high osmolarity food from
stom...
Management
- Spontaneous relief.
- Dietary
- Long acting Octreotide
Metabolic Disturbances
- Iron deficiency Anaemia
- Impairment of Vitamin B12 metabolism
- Decreased absorption of calcium...
Afferent loop Syndrome
- Blockage of afferent limb of loop causes
the bile and pancreatic secretions to
collect in the af...
Management
- A surgical emergency
- A high index of suspicion.
- Convert Billroth II to I.
- Enteroenterostomy (e.g Braun...
Efferent loop syndrome
- Quite rare
- Usullay from herniation of limb behind
anastomosis (R-L fashion).
- Upper quadrant ...
Duodenal Blow out:
-Usually occurs 4-5th
postop day.
-Leak from Duodenal
stump
-Life threatening.
-Management Control
fis...
Postvagotomy diarrhea
-Occurs in >30% of patients as part of
Dumping synd. Usually disappears after 3-
4 months.
-Managem...
Postvagotomy Gastroparesis
- Occurs in both TV&SV, not in HSV.
- Paresis allows liquid(loss of receptive
relaxation) not ...
Alkaline Reflux Gastritis
- Severe epigastric pain with bilious
vomiting and weight loss. Usually after
Billroth II.
- Di...
Blind Loop syndrome
Bacterial overgrowth in static loop
causing bind with B12 and deconjugate
bile acid which results in ...
Follow UpFollow Up
i-H.Pylori Eradication
ii-H.pylori screening(to document
eradication)-serology
-13C blood urea test
iii...
PrognosisPrognosis
Age
H pylori reserve
Duration
Co morbidities
Previous surgeries
Previous failed Medical therapy f...
CONCLUSIONCONCLUSION
Though PUD is largely medically managed
with the place of the surgeon gradually
being relegated to th...
Thank YouThank You
Benign gastric outlet obstruction
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Benign gastric outlet obstruction

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Benign gastric outlet obstruction

  1. 1. BENIGN GASTRIC OUTLETBENIGN GASTRIC OUTLET OBSTRUCTIONOBSTRUCTION By Dr E.Aravind Under Guidance of Dr DSVL Narasimham MS Dr R Hemanthi MS Dr P Sitaram MS
  2. 2. Gastric outlet obstruction (GOO) represents a clinical and pathophysiological consequence of any disease process which produces mechanical impediment to gastric emptying. Classification 2 groups Benign causes Malignant causes
  3. 3. EpidemiologyEpidemiology Until the late 1970s benign disease was responsible for a majority of cases Recent decades 50 to 80 percent cases have been attributed to malignancy. Incidence of GOO has been reported to be less than 5% in patients with peptic ulcer disease (PUD), which was earlier the leading benign cause
  4. 4. ETIOLOGYETIOLOGY
  5. 5. PEPTIC ULCER DISEASEPEPTIC ULCER DISEASE
  6. 6. Most common cause previously Decline after discovery of Helicobacter pylori and proton pump inhibitors Occurs both in acute and chronic ulcers Acute ulcers inflammation induced edema, spasm, tissue deformation and pyloric dysmotility Chronic ulcers scarring and tissue remodeling Commonly associated with Duodenal Ulcers
  7. 7. GOO associated with Chronic PUD It includes pathologic entities such as: -Chronic PUD with active edematous ulcer; -Chronic PUD with antral cicatrisation; -Chronic PUD with Pyloric stenosis; -Hour glass stomach; -Teapot stomach
  8. 8. Corrosive injuryCorrosive injury Ingestion of both acid and alkali Antral or pyloric scarring
  9. 9. DrugsDrugs  Mostly NSAIDs and Opium products  NSAIDs cause GOO by diminishing the levels of prostaglandin E2 causing pyloric edema and scarring and increasing histamine release leading to increased gastric secretion, reduction of mucosal absorption, and gastric motility disturbances.
