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A PROSPECTIVE STUDY OF PRESENTATIONS OF GASTRIC OUTLET OBSTRUCTION.

BACKGROUND

Gastric outlet obstruction was described by Sir James Walton as- "The stomach you can hear, the stomach you can feel and the stomach you can see." Gastric Outlet Obstruction (GOO) is the more accurate term for the commonly used term 'pyloric stenosis,' as the site of obstruction is rarely the pylorus itself. The obstruction is usually in the first part of duodenum secondary to cicatrised duodenal ulcer or proximally where the diagnosis of carcinoma is most probable. [1] Until introduction of effective ulcer therapy [H2 receptor blockers and proton pump inhibitors], duodenal ulcer was the most common cause of gastric outlet obstruction. But with increased awareness of the disease, change in the dietary habits and availability of H2 receptor blockers and Proton Pump Inhibitors and recent findings of association of Helicobacter pylori with the causation of peptic ulcer diseases and its effective eradication with H. pylori kits all have resulted in decreased incidence of patients requiring surgery and also the complications like pyloric stenosis have reduced. [2] At the same time the incidence of antral carcinoma of stomach producing GOO has comparatively increased, which may be due to increased early diagnosis of the condition with the help of flexible fiberoptic endoscope. [3,4]

This study has been taken up to review the changes in the presentation of gastric outlet obstruction in view of changing trends in the management, because of new drugs and investigatory modalities.

MATERIALS AND METHODS

A prospective cross-sectional study conducted at KR Hospital, Mysuru, attached to Mysuru Medical College and Research Centre, Mysuru from August 2016 to August 2018. In total, 64 in-patients of gastric outlet obstruction have been studied. Inclusion criteria for the study were patients presenting with gastric outlet obstruction who are treated on an in-patient basis, patients willing for investigations and treatment.

Patients with following were included in Study-

1. Presence of projectile vomiting of undigested food material, succussion splash heard 3-4 hours after meal, visible gastric peristalsis, presence of mass with above features.

2. Gastric overnight aspirate of > 200 mL in fasting state.

3. Positive saline load test: Retention of more than 400 mL of normal saline 30 minutes after administration of 750mL of normal saline.

4. Upper GI scopy (OGD) demonstrating Gastric outlet obstruction.

Exclusion Criteria

For the study were patients aged 20 years and below, pregnant females, patients with a recent history of any abdominal surgeries.

Detailed history, physical examination and investigation was done in all cases. Saline load test was performed in all cases. Upper gastrointestinal scopy was done in all cases for confirmation of diagnosis. Biopsies were taken wherever required. Barium meal examination was done in 2 cases of corrosive oesophageal stricture as the scope could not be passed beyond. Routine investigations like Hb%, Bleeding time, Clotting time, Random blood sugar, Blood urea, Serum creatinine, S. electrolytes, Blood grouping and Urine analysis was done in all cases.

RESULTS

Incidence of gastric outlet obstruction was more between 51-60 yrs. of age. Majority of cases of CA pyloric antrum was noted in the age group of 51-60 yrs. (31.25%). Obstruction caused due to duodenal ulcer was noted in 4150 yrs. age group (30.4%).

M: F in carcinoma antrum was 2.2: 1 and M: F ratio in cicatrised duodenal ulcer was 3.33: 1.

All (100%) patients had vomiting of undigested food contents of meals taken earlier.

Loss of appetite was the next major symptom in our study group. 93.75% of patients with carcinoma antrum complained of weight loss and anorexia. 76.9% of patients with duodenal ulcer complained of loss of appetite.

Abdominal pain was noted in 71.8% of patients.

Epigastric mass was palpable in 62.5% of patients with carcinoma stomach.

53.8% of patients with duodenal ulcer were having O blood group. 37.5% of patients with carcinoma stomach had A blood group.

DISCUSSION

Discussion is mainly on analysis and observation made regarding presenting symptoms, signs, investigations in 64 cases of gastric outlet obstruction admitted to KR Hospital, Mysuru attached to Mysuru Medical College, Mysuru during the time period from August 2016 to August 2018.

Commonest cause of gastric outlet obstruction was carcinoma of pyloric antrum (32) followed by cicatrised duodenal ulcer (26). These results are similar to results of studies conducted by Sukumaran [5] and Godadevi [6] in India.

