What is the management approach for gastric outlet obstruction?

Management of Gastric Outlet Obstruction

Initial Workup

Perform upper endoscopy immediately to visualize the obstruction, obtain multiple biopsies for histologic diagnosis, and assess feasibility of endoscopic intervention 1, 2. This is the critical first step to differentiate benign from malignant causes and guide subsequent management.

Essential Diagnostic Studies

• CT scan with oral and IV contrast to determine location, cause, extent of obstruction, assess for metastatic disease, and evaluate resectability 1, 2
• Laboratory evaluation including complete blood count (assess anemia), comprehensive metabolic panel (electrolytes, renal function), and coagulation profile 1
• Physical examination should specifically assess for abdominal distension, visible peristalsis, succussion splash, and perform digital rectal examination if colorectal malignancy suspected 1

Immediate Supportive Care

• Nasogastric tube placement for gastric decompression and aspiration prevention 1, 2
• IV fluid resuscitation with isotonic crystalloids to correct dehydration and electrolyte abnormalities 1, 2
• Anti-emetics for symptom control and bowel rest until obstruction relieved 1, 2

Treatment Algorithm Based on Etiology and Prognosis

For Malignant Gastric Outlet Obstruction

The treatment approach hinges on three critical factors: life expectancy, functional status, and surgical fitness 3, 4.

Patients with Life Expectancy >2 Months AND Good Functional Status AND Surgically Fit:

Laparoscopic gastrojejunostomy is the recommended approach 3, 1, 4. This provides:

• Lower blood loss and shorter hospital stay compared to open surgery 3
• Fewer limitations in food texture/consistency 4
• Better long-term symptom relief 4
• More durable results with fewer re-interventions compared to stenting 5, 6

Important caveat: Up to 50% may develop delayed gastric emptying after surgery due to food accumulation in the antrum 4. Poor nutritional status, ascites, and poor functional status are independent predictors of clinical failure 4.

Patients with Life Expectancy <2 Months OR Poor Surgical Candidates:

Endoscopic self-expanding metal stent (SEMS) placement is recommended 3, 1. This provides:

• Faster oral intake resumption (typically within days) 6
• Shorter hospital stay 3, 6
• Rapid clinical improvement 5

Critical contraindications for enteral stents:

• Multiple luminal obstructions 3, 1
• Severely impaired gastric motility 3, 1
• Presence of ascites 4

In these scenarios, placement of venting gastrostomy should be considered instead 3, 1. If ascites is present, it must be drained before venting gastrostomy placement to reduce infectious complications 3, 1.

Alternative: EUS-Guided Gastrojejunostomy

EUS-guided gastrojejunostomy is an acceptable alternative to surgical gastrojejunostomy and enteral stent placement, depending on endoscopist experience 3. Recent data shows:

• Similar long-lasting symptom relief as surgical gastrojejunostomy 7
• Shorter procedure duration and hospital stay compared to surgery 7
• Lower post-procedure ileus rate 7

Major limitation: No dedicated FDA-approved devices currently available 3. Stent misdeployment occurs in 12% of patients 4.

For Resectable Gastric Cancer with Obstruction

Surgical resection (distal or total gastrectomy with D2 lymphadenectomy) is the primary treatment 2. Palliative resection provides the longest median symptom-free and overall survival compared to other palliative methods 6.

Do NOT place esophageal SEMS as bridge to surgery - this approach has higher mortality and morbidity, lower R0 resections, shorter time to recurrence, and worse overall survival 3.

For Benign Gastric Outlet Obstruction

Endoscopic balloon dilatation is first-line treatment 8, 9, combined with:

• Proton pump inhibitors 8
• H. pylori eradication (strongly associated with successful relief without surgery) 8, 9
• Discontinuation of NSAIDs (continued use associated with recurrent obstruction) 9

Surgical gastrojejunostomy may be indicated if endoscopic approaches fail after multiple attempts (typically >4-6 sessions), complications occur, or anatomically unfavorable strictures exist 1. In benign disease, surgical gastrojejunostomy has better technical success than EUS-guided gastrojejunostomy 7.

Critical Management Pitfalls

• Severe uncontrolled pain after gastric stent placement requires immediate endoscopic stent removal 1
• Never place feeding tubes distal to obstruction in cases requiring surgical correction 1
• Advance diet gradually only after obstruction is definitively relieved and no complications present 1
• Nutritional support via jejunal feeding tube may be necessary if oral intake cannot be resumed within 5-7 days 1