History

Nausea and vomiting are the cardinal symptoms of gastric outlet obstruction (GOO). Vomiting usually is described as nonbilious, and it characteristically contains undigested food particles. In the early stages of obstruction, vomiting may be intermittent and usually occurs within 1 hour of a meal.

Patients with GOO resulting from a duodenal ulcer or incomplete obstruction typically present with symptoms of gastric retention, including early satiety, bloating or epigastric fullness, indigestion, anorexia, nausea, vomiting, epigastric pain, and weight loss. They are frequently malnourished and dehydrated and have a metabolic insufficiency. Weight loss is frequent when the condition approaches chronicity and is most significant in patients with malignant disease.

Abdominal pain is not frequent and usually relates to the underlying cause (eg, peptic ulcer disease [PUD] or pancreatic cancer).

Physical Examination

Physical examination often demonstrates the presence of chronic dehydration and malnutrition. A dilated stomach may be appreciated as a tympanitic mass in the epigastric area and/or left upper quadrant.

Dehydration and electrolyte abnormalities can be demonstrated by routine laboratory examinations. Increases in blood urea nitrogen (BUN) and creatinine are late features of dehydration.

Prolonged vomiting causes loss of hydrochloric acid and produces an increase of bicarbonate in the plasma to compensate for the lost chloride and sodium. The result is a hypokalemic hypochloremic metabolic alkalosis. Alkalosis shifts the intracellular potassium to the extracellular compartment, and the serum positive potassium is increased factitiously. With continued vomiting, the renal excretion of potassium increases in order to preserve sodium. The adrenocortical response to hypovolemia intensifies the exchange of potassium for sodium at the distal tubule, with subsequent aggravation of the hypokalemia.

Workup

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Media Gallery

Upper endoscopy showing multiple gastric polyps. Such polyps are a major cause of gastric outlet obstruction.
Anatomic changes associated with pyloric stenosis.
Plain radiograph of the abdomen. Enlarged stomach with calcified content.
Contrast study demonstrating an enlarged stomach. The point of obstruction is visualized at the pyloric-duodenal junction (string sign).
Completed myotomy in open pyloromyotomy for hypertropic pylotic stenosis.
Robotic-assisted esophagectomy pyloroplasty. Courtesy of Memorial Sloan-Kettering Cancer Center, featuring Inderpal S. Sarkaria, MD.

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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: Nothing to disclose.

Coauthor(s)

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.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

John Geibel, MD, MSc, DSc, AGAF Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, Professor, Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow; Fellow of the Royal Society of Medicine

John Geibel, MD, MSc, DSc, AGAF 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, Society for Surgery of the Alimentary Tract

Disclosure: Nothing to disclose.

Additional Contributors

Brian J Daley, MD, MBA, FACS, FCCP, CNSC Professor and Program Director, Department of Surgery, Chief, Division of Trauma and Critical Care, University of Tennessee Health Science Center College of Medicine

Brian J Daley, MD, MBA, FACS, FCCP, CNSC is a member of the following medical societies: American Association for the Surgery of Trauma, Eastern Association for the Surgery of Trauma, Southern Surgical Association, American College of Chest Physicians, American College of Surgeons, American Medical Association, Association for Academic Surgery, Association for Surgical Education, Shock Society, Society of Critical Care Medicine, Southeastern Surgical Congress, Tennessee Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

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.

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.

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.

Gastric Outlet Obstruction Clinical Presentation

History

Physical Examination

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