  10. 10. Inflammatory causesInflammatory causes Crohn’s disease Tuberculosis Chronic pancreatitis Annular pancreas Duodenal obstruction common due to pancreatic and biliary duct strictures
  11. 11. Rare causesRare causes Gastric bezoars Large gastric polyps Gastric vovlulus Bouveret’s syndrome Amyloidosis
  12. 12. PathogenesisPathogenesis Intrinsic or extrinsic obstruction of the pyloric channel or duodenum Depends upon the underlying etiology
  13. 13. Obstruction of the stomach Hypertrophy of the stomach Dilatation Gastritis & depressed acid secretion
  14. 14. Complications /EffectsComplications /Effects Malnourishment – weight loss Iron deficiency anaemia Vomiting of gastric content resulting in: - dehydration - shock - electrolyte imbalance( Na, Cl, K) - metabolic alkalosis -paradoxic aciduria - acute kidney injury
  15. 15. Clinical PresentationClinical Presentation
  16. 16. HistoryHistory AGE:20-45 years with peak 30-35 years Known or suspected case of chronic PUD Epigastric and Lt hypochondrial pain : -relieved by alkali, food. -gnawing/biting -periodic (spontaneous healing) -association with food and time of day -radiates to the back -Generalized
  17. 17. Anorexia, nausea. Easy satiety Vomiting: -characteristic unpleasant -copious -projectile -Non bilious -Food taken several days ago.
  18. 18. Feeling of unwell Appetite is maintained but fear of pain often prevent patient from eating Weight loss. Abdominal swelling
  19. 19. General examinationGeneral examination Wasted Dehydrated Pallor Shock
  20. 20. Epigastric / Rt hypochondrial tenderness Distended abdomen Visible gastric peristalsis Succussion splash Goldstein saline load test
  21. 21. Investigationsnvestigations
  22. 22. Hemoglobin Serum Electrolytes ECG Blood Gases Urine analysis Serum Gastrin levels
  23. 23. Detection of H.pylori Non invasive: serology carbon labelled urea breath test Invasive: ◦ Rapid urease test,histology and culture.
  24. 24. Plain x-ray of abdomen - shows marked gastric air bubble (black arrows) and a downward shift of transverse colon (white arrows)
  25. 25. Barium meal: -markedly dilated stomach with a lot of residue -presence of an ulcer crater -filling defect at the duodenal cap. -trifoliate duodenum
  26. 26. CT Abdomen – shows dilated stomach, any other extrinsic pathology
  27. 27. EndoscopyEndoscopy To establish the diagnosis Identify a specific cause Therapeutic benefit Endoscopic biopsies to identify H. pylori and to exclude malignant conditions causing GOO
  28. 28. ManagementManagement
  29. 29. Symptomatic GOO needs hospitalization. Fluid resuscitation Management of Metabolic alkalosis Nasogastric decompression Total parental nutrition Definitive management can be instituted after establishment of diagnosis and correction of underlying metabolic abnormalities
  30. 30. Endoscopic balloon dilatation (EBD)  Safe and effective alternative in the management in surgically unfit patients.  A through-the-scope (TTS) 5 mm balloon with a 150 cm long catheter is used.  Balloons are available from 6 mm to 20 mm  The procedure is repeated 1-2 weekly until adequate dilatation of 15-18 mm is achieved
  31. 31. Complications of EBD - Self limiting pain - Bleeding - Perforation Eradication of H. pylori Proton pump Inhibitors Tuberculosis, Crohn’s disease, and pancreatitis causing GOO also respond to EBD they have more recurrences unless the basic disease is managed and adequately treated
  32. 32. Intralesional steroids like Triamcinolone and endoscopic incision along with Endoscopic balloon dilatation increase the efficacy of EBD Placement of biodegradable stents mainly in caustic injury
  33. 33. Surgery for Benign GOOSurgery for Benign GOO Surgery forms the final option for patients presenting with refractory GOO A jejunostomy tube should be placed along with surgery
  34. 34. Goal of surgery for ulcer - Reduce gastric acid secretions Achieved by - Vagotomy – decrease stimulus - Anterectomy – decrease gastrin secretion
  35. 35. Vagotomy, antrectomy and gastrojejunostomy Gastrojejunostomy can be Billroths I or II some times Rouxen- Y Gastrojejunostomy
  36. 36. Vagotomy Truncal Vagotomy – need a drainage procedure Finneys pyloroplasty or Heineke-Mikulicz pyloroplasty Selective Vagotomy
  37. 37. Highly Selective Vagotomy
  38. 38. Billroth I Gastrojejuostomy Billroth II Gastrojejunostomy
  39. 39. Rouxen- Y Gastrojejunostomy
  40. 40. High Selective Vagotomy with Gastrojejunostomy is the recommended procedure Truncal Vagotomy and gastrojejunostomy most commonly done surgery
  41. 41. Post Vagotomy testsPost Vagotomy tests i)Pentagastrin test -Peak acid output reduction of >/50% is indicative of completeness. ii)Insulin (Hollander’s) test - Prognostic Done 1week post vagotomy. If positve in a short time, recurrence risk is high.
