REVIEW

ANDREE H. KOOP, MD WILLIAM C. PALMER, MD FERNANDO F. STANCAMPIANO, MD

Division of Community Internal Medicine, Division of Gastroenterology and Hepatology, Division of Community Internal Medicine,
Mayo Clinic, Jacksonville, FL Mayo Clinic, Jacksonville, FL Mayo Clinic, Jacksonville, FL

Gastric outlet obstruction:

A red flag, potentially manageable
ABSTRACT 72-year-old woman presents to the
Gastric outlet obstruction is a common condition in
A emergency department with progressive
nausea and vomiting. One week earlier, she
which mechanical obstruction in the distal stomach, py- developed early satiety and nausea with vom-
lorus, or duodenum causes nausea, vomiting, abdominal iting after eating solid food. Three days later
pain, and early satiety. This article reviews the changing her symptoms progressed, and she became un-
etiology of this disorder and advances in its treatment. able to take anything by mouth. The patient
also experienced a 40-lb weight loss in the
KEY POINTS previous 3 months. She denies symptoms of
Causes of gastric outlet obstruction fall into 2 categories: abdominal pain, hematemesis, or melena. Her
benign and malignant. The cause should be presumed to medical history includes cholecystectomy and
type 2 diabetes mellitus, diagnosed 1 year ago.
be malignant until proven otherwise.
She has no family history of gastrointestinal
malignancy. She says she smoked 1 pack a day
Peptic ulcer disease, a benign cause, used to account for in her 20s. She does not consume alcohol.
most cases of gastric outlet obstruction. It is still common On physical examination, she is normoten-
but has declined in frequency with the development of sive with a heart rate of 105 beats per minute.
acid-suppressing drugs. The oral mucosa is dry, and the abdomen is
mildly distended and tender to palpation in
Gastric cancer used to be the most common malignant the epigastrium. Laboratory evaluation re-
cause but has declined in frequency in Western countries veals hypokalemia and metabolic alkalosis.
Computed tomography (CT) reveals a
with treatment for Helicobacter pylori infection. Now,
mass 3 cm by 4 cm in the pancreatic head. The
pancreatic cancer predominates. mass has invaded the medial wall of the duo-
denum, with obstruction of the pancreatic and
Endoscopic stenting is an effective, minimally invasive common bile ducts and extension into and oc-
treatment for patients with malignant gastric outlet ob- clusion of the superior mesenteric vein, with
struction and poor prognosis, allowing resumption of oral soft-tissue expansion around the superior mes-
intake and improving quality of life. enteric artery. CT also reveals retained stom-
ach contents and an air-fluid level consistent
with gastric outlet obstruction.

■ INTRINSIC OR EXTRINSIC BLOCKAGE

Gastric outlet obstruction, also called pyloric
obstruction, is caused by intrinsic or extrinsic
mechanical blockage of gastric emptying, gen-
erally in the distal stomach, pyloric channel,
or duodenum, with associated symptoms of
doi:10.3949/ccjm.86a.18035 nausea, vomiting, abdominal pain, and early
CL E V E L AND CL I NI C J O URNAL O F M E DI CI NE V O L UM E 86 • NUM BE R 5 M AY 2 0 1 9 345
 GASTRIC OUTLET OBSTRUCTION

