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Year : 2019 | Volume : 7 | Issue : 2 | Page : 50 - 52  


Original Articles
A Clinical study of variable presentations and management options of gastric outlet obstruction in a tertiary care Centre, Karimnagar

Sathish Kumar B 1, Venkat Reddy M 2, Satya Dev M 3, Surya Narayana Reddy V 4

1,2 Assoc. Professor, 3, 4 Professor,  Department of General Surgery, Chalmeda Anand Rao Institute of Medical Sciences, Karimnagar-505001, Telangana, India.

*Corresponding Author                                                                                                   

Dr. Venkat Reddy M                                                                                                                    

Email: venkatrdd120@gmail.com

Abstract:

Background: The management of gastric outlet obstruction poses diagnostic and therapeutic challenges to general surgeons practicing in resource-limited countries. The outcome of treatment of gastric outlet obstruction may be poor especially in developing countries where advanced diagnostic and therapeutic facilities are not readily available in most centers.

Objective: To evaluate the variable presentations and management options of gastric outlet obstruction (GOO) in a tertiary care centre, Karimnagar.

Methods: The study was a prospective follow up study; total 30 patients of Gastric outlet obstruction (GOO) have been included in this study. Patients have been selected from those attending to General Surgery Department, Chalmeda Anand Rao Institute of Medical Sciences during the period of November 2015 to November 2017.

Results: Out of 30 cases studied 20 cases are males and 10 females with GOO patients. The male to female ratio was 2:1. With regards to individual etiologies carcinoma stomach male to female ratio 1.4: 1 and chronic duodenal ulcers are seen in ratio of 2.5:1.

Conclusion: In present day, carcinoma stomach appears to be the most common cause of gastric outlet obstruction. Malignant GOO had poor prognosis and mostly palliation is done. It focuses on the fact that there is delayed presentation with patients of upper gastro intestinal malignancy.

Keywords: Gastric Outlet Obstruction, carcinoma stomach, duodenal ulcer, surgical management options

INTRODUCTION:

Gastric outlet obstruction (GOO) may be caused by a heterogeneous group of diseases that include both benign and malignant conditions. 1

Globally, the incidence of gastric outlet obstruction has been reported to be less than 5% in patients with peptic ulcer disease, which is the leading benign cause of the problem, whereas the incidence of gastric outlet obstruction in patients with peripancreatic malignancy, the most common malignant etiology, has been reported as 15-20%. 2-3

Gastric outlet obstruction has been reported to be more prevalent in people with low socio-economic status. 4

In present study, the most of patients had either primary or no formal education and more than seventy-five percent of them were unemployed. The majority of patients in the present study came from the rural areas located a considerable distance from the study area.

The management of gastric outlet obstruction poses diagnostic and therapeutic challenges to general surgeons practicing in resource-limited countries. The outcome of treatment of gastric outlet obstruction may be poor especially in developing countries where advanced diagnostic and therapeutic facilities are not readily available in most centers. 5

Gastric outlet obstruction is usually a preterminal event in patients with advanced malignancies of the stomach, pancreas, and duodenum.

The purpose of study was to evaluate the variable presentations and management options of gastric outlet obstruction in a tertiary care centre, Karimnagar. 

METHODS:

Patients have been selected from those attending to Department of General surgery, Chalmeda Anand Rao Institute of Medical Sciences, Karimnagar during period of November 2015 to November 2017. Total sampling size was 30 patients of GOO have been included in this study.

Inclusion Criteria:

  • All patients admitted to the surgery wards with a clinical diagnosis of GOO.
  • Endoscopic evidence of GOO.
  • Radiological evidence of GOO. 

Exclusion Criteria:

  • Patients below 20 years.
  • Gatroduodenal tuberculosis
  • Patients with diabetic gastro paresis.

Ethics Approval

All participants signed an informed consent approved by the Institute Ethics committee, Chalmeda AnandRao Institute of Medical Sciences, Karimnagar.

RESULTS:

Table 1: Etiologies Vs Gender distribution

Diagnosis

Male

Female

Carcinoma Stomach

11

8

Cacrinoma Head of Pancreas

1

0

Chronic Duodenal ulcer

5

2

Cholangio Carcinoma

1

0

Pancreatic Carcinoma

2

0

Out of 30 cases studied 23 are due to malignant causes out of which 19 are due to Carcinoma stomach, 4 due to other malignancies and 7 cases due to cicatrizing chronic duodenal ulcer (Table 1). Most of the patients were in 50-60 aged groups.

