Gastric outlet obstruction at Bugando Medical Centre in Northwestern Tanzania: a prospective review of 184 cases

Aetiology and clinical spectrum of gastric outlet obstruction in North West India

Our study to evaluate the aetiological and clinical spectrum of gastric outlet obstruction (GOO) in North-west India showed malignant cause (54.9%) was more common than benign (45.1%). Common causes of malignancy were gall bladder (37.5%), gastric (31.8%) and pancreatic carcinoma (19.6%); commonest benign causes were opioid abuse (29%), peptic ulcer disease (21.6%), ingestion of corrosives (20.2%) and chronic pancreatitis (12.3%).

Gastric outlet obstruction due to peptic ulcer disease in a 5 years-old female child. Case report. June 23, 2022

INTRODUCTION AND IMPORTANCE

Gastric outlet obstruction (GOO) is a spectrum of congenital and acquired conditions that prevent the passage of gastric contents beyond the proximal duodenum. Peptic ulcer disease (PUD), which causes GOO, is extremely rare in children, with an incidence of 1 per 100,000 live births. Because of the rarity of the disease in children, we report a case of GOO due to PUD in a 5-year-old child.

CASE PRESENTATION

We report a case of an acquired GOO due to PUD in a 5-year-old female child who presented with vomiting, weight loss, and epigastric pain of 3 months' duration. Her diagnosis of GOO secondary to PUD was made by upper gastrointestinal (UGI) endoscopy despite a negative stool H. pylori antigen. She was managed with proton pump inhibitor (PPI), which results in improvement of signs and symptoms. She has been on follow-up for the last 6 months and has remained asymptomatic.

CLINICAL DISCUSSION

H. pylori-positive GOO is successfully treated with PPI and antibiotic therapy. The role of H. pylori therapy in PUD-related GOO is less clear, although eradication is warranted as a primary intervention.

CONCLUSION

GOO secondary to PUD may occur in the absence of Helicobacter pylori infection (HPI). Our patient demonstrated response to medical management in the acute phase of ulceration.

Point-of-care Ultrasound Diagnosis of Gastric Outlet Obstruction Syndrome

Gastric Outlet Obstruction (GOO) is a clinical syndrome characterized by postprandial vomiting, epigastric pain, and abdominal distension due to mechanical or motility disorders. The suspicion will mainly rely on abdominal radiological imaging (computed tomography, barium studies) that might not be widely available or even be contraindicated. We report a 65-year-old male who developed progressive epigastralgia, anorexia, and vomiting. Physical examination revealed mild abdominal distension and epigastric tenderness on deep palpation. With the presumptive diagnosis of gastric outlet obstruction, an abdominal point-of-care ultrasound (POCUS) was performed and showed impaired gastric emptying and a "target sign." A gastroscopic exploration confirmed inflammatory pyloric stenosis due to coexisting antral and duodenal ulcers. POCUS could play an essential role in the easy ultrasonographic diagnosis of gastroparesis, helping to differentiate from other causes of obstruction and even raise suspicion in the diagnosis of pyloric stenosis as a consequence of a GGO. POCUS may serve as a first-line imaging test that can raise suspicion of this difficult to diagnose and probably underreported disease.

Endoscopic Balloon Dilation of Gastric Stenosis secondary to Polyarteritis Nodosa and Arterial Thrombosis in an Adolescent

A 13-year-old female with polyarteritis nodosa underwent a partial gastrectomy for ischemic necrosis and gastric perforation following left gastric artery thrombosis. She later presented with vomiting, early satiety, weight loss, and severe malnutrition, when she was diagnosed with an occlusive gastric stricture. She successfully underwent repeated therapeutic endoscopic balloon dilations until the endpoint of 15-18 mm lumen was achieved without any complications, and her symptoms resolved.

Effects of Preoperative Pyloric Stenosis on Outcomes and Nutritional Status in 73 Patients Following Curative Gastrectomy for Gastric Cancer: A Retrospective Study from a Single Center

Background

The aim of this study was to explore the potential impact of pyloric stenosis (PS) on the nutritional status, the incidence of postoperative complications, and the long-term prognosis of distal gastric cancer (GC) patients after curative resection.

Material/Methods

We retrospectively analyzed the data of 343 GC patients who underwent curative gastrectomy for gastric cancer between January 2010 and December 2013. All patients were divided into 2 groups according to the status of PS. Their clinical and pathological features, nutritional indicators, and incidence of postoperative complications were compared and potential prognostic factors were analyzed using the propensity score matching analysis (PSM).