TABLE 1 satiety. It is encountered in both the clinic

and the hospital.
Causes of gastric outlet obstruction Here, we review the causes, diagnosis, and
management of this disorder.
Benign
Peptic ulcer disease ■ BENIGN AND MALIGNANT CAUSES
Nonsteroidal anti-inflammatory drug-associated Causes of obstruction are classified as either
stricture benign or malignant (Table 1). However, all
Caustic ingestion cases of gastric outlet obstruction should be
Postsurgical stricture or scarring assumed to be due to underlying malignancy
unless proven otherwise.1
Acute pancreatitis
In a retrospective study of 76 patients hospi-
Pancreatic pseudocyst talized with gastric outlet obstruction between
Annular pancreas and chronic pancreatitis 2006 and 2015 at our institution,2 29 cases
Radiation-induced stricture
(38%) were due to malignancy and 47 (62%)
were due to benign causes. Pancreatic adeno-
Bezoar or foreign body carcinoma accounted for 13 cases (17%), while
Benign tumor (adenoma, lipoma, stromal tumor, gastric adenocarcinoma accounted for 5 cases
carcinoid) (7%); less common malignant causes were chol-
Pancreatic heterotopia angiocarcinoma, cancer of the ampulla of Vater,
duodenal adenocarcinoma, hepatocellular car-
Crohn disease
cinoma, and metastatic disease. Of the benign
Eosinophilic gastroenteritis causes, the most common were peptic ulcer dis-
Tuberculosis ease (13 cases, 17%) and postoperative strictures
Adult hypertrophic pyloric stenosis or adhesions (11 cases, 14%).
These numbers reflect general trends
Amyloidosis around the world.
Suspect Bouveret syndrome (gallstone)
obstruction Less gastric cancer, more pancreatic cancer
Ladd band
The last several decades have seen a trend to-
in cases Diaphragmatic hernia ward more cases due to cancer and fewer due
of progressive Gastric volvulus to benign causes.3–14
In earlier studies in both developed and
nausea, Percutaneous endoscopic gastrostomy tube migration
developing countries, gastric adenocarcinoma
vomiting, Malignant
was the most common malignant cause of
abdominal pain, gastric outlet obstruction. Since then, it has
Pancreatic cancer, cystic neoplasm become less common in Western countries,
early satiety Gastric cancer although it remains more common in Asia
Gallbladder and bile duct cancer and Africa.7–14 This trend likely reflects envi-
ronmental factors, including decreased preva-
Hepatocellular carcinoma
lence of Helicobacter pylori infection, a major
Ampullary cancer risk factor for gastric cancer, in Western coun-
Duodenal cancer tries.15–17
Gastric lymphoma (mucosa-associated lymphoid
At the same time, pancreatic cancer is on
tissue) the rise,16 and up to 20% of patients with pan-
creatic cancer develop gastric outlet obstruc-
Metastatic disease (colon, ovary, breast, lung) tion.18 In a prospective observational study
Retroperitoneal sarcoma of 108 patients with malignant gastric outlet
Retroperitoneal lymphadenopathy obstruction undergoing endoscopic stenting,
pancreatic cancer was by far the most common
Gastrointestinal stromal tumor
malignancy, occurring in 54% of patients, fol-
lowed by gastric cancer in 13%.19
346 C LEV ELA N D C L INIC J OURNAL OF MEDICINE VOL UME 86 • NUM BE R 5 M AY 2019
 KOOP AND COLLEAGUES

