What are the causes and symptoms of gastric outlet obstruction (GOO)?

From the Guidelines

Gastric outlet obstruction should be managed with endoscopic placement of a self-expanding metal stent (SEMS) as the primary treatment option, as it is a safe and effective minimally invasive palliative treatment that can alleviate symptoms and improve quality of life. This condition is a mechanical blockage that prevents food and liquids from properly emptying from the stomach into the small intestine, and can be caused by benign or malignant processes, with peptic ulcer disease and gastric cancer being common culprits 1. Patients typically present with persistent vomiting (often containing undigested food), early satiety, upper abdominal pain, and weight loss. Diagnosis involves upper endoscopy to visualize the obstruction and obtain biopsies if malignancy is suspected, along with imaging studies like CT scans or upper GI series.

Initial management includes nasogastric tube decompression, correction of fluid and electrolyte imbalances, and acid suppression with proton pump inhibitors such as omeprazole 40mg twice daily. For benign obstructions caused by peptic ulcer disease, endoscopic balloon dilation may be attempted, while malignant obstructions might require stent placement 2. The primary goals of palliation for patients with malignant gastric obstruction are to reduce nausea and vomiting and, when possible, allow resumption of an oral diet.

Some key points to consider in the management of gastric outlet obstruction include:

• Endoscopic placement of a SEMS is a safe and effective minimally invasive palliative treatment that can alleviate symptoms and improve quality of life 1
• Surgery (gastrojejunostomy or gastrectomy in selected patients), external beam RT, chemotherapy, and placement of enteral stent for relief of gastric outlet obstruction, or esophageal stent for EGJ/cardia obstruction are also used 3
• Nutritional support is crucial during treatment, and patients should be monitored for complications like aspiration pneumonia, dehydration, and malnutrition
• Ascites, if present, should be drained prior to venting gastrostomy tube placement to reduce the risk of infectious complications 2

From the Research

Definition and Causes of Gastric Outlet Obstruction

• Gastric outlet obstruction (GOO) is a clinical syndrome characterized by a variety of symptoms, including epigastric pain and postprandial vomiting due to mechanical obstruction 4, 5.
• The obstructions typically involved in GOO can be benign or malignant, with peptic ulcer disease being the most common cause of benign GOO, and malignant causes including gastric cancer, lymphoma, and gastrointestinal stromal tumor 5.
• The eradication of Helicobacter pylori (H. pylori) and the use of proton pump inhibitors have changed the predominant causes of GOO from benign to malignant diseases 5.

Treatment Options for Gastric Outlet Obstruction

• Treatment of GOO depends on the underlying cause, and may include proton pump inhibitors, H. pylori eradication, endoscopic treatments, or surgery 5.
• Endoscopic management of benign disease is mainly based on balloon dilation, augmented by the use of covered self-expanding metal stents (SEMS) in refractory disease 4.
• Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) is increasingly used as an alternative method, although more studies with longer follow up are needed before it can be considered as a recommended therapy 4, 6.
• Endoscopic management of malignant GOO is based on SEMS placement as an alternative to palliative surgery, because it is a cost-effective method 4.

Benefits and Outcomes of Endoscopic Treatment

• Minimally invasive endoscopic options can provide similar clinical outcomes with fewer adverse events, faster resumption of oral feeding, and shorter hospitalizations compared to surgery 6, 7.
• EUS-GE with a lumen-apposing metal stent has revolutionized treatment, especially in individuals who are not ideal surgical candidates 6.
• About 65% of patients with peptic ulcer-induced gastric outlet obstruction have sustained symptom relief with endoscopic balloon dilation, but many require more than one dilation session 7.