Results

Seventy-four (21.6%) patients had PS. Patients with PS had worse survival outcomes than those without PS (χ²=21.369, P<0.001). Multivariate survival analysis demonstrated that PS, depth of invasion, and lymph node metastasis (all P<0.05) were the independent predictors of overall survival (OS). Patients with PS had significantly higher lymph node metastasis in No. 3, 4sb, 4d, 6, 8a, 9, and 14v lymph nodes. Patients with PS had significantly lower preoperative BMI, more weight loss, and lower prealbumin than those without PS. There were no significant differences between the 2 groups in postoperative complications, morbidity, or mortality.

Conclusions

Distal GC patients with PS have poor clinicopathological and nutritional status and poor prognosis. However, PS does not increase surgery-related morbidity and mortality.

In-Hospital Postoperative Mortality Rates for Selected Procedures in Tanzania's Lake Zone

BACKGROUND

Postoperative mortality rate is one of six surgical indicators identified by the Lancet Commission on Global Surgery for monitoring access to high-quality surgical care. The primary aim of this study was to measure the postoperative mortality rate in Tanzania's Lake Zone to provide a baseline for surgical strengthening efforts. The secondary aim was to measure the effect of Safe Surgery 2020, a multi-component intervention to improve surgical quality, on postoperative mortality after 10 months.

METHODS

We prospectively collected data on postoperative mortality from 20 health centers, district hospitals, and regional hospitals in Tanzania's Lake Zone over two time periods: pre-intervention (February to April 2018) and post-intervention (March to May 2019). We analyzed postoperative mortality rates by procedure type. We used logistic regression to determine the impact of Safe Surgery 2020 on postoperative mortality.

RESULTS

The overall average in-hospital non-obstetric postoperative mortality rate for all surgery procedures was 2.62%. The postoperative mortality rates for laparotomy were 3.92% and for cesarean delivery was 0.24%. Logistic regression demonstrated no difference in the postoperative mortality rate after the Safe Surgery 2020 intervention.

CONCLUSIONS

Our results inform national surgical planning in Tanzania by providing a sub-national baseline estimate of postoperative mortality rates for multiple surgical procedures and serve as a basis from which to measure the impact of future surgical quality interventions. Our study showed no improvement in postoperative mortality after implementation of Safe Surgery 2020, possibly due to low power to detect change.

Gastric outlet obstruction secondary to peptic ulcer disease, previously misdiagnosed as idiopathic hypertrophic pyloric stenosis in a 16-year-old girl: a case report

Gastric outlet obstruction encompasses a broad spectrum of conditions characterized by complete or incomplete obstruction of the distal stomach, which interrupts gastric emptying and prevents the passage of gastric contents beyond the proximal duodenum. Idiopathic hypertrophic pyloric stenosis is the most common cause with an incidence of 1.5–3 per 1000 live births. However, it is excluded; other causes in children such as peptic ulcer disease are relatively rare. We report a case of an acquired gastric outlet obstruction due to peptic ulcer disease, previously misdiagnosed as idiopathic hypertrophic pyloric stenosis in a 16-year-old girl. Beyond the rarity of this clinical event, this case highlights the challenges of the aetiological diagnosis of gastric outlet obstruction with subsequent therapeutic issues, and is the first documented case in Cameroon.

Long-term Results of Endoscopic Balloon Dilatation for Gastric Outlet Obstruction Caused by Peptic Ulcer Disease

BACKGROUND Gastric outlet obstructions (GOO) is a disabling complication of peptic ulcer disease (PUD). The introduction of endoscopic through the scope balloon dilatation (EBD) has eased the management but there are few reports on the long term results of this modality of treatment on patients' symptoms. METHODS Over a period of 4 years from January 2012 to December 2015 in two major referral hospitals affiliated to Shiraz university, medical endoscopy reports were reviewed retrospectively to identify those who received EBD for the treatment of GOO due to PUD .All of these patients were recalled and their current status were evaluated. RESULTS 22 consecutive patients with symptomatic GOO secondary to benign stricture underwent endoscopic balloon dilatation by a single operator. Of them, 14 had balloon dilatation twice and 6 had ballooning three times. The interval between the first referral and the last follow-up was 25.2 ± 10.3 (min: 4.8 max:43.4) months. The averages of maximum balloon size were 14.4 ± 5 mm in the first session, 14.3 ± 3.1mm in the second session, and 16 ± 2.4 mm in the third session. 73% of the patients had a significant improvement in clinical symptom with two sessions of EBD and did not require repeat dilatation. CONCLUSION EBD is a safe and efficient method in the management of GOO with good long term results.

