Gastric outlet obstruction

Question 1

What is GOO?

Answer 1

• Mechanical obstruction of proximal GI tract
• Some level between gastric pylorus and proximal duodenum
• = inability of stomach to empty

Question 2

Causes of GOO?

Answer 2

• PUD - leading to stricturing of stomach/duodenum
• Gastric or small bowel cancer - inc lymphoma, GI stromal tumour
• Iatrogenic - anastomotic stricture following gastrectomy
• Pancreatic pseudocyst
• Bouveret syndrome
• Gastric bezoar

Question 3

Symptoms of GOO

Answer 3

• Epigastric pain
• Post-prandial vomitting
• Early satiety
• No change in bowel habit usually initially

Question 4

Examination findings of GOO

Answer 4

• Dehydrated - vomitting
• Hypovolaemic - tachy, hypotensive, low UO
• Tender and distended upper abdomen
• Can have localised tenderness and guarding

Question 5

What is Bouveret syndrome?

Answer 5

• GOO secondary to gallstone impacted in pylorus or proximal duodenum
• Occurs in patients with cholecystoduodenal fistula - from recurrent cholecystitis episodes

Question 6

Management Bouveret syndrome

Answer 6

• Endoscopic attempt at removal
• If not possible - surgery with enterotomy to remove stone (cut open bowel)

Question 7

What is gastric bezoar?

Answer 7

Agglutination of ingested material that is insoluble or indigestible in the gastrointestinal tract

Question 8

What is heard on auscultation of GOO?

Answer 8

Succession splash during sudden movement of patient - sloshing sound in stethoscope
Due to presence of fluid and gas in a dilated stomach

Question 9

Differential for GOO

Answer 9

• Gastroparesis - delayed gastric emptying
• Endoscopy +/- CT imaging will help differentiate as no mechanical obstruction in gastroparesis

Question 10

Bedside and bloods for ?GOO

Answer 10

• FBC
• CRP
• U&E - assess for AKI
• Clotting screen
• Group and save - surgical work up

Question 11

Imaging for ?GOO

Answer 11

• CT scan + IV contrast
• AXR - gastric fluid level seen sometimes
• Then may have upper GI endoscopy to confirm diagnosis (eg via biopsy for malignancy) and therapeutic use

Question 12

Management GOO - immediate

Answer 12

• IV fluids
• NG tube - decompress
• IV PPI
• Endoscopy can be used in certain cases to dilate benign strictures (either balloon or stenting) or remove any obstruction eg gallstones

Question 13

Surgical intervention GOO

Answer 13

• Mainstay usually - esp if malignancy or if endoscopic failed
• Specific procedure depends on cause, some can have primary resection or bypass via gastrojejunostomy (stomach joined to jejenum to drain into)