Less peptic ulcer disease, but still common tuberculosis had the best outcomes with ap-
Peptic ulcer disease used to account for up to propriate treatment.
90% of cases of gastric outlet obstruction, and Other reported causes include Bouveret
it is still the most common benign cause. syndrome (an impacted gallstone in the proxi-
In 1990, gastric outlet obstruction was es- mal duodenum), phytobezoar, diaphragmatic
timated to occur in 5% to 10% of all hospital hernia, gastric volvulus, and Ladd bands (peri-
admissions for ulcer-related complications, toneal bands associated with intestinal malro-
accounting for 2,000 operations annually.20,21 tation).7,28,29
Gastric outlet obstruction now occurs in fewer
than 5% of patients with duodenal ulcer dis- ■ PRESENTING SYMPTOMS
ease and fewer than 2% of patients with gas- Symptoms of gastric outlet obstruction in-
tric ulcer disease.22 clude nausea, nonbilious vomiting, epigastric
Peptic ulcer disease remains an important pain, early satiety, abdominal distention, and
cause of obstruction in countries with poor ac- weight loss.
cess to acid-suppressing drugs.23 In our patients, the most common pre-
Gastric outlet obstruction occurs in both senting symptoms were nausea and vomiting
acute and chronic peptic ulcer disease. In (80%), followed by abdominal pain (72%);
acute peptic ulcer disease, tissue inflammation weight loss (15%), abdominal distention
and edema result in mechanical obstruction.
(15%), and early satiety (9%) were less com-
Chronic peptic ulcer disease results in tissue
mon.2
scarring and fibrosis with strictures.20
Patients with gastric outlet obstruction
Environmental factors, including im-
secondary to malignancy generally present
proved diet, hygiene, physical activity, and
with a shorter duration of symptoms than
the decreased prevalence of H pylori infection,
those with peptic ulcer disease and are more
also contribute to the decreased prevalence
likely to be older.8,13 Other conditions with
of peptic ulcer disease and its complications,
an acute onset of symptoms include gastric
including gastric outlet obstruction.3 The con-
polyp prolapse, percutaneous endoscopic gas-
tinued occurrence of peptic ulcer disease is as- Cancer
trostomy tube migration, gastric volvulus, and
sociated with widespread use of low-dose aspi- is a common
gallstone impaction.
rin and nonsteroidal anti-inflammatory drugs
Patients with gastric outlet obstruction cause of
(NSAIDs), the most common causes of peptic
associated with peptic ulcer disease generally
ulcer disease in Western countries.24,25 gastric outlet
have a long-standing history of symptoms, in-
Other nonmalignant causes of gastric out-
let obstruction are diverse and less common.
cluding dyspepsia and weight loss over several obstruction
years.4
They include caustic ingestion, postsurgical and should
strictures, benign tumors of the gastrointesti- be suspected
■ SIGNS ON EXAMINATION
nal tract, Crohn disease, and pancreatic dis-
orders including acute pancreatitis, pancreatic On examination, look for signs of chronic until proven
pseudocyst, chronic pancreatitis, and annular gastric obstruction and its consequences, such otherwise
pancreas. Intramural duodenal hematoma as malnutrition, cachexia, volume depletion,
may cause obstruction after blunt abdominal and dental erosions.
trauma, endoscopic biopsy, or gastrostomy A succussion splash may suggest gastric
tube migration, especially in the setting of a outlet obstruction. This is elicited by rocking
bleeding disorder or anticoagulation.26 the patient back and forth by the hips or ab-
Tuberculosis should be suspected in coun- domen while listening over the stomach for a
tries in which it is common.7 In a prospective splash, which may be heard without a stetho-
study of 64 patients with benign gastric out- scope. The test is considered positive if pres-
let obstruction in India,27 16 (25%) had cor- ent 3 or more hours after drinking fluids and
rosive injury, 16 (25%) had tuberculosis, and suggests retention of gastric materials.30,31
15 (23%) had peptic ulcer disease. Compared In thin individuals, chronic gastric outlet
with patients with corrosive injury and pep- obstruction makes the stomach dilate and
tic ulcer disease, patients with gastroduodenal hypertrophy, which may be evident by a pal-
CL E V E L AND CL I NI C J O URNAL O F M E DI CI NE V O L UM E 86 • NUM BE R 5 M AY 2 0 1 9 347
 GASTRIC OUTLET OBSTRUCTION

A gestive of metastatic gastric cancer, such as

an enlarged left supraclavicular lymph node
(Virchow node) or periumbilical lymph node
(Sister Mary Joseph nodule). The Virchow
node is at the junction of the thoracic duct
and the left subclavian vein where the lym-
phatic circulation from the body drains into
the systemic circulation, and it may be the
first sign of gastric cancer.32 Sister Mary Joseph
nodule (named after a surgical assistant to Dr.
William James Mayo) refers to a palpable mass
at the umbilicus, generally resulting from me-
tastasis of an abdominal malignancy.33

