Pyloric Obstruction

• • History of symptomatic peptic ulcer disease

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

  • Vomitus contains undigested food

Epidemiology

• • 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

Symptoms and Signs

• • 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

Laboratory Findings

• • 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

Imaging Findings

• • 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

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

Rule Out

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

• • 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

When to Admit

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

• • Replacement of fluid and electrolytes

  • NG tube for decompression

Surgery

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

Indications

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

  • Recurrent obstruction of any degree

Contraindications

• • Inadequate trial of conservative treatment

Medications

• • H2 blockers, proton pump inhibitors

  • Treatment of H pylori infection

  • Total parenteral nutrition if patient is malnourished

Treatment Monitoring

• • Saline load test: 700 ...