Gastric Outlet Obstruction

For 2 weeks, a 60-year-old man had severe nausea and vomiting. Two years earlier, he had had a cholangiocarcinoma, which was treated with palliative cholecystectomy followed by a course of rebeccamycin, an investigational chemotherapeutic agent. John C. Rhee, MD, of Pittsburgh, writes that an abdominal radiograph was surprisingly unremarkable. However, results of a barium swallow x-ray study revealed a massively dilated stomach, which extended to the patient’s pelvis. A large amount of debris and secretions was also noted. These findings were consistent with gastric outlet obstruction. A nasogastric tube was inserted for decompression. A CT scan without contrast of the abdomen revealed a grossly distended, fluid-filled stomach . Apparent transition was noted in the region of the proximal duodenum. Malignancies, peptic ulcer disease, inflammatory processes (such as Crohn disease and pancreatitis), and congenital abnormalities can cause gastric outlet obstruction. In one report, malignancies accounted for 61% of cases of gastric outlet obstruction.¹ Although no tumor was seen in this patient, the obstruction was most likely caused by a recurrent tumor in the region of the gallbladder fossa and porta hepatis. Gastric outlet obstruction is managed with either gastrojejunostomy or enteral stenting. The latter has been shown to be well tolerated in patients with malignant gastric outlet obstruction.² This patient underwent enteral stent placement, which temporarily relieved his symptoms. Unfortunately, he died of progressive metastatic disease several months later.