■ SIGNS ON FURTHER STUDIES

Laboratory evaluation may show signs of poor
oral intake and electrolyte abnormalities
secondary to chronic nausea, vomiting, and
dehydration, including hypochloremic meta-
bolic alkalosis and hypokalemia.
B The underlying cause of gastric outlet ob-
struction has major implications for treatment
and prognosis and cannot be differentiated
by clinical presentation alone.1,9 Diagnosis is
based on clinical features and radiologic or
endoscopic evaluation consistent with gastric
outlet obstruction.
Plain radiography may reveal an enlarged
gastric bubble, and contrast studies may be
useful to determine whether the obstruction
is partial or complete, depending on whether
the contrast passes into the small bowel.
CT or magnetic resonance imaging may
show gastric distention with retained stomach
contents, suggesting a gastric, pyloric, duode-
nal, or pancreatic mass (Figure 1).
Upper endoscopy is often needed to es-
tablish the diagnosis and cause. Emptying
Figure 1. Computed tomography of the abdomen in the the stomach with a nasogastric tube is recom-
axial plane shows gastric distention (A, arrow) and a 3.9-cm mended before endoscopy to minimize the risk
mass at the pancreatic head, with compression of the de- of aspiration during the procedure, and endo-
scending duodenum (B, arrow), resulting in gastric outlet tracheal intubation should be considered for
obstruction. The patient, a 72-year-old woman, presented
with 1 week of nausea and vomiting and was found to airway protection.34 Findings of gastric outlet
have pancreatic cancer. She was treated with endoscopic obstruction on upper endoscopy include re-
stenting. tained food and liquid. Endoscopic biopsy is
important to differentiate between benign
pably thickened stomach with visible gastric and malignant causes. For patients with ma-
peristalsis.4 lignancy, endoscopic ultrasonography is useful
Other notable findings on physical ex- for diagnosis via tissue sampling with fine-nee-
amination may include a palpable abdominal dle aspiration and locoregional staging.35
mass, epigastric pain, or an abnormality sug- A strategy. Most patients whose clinical
348 C LEV ELA N D C L INIC J OURNAL OF MEDICINE VOL UME 86 • NUM BE R 5 M AY 2019
 KOOP AND COLLEAGUES

presentation suggests gastric outlet obstruc- crease gastric secretions41

tion require cross-sectional radiologic imag- • Medications for pain and nausea, if needed.
ing, upper endoscopy, or both.36 CT is the pre- Definitive treatment of gastric outlet ob-
ferred imaging study to evaluate for intestinal struction depends on the underlying cause,
obstruction.36,37 Patients with suspected com- whether benign or malignant.
plete obstruction or perforation should under-
go CT before upper endoscopy. Oral contrast Management of benign
may interfere with endoscopy and should be gastric outlet obstruction
avoided if endoscopy is planned. Additionally, Symptoms of gastric outlet obstruction resolve
giving oral contrast may worsen patient dis- spontaneously in about half of cases caused by
comfort and increase the risk of nausea, vom- acute peptic ulcer disease, as acute inflamma-
iting, and aspiration.36,37 tion resolves.9,22
Following radiographic evaluation, up- Endoscopic dilation is an important op-
per endoscopy can be performed after gastric tion in patients with benign gastric outlet
decompression to identify the location and obstruction, including peptic ulcer disease.
extent of the obstruction and to potentially Peptic ulcer disease-induced gastric outlet
provide a definitive diagnosis with biopsy.36 obstruction can be safely treated with endo-
scopic balloon dilation. This treatment almost
■ DIFFERENTIATE FROM GASTROPARESIS always relieves symptoms immediately; how-
ever, the long-term response has varied from
Gastroparesis is a chronic neuromuscular dis- 16% to 100%, and patients may require more
order characterized by delayed gastric empty- than 1 dilation procedure.25,42,43 The need for 2
ing without mechanical obstruction.38 The or more dilation procedures may predict need
most common causes are diabetes, surgery, for surgery.44 Gastric outlet obstruction after
and idiopathy. Other causes include viral in- caustic ingestion or endoscopic submucosal
fection, connective tissue diseases, ischemia, dissection may also respond to endoscopic bal-
infiltrative disorders, radiation, neurologic loon dilation.36
disorders, and paraneoplastic syndromes.39,40 Eradication of H pylori may be effective Common
Gastric outlet obstruction and gastropa- and lead to complete resolution of symptoms
resis share clinical symptoms including nau- in patients with gastric outlet obstruction due
malignant
sea, vomiting, abdominal pain, early satiety, to this infection.45–47 causes include
and weight loss and are important to differ- NSAIDs should be discontinued in pa-
entiate.36,38 Although abdominal pain may be pancreatic
tients with peptic ulcer disease and gastric
present in both gastric outlet obstruction and outlet obstruction. These drugs damage the and gastric
gastroparesis, in gastroparesis it tends not to gastrointestinal mucosa by inhibiting cyclo- cancers
be the dominant symptom.40 oxygenase (COX) enzymes and decreasing
Gastric scintigraphy is most commonly synthesis of prostaglandins, which are impor-
used to objectively quantify delayed gastric tant for mucosal defense.48 Patients may be
emptying.39 Upper endoscopy is imperative to unaware of NSAIDs contained in over-the-
exclude mechanical obstruction.39 counter medications and may have difficulty
discontinuing NSAIDs taken for pain.49
■ MANAGEMENT These drugs are an important cause of
Initially, patients with signs and symptoms of refractory peptic ulcer disease and can be
gastric outlet obstruction should be given: detected by platelet COX activity testing,
• Nothing by mouth (NPO) although this test is not widely available. In
• Intravenous fluids to correct volume deple- a study of patients with peptic ulcer disease
tion and electrolyte abnormalities without definite NSAID use or H pylori infec-
• A nasogastric tube for gastric decompres- tion, up to one-third had evidence of surrepti-
sion and symptom relief if symptoms per- tious NSAID use as detected by platelet COX
sist despite being NPO activity testing.50 In another study,51 platelet
• A parenteral proton pump inhibitor, re- COX activity testing discovered over 20%
gardless of the cause of obstruction, to de- more aspirin users than clinical history alone.
CL E V E L AND CL I NI C J O URNAL O F M E DI CI NE V O L UM E 86 • NUM BE R 5 M AY 2 0 1 9 349
 GASTRIC OUTLET OBSTRUCTION