Stents and surgical interventions in the palliation of gastric outlet obstruction: a systematic review

Background and study aims: Palliative treatment of gastric outlet obstruction can be done with surgical or endoscopic techniques. This systematic review aims to compare surgery and covered and uncovered stent treatments for gastric outlet obstruction (GOO). Patients and methods: Randomized clinical trials were identified in MEDLINE, Embase, Cochrane, LILACs, BVS, SCOPUS and CINAHL databases. Comparison of covered and uncovered stents included: technical success, clinical success, complications, obstruction, migration, bleeding, perforation, stent fracture and reintervention. The outcomes used to compare surgery and stents were technical success, complications, and reintervention. Patency rate could not be included because of lack of uniformity of the extracted data. Results: Eight studies were selected, 3 comparing surgery and stents and 5 comparing covered and uncovered stents.The meta-analysis of surgical and endoscopic stent treatment showed no difference in the technical success and overall number of complications. Stents had higher reintervention rates than surgery (RD: 0.26, 95 % CI [0.05, 0.47], NNH: 4). There is no significant difference in technical success, clinical success, complications, stent fractures, perforation, bleeding and the need for reintervention in the analyses of covered and uncovered stents. There is a higher migration rate in the covered stent therapy compared to uncovered self-expanding metallic stents (SEMS) in the palliation of malignant GOO (RD: 0.09, 95 % CI [0.04, 0.14], NNH: 11). Nevertheless, covered stents had lower obstruction rates (RD: - 0.21, 95 % CI [-0.27, - 0.15], NNT: 5). Conclusions: In the palliation of malignant GOO, covered SEMS had higher migration and lower obstruction rates when compared with uncovered stents. Surgery is associated with lower reintervention rates than stents.

Update on endoscopic management of gastric outlet obstruction in children

Endoscopic balloon dilatation (EBD) and surgical intervention are two most common and effective treatments for gastric outlet obstruction. Correction of gastric outlet obstruction without the need for surgery is an issue that has been tried to be resolved in these decades; this management has developed with EBD, advanced treatments like local steroid injection, electrocauterization, and stent have been added recently. The most common causes of pediatric gastric outlet obstruction are idiopathic hypertrophic pyloric stenosis, peptic ulcer disease followed by the ingestion of caustic substances, stenosis secondary to surgical anastomosis; antral web, duplication cyst, ectopic pancreas, and other rare conditions. A complete clinical, radiological and endoscopic evaluation of the patient is required to make the diagnosis, with complimentary histopathologic studies. EBD are used in exceptional cases, some with advantages over surgical intervention depending on each patient in particular and on the characteristics and etiology of the gastric outlet obstruction. Local steroid injection and electrocauterization can augment the effect of EBD. The future of endoscopic treatment seems to be aimed at the use of endoscopic electrocauterization and balloon dilatations.

CT of gastro-duodenal obstruction

Gastro-duodenal obstruction encompasses a spectrum of benign and malignant disease. Historically, chronic peptic ulcer disease was the main cause of gastro-duodenal obstruction, whereas now malignant cause with gastric carcinomas for gastric obstruction and pancreatic tumors for duodenal obstruction predominate. This paper reviews the role of CT in diagnosing gastro-duodenal obstruction, its level, its cause by identifying intraluminal, parietal, or extrinsic process, and the presence of complication.

Aetiological spectrum of benign gastric outlet obstruction in India: new trends

There is a paucity of data on the spectrum of benign gastric outlet obstruction in India. Our aim was to evaluate its spectrum and to identify the subgroup which would be most amenable to endoscopic therapy. We studied 64 patients whose aetiology revealed in approximately equal proportions: corrosive injury; gastroduodenal tuberculosis (TB); and peptic ulcer disease. The median number of endoscopic dilations required was two for TB, four for peptic ulcer disease and five for corrosive injury. Gastroduodenal TB and corrosive injury appear now to be more, or at least as, common as peptic ulcer disease as causes of benign gastric outlet obstruction in India. Gastroduodenal TB responds best to endoscopic therapy.

