What is the next step in management for a patient with gastric outlet obstruction and pyloric stricture on gastroscopy?

Management of Pyloric Stricture in Gastric Outlet Obstruction

Endoscopic balloon dilatation is the recommended first-line treatment for patients with gastric outlet obstruction due to pyloric stricture identified on gastroscopy. 1

Initial Management Approach

Endoscopic Balloon Dilatation

• First-line therapeutic intervention for pyloric strictures causing gastric outlet obstruction 1
• Success rates of 80-88% have been reported in initial management 2, 1
• Technique:
  • Wire-guided or endoscopically controlled balloon dilatation techniques should be used 1
  • For tight strictures, initial dilatation may be limited to 1-2 size increments (2×1 mm) 1
  • For less tight strictures, larger increments (4×1 mm or 3×2 mm) may be safely used 1

Procedural Considerations

• Fluoroscopic guidance is recommended for complex strictures to enhance safety 1
• Carbon dioxide insufflation rather than air is preferred during endoscopy to minimize luminal distension and post-procedural pain 1
• Patients typically require several sessions to achieve resolution of symptoms 1

Post-Procedure Management

• Monitor patients for at least 2 hours in the recovery room 1
• Provide clear written instructions regarding fluids, diet, and medications 1
• Routine imaging and contrast studies are not necessary unless patients develop persistent chest pain, fever, breathlessness, or tachycardia 1

Follow-Up and Subsequent Management

• Schedule follow-up endoscopy to assess response to dilatation
• Be aware that recurrence rates can be high (up to 84% in some studies) with longer follow-up periods 3
• If symptoms recur, consider repeat dilatation sessions

When to Consider Surgery

• Failure to negotiate the stricture endoscopically 2
• Persistent gastric outlet obstruction despite dilatation 2
• Need for more than two courses of endoscopic balloon dilatation to relieve symptoms (strong predictor of treatment failure) 4
• When endoscopic methods are unsuccessful, conversion to surgical intervention is indicated 1

Potential Complications to Monitor

• Perforation (rare but serious)
• Bleeding
• Recurrent obstruction

Special Considerations

• For malignant gastric outlet obstruction, self-expandable metal stents may be more appropriate than balloon dilatation 1
• In patients with food bolus obstruction, urgent endoscopic intervention is recommended with biopsy to rule out eosinophilic esophagitis or other underlying pathologies 1

Endoscopic balloon dilatation offers a minimally invasive approach with good initial success rates, potentially avoiding the need for surgery in many patients. However, patients should be informed about the possibility of requiring multiple dilatation sessions and the risk of recurrence requiring surgical intervention.