What is the best management approach for a patient with partial gastric outlet obstruction (GOO)?

Management of Partial Gastric Outlet Obstruction

For partial gastric outlet obstruction, initiate conservative management with nasogastric decompression, IV fluid resuscitation, bowel rest, and anti-emetics, while simultaneously performing upper endoscopy with biopsy and CT imaging to determine the underlying etiology (benign vs. malignant), which will then dictate definitive treatment strategy. 1

Initial Stabilization and Workup

Immediate Supportive Measures

• Place a nasogastric tube for gastric decompression to prevent aspiration pneumonia and relieve symptoms 1
• Administer IV isotonic crystalloids for fluid resuscitation to correct dehydration and electrolyte abnormalities from vomiting 1, 2
• Insert Foley catheter to monitor urine output and assess volume status 1
• Provide anti-emetics for symptom control (dopamine receptor antagonists like metoclopramide or prochlorperazine) 3, 1
• Maintain strict bowel rest until obstruction is relieved 1, 2

Essential Diagnostic Studies

• Obtain upper endoscopy immediately to visualize the obstruction, obtain multiple biopsies to differentiate benign from malignant causes, and assess feasibility of endoscopic intervention 1, 2
• Order CT scan with oral and IV contrast to determine location, extent of obstruction, assess for metastatic disease, and evaluate resectability 1, 2
• Check complete blood count for anemia from chronic bleeding 1, 2
• Obtain comprehensive metabolic panel to identify electrolyte abnormalities (particularly hypochloremic metabolic alkalosis), renal dysfunction, and liver function 1, 2
• Consider coagulation profile if surgical intervention is anticipated 1

Treatment Algorithm Based on Etiology

For Malignant Gastric Outlet Obstruction

Resectable Disease

Surgical resection (distal or total gastrectomy with D2 lymphadenectomy) is the primary treatment for resectable gastric cancer with obstruction, as it provides the longest median symptom-free and overall survival 1, 2

Unresectable/Metastatic Disease with Life Expectancy >2 Months

• Laparoscopic gastrojejunostomy is recommended for patients with good functional status who are surgically fit, as it provides lower blood loss, shorter hospital stay, and more durable long-term results with lower reintervention rates 1, 4
• EUS-guided gastroenterostomy is an acceptable alternative to surgical gastrojejunostomy depending on endoscopist expertise, offering similar long-lasting symptom relief 1, 5, 6

Unresectable Disease with Life Expectancy <2 Months or Poor Surgical Candidates

• Endoscopic self-expanding metal stent (SEMS) placement is preferred, providing faster oral intake resumption (typically within days), shorter hospital stays, and immediate symptom relief 1, 2, 4
• Use fully covered or partially covered SEMS to maintain luminal patency 1
• Monitor for severe uncontrolled pain after stent placement, which requires immediate endoscopic stent removal 1, 4

Contraindications to Enteral Stenting

Do not place enteral stents in patients with multiple luminal obstructions, severely impaired gastric motility, or presence of ascites 1

• Instead, consider placement of venting gastrostomy for symptom relief 1
• Drain ascites before venting gastrostomy placement to reduce infectious complications 1, 4

For Benign Gastric Outlet Obstruction

Peptic Ulcer Disease

• Initiate high-dose proton pump inhibitors for gastritis or gastroesophageal reflux 3, 7
• Test for and eradicate Helicobacter pylori if present 7
• Consider endoscopic balloon dilation if stricture persists after medical management 1, 8

Refractory Benign Strictures

• Perform endoscopic balloon dilation as first-line intervention 8
• If balloon dilation fails after multiple attempts (typically >4-6 sessions), place temporary covered SEMS for 4-8 weeks to allow tissue remodeling 1, 8
• Reserve surgical intervention (conversion to Roux-en-Y gastric bypass or stricturoplasty with seromyotomy) for failed endoscopic approaches, presence of complications, or anatomically unfavorable strictures 1

Corticosteroid Trial for Partial Obstruction

Consider corticosteroids for gastric outlet obstruction as they may reduce inflammation and edema, particularly in malignant cases 3

Nutritional Support Considerations

• If oral intake cannot be resumed within 5-7 days, provide nutritional support via jejunal feeding tube placed distal to the obstruction 1
• For EGJ/gastric cardia obstruction, consider feeding gastrostomy tubes 1
• For distal gastric obstruction, use jejunal feeding tubes 1
• Avoid overly aggressive enteral or parenteral nutrition in patients with very limited life expectancy (weeks to days), as this can increase suffering 3

Critical Pitfalls to Avoid

• Never place feeding tubes distal to obstruction in cases requiring anatomic surgical correction (e.g., malrotation, diaphragmatic herniation)—these require definitive surgical repair, not nutritional bypass 1
• Do not use enteral stents in patients with multiple sites of obstruction or severe gastric dysmotility, as they provide limited benefit 1
• Avoid stent placement without first draining significant ascites due to increased infection risk 1, 4
• Do not delay endoscopic stent removal if severe uncontrolled pain develops post-placement 1, 4