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Preoperative Case Presentation & Sharing of Information on Vomiting. Jeffy G. Guerra, MD Level III Surgery Resident OMMC-Surgery 053006. General Data:. C.P., 68F SAB, Mla. Chief Complaint:. Vomiting. History of Present Illness:.
Jeffy G. Guerra, MD
Level III Surgery Resident
8 years PTA epigastric pain, on/off, moderate, slightly relieved by antacid consult : ulcer
lost to follow-up
admitted: IV started, H2 block and BT, 2 units,
apparently d/c well
Dx: UGIB 2 PUD
R/O Gastric Malignancy
CBC, PC, BT, CXR electrolytes done
(+) Saline loading test
BT, 2 u PRBC ordered
Family History: no history of cancer in the family
Personal Social History: non-smoker
non-alcoholic beverage drinker
Gastric Outlet Obstruction; pyloric channel, secondary to healed pyloric ulcer, 98% obstructing
No Biopsy done
*Csendes A. et al. RCT on three techniques for GOO treatment.
*Millat B. Surgical treatment of complicated Duodenal ulcer: RCT
Gastric stases. Delayed emptying of normal amounts of acid with increased exposure
a) Helicobacter pylori infection. 90% of patients with DU and 50% of patients with GU
b) NSAID use. The mucus gel layer contains bicarbonate. This layer adheres to the gastric mucosa. It protects the mucosa against back diffusion of hydrogen ions. NSAID’s suppress mucus cell function.
5) Genetic predisposition
1) Epigastric pain – Central or slightly to the right
Burning or gnawing
Can spread to the back
Relieved by ingestion of food or anti-acid
Pain occurs when patient is hungry
3) Weight gain ( Pain relieved by ingestion of food)
4) Epigastric tenderness just to the right of the midline, may be absent.
1) Epigastric pain – Brought on by meals often within 30 minutes
2) Nausea and vomiting
3) Weight loss
4) Epigastric tenderness
3) Gastric outlet obstruction
1) Non-healing ulcer ( 8 – 12 weeks for GU, DU can be managed conservatively for longer since the risk for malignancy is low)
b) Bleeding if massive,
c) Gastric outlet obstruction that does not clear up on conservative management.
1) Resussitation initially with 0.9% sodium chloride. Potassium supplementation only after good urine output is established.
2) Gastric lavage with thick stomach tube ( 32 F) to remove food residue.
3) Diagnostic tests after gastric lavage : Gastroscopy with biopsies with or without barium meal to rule out malignancy.
5) A nasogastric tube is passed. The patient may drink water. The amount of oral intake and drainage is charted. This gives an impression whether the obstruction is resolving.
6) Balloon dilatation of pyloric channel is possible but seldom produces a final solution.
a)Recurrent ulcer (anastomotic,stomal,marginal)
b) gastrojejenocolic fistula
a) Chronic afferent loop obstruction after BII anastomoses – abdominal pain relieved by vomiting , vomit mainly bile without food.
b) Chronic efferent loop obstruction
c) Internal herniation, jejenogastric intussusception and late gastroduodenal obstruction
a) Alkaline reflux gastritis – reflux of bile into stomach. Pain not relieved with vomiting. Vomitus contains food and bile.
b) Dumping(I)Early dumping – symptoms within 20 minutes after meal. Gastro-intestinal : Abdominal cramps, satiety, nausea, vomiting and explosive diarrhea. Cardiovascular : sweating, dizziness, weakness,dyspnea, palpitations and flushing.
a) Malabsorption of protein, carbohydrates and fat
b) Early satiety
c) Anemia : Fe, folate and B12 deficiency. B12 problems mostly after total or near total gastrectomy.
8. Siu WT, Tang CN, Law BK, et al: Vagotomy and gastrojejunostomy for benign gastric outlet obstruction. J Laparoendosc Adv Surg Tech A 2004 Oct; 14(5): 266-9[Medline].
9. Haglund UH, Jansson RL, Lindhagen JG, Lundell LR, Svartholm EG, Olbe LC.Primary Roux-Y gastrojejunostomy versus gastroduodenostomy after antrectomy and selective vagotomy.Am J Surg. 1992 Apr;163(4):457-8.
1. Cycles of inflammation and repair may cause obstruction at the gastroduodenal junction as a result of edema, muscular spasm and fibroses.
2. Edema and spasm can resolve with medical treatment.
3. Obstruction is mainly caused by DU and prepiloric GU.
4. Malignant tumors is the other important cause of gastric outlet obstruction.