eMedicine Specialties > General Surgery > Abdomen

Gastric Outlet Obstruction: Workup

Author: Andres E Castellanos, MD, Assistant Professor, Associate Surgical Residency Program Director, Department of Surgery, Drexel University College of Medicine
Coauthor(s): Elisa A Stein, MD, Staff Physician, Department of Surgery, Drexel University College of Medicine, Hahnemann University Hospital; Barry D Mann, MD, Program Director, Associate Professor, Department of Surgery, Division of General Surgery, MCP Hahnemann University; Erica Rachel Podolsky, MD, Resident Physician, Division of General Surgery, Drexel University College of Medicine
Contributor Information and Disclosures

Updated: Oct 29, 2009

Workup

Laboratory Studies

  • Obtain a CBC. Check the hemoglobin and hematocrit to rule out the possibility of anemia.
  • Obtain an electrolyte panel. As noted previously, identifying and correcting electrolyte abnormalities that tend to occur is essential.
  • Liver function tests may be helpful, particularly when a malignant etiology is suspected.
  • A test for H pylori is helpful when the diagnosis of PUD is suspected.

Imaging Studies

  • Plain abdominal radiographs, contrast upper GI studies (Gastrografin or barium), and CT scans with oral contrast are helpful. (See images below and Images 3-4.)
  • Plain radiographs, including the obstruction series (ie, supine abdomen, upright abdomen, chest posteroanterior), can demonstrate the presence of gastric dilatation and may be helpful in distinguishing the differential diagnosis.
Plain radiograph of the abdomen. Enlarged stomach...

Plain radiograph of the abdomen. Enlarged stomach with calcified content.

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Plain radiograph of the abdomen. Enlarged stomach...

Plain radiograph of the abdomen. Enlarged stomach with calcified content.


Contrast study demonstrating an enlarged stomach....

Contrast study demonstrating an enlarged stomach. The point of obstruction is visualized at the pyloric-duodenal junction (string sign).

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Contrast study demonstrating an enlarged stomach....

Contrast study demonstrating an enlarged stomach. The point of obstruction is visualized at the pyloric-duodenal junction (string sign).


Diagnostic Procedures

  • Upper endoscopy can help visualize the gastric outlet and may provide a tissue diagnosis when the obstruction is intraluminal.
  • The sodium chloride load test is a traditional clinical nonimaging study that may be helpful.
    • The traditional sodium chloride load test is performed by infusing 750 cc of sodium chloride solution into the stomach via a nasogastric tube (NGT).
    • A diagnosis of gastric outlet obstruction (GOO) is made if more than 400 cc remain in the stomach after 30 minutes.
  • Nuclear gastric emptying studies measure the passage of orally administered radionuclide over time. Unfortunately, both the nuclear test and the saline load test may produce abnormal results in functional states.
  • Barium upper GI studies are very helpful because they can delineate the gastric silhouette and demonstrate the site of obstruction. An enlarged stomach with a narrowing of the pyloric channel or first portion of the duodenum helps differentiate GOO from gastroparesis.
  • The specific cause may be identified as an ulcer mass or intrinsic tumor.
  • In the presence of PUD, perform endoscopic biopsy to rule out the presence of malignancy.
  • In the case of peripancreatic malignancy, CT scan–guided biopsy may be helpful in establishing a preoperative diagnosis.
  • Needle-guided biopsy also may be helpful in establishing the presence of metastatic disease. This knowledge may impact the magnitude of the procedure planned to alleviate the GOO.

Histologic Findings

Histologic findings relate to the individual underlying cause.

More on Gastric Outlet Obstruction

Overview: Gastric Outlet Obstruction
Workup: Gastric Outlet Obstruction
Treatment: Gastric Outlet Obstruction
Follow-up: Gastric Outlet Obstruction
Multimedia: Gastric Outlet Obstruction
References
Further Reading
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References

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Further Reading

Clinical guidelines:
ACR Appropriateness Criteria® vomiting in infants up to 3 months of age. American College of Radiology - Medical Specialty Society. 1995 (revised 2008). 8 pages. NGC:007011

Evidence based clinical practice guideline hypertrophic pyloric stenosis. Cincinnati Children's Hospital Medical Center - Hospital/Medical Center. 2001 Aug 8 (revised 2007 Nov 4). 17 pages. NGC:006224

Surgical treatment of pancreatic cancer. Society for Surgery of the Alimentary Tract, Inc - Medical Specialty Society. 1996 (revised 2004 May 15). 3 pages. NGC:003753

Clinical trials:
Frequency of Formula Change Prior to the Accurate Diagnosis of Pyloric Stenosis

Magnetic Anastomosis Device Relief of Malignant Gastric Outlet Obstruction (MAD)

Open vs Laparoscopic Pyloromyotomy for Pyloric Stenosis

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Keywords

gastric outlet obstruction, pancreatic cancer, peptic ulcer, pyloric stenosis, gastric cancer, peptic ulcer disease, vagotomy, gastrojejunostomy, gastric outlet, pyloroplasty, periampullary cancer, antrectomy, gastric obstruction

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Contributor Information and Disclosures

Author

Andres E Castellanos, MD, Assistant Professor, Associate Surgical Residency Program Director, Department of Surgery, Drexel University College of Medicine
Andres E Castellanos, MD is a member of the following medical societies: American College of Surgeons
Disclosure: Sanofi-adventis Consulting fee Consulting

Coauthor(s)

Elisa A Stein, MD, Staff Physician, Department of Surgery, Drexel University College of Medicine, Hahnemann University Hospital
Elisa A Stein, MD is a member of the following medical societies: American College of Physicians, American Medical Association, American Medical Student Association/Foundation, American Medical Women's Association, and Philadelphia County Medical Society
Disclosure: Nothing to disclose.

Barry D Mann, MD, Program Director, Associate Professor, Department of Surgery, Division of General Surgery, MCP Hahnemann University
Barry D Mann, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for Cancer Education, American College of Surgeons, American Society of Bariatric Physicians, Association for Surgical Education, Society for Surgery of the Alimentary Tract, and Society of Surgical Oncology
Disclosure: Nothing to disclose.

Erica Rachel Podolsky, MD, Resident Physician, Division of General Surgery, Drexel University College of Medicine
Erica Rachel Podolsky, MD is a member of the following medical societies: American College of Surgeons
Disclosure: Nothing to disclose.

Medical Editor

Brian James Daley, MD, MBA, FACS, Associate Program Director, Professor, Department of Surgery, Division of Trauma and Critical Care, University of Tennessee School of Medicine
Brian James Daley, MD, MBA, FACS is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Chest Physicians, American College of Surgeons, American Medical Association, Association for Academic Surgery, Association for Surgical Education, Eastern Association for the Surgery of Trauma, Shock Society, Society of Critical Care Medicine, Southeastern Surgical Congress, and Tennessee Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Michael A Grosso, MD, Consulting Staff, Department of Cardiothoracic Surgery, St Francis Hospital
Michael A Grosso, MD is a member of the following medical societies: American College of Surgeons, Society of Thoracic Surgeons, and Society of University Surgeons
Disclosure: Nothing to disclose.

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MA, Vice Chairman, Professor, Department of Surgery, Section of Gastrointestinal Medicine and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital
John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract
Disclosure: AMGEN Royalty Other

 
 
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