Gastric outlet obstruction (often abbreviated as GOO) is a medical condition where there is an obstruction at the level of the pylorus

Pylorus

The pylorus is the region of the stomach that connects to the duodenum . It is divided into two parts:* the pyloric antrum, which connects to the body of the stomach.* the pyloric canal, which connects to the duodenum....

, which is the outlet of the stomach

Stomach

The stomach is a muscular, hollow, dilated part of the alimentary canal which functions as an important organ of the digestive tract in some animals, including vertebrates, echinoderms, insects , and molluscs. It is involved in the second phase of digestion, following mastication .The stomach is...

. Individuals with gastric outlet obstruction will often have recurrent vomiting of food that has accumulated in the stomach, but which cannot pass into the small intestine

Duodenum

The duodenum is the first section of the small intestine in most higher vertebrates, including mammals, reptiles, and birds. In fish, the divisions of the small intestine are not as clear and the terms anterior intestine or proximal intestine may be used instead of duodenum...

 due to the obstruction. The stomach often dilates to accommodate food intake and secretions. Causes of gastric outlet obstruction include both benign causes (such as peptic ulcer disease affecting the area around the pylorus), as well as malignant causes, such as gastric cancer. Treatment of the condition depends upon the underlying cause; it can involve endoscopic

Endoscopy

Endoscopy means looking inside and typically refers to looking inside the body for medical reasons using an endoscope , an instrument used to examine the interior of a hollow organ or cavity of the body. Unlike most other medical imaging devices, endoscopes are inserted directly into the organ...

 therapies (such as dilation of the obstruction with balloons or the placement of self expandable metallic stents), other medical therapies, or surgery to resolve the obstruction.

Symptoms

Projectile vomiting, which may also occur with an Epidural Hematoma or meningitis, constipation, loss of weight,sometimes epigastric pain.

Causes

The causes are divided into benign or malignant. Projectile vomiting may also occur with an Epidural Hematoma.

Benign

Peptic ulcer disease.

Infections, such as tuberculosis

Tuberculosis

Tuberculosis, MTB, or TB is a common, and in many cases lethal, infectious disease caused by various strains of mycobacteria, usually Mycobacterium tuberculosis. Tuberculosis usually attacks the lungs but can also affect other parts of the body...

; and infiltrative diseases, such as amyloidosis

Amyloidosis

In medicine, amyloidosis refers to a variety of conditions whereby the body produces "bad proteins", denoted as amyloid proteins, which are abnormally deposited in organs and/or tissues and cause harm. A protein is described as being amyloid if, due to an alteration in its secondary structure, it...

.

A rare cause of gastric outlet obstruction is obstruction with a gallstone, also termed Bouveret's syndrome.

Malignant

Tumours of the stomach, including adenocarcinoma

Adenocarcinoma

Adenocarcinoma is a cancer of an epithelium that originates in glandular tissue. Epithelial tissue includes, but is not limited to, the surface layer of skin, glands and a variety of other tissue that lines the cavities and organs of the body. Epithelium can be derived embryologically from...

 (and its linitis plastica

Linitis plastica

Linitis plastica, also known as Brinton's disease or leather bottle stomach, is a morphological variant of diffuse stomach cancer....

 variant), lymphoma

Lymphoma

Lymphoma is a cancer in the lymphatic cells of the immune system. Typically, lymphomas present as a solid tumor of lymphoid cells. Treatment might involve chemotherapy and in some cases radiotherapy and/or bone marrow transplantation, and can be curable depending on the histology, type, and stage...

, and gastrointestinal stromal tumours;

Pathophysiology

In a peptic ulcer it is believed to be a result of oedema and scarring of ulcer, followed by healing and fibrosis, which leads to obstruction of the gastroduodenal junction (usually an ulcer in the first part of the duodenum). In a malignancy usually a malignancy of the antrum of the stomach or the pancreas.

Clinical Features

The main symptom is that of vomiting which typically occurs after meals of undigested food, devoid of any bile. You may also find a history of previous peptic ulcers and loss of weight.

Signs to look for upon examination are wasting

Wasting

In medicine, wasting refers to the process by which a debilitating disease causes muscle and fat tissue to "waste" away. Wasting is sometimes referred to as "acute malnutrition" because it is believed that episodes of wasting have a short duration, in contrast to stunting, which is regarded as...

 and dehydration

Dehydration

In physiology and medicine, dehydration is defined as the excessive loss of body fluid. It is literally the removal of water from an object; however, in physiological terms, it entails a deficiency of fluid within an organism...

. visible Peristalsis may be present.Succussion splash which is a splash-like sound heard over the stomach in the left upper quadrant of the abdomen on shaking the patient, with or without the stethoscope

Stethoscope

The stethoscope is an acoustic medical device for auscultation, or listening to the internal sounds of an animal body. It is often used to listen to lung and heart sounds. It is also used to listen to intestines and blood flow in arteries and veins...

.
Laboratory features to look for include hypochloremic hypokalemic Metabolic alkalosis (due loss of HCL

HCL

HCL or HCl can stand for:* Hairy cell leukemia, an uncommon and slowly progressing B cell leukemia* Hardware compatibility list...

), and an electrolyte imbalance.

Investigations

the most confirmatory investigation is endoscopy of upper GIT.

Abdominal X-ray - Gastric fluid level.
Ba meal and follow through - enlarged stomach and pyloroduodenal stenosis.
Gastroscopy - Help with cause and therapeutic.

Treatment of gastric outlet obstruction depends on the cause, but may include either surgery

Surgery

Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...

 or medical. In patients with peptic ulcer disease, the oedema will usually settle with conservative management with nasogastric suction, replacement of fluids and electrolytes and proton pump inhibitors.

Surgical.

Indicated in cases of failed medical therapy and recurrent obstruction.
The surgery usually performed is an Antrectomy(which is the partial removal of the stomach), Vagotomy (which is severing of the vagus nerve) and Billroth I

Billroth I

Billroth I, more formally Billroth's operation I, is an operation in which the pylorus is removed and the distal stomach is anastomosed directly to the duodenum....

(which involves anastomosing the duodenum to the distal stomach) or gastrojejunostomy. This helps reduce acid in the stomach which is responsible for the peptic ulcer.