Most patients affected due to carcinoma of pyloric antrum were in the age group between 5th and 7th decades. Majority (31.25%) of the patients presenting with this disease were in the age group of 51-60 years. Maximum incidence of duodenal ulcer sequel patients was noted in age group of 41-50 yrs. (30.4%).

Male-to-female ratio, GOO was 2.2: 1 overall. Male-to-female ratio in duodenal ulcer patients was 3.33: 1 and was 2.2: 1 in carcinoma pyloric antrum suggesting predominance of disease in males. In series of Fischer [7] et al, men outnumbered women by 2: 1.

Our study showed 65.6% of patients were smokers and 62.5% were alcoholics. 76.9% of patients with duodenal ulcer sequel patients were smokers and 53.8% were alcoholics. These values are similar to study results conducted by Donald D Kozoll and Karl A Meyer [8] who reported incidence of alcoholism and smoking to be 76.2% and 52.3% respectively in their study. This suggests alcohol and tobacco are significant risk factors for causation of duodenal ulcer.

Postprandial vomiting was the main symptom (100%) in all cases of gastric outlet obstruction, which was projectile in nature with vomitus being partially digested food material. Loss of appetite (78.12%) and loss of weight (62.5%) were other major symptoms. Abdominal pain was noted in 71.8% of patients with gastric outlet obstruction. Studies conducted by Yogiram and Chowdhary [9] and Michael Schwartz [1] 0 also show abdominal pain, vomiting, loss of weight and appetite as the major presenting complaints.

Weight loss was noted in 59.5% of patients in series of Donald D Kozoll and Karl A Meyer [8] and 32% in series of Harvey J Dworken and Harold P Roth [11] suggesting weight loss to be significant in patients with pyloric obstruction. Loss of weight (87.5%) was present in majority of patients in our study.

Majority (87.5%) of patients with carcinoma stomach were anaemic, probably due to less amount of nutrition and microscopic blood loss and cancer cachexia. Yogiram and Chowdhary [9] noted the presence of visible gastric peristalsis in 74% of patients. Visible gastric peristalsis was noted in 43.75% of patients with carcinoma antrum.

Succussion splash was seen in 69.2% of patients with cicatrising duodenal ulcer. Succussion splash was not a major (37.5%) finding in patients with malignancy, which is similar to observation made by Harold Ellis. [12]

37.5% of patients with carcinoma pyloric antrum belonged to 'A' blood group. Blood group 'O' was the major (53.8%) group noted in patients with cicatrising duodenal ulcer.

This is significant as persons with 'O' blood group are about three times more likely to develop acid peptic disease.

CONCLUSION

Commonest cause of gastric outlet obstruction in our study was carcinoma of pyloric antrum followed by cicatrised duodenal ulcer. Two cases were due to corrosive stricture and one due to carcinoma head of pancreas. Recent studies show that carcinoma pyloric antrum has replaced cicatrised duodenal ulcer as a leading cause of gastric outlet obstruction. The incidence of obstruction due to carcinoma of pyloric antrum is more common in recent times as per our study results, most probably due to successful treatment of duodenal ulcers by drugs such as proton pump inhibitors, H.pylori kit and early diagnosis of carcinoma pylorus due to newer investigatory modalities. Gastric outlet obstruction is more in males than females. It is associated with smoking and alcohol consumption, vomiting of undigested food consumed earlier was the commonest symptom. Majority of GOO with duodenal ulcer sequel were of blood group 'O' and carcinoma pyloric antrum patients were of blood group 'A'.

REFERENCES

[1] Cuschieri A, Hanna GB. Essential surgical practice: higher surgical training in general surgery. 5th edn. Hodder Arnold 2013: p. 565.

[2] Dempsey D, Ashley S, Mercer DW, et al. Peptic ulcer surgery in the H. pylori era: indications for operation. Contemp Surg 2001;57:434-41.

[3] Williams NS, Bullstrode CJK, O'Connell PR. Bailey and Love's: short practice of surgery. 26th edn. Hodder Arnold 2013: p. 1036-55.

[4] Shone DN, Nikoomanesh P, Smith-Meek MM, et al. Malignancy is the most common cause of gastric outlet obstruction in the era of H2 blockers. American Journal of Gastroenterology 1995;90(10):1769-70.

[5] Sukumar V, Ravindran C, Prasad RV. Demographic and etiological patterns of gastric outlet obstruction in Kerala, South India. North American Journal of Medical Sciences 2015;7(9):403-6.

[6] Godadevi TSRSVR, Reddy RA. A clinical study and management of gastric outlet obstruction in adults. Int J Sci Stud 2016;4(6):104-8.

