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  • • History of symptomatic peptic ulcer disease

    • Anorexia, vomiting, and failure to gain relief from antacids

    • Vomitus contains undigested food

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Epidemiology

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  • • Duodenal ulcer is a more common cause of obstruction than gastric ulcer

    • Gastric ulcers that cause obstruction are close to the pylorus

    • Obstruction is less common than either bleeding or perforation

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Symptoms and Signs

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  • • History of symptomatic peptic ulcer disease

    • Increasing ulcer pain with anorexia, vomiting of undigested food, and failure to gain relief from antacids

    • Absence of bile pigment in vomitus reflects level of duodenal obstruction

    • Weight loss, dehydration, and malnutrition may be marked

    • Peristalsis of the distended stomach may be visible

    • Upper abdominal distention and tenderness are usually apparent

    • Tetany with advanced alkalosis

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Laboratory Findings

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  • • Serum studies show hypochloremia, hypokalemia, hyponatremia, and increased HCO3

    • Anemia in about 25% of patients

    • Prolonged vomiting leads to metabolic alkalosis with dehydration, which may lead to prerenal azotemia

    • Large amounts of sodium and HCO3- are excreted in the urine

    • Test for infection with Helicobacter pylori

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Imaging Findings

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  • Abdominal x-rays: May show a large gastric fluid level

    Contrast radiographic upper GI series: Shows retention of contrast proximal to the obstruction, with luminal narrowing at the level of the obstruction

    Gastroscopy: Demonstrates luminal narrowing and is indicated to rule out an obstructing neoplasm

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  • • Consider obstruction in any patient with a history of peptic ulcer disease and prolonged vomiting, abdominal distention, and pain

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Rule Out

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  • • Obstruction due to peptic ulcer must be differentiated from that caused by a malignant tumor of the antrum, the duodenum, or the pancreas

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  • • Contrast radiographic upper GI series to confirm the diagnosis

    • Upper GI endoscopy to rule out malignancy as the cause of obstruction

    • CBC and serum electrolytes

    • Evaluation for H pylori infection

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When to Admit

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  • • High-grade obstruction with ongoing vomiting, inability to tolerate oral intake, severe dehydration, or derangement of serum electrolytes

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  • • Replacement of fluid and electrolytes

    • NG tube for decompression

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Surgery

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  • • If conservative management fails, truncal or parietal cell vagotomy and drainage procedure is indicated

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Indications

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  • • Failure of the obstruction to resolve completely within 5-7 days

    • Recurrent obstruction of any degree

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Contraindications

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  • • Inadequate trial of conservative treatment

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Medications

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  • • H2 blockers, proton pump inhibitors

    • Treatment of H pylori infection

    • Total parenteral nutrition if patient is malnourished

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Treatment Monitoring

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  • Saline load test: 700 mL of saline is infused; 30 minutes later, the stomach is ...

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