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GASTRIC OUTLET OBSTRUCTION DUE TO ADENOCARCINOMA OF THE DUODENUM INFILTRATING THE HEAD OF PANCREAS: A CASE REPORT.

Byline: Prince Naeem1 Rizwan Ahmed KhanHamad Bin Rashid and Mamoona Chaudhry

Abstract: Gastric outlet obstruction (GOO) or Pyloric obstruction is not a sole disorder. It is a clinical and pathophysiological consequence of many disease processes that produce mechanical obstruction to gastric emptying due to complete or impartial obstruction of distal stomach pylorus or proximal duodenum.A case of 55 years old male with complains of epigastric pain nausea postprandial vomiting and weakness. On physical examination patient was pallor lethargic and weak with normal respiratory and cardiovascular findings. Abdominal ultrasonography showed distended stomach filled with contents at the level of gastric outlet.Histopathology report showed chronic inflammatory cells and predicted a nonspecific Duodenitis. A surgical procedure Whipple Operation" was performed under general anesthesia with E.T.T in which the tumor was removed.Gastric Outlet Obstruction is a complex disorder to diagnose.

Although it is rare but still one should consider adenocarcinoma in any patient who is presented with nonspecific gastrointestinal complaints since this can lead to earlier diagnosis.

Keywords: Gastric outlet obstruction Gastro endoscopy Adenocarcinoma

INTRODUCTION

Gastric outlet obstruction (GOO) is not a single disorder; it is a group of clinical and pathophysiological consequence of many disease processes that produce a mechanical barrier to gastric emptying. It can eitherbe mechanical or of functional origin such as edema from peptic ulcer neoplasm foreign bodies or aging. The basic cause may be divided into benign or malignant conditions [1 2]. Benign cause has become less common and 5080% of cases have been attributed to malignancy [3]. The incidence rate of gastric outlet obstruction is not known precisely[1]. Historically GOO has been considered a disease process synonymous with chronic peptic ulcer disease. However since the advent of proton pump inhibitors the complications from peptic ulcer disease have drastically decreased with a change in ratio between benign and malignant gastric outlet obstruction. The incidence rate has been decreased particularly because of its association with peptic ulcer.

Pancreatic adenocarcinoma with extension to the duodenum or stomach is a common cause of malignant GOO whereas peptic ulcer gastric polyps ingestion of caustics congenital duodenal webs and pancreatic pseudocysts are the other benign causes of GOO.

Case PresentationA male patient of 55 years of age was brought to the emergency department of local hospital with three days history of epigastric pain nausea postprandial vomiting and weakness. During history it was revealed that the patient was in his usual state of health one month ago and thenhe developed intermittent episodes of recurrent nausea vomiting sometimes even without taking meal. He had a generalized body weakness and significant weight loss over this period while there was no previous medical or surgical history. On physical examination patient was pallor lethargic and weak with normal respiratory and cardiovascular findings. Laboratory findings were fluctuating at a lower level and were not significantly abnormal. Patient was shifted to parenteral nutrition and keptnothing by mouth(NPO) along with the start of PPIs (Proton Pump Inhibitors). Nasogastric (NG) tubewas passed for the gastric decompression. Abdominal ultrasonography and upper gastrointestinal endoscopy (UGE) was done to evaluate the cause of the Gastric Outlet Obstruction. Upper G.I. Endoscopy showed fluid filled stomach blocked duodenal lumen and showed an echogenic mass. Biopsies were taken and sent to laboratory for histopathological examination. Abdominal ultrasonography showed distended stomach filled with contents at the level of gastric outlet. CT scan was recommendedfor further evaluation of echogenic mass that showed grossly distended stomach and pylorus while 1st and 2nd part of duodenum with no definite mass or lesion. Portal vein and SMA were well visualized. On 6th day histopathology report showed chronic inflammatory

cells and predicted a non-specific Duodenitis. On instillation of barium via NG tube stomach was found distended while duodenal cap appeared markedly dilated with abruptly tapering. Thus surgical treatment was decided as exploratory laprotomy was planned. A surgical procedureWhipple Operation" was performed under general anesthesia with E.T.T in which the tumor was removed and wound was stitched layer by layer after the resection of a part of duodenum a portion of the Pancreas (the head) and the gall bladder wereremovedand the small intestine was brought up to the Pylorus (the valve at the bottom of the stomach) and the Liver and Pancreas digestive enzymes and bile duct were connected to the small intestine below the Pylorus. Patient was kept NPO and on parenteral nutritionnext three days. Post-operative recovery of the patient was monitored properly and found to be progressing positively.