[7] Fischer RD, Ebert PA, Zuidema GD. Obstructing peptic ulcers. Results of treatment. Arch Surg 1967;94(5):724-7.

[8] Kozoll DD, Meyer KA. Obstructing gastroduodenal ulcers: general factors influencing incidence and mortality. Archives of Surgery 1964;88(5):793-9.

[9] Yogiram B, Chowdary NVS. Duodenal (ulcer) stenosis in Andhra Pradesh. A 10 year study. Ind J Surg 1983: p. 12-6.

[10] Schwartz MC. Gatric outlet obstruction in peptic ulcer disease, an indication for surgery. Am J Surgery 1982;143:90.

[11] Dworken HJ, Roth HP. Pyloric obstruction associated with peptic ulcer: a clinicopathological analysis of 158 surgically treated cases. JAMA 1962;180(12):1007-10.

[12] Ellis H. Pyloric stenosis. In: Nyhus LM, Wastell C, eds. Surgery of the stomach and duodenum. 4th edn. Boston: Little Brown Publications 1986: p. 475.

Prakash S. S (1), Raghavendra Prabhu T. C (2)

(1) Assistant Professor, Department of Surgical Oncology, K. R. Hospital, MMC RI, Mysore, Karnataka, India.

(2) Postgraduate Student, Department of Surgical Oncology, K. R. Hospital, MMC RI, Mysore, Karnataka, India.

'Financial or Other Competing Interest': None.

Submission 14-11-2018, Peer Review 27-11-2018, Acceptance 29-11-2018, Published 10-12-2018.

Corresponding Author: Dr. Raghavendra Prabhu T. C, S/o. T. Chikkaiah, D. No. 139, Sri Raghavendra Krupa, Havanoor Extension, Bangalore-073, Karnataka, India.

E-mail: dr_prabhu084@yahoo.co.in

DOI: 10.14260/jemds/2018/1181
Table 1. Causes of Gastric Outlet Obstruction

Causes                       No. of Patients   Percentage

Carcinoma pyloric antrum     32                50
Cicatrised duodenal ulcer    26                40.6
Corrosive antral stricture   4                 6.25
Carcinoma head of pancreas   2                 3.125
Total                        64                100

Table 2. Age Distribution

Age (Years)   No. of Patients   Percentage (%)

0-10          0                 0
11-20         0                 0
21-30         4                 6.25
31-40         10                15.625
41-50         16                25
51-60         18                28.8
61-70         10                15.625
71-80         6                 9.375

Table 3. Age distribution and causes of Gastric Outlet
Obstruction

Age Group   Carcinoma     Cicatrised   Corrosive   Carcinoma
            Pyloric       Duodenal     Antral      Head of
            Antrum        Ulcer        Stricture   Pancreas

21-30       0             2 (7.6%)     2 (50%)     0
31-40       4 (12.5%)     4 (15.2%)    2 (50%)     0
41-50       8 (25%)       8 (30.40%)   0           0
51-60       10 (31.25%)   6 (22.8%)    0           2 (100%)
61-70       6 (18.75%)    4 (15.2%)    0           0
71-80       4 (12.5%)     2 (7.6%)     0           0

Table 4. Sex Distribution

Sex       Total   Carcinoma   Cicatrised   Corrosive   Others
          No.     Antrum      Duodenal     Antral
                              Ulcer        Stricture

Males     44      22          20           2           0
Females   20      10          6            2           2

Table 5. Signs

Signs         Total No.    Carcinoma   Cicatri-     Corrosive   Others
                           Antrum      sing         Antral
                                       Ulcer        Stricture

Pallor        50           28          18           4           0
              (78.12)      (87.5)      (69.2)       (100)
Dehydration   28 (43.75)   12 (37.5)   14 (53.8)    2 (50)      0
VGP           32           14          18           0           0
              (50)         (43.75)     (69.2)
Epigastric    20 (31.25)   2 (6.25)    12 (46.15)   4 (100)     0
Tenderness
Mass          22           20          0            0           2
              (34.75)      (62.5)                               (100)
Succussion    30           12          18           0           0
Splash        (46.87)      (37.5)      (69.2)
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Article Details
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Title Annotation:Original Research Article
Author:S., Prakash S.; C., Raghavendra Prabhu T.
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Report
Geographic Code:9INDI
Date:Dec 10, 2018
Words:1975
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