A Surgery for patients with benign gastric

outlet obstruction is used only when medi-
cal management and endoscopic dilation fail.
Ideally, surgery should relieve the obstruction
and target the underlying cause, such as peptic
ulcer disease. Laparoscopic surgery is generally
preferred to open surgery because patients can
resume oral intake sooner, have a shorter hos-
pital stay, and have less intraoperative blood
loss.52 The simplest surgical procedure to re-
lieve obstruction is laparoscopic gastrojeju-
nostomy.
Patients with gastric outlet obstruction
and peptic ulcer disease warrant laparoscopic
vagotomy and antrectomy or distal gastrec-
tomy. This removes the obstruction and the
stimulus for gastric secretion.53 An alternative
is vagotomy with a drainage procedure (pylo-
roplasty or gastrojejunostomy), which has a
similar postoperative course and reduction in
gastric acid secretion compared with antrec-
B tomy or distal gastrectomy.53,54
Daily proton pump inhibitors can be used
for patients with benign gastric outlet obstruction
not associated with peptic ulcer disease or risk
factors; for such cases, vagotomy is not required.
Management of malignant
gastric outlet obstruction
Patients with malignant gastric outlet obstruc-
tion may have intractable nausea and abdomi-
nal pain secondary to retention of gastric con-
tents. The major goal of therapy is to improve
symptoms and restore tolerance of an oral diet.
The short-term prognosis of malignant gastric
outlet obstruction is poor, with a median sur-
vival of 3 to 4 months, as these patients often
have unresectable disease.55
Surgical bypass used to be the standard of
care for palliation of malignant gastric obstruc-
tion, but that was before endoscopic stenting
was developed.
Figure 2. Esophagogastroduodenoscopy (A) shows a large
submucosal mass in the duodenal bulb (upper arrow),
Endoscopic stenting allows patients to re-
with localized erosions (lower arrow). The mass was 40 × sume oral intake and get out of the hospital
41 mm in cross-sectional diameter on endoscopic ultra- sooner with fewer complications than with
sonography. Fine-needle aspiration and pathology study open surgical bypass. It may be a more ap-
revealed pancreatic adenocarcinoma. The obstruction was propriate option for palliation of symptoms in
successfully opened (B) with a 22-mm × 12-cm WallFlex patients with malignant obstruction who have
stent (Boston Scientific). The patient tolerated a liquid a poor prognosis and prefer a less invasive in-
diet after the procedure. tervention.55,56
Endoscopic duodenal stenting of malig-
nant gastric outlet obstruction has a success
350 C LEV ELA N D C L INIC J OURNAL OF MEDICINE VOL UME 86 • NUM BE R 5 M AY 2019
 KOOP AND COLLEAGUES

