NSAIDs-Related Pyloroduodenal Obstruction and Its Endoscopic Management. Diagn Ther Endosc. 2011;2011:967957. [PMID: 21747657 PMCID: PMC3130975 DOI: 10.1155/2011/967957]

ASGE guideline on the role of endoscopy in the management of benign and malignant gastroduodenal obstruction

This American Society for Gastrointestinal Endoscopy guideline provides evidence-based recommendations for the endoscopic management of gastric outlet obstruction (GOO). We applied the Grading of Recommendations, Assessment, Development and Evaluation methodology to address key clinical questions. These include the comparison of (1) surgical gastrojejunostomy to the placement of self-expandable metallic stents (SEMS) for malignant GOO, (2) covered versus uncovered SEMS for malignant GOO, and (3) endoscopic and surgical interventions for the management of benign GOO. Recommendations provided in this document were founded on the certainty of the evidence, balance of benefits and harms, considerations of patient and caregiver preferences, resource utilization, and cost-effectiveness.

Management of gastric outlet obstruction: Focusing on endoscopic approach

Gastric outlet obstruction (GOO) is a medical condition characterized by epigastric pain and postprandial vomiting due to mechanical obstruction. The obstructions typically involved in GOO can be benign or malignant. Peptic ulcer disease is the most common cause of benign GOO, and malignant causes include gastric cancer, lymphoma, and gastrointestinal stromal tumor. With the eradication of Helicobacter pylori (H. pylori) and the use of proton pump inhibitors, the predominant causes have changed from benign to malignant diseases. Treatment of GOO depends on the underlying cause: Proton pump inhibitors, H. pylori eradication, endoscopic treatments including balloon dilatation or the placement of self-expandable stents, or surgery.

Choledochoscope with stent placement for treatment of benign duodenal strictures: A case report

BACKGROUND

Endoscopically or fluoroscopically guided dilation is a safe and effective alternative to surgery for patients with benign strictures of the gastric outlet.

CASE SUMMARY

We describe two cases where a novel approach with a Spyglass^® choledochoscope in assessing the extent of benign duodenal strictures and aiding in placement of duodenal stents for treatment of the strictures. Choledochoscope-guided wire and stent placement was successful in all cases, leading to symptom resolution related to benign duodenal obstruction. No major adverse events were observed.

CONCLUSION

Choledochoscope-guided assessment and endoscopic therapy is a viable approach in relieving duodenal obstruction, if the conventional combined fluoroscopic and endoscopic methods fail.

Etiological spectrum and response to endoscopic balloon dilation in patients with benign gastric outlet obstruction

BACKGROUND AND AIMS

Peptic ulcer disease (PUD)-related gastric outlet obstruction (GOO) is known to respond favorably to endoscopic balloon dilation (EBD). However, data on efficacy of EBD for other etiologies of benign GOO are sparse. We aimed to compare the response of EBD among different etiologies of GOO.

METHODS

Records of all patients with benign GOO who underwent EBD at our tertiary-care center between January 1998 and December 2017 were analyzed. Dilation was done by using through-the-scope balloons. Procedural and clinical success of EBD was compared among different etiologies.

RESULTS

A total of 306 patients were evaluated, of whom 264 (mean [± standard deviation] [SD] age 37.89 ± 17.49 years; men 183, women 81) underwent dilation. Etiologically, caustic ingestion was the commonest cause of GOO (53.8%) followed by PUD (26.1%) and medication-induced (8.3%). Overall procedural and clinical success was achieved in 200 (75.7%) and 243 (92.04%) patients, respectively, requiring a mean (± SD) of 2.55 (2.8) and 5.37 (3.9) sessions, respectively. Caustic-induced GOO responded less favorably, requiring a higher number of dilation sessions and having more refractory strictures than other etiologies. Medication-induced GOO performed worse than PUD-related GOO. Of the 264 patients, 9 (3.4%) had perforations during EBD, 3 had contained leaks and were managed conservatively, and 6 underwent successful surgery.

CONCLUSION

EBD is successful in a majority of patients with benign GOO, with caustic-induced GOO and medication-induced GOO being more difficult than PUD-related GOO.

Small intestine strictures in opium addicts: An unrecognized cause of intestinal obstruction

Strictures of the small intestine have been attributed many causes of Crohn's disease, nonsteroidal anti-inflammatory drugs, neoplastic, post-surgical, and corrosive ingestion. Opium as a cause of small intestine strictures has not been described. Six cases of opium addicts diagnosed with small intestine strictures were selected after excluding the possible etiology of strictures. Investigations like upper gastrointestinal endoscopy, colonoscopy (in patients with small intestinal obstruction), barium meal follow-through, and histopathology of strictures were done in all patients. Among the six cases, two patients were diagnosed with small intestinal obstruction and four patients with gastric outlet obstruction. Histopathology of the strictures revealed marked thickening of submucosa with infiltration by lymphocytes, plasma cells, and plenty of eosinophils. There was dilatation of vessels and lymphatics. The granulomatous reaction was not seen. These histological features are suggestive of concentric fibrous thickening in submucosa with stricture formation possibly as a result of drug abuse like opioids and opioid-like products resulting in transient ischemia of the small intestine leading to fibrosis. Patients were managed by surgery and deaddiction treatment was given to prevent further complications. Opium and opioid-like drugs can cause small intestinal strictures causing ulceration and fibrosis in opioid-dependent patients.

A Case of Delayed Duodenal Obstruction Due to Traumatic Fibrosis Following Seromuscular and Intramural Injury

Objective:

Traumatic duodenal obstructions are rare, and most are caused by compression from intramural or retroperitoneal macroscopic hematomas. This report describes a very rare type of delayed traumatic duodenal obstruction without macroscopic intramural or extraluminal hematoma caused by traumatic fibrosis due to seromuscular and intramural injury and microscopic hemorrhage.

Case presentation:

A 31-year-old man was transferred to our center due to polytrauma with nausea and vomiting on day 53 after an accident. Gastrointestinal fiberscopy (GIF) on day 57 revealed an active stage small duodenal ulcer with patency of the pyloric ring. Although the patient underwent subdural drainage, the nausea and vomiting continued. A repeat GIF on day 91 revealed a duodenal ulcer with severe pyloric stenosis. GIF after nasogastric drainage on day 102 identified a severe pinhole stenosis. We performed surgery on day 106 and observed a constricted duodenal bulb due to a tumorous scar. We resected the stenotic section of the duodenal bulb including the pyloric ring.

Conclusion:

The histopathologic examination revealed constriction and fibrosis. Surgical options should be considered for patients with delayed duodenal obstruction without macroscopic hematoma around the duodenum after several months of hospitalization.