Table 2: Surgical procedures performed

Surgical procedures

Male

Female

Distal Gastrectomy with Billroth II reconstruction ( DG + B-II)

6

3

Feeding Jejunostomy (FJ)

3

0

Gastrojejunostomy (GJ)

1

0

GJ+ Truncal Vagotomy (TV)

2

1

Palliative Gastrojejunostomy (Pal. GJ)

7

6

Total Gastrectomy (TJ)

1

0

 

Figure 1: showed Gender distribution of surgical procedures

Table 2 and Figure 1 showing Truncal vagotomy and gastrojejunostomy were done 3 cases. Distal gastrectomy with Billroth II reconstruction is done in 9 cases of ca stomach. Palliative Gastrojejunostomy was done in 13 cases. Total gastrectomy was done in 1 case.  Feeding jejunostomy in 3 cases.

Table 3: Etiology and age distribution

Etiology

30-40

41-50

51-60

61-70

71-80

Carcinoma Stomach

2

4

7

5

1

Carcinoma Head of Pancreas

0

0

1

0

0

Chronic Duodenal ulcer

2

0

4

0

1

Cholangio Carcinoma

0

0

0

1

0

Pancreatic Carcinoma

1

0

0

0

1

 

Figure 2: Age distribution and surgical procedures

Figure 3: Etiology and age distribution

DISCUSSION: 

Gastric outlet obstruction (GOO) involves obstruction in the antro-pyloric region or duodenal bulb. Malignancy is common cause of GOO in adults, but many patients with GOO have benign causes. 6, 7 This study focused on various etiologies of GOO, their prevalence, the management options and outcome of the management.

Surgical treatment has better results on long term follow up but it cannot be offered, initially, to patients with poor clinical status because of increased morbidity and mortality. Based on the fact that less than 40% of patients who require palliative care are fit to undergo a surgical procedure, the need to achieve this objective with a less invasive, safer and effective method has been made clear. 8, 9, 10

In this study, total 30 patients with gastric outlet obstruction were diagnosed and offered various treatments. The age and sex modal distribution was 60 to 69 years for males and 40 to 49 for females. The male preponderance may be attributable to the higher incidence of gastric cancers in the male population hence the presence of a distal advanced gastric cancer is likely to obstruct the pyloric channel.

Gastric outlet obstruction due to carcinoma stomach is a leading cause of cancer deaths second only to lung cancer. 11 The commonest cause of gastric outlet obstruction is cicatrized duodenal ulcer. The next commonest cause is carcinoma of pyloric antrum. The values are close to the values observed by H. Ellis 1 series.

In this study, chronic duodenal ulcer cases maximum incidence seen in age group of 51-60 years. Previously duodenal ulcer was the most common cause of GOO. These observations shows increase of Ca stomach and reduction in ulcer related GOO. These findings correlate with S. Essoun, JC et al study showed to individual incidences carcinoma stomach was the most common malignancy with 51% in present study. 12

In present study showed 4 patients were got wound infection with discharge in carcinoma of stomach and followed conservative management. There was no complication was found during 1 year follow up care of gasrtojunostomy for duodenal ulcer. All cases of duodenal ulcer were discharged post operatively after 8-10 days and advised anti H pylori regimen and proton pump inhibitors.

Follow up

All cases of peptic ulcer followed postoperatively till date showed no complaints. 3 cases of periampullary and 4 cases of CA stomach died within 1 month of surgery before receiving adjuvant treatment. 7 cases of carcinoma stomach died within 6 months of follow up. Remaining 13 cases were receiving chemotherapy.

CONCLUSION:

In our study, the commonest cause of GOO in adults is carcinoma stomach followed by cicatrizing chronic duodenal ulcer. Malignant GOO had poor prognosis and mostly palliation is done. It focuses on the fact that there is delayed presentation with patients of upper gastro intestinal malignancy. Upper GI endoscopy (UGIE) for all patients presenting with chronic dyspepsia can be suggested as a screening modality to identify the cause of dyspepsia and to detect cases of Carcinoma stomach at early stage.

REFERENCES: 

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  2. Tendler DA. Malignant gastric outlet obstruction: bridging another divide. Am J Gastroenterol. 2002; 97:4.
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  8. Piesman M, Kozarek RA, Brandabur JJ, Pleskow DK, et al. Improved oral intake after palliative duodenal stenting for malignant obstruction: a prospective multicenter clinical trial. Am J Gastroenterol. 2009; 104:2404-2411.
  9. Aslanian H, Jamidar P. The duodenal stent-in-stent: a stent at the crossroads. Gastrointest Endosc. 2009; 70:778-779.
  10. Johnson CD, Ellis H. Gastric outlet obstruction now predicts malignancy. Br J Surg.1990; 77:1023-1024.
  11. Alexander HR, Kelsun DP, Tepper JE. Cancer of the Stomach, In: Vincent T. Devita Jr, Hellman S, Rosenberg SA, Ed(s). Cancer: Principles and practice of oncology, 6th Ed. Lippincott Williams and Wilkins, Philadelphia, 2001:1092.
  12. Essoun S, Dabuko, JCB. Update of etiological Patterns of Adult Gastric Outlet Obstruction in Accra, Ghana. Int J Clin Med. 2014; 5:059-64

 





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