DISCUSSION

Gastric outlet obstruction (GOO) represents a group of clinical and pathophysiological consequence of many disease processes which produce mechanical impediment to gastric emptying. Intrinsic or extrinsic obstruction of the pyloric channel or duodenum is the usual pathophysiology of GOO and the mechanism of obstruction depends upon the underlying etiology. The cause of the obstruction may bebenign or malignant disease. The incidence rate of gastric outletobstructionis notknownprecisely.Though malignancy remains a common cause of GOO in adults a significant number of patients with GOO have benign causes. Until the late 1970's benign disease was responsible for a majority of cases of GOO in adults while malignancies accounted for only 10 to 39 % of cases [4]. Contrasting to this in the recent decades due to the discovery of Helicobacter pylori and proton pump inhibitors 50 to 80 percent cases have been attributed to malignancy [2 5]. Gastric adenocarcinoma accounts for the majority of malignant gastric cancer. It arises from the glandular epithelium of the gastric mucosa. The most widely used Lauren histological classification system divides gastric adenocarcinoma into two types including intestinal and diffused gastric adenocarcinoma. The intestinal type which is usually well-differentiated originates from recognizable pre-cancerous conditions such as gastric atrophy or intestinal metaplasia. It has a tendency to form glandular structures and spreads to distant organs hematogenously. The diffuse type is poorly differentiable lacks gland formation and is composed of signet ring cells. Early metastases via lymphatic invasion commonly occur. The patient has moderately differentiated intestinal type adenocarcinoma. Adenocarcinoma of the duodenum is a rare disease and diagnosis is always late in being confirmed because of the non-specific symptoms consequently leading to

poor prognosis. Duodenal cancer is a cancer in the beginning section of the small intestine and its histology is usually reported as adenocarcinoma. Symptoms of this cancer can be pain in the abdomen weight loss weakness and fatigue [6]. As the size of the tumor increase it can block the passage of digested food and thus can cause obstruction. This obstruction causes pain with severe nausea and vomiting. Known risk factors for gastric adenocarcinoma in the general population include Helicobacter pylori infection atrophic gastritis a diet high in nitrates and salt fried or fatty foods low fruits and vegetables intake smoking male gender and positive family history[7].

The treatment strategy includeWhipple procedure which is a complicated surgical procedure involving the pancreas duodenum and other organs. This surgical procedure is performed to treat cancerous tumors on the head of the pancreas malignant tumors involving common bile duct duodenal papilla duodenum near the pancreas and/or pancreatitis with or without definitive cause. In this procedure the duodenum a portion of the Pancreas (the head) and the gall bladder are usually removedand the small intestine is brought up to the Pylorus (the valve at the bottom

of the stomach) and the Liver and Pancreas digestive enzymes and bile are connected to the small intestine below the Pylorus [6 8]. For tumors of the first portion Santoro et al. [9] advised a partial pancreaticoduodenectomy because lymphadenectomy must include both tributary districts (celiac and mesenteric) [9]. Surgery forms the final option for patients presenting with refractory GOO. Most common surgeries for peptic strictures include vagotomy and antrectomy vagotomy and pyloroplasty truncalvagotomy and gastrojejunostomy pyloroplasty and laparoscopic variants.

The symptoms of GOO are difficult to differentiate regardless of the etiology. The most common clinical features of GOO include nausea and vomiting epigastric pain early satiety abdominal distension and weight loss[23]. However onset of symptoms of GOO varies depending upon the etiology. It may be either abrupt or quiet.

CONCLUSION

Although it is rare still one should consider adenocarcinoma in any patient who is presented with non-specific gastrointestinal complaints since this can lead to an early diagnosis. This report highlights the importance of regular outpatient visits in patients with a history of neoplasm even if they have undergone surgery and especially if they have not been treated with chemotherapy. Particular attention should be paid to new obstructive symptoms as possible consequences of late post-surgical or unusual peritoneal metastatic complications.

Written informed consent was obtained from the son of the patient for publication of this case report and any accompanying images.

Author's Contributions

RAK conducted the surgical procedure and diagnosis PNassisted RAKgathered the data HBRperceived the idea. PN HBR and MC wrote the manuscript. All authorshave read and approved the final manuscript.

REFERENCES

1. Samad A. Khanzada TW.Shoukat I. Gastric outlet obstruction: change in etiology.Pak J of Surg;23:29322007.

2. Guner A. Kahraman I. Aktas A. Kece C. Reis E. Gastric outlet obstruction due to duodenal bezoar: A case report. Int J Surg Case Rep3(11): 523-5252012.

3. Huang YC. Chen HM. Jan YY. Huang TL. Chen MF. Ectopic pancreas with Gastric outlet obstruction: Report of Two Cases and Literature Review. Chang Gung Med J 25:72002.

4. Appasani S. Kochhar S. Nagi B. Gupta V. Kochhar R.Benign gastric outlet obstruction spectrum and management.Tropical Gastroenterology 32(4):259266 2011.5. Shone DN. Nikoomanesh P. Smith-Meek MM. Bender JS. Malignancy is the most common cause of gastric outlet obstruction in era of H2 blockers. American J of Gastroenterology90:1769-1770 1995. 6. Lee CC. Ng WK. Lin KW Lai TW Li SM. Adenocarcinoma of the duodenum-case report. Hong Kong Med J14:67-9 2008.

7. Otabor AI.AbdessalamFS. Erdman HS. Hammond S. BesnerEG. Gastric outlet obstruction due to adenocarcinoma in a patient with Ataxia-Telangiectasia syndrome.World Journal of Surgical Oncology7:29 2009.

8.Markogiannakis H. Theodorou D. Toutouzas KG.Gloustianou G. Katsaragakis S.BramisI. Adenocarcinoma of the third and fourth portion of the duodenum: a case report and review of the literature Cases Journal1:98 2008.

9. Santoro E. Sacchi M. Scutari F. Carboni F. Graziano F. Primaryadenocarcinoma of the duodenum: treatment andsurvival in 89 patients. Hepatogastroenterology44: 1157-1163 1997.
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Publication:Science International
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Date:Sep 30, 2014
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