From the Guidelines
Gastric outlet obstruction is a condition where the passage between the stomach and small intestine becomes blocked, preventing food and liquids from properly emptying from the stomach, and its management should prioritize palliation to reduce nausea and vomiting and allow resumption of an oral diet, as outlined in the NCCN clinical practice guidelines in oncology 1.
Definition and Causes
Gastric outlet obstruction is characterized by a blockage of the passage between the stomach and small intestine, which can be partial or complete, and typically causes symptoms like persistent vomiting, feeling full quickly, upper abdominal pain, bloating, and weight loss. The most common causes include peptic ulcer disease, scarring from previous ulcers, tumors (benign or cancerous), and inflammatory conditions. In children, pyloric stenosis is a common cause.
Diagnosis and Treatment
Diagnosis usually involves imaging tests like upper endoscopy, CT scans, or upper GI series with contrast. Treatment depends on the underlying cause but may include medications to reduce stomach acid, antibiotics if H. pylori infection is present, placement of a nasogastric tube for decompression, and often surgery or endoscopic procedures to relieve the obstruction. For patients with malignant gastric obstruction, endoscopic placement of a self-expanding metal stent (SEMS) is a safe and effective minimally invasive palliative treatment, as suggested by the NCCN guidelines 1 and supported by a clinical practice update from the AGA 1.
Management Considerations
When obstruction cannot be alleviated or bypassed, the primary goal is to reduce the symptoms of obstruction via venting gastrostomy. Percutaneous, endoscopic, surgical, or interventional radiology gastrostomy tube placement may be performed for gastric decompression, if tumor location permits. The insertion of an enteral stent should be considered for patients with gastric outlet obstruction who are not candidates for gastrojejunostomy, as recommended by the AGA clinical practice update 1. Without treatment, gastric outlet obstruction can lead to serious complications including malnutrition, dehydration, and electrolyte imbalances, making prompt medical attention essential. Key considerations in management include:
- Reducing nausea and vomiting
- Allowing resumption of an oral diet
- Individualizing treatment options based on clinical appropriateness
- Considering the insertion of an enteral stent for patients not candidates for gastrojejunostomy
- Prioritizing palliation for patients with malignant gastric obstruction, as outlined in the NCCN guidelines 1.
From the Research
Definition and Causes of Gastric Outlet Obstruction
- Gastric outlet obstruction (GOO) is a condition characterized by mechanical obstruction of the pylorus, distal stomach, or duodenum, causing severe symptoms such as nausea, vomiting, abdominal pain, and early satiety 2.
- The etiology of GOO includes both benign and malignant disorders, with peptic ulcer disease being a common cause of benign GOO, and malignant causes including gastric cancer, lymphoma, and gastrointestinal stromal tumor 3.
- The predominant causes of GOO have changed from benign to malignant diseases with the eradication of Helicobacter pylori (H. pylori) and the use of proton pump inhibitors 3.
Symptoms and Treatment Options
- Symptoms of GOO include epigastric pain, postprandial vomiting, nausea, vomiting, abdominal pain, and early satiety 2, 3.
- Treatment options for GOO include initial conservative therapeutic protocols, endoscopic treatments such as balloon dilation, enteral stenting, and endoscopic ultrasound-guided gastroenterostomy (EUS-GE), as well as surgical gastroenterostomy 2, 4.
- Endoscopic management of GOO can provide similar clinical outcomes with fewer adverse events, faster resumption of oral feeding, and shorter hospitalizations compared to surgery 4.
- EUS-GE with a lumen-apposing metal stent has revolutionized treatment, especially in individuals who are not ideal surgical candidates 4.
Diagnosis and Treatment Outcomes
- Endoscopy is the preferred method for diagnosis of GOO 5.
- Outcomes of endoscopic treatment may be improved with effective ulcer therapy with acid reduction and eradication of H. pylori 5.
- About 65% of patients with peptic ulcer-induced GOO have sustained symptom relief with endoscopic balloon dilation, but many require more than one dilation session 5.