  42. 42. ComplicationsComplications Early complications - Haemorahage - Injury to surrounding organs like spleen, liver, pancreas, thoracic duct - Anesthetic complications
  43. 43. Post Gasterectomy SyndromesPost Gasterectomy Syndromes Dumping Syndrome - Rapid passage of high osmolarity food from stomach to small intestine leading to rapid shift of fluid - luminal distension - autonomic responses - Gastrointestinal and Cardiovascular complaints - 20-30 after intake of meals - Nausea vomittings epigastric fullness cramping abdominal pain and explosive diarrhoea - Cardiovascular symptoms- flushing, diaphoresis, palpitations,dizziness, fainting,blurring of vision
  44. 44. Management - Spontaneous relief. - Dietary - Long acting Octreotide
  45. 45. Metabolic Disturbances - Iron deficiency Anaemia - Impairment of Vitamin B12 metabolism - Decreased absorption of calcium leading to osteomalicia and osteoporosis
  46. 46. Afferent loop Syndrome - Blockage of afferent limb of loop causes the bile and pancreatic secretions to collect in the afferent limb with increasing pressure these enter the stomach. - Causing projectile bilious vomiting not containing food and relieves symptoms - Investigate with UGIE and Radio nucleotide scan
  47. 47. Management - A surgical emergency - A high index of suspicion. - Convert Billroth II to I. - Enteroenterostomy (e.g Braun, easier) below the stoma. - Creation of a Roux-en-Y
  48. 48. Efferent loop syndrome - Quite rare - Usullay from herniation of limb behind anastomosis (R-L fashion). - Upper quadrant pain colicky in nature, bilious vomiting and abdominal distension - Investigation – CECT Abdomen - Management -Reduce retroanastomosis hernia -Close retroanastomosis space.
  49. 49. Duodenal Blow out: -Usually occurs 4-5th postop day. -Leak from Duodenal stump -Life threatening. -Management Control fistula and sepsis -Enteroenterostomy later.
  50. 50. Postvagotomy diarrhea -Occurs in >30% of patients as part of Dumping synd. Usually disappears after 3- 4 months. -Management-self limiting -Cholestyramine(4g tds) .
  51. 51. Postvagotomy Gastroparesis - Occurs in both TV&SV, not in HSV. - Paresis allows liquid(loss of receptive relaxation) not solid(dependent on antral pump mechanism) - Management - Prokinetics
  52. 52. Alkaline Reflux Gastritis - Severe epigastric pain with bilious vomiting and weight loss. Usually after Billroth II. - Diagnosis largely clinical but HIDA scan shows bile reflux into stomach/esoph endoscopy show beefy red ,friable mucosa. -Management-Billroth II to a Roux-en-Y GJ.
  53. 53. Blind Loop syndrome Bacterial overgrowth in static loop causing bind with B12 and deconjugate bile acid which results in deficiency of Vitamin B12 and Megaloblastic anemia. Retained Antrum syndrome From retained terminal antrum in the duodenal stump continually bathed in alkaline secretion - increased gastrin release - increased acid secretion - recurrent ulcer.
  54. 54. Follow UpFollow Up i-H.Pylori Eradication ii-H.pylori screening(to document eradication)-serology -13C blood urea test iii-BAO output monitoring iv-Yearly upper GI endoscopy+biopsy. v-Nutritional supplementation. vi-Life style modification(alcohol,smoking)
  55. 55. PrognosisPrognosis Age H pylori reserve Duration Co morbidities Previous surgeries Previous failed Medical therapy for H.pylori Overall prognosis is good with improved surgical and medical therapy
  56. 56. CONCLUSIONCONCLUSION Though PUD is largely medically managed with the place of the surgeon gradually being relegated to the background following improved medical therapy. However, considering high proportion of people being of low socioeconomic status in our country the surgeon’s place can not be overemphasized.
  57. 57. Thank YouThank You

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