rate of greater than 90%, and most patients In most of the studies comparing endo-
can tolerate a mechanical soft diet afterward.34 scopic stenting with surgery, the surgery was
The procedure is usually performed with a open gastrojejunostomy; there are limited
9-cm or 12-cm self-expanding duodenal stent, data directly comparing stenting with laparo-
22 mm in diameter, placed over a guide wire scopic gastrojejunostomy.55 Endoscopic stent-
under endoscopic and fluoroscopic guidance ing is estimated to be significantly less costly
(Figure 2). The stent is placed by removing than surgery, with a median cost of $12,000
the outer catheter, with distal-to-proximal less than gastrojejunostomy.58 As an alterna-
stent deployment. tive to enteral stenting and surgical gastrojeju-
Patients who also have biliary obstruction nostomy, ultrasonography-guided endoscopic
may require biliary stent placement, which is gastrojejunostomy or gastroenterostomy with
generally performed before duodenal stent- placement of a lumen-apposing metal stent is
ing. For patients with an endoscopic stent emerging as a third treatment option and is
who develop biliary obstruction, endoscopic under active investigation.59
retrograde cholangiopancreatography can be Patients with malignancy that is potential-
attempted with placement of a biliary stent; ly curable by resection should undergo surgical
however, these patients may require biliary evaluation before consideration of endoscopic
drain placement by percutaneous transhepatic stenting. For patients who are not candidates
cholangiography or by endoscopic ultrasono- for surgery or endoscopic stenting, a percuta-
graphically guided transduodenal or transgas- neous gastrostomy tube can be considered for
tric biliary drainage. gastric decompression and symptom relief.
From 20% to 30% of patients require re-
peated endoscopic stent placement, although ■ CASE CONCLUDED
most patients die within several months after
stenting.34 Surgical options for patients who The patient underwent esophagogastroduo-
do not respond to endoscopic stenting include denoscopy with endoscopic ultrasonography
open or laparoscopic gastrojejunostomy.55 for evaluation of her pancreatic mass. Before
Laparoscopic gastrojejunostomy may pro- the procedure, she was intubated to minimize Before
vide better long-term outcomes than duode- the risk of aspiration due to persistent nausea endoscopy,
nal stenting for patients with malignant gas- and retained gastric contents. A large submu-
cosal mass was found in the duodenal bulb. empty
tric outlet obstruction and a life expectancy
longer than a few months. Endoscopic ultrasonography showed a mass the stomach
A 2017 retrospective study of 155 patients within the pancreatic head with pancreatic with a naso-
with gastric outlet obstruction secondary to duct obstruction. Fine-needle aspiration biopsy
unresectable gastric cancer suggested that was performed, and pathology study revealed gastric tube
those who underwent laparoscopic gastroje- pancreatic adenocarcinoma. The patient un- to minimize
junostomy had better oral intake, better tol- derwent stenting with a 22-mm by 12- cm the risk
erance of chemotherapy, and longer overall WallFlex stent (Boston Scientific), which led
survival than those who underwent duode- to resolution of nausea and advancement to a of aspiration,
nal stenting. Postsurgical complications were mechanical soft diet on hospital discharge. and consider
more common in the laparoscopic gastrojeju- She was scheduled for follow-up in the out-
nostomy group (16%) than in the duodenal patient clinic for treatment of pancreatic can-
endotracheal
stenting group (0%).57 cer. ■ intubation
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