Gastric outlet obstruction and secondary small bowel obstruction secondary to…migrating tumor???

Ariel Shuchleib, MD, Omar Bellorin, MD, Saurabh Sharma, MD, Litong Du. New York Presbyterian Queens

Introduction: Gastric outlet obstruction (GOO) is a blockage in the outflow of the stomach that is characterized by abdominal pain and postprandial emesis of undigested food. It is secondary to a mass, scar tissue or an inflammatory process. Historically the most common cause was peptic ulcer disease but an unusual etiology today due to usage of proton pump inhibitors and H2 blockers.

Small bowel obstruction (SBO) is the interruption of the flow of the intestinal content for which the etiology is variable, and the most common cause is adhesions secondary to previous surgeries; but masses, hernias, and intussusception among others are also common causes of SBO.

Case report: 81 year old Chinese female presented with abdominal pain and emesis for two days. Blood work was unremarkable and she underwent a CT scan that showed a distended stomach and duodenum, with a mass in the third portion of the duodenum. The stomach was decompressed with nasogastric tube. She had an upper endoscopy that was unremarkable. Due to lack of resolution of symptoms an upper GI series was done and it showed a 4×3 cm mass that had migrated to the mid ileum obstructing the small bowel.

She was then taken to the OR for a diagnostic laparoscopy during which the mass was seen, an enterotomy was performed in the mid ileum, a phytobezoar was extracted and the bowel was closed in a transverse fashion in 2 layers.

Upon further questioning, the patient endorsed that she ate dried seeds on a regular basis that she swallowed without chewing them.

Discussion: Any pathology that mechanically obstructs the emptying of the stomach produces gastric outlet obstruction. The etiology can be a benign or malignant process. Before the era of PPIs and H2 blockers the most common etiology was peptic ulcer disease, however, today over 50% of the cases are attributable to malignancy. Another less common etiology is a bezoar. A bezoar is a concretion of non-digestible material in the gastrointestinal tract that can present with a variety of clinical manifestations, like: gastritis, gastric ulcers, perforation, or small bowel obstruction and GOO as in this case.

There are multiple options for management in these patients: enzymatic treatment with Papain or Cellulase to try to dissolve the bezoar, endoscopic fragmentation and removal, less orthodox alternatives with questionable efficacy like cola, and surgery.

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