Demographic and Etiological Patterns of Gastric Outlet Obstruction in Kerala, South India

Background:

In the modern era, the major cause of gastric outlet obstruction (GOO) is known to be a malignancy, especially in the developed world. Many books and articles do suggest that the benign causes continue to be the major cause of GOO in the developing world however, there is growing evidence proving the contrary. Males were (more commonly) affected females and individuals in their fifth and sixth decade have been the predominant age group in the majority of studies. There is a minimal data of GOO from South India.

Aims:

A retrospective analysis of the endoscopic findings of patients presenting with features of GOO to determine the demographic and etiological patterns.

Materials and Methods:

A retrospective study of the endoscopic findings of patients with GOO from January 2005 to January 2014 was done. The diagnosis of GOO was based on clinical presentation, and an inability during the upper endoscopy to enter the second portion of the duodenum as documented in the endoscopy registers. Patients who have already been diagnosed with malignancy prior to the endoscopy were excluded from the study; so were the patients with gastroparesis.

Results:

A total of 342 patients with GOO underwent the endoscopy during the study period. The causes for benign obstruction were predominantly peptic ulcer disease. The major cause for malignant obstruction was carcinoma of stomach involving the distal stomach. The male to female ratio was 3.2:1. The patients with malignancy were older than patients with benign disorders. Most of the patients were in the sixth and seventh decade. The risk of malignancy was higher with increasing age, especially in women. A fourth of all carcinoma stomach presented with GOO.

Conclusion:

The study demonstrates that the cause for GOO in Kerala, South India is predominantly malignancy. The etiological and demographic patterns were similar to the studies conducted in the developed nations.

Balloon dilatation in patients with gastric outlet obstruction related to peptic ulcer disease

BACKGROUND AND STUDY AIMS

Gastric outlet obstruction (GOO) is a rare complication of peptic ulcer disease (PUD). The endoscopic balloon dilatation (EBD) associated with medical treatment of Helicobacter pylori is a successful method in the management of pyloric stenosis. The aim of this study was to describe epidemiological, clinical, and endoscopic characteristics of GOO related to PUD and to evaluate the effectiveness, safety, and outcome of EBD.

PATIENTS AND METHODS

In a retrospective study of patients seen between 1999 and 2009 with symptoms of GOO secondary to PUD, pyloro-bulbar stenosis was confirmed by endoscopic examination. Balloon dilatation was performed when obstruction persisted after treatment with double-dose proton-pump inhibitor (PPI) intravenously for 7-10days. The H. pylori status was assessed with histology, and eradication therapy was prescribed for infection.

RESULTS

A total of 45 consecutive patients (38 males, 7 females median age, 51.9years; range, 20-58years) with symptoms of GOO secondary to PUD underwent EBD. Median follow-up time of the 45 patients was 32months (range, 4-126months). The immediate success rate of the procedure was 95.5%. Clinical remission was noted in 84.4% of the patients. Remission without relapse was observed in 55.8%, 30months after the dilatation. Pyloric stenosis relapsed in 15 patients (39.5%) after a median period of 22.9months. The dilatation was complicated in three patients (6.7%, two perforations and one bleeding). A total of 13 patients (29%) underwent surgery. H. pylori was found to be positive in 97.7% of the patients, and was eradicated in 78.4% of them. Smoking and failure of H. pylori eradication were associated with the relapse of the stenosis.

CONCLUSION

EBD is a simple, effective, and safe therapy for the GOO related to PUD, producing short- and long-term remission.

Evidence-based nursing in infants with congenital megacolon

AIM: To investigate the clinical significance of evidence-based nursing in infantile patients with congenital megacolon.

METHODS: Fifty infantile patients with congenital megacolon hospitalized at our hospital from January 2008 to December 2013 were retrospectively analyzed. According to the measure of nursing intervention after admission, the patients were divided into either a conventional nursing group or an evidence-based nursing group. The nursing effects were compared between the two groups.

RESULTS: Complications occurred only in 3 cases in the evidence-based nursing group, and none of them had multiple simultaneous complications. In contrast, complications occurred in 61 children in the conventional nursing group, of whom 6 developed only one complication, 17 had two concurrent complications, and 7 had three complications (χ² = 41.667, P = 0.000). The incidences of water and electrolyte imbalance, malnutrition, and hemodynamic instability were significantly lower in the evidence-based nursing group than in the conventional nursing group (P < 0.05). The length of hospital stay and the incidence of anastomotic obstruction were also significantly lower in the evidence-based nursing group than in the conventional nursing group (P < 0.05).

CONCLUSION: Evidence-based nursing may be helpful to reduce the incidence of complications and shorten the length of hospital stays in patients with congenital megacolon.