Etiological profile of gastric outlet obstruction and its treatment: a hospital based prospective study in a tertiary care center, north-east India

and Nishad Deka 2 . 1. Associate Professor, Dept. of General Surgery, Silchar Medical College & Hospital, Silchar, India. 2. Postgraduate Trainee, Dept. of General Surgery, Silchar Medical College & Hospital, Silchar, India. 3. Registrar, Dept. of General Surgery, Silchar Medical College & Hospital, Silchar, India. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History

GOO can be a diagnostic and treatment dilemma. As part of the initial workup, the possibility of functional causes of obstruction, such as gastroparesis due to diabetes or paralytic ileus due to any metabolic cause should be excluded. Once a mechanical obstruction is confirmed, definitive treatment is based on recognition of the specific underlying cause i.e. benign and malignant. Diagnosis and treatment should be done as early as possible, as delay may result in further compromise of the patient's nutritional status and also increase the oedematous tissue, which complicate surgical intervention.
Cicatrised DU was the most common cause of GOO [1] but due to wider usage of H2 blockers and PPIs, better health care facilities with new investigating equipments & techniques, its incidence is on decline and is replaced by carcinoma stomach which is detected early by new investigating modalities.
The lack of uniformity in criteria in accepting a case of GOO lead to differences in incidences and clinical features in different centres, still, any one of the following can be used to diagnose gastric outlet obstruction. 1. Projectile vomiting of undigested food consumed previous day. 2. Visible gastric peristalsis (VGP). 3. Gastric succussion splash 3-4 hours after the last meal. 4. Palpable hypertrophied stomach. 5. Delayed emptying of stomach on barium meal studies. 6. A gastric residue of more than 500 ml in an adult. 7. An aspirate of more than 250 ml on saline load test.
Aims & objectives:-1. To identify the causes of GOO in adults. 2. To review the changes in presentation of GOO in view of changing trends in the management because of new drugs and investigatory modalities. 3. To evaluate diagnostic methods and management strategies of GOO in adults.

Material and Methods:-
This is a clinical observational study comprising of 70 consecutive cases of GOO in adults due to various causes. Patients for the study were selected from the surgical units of Silchar Medical College and hospital, Silchar during the period of July 2014 to December 2016.
The pre-requisites for selecting a patient in this study were as follows: 1. One or more of the following clinical features; projectile vomiting, especially persistent vomiting of undigested food; gastric succusion splash heard 3-4 hours after the last meal; visible gastric peristalsis or presence of a palpably distended and hypertrophied stomach. 2. Fasting overnight gastric aspirate more than 200ml. 3. Saline load test of Goldstein: The volume of saline remaining half an hour after instillation of 600 ml of 0.9% NS solution. Any volume more than 250 ml. was considered significant. 4. Upper Gastro intestinal endoscopy demonstration / Radiological demonstration of gastric outlet obstruction. 5. Demonstration at operation of gross narrowing of the gastric outlet.
The cases that were willing to undergo surgery, 20 years or more in age, irrespective of sex were included in this study while patient having functional cause of obstruction were excluded. After admission of the patient a detailed clinical history was taken. Physical examination was carried out in detail, noting the state of hydration and 2260 nutritional status. Particular attention was paid to abdominal examination for the presence of VGP, tenderness, palpable masses and succussion splash.
On the basis of the history and physical findings, a diagnosis of GOO was made and the patient investigated. Saline load test performed bedside in every patients.

Results and Observations:-
The clinical material for this study consists of 70 adult patients with gastric outlet obstruction. All these patients were selected from the general surgical units of Silchar Medical College & Hospital, Silchar. A thorough study of these cases was made regarding the history, clinical examination, investigations, operative findings, treatment, postoperative management and tables & figures are depicting clinical parameters is also presented.
Out of 70 cases, 42(60%) cases had malignant growth in the gastric antrum as shown in figure 2, 24(34%) cases had cicatrized duodenal ulcer as shown in figure 1, 2(3%) had gastric trichobezoar, 1(1.5%) had pseudo pancreatic cyst and 1(1.5%) had carcinoma head of the pancreas as the cause of gastric outlet obstruction. Distribution according pathology is shown in Table 1.  due to antral carcinoma.
The endoscopic biopsy specimen from gastric mucosa was taken from 67(95.7%) cases, except for GOO due to gastric trichobezoar and pseudo pancreatic cyst. 50% of cicatrised duodenal ulcer cases were H.pylori positive.
H.pylori quick test results are shown in figure 3.
2261 The maximum incidence (40%) of GOO was seen in 50-59 years of age of which 28.5% was due to antral carcinoma, while 40-49 years age group incidence was 30% of which 20% was due to cicatrized DU, one case of pseudo pancreatic cyst was seen in 30-39 years of age group, one case of carcinoma head of the pancreas was seen in 60-69years age group. and two cases of gastric Trichobezaor was seen as a cause of G.O.O. Distribution according to underlying pathology is shown in table 2. In this series 46(65.7%) patients were males and 13 (34.3%) patients were female. Male to female ratio (M:F) was 1.9:1 as seen in figure 4.
In this series, 28 patients (40%) were farmers, 18(26%) patients were manual labourers, 10 (14%) patients were Drivers, 9 (13%) patients were housewives and 5 (7%) patients were businessman as seen in figure no 5.   Most common surgical operation done was Truncal vagotomy with posterior gastro-jejunostomy for cicatrized duodenal ulcers followed by Billroth II gastrectomy for antral carcinoma, Gastric Trichobezaor were removed by gastrotomy in two cases and pseudo pancreatic cyst was drained by Jurasz Cysto-gastrostomy as shown in table 4. Six patients of antral carcinoma died in post-operative period, four with electrolyte imbalance and the other two because of severe lower respiratory tract infection and septicaemia. Post-operative hospitalization ranged from 8 to 21 days with an average of 14 days. Sutures were removed between 7th and 10th post-operative day.

Follow up:-
All the 64 cases were followed up post operatively for the period of 6 months. All the antral carcinoma patients received chemotherapy post operatively, of 34 patients 15 who underwent Billroth II resection received cisplatin and 5 FU regimen and rest with unresectable disease received epirubicin, cisplatin and 5 fluorouracil (5FU) regimen for 6 cycles at an interval of 21 days. Before every cycle complete blood count, liver and renal functions were assessed and 8 patients lost the follow up after 3 months. All 24 cases of duodenal ulcer were symptom free; Patients with gastric bezoar followed up and were symptom free; also patient with pseudo pancreatic cyst was followed up and he had recurrent attacks of dull aching pain in epigastrium, dyspepsia and was given oral opioid analgesics along with proton pump inhibitor (PPI) and pancreatic enzyme supplementation. On follow up of patient with CA head of pancreas he is found to be jaundice free and receiving adjuvant chemotherapy as in table 5.  [9]. This higher incidence in males, worldwide can be explained as because of more consumption of gastric irritants by males compared to females.
In our series 40% of the patients were farmers, 26% manual labourers and 14% were drivers who gave history of irregular diet habits, which seems to contribute to disease process. The series of Donald D Kozoll & Karl A Meyer [10] also showed the same pattern with non-skilled day labourer group listed most frequently with obstruction.
All the cases were subjected to serum electrolyte estimation in our study. Out of them 18 cases (25.7%) showed electrolyte imbalance. In series of Maichel L Schwartz [11] electrolyte imbalance was present in 30%.
Common symptoms and signs in our study were vomiting, pain abdomen & dyspepsia and succussion splash, VGP & pallor respectively.