Sections

Workup

Laboratory Studies

Obtain a complete blood count (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 peptic ulcer disease (PUD) is suspected.

Imaging Studies

Plain abdominal radiography, contrast upper gastrointestinal (GI) studies (Gastrografin or barium), and computed tomography (CT) with oral contrast are helpful. (See the images below.) 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 with calcified content.

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

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Diagnostic Procedures

Upper endoscopy (see the image below) can help visualize the gastric outlet and may provide a tissue diagnosis when the obstruction is intraluminal.

Upper endoscopy showing multiple gastric polyps. Such polyps are a major cause of gastric outlet obstruction.

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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 mL 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 mL remains 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-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 relate to the individual underlying cause.

Treatment & Management

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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 Workup

Laboratory Studies

Imaging Studies

Diagnostic Procedures

References

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