AND ITS SURGICAL MANAGEMENT DEFINITION Gastric Outlet Obstruction is clinical or pathophysiological consequence of any disease process that produces mechanical impediment to gastric emptying ID: 920568
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GASTRIC OUTLET OBSTRUCTION AND ITS SURGICAL MANAGEMENT
Slide2DEFINITIONGastric Outlet Obstruction is clinical or pathophysiological consequence of any disease process that produces mechanical impediment to gastric emptying
Slide3Gastric Outlet Obstruction
Slide4EtiologyBENIGNPeptic Ulcer disease
Ingestion of Caustics
Trichobezoars
( Hairballs)
Adult hypertrophic Pyloric stenosis
Pyloric mucosal diaphragm
Pancreatic
Pseudocysts
Slide5BARIATRIC PROCEDURESVertical banded gastroplasty
Roux-en-Y gastric bypass
Slide6ETIOLOGYMALIGNANTCarcinoma of StomachPeriampullary
carcinomas
Carcinoma Head of pancreas
ampullary
carcinoma
Carcinoma of second part of duodenum
cholangiocarcinomas
Slide7PRESENTATIONHISTORY
Epigastric
or left
hyochondrial
pain
> which is most common feature in peptic ulcer disease
vomiting
>unpleasant smell
> copious amounts
>projectile
>
NON BILIOUS
>contains undigested food particles taken hours to several days ago
Slide8HistoryFeeling of unwellAnorexia NauseaEarly satiety
Weight loss
Abdominal swelling
Slide9EXaminationGENERAL PHYSICAL EXAMINATIONChronically ill looking patient
Wasted
Dehydrated
Pale
Left
supraclavicular
lymphadenopathy
(with malignant obstruction)
Slide10ExaminationABDOMINALDistended stomach ( fullness in epigastrium)Visible Gastric
Peristalisis
Succussion
splash
Hepatosplenomegally
Look for
Ascities
( sign of Carcinoma spread)
Slide11Epigastric fullness
Slide12Succussion splashSloshing sound heard through stethoscope place over
epigastrium
during sudden movement of the patient
Slide13.
Slide14CLINICAL FEATURESMETABOLIC EFFECTSVomiting of Hydochloric
acid ( HCL) leads to
hypochloremic
metabolic alkalosis
Kidneys respond by excreting Bicarbonate and conserving chloride
This bicarbonate is excreted with sodium
So with time patient becomes more profoundly dehydrated and
hyponatremic
Slide15Metabolic effectsBecause of dehydration body responds to preserve intravascular volume by sodium retentionNow potassium and hydrogen are excreted in preference to preserve sodium
This leads to paradoxical
aciduria
( acidic urine despite metabolic alkalosis)
Hypokalemia
ensues
Slide16Metabolic effectsAlkalosis leads to lowering of circulating ionised calcium This can lead to
tetany
Slide17INVESTIGATIONSCBCS/E
LFT
Test for H pylori
Slide18InvestigationsABG s : Metabolic AlkalosisUrine C/E: paradoxical aciduria
Slide19RadiologyPlane Xray Erect Abdomen:
Large Gastric shadow and Large amount of Gastric fluid
Slide20Plane Xray Abdomen
Slide21Barium Meal6 hour peroid of fasting is observed prior to studyBarium
sulphate
is ingested by the patient
Xray
images are taken at 20 to 30 minutes interval in supine position
Slide22Barium meal
Slide23Upper GI endoscopy visualize Gastric Outlet Biopsy
Slide24Gastric outlet obstruction
Slide25CT scanFor extraluminal obstruction Periampullary
carcinomas
Slide26ManagementTwo Aims1.Correct metabolic abnormality
2.Deal with mechanical obstruction
Slide27Correcting Metabolic AbnormalitiesPass double large Bore IV linePass wide bore
nasogastric
tube to empty the stomach
Sometimes an
orogastric
tube is required to
lavage
and empty the stomach as
nasogastric
tube may not be sufficiently large to deal with contents of the stomach
Slide28Correcting metabolic abnormalitiesIntravenous Normal Saline (0.9% NaCI) with Potassium Supplementation
Correct anemia
Slide29managementEarly cases may settle with conservative management
NPO
ANTACIDS
PPI
as the edema around the ulcer diminishes as the ulcer is healed
Slide30Surgery for benign GOO
Slide31Pyloroplasty with vagotomy
Slide32Truncal Vagotomy and Antrectomy and Billroth Reconstructions
Slide33PYLOROPLASTYFINEYJABOULEYSHeineke-Mikulicz
Slide34Slide35Slide36Slide37GASTROJEJUNOSTOMY
Slide38BALLOON DIALATATIONENDOSCOPIC DALATION Repeated dilatations neededMay cause
perforation
Slide39Endoscopic stenting for unresectable tumor
Slide40stenting