Signs and Symptoms
History
- Symptoms may be intermittent until obstruction becomes complete
- Nausea and vomiting, usually nonbilious
- Abdominal pain, variable in character and often vague
- Early satiety and epigastric fullness
- Epigastric discomfort relieved with emesis
- Weight loss, failure to thrive
Physical Exam
- Vital signs:
- May be normal
- Tachycardia, hypotension if volume depletion is significant
- Abdominal exam:
- Variable amount of epigastric/abdominal distention
- Tympanitic to auscultation
- Succession splash >4 hr after eating
- Digital rectal exam: Evaluate for occult blood
- Signs of dehydration in eyes, oral pharynx, mucous membranes, skin turgor
- Signs of malnutrition in chronic or late obstruction
- Weight loss when chronic and with malignancy
Geriatric Considerations |
- Abdominal pain, nausea/vomiting: GI symptoms may be more vague/subtle in elderly patients
- If appropriate, consider other causes of symptoms (cardiac causes, neurologic causes)
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Pediatric Considerations |
- Idiopathic hypertrophic pyloric stenosis:
- Most common cause in pediatric population
- “Typical” patient is male (Caucasian and U.S.-born Asians more common)
- Usually 2-8 wk old but may be diagnosed as early as first wk and up to 3 mo of age
- Initially intermittent, nonprojectile, postprand ial vomiting, which progresses to projectile, nonbilious vomiting
- A midepigastric peristaltic wave occurring prior to vomiting may be visible on exam
- Epigastric “olive” mass may be palpable in 80-90% of patients
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Essential Workup
Careful history and physical exam
Diagnostic Tests & Interpretation
Lab
- CBC:
- Anemia if malignancy or GI blood loss
- High hematocrit indicating hemoconcentration
- Electrolytes, BUN/creatinine, glucose:
- Hypokalemia
- Hypochloremic metabolic alkalosis
- Hypoglycemia
- Prerenal azotemia
- Urinalysis
- Amylase/lipase
- Liver profile, if malignancy suspected
- H. pylori, if PUD suspected
Imaging
- Plain abdominal radiographs (obstructive series):
- Often nondiagnostic
- Dilated stomach or absence of air in bowel distally may be suggestive
- Abdominal US:
- Used most in pediatric population
- No ionizing radiation
- Elongated hypertrophic pyloric sphincter
- Abdominal CTs are often very helpful for detecting neoplastic, intraluminal, and extraluminal causes of obstruction
- Most commonly used modality in adults
- Radiation load is especially undesirable in pediatric population; ultrasound and fluoroscopic UGI series are preferred initial approaches
Diagnostic Procedures/Surgery
- Upper GI series:
- To demonstrate site and character of obstruction
- “String sign,” “double track sign,” “beak sign,” “shoulder sign” are characteristic findings in pyloric stenosis
- Upper endoscopy:
- To visualize gastric interior, gastric outlet, proximal duodenum
Differential Diagnosis
- Proximal bowel obstruction
- Exacerbation of PUD
- Gastroenteritis
- Cholelithiasis
- Cholecystitis
- Acute pancreatitis
- Diabetic gastroparesis
- Psychogenic vomiting
Prehospital
- Vital signs, airway stabilization, oxygen administration, IV access
- Fluid resuscitation if dehydrated, vomiting
Initial Stabilization/Therapy
- 0.9% NS IV fluid resuscitation significant volume losses:
- Adults: 1 L bolus
- Peds: 20 mL/kg bolus
- Correction of electrolyte abnormalities, especially hypokalemia
ED Treatment/Procedures
- Nasogastric tube (NGT)
- Foley catheter to monitor urine output
- Surgical consultation/intervention:
- Endoscopic balloon dilatation of benign strictures
- Enteral stent placement (malignant causes)
- Gastrojejunostomy (malignant causes)
- Vagotomy and antrectomy or pyloroplasty or gastrojejunostomy or other variation (benign causes)
Medication
- Famotidine: Adults: 20 mg (peds: 0.6-0.8 mg/kg/24 hr div. q6-8h) IV q12h or
- Ranitidine: 50 mg (peds: 2-4 mg/kg/24 hr div. q6-8h) IV q8h
- Pantoprazole: Adults: 40 mg IV (also H. pylori treatment as needed)
Disposition
Admission Criteria
Most patients with gastric outlet obstruction will be admitted for fluid resuscitation, electrolyte repletion, gastroenterologic and surgical evaluation
Discharge Criteria
Rarely, patients may be considered for discharge if:
- Symptoms of abdominal pain, vomiting have resolved
- Evaluated and cleared by surgeon or gastroenterologist during presentation
- Lab parameters, imaging, and patient's volume status are normal
Issues for Referral
Surgical and gastroenterology consultations
Follow-up Recommendations
Any discharged patient should follow up with surgeon and /or gastroenterologist:
- Specific instructions to return if symptoms recur
- DadaSA, FuhrmanGM. Miscellaneous disorders and their management in gastric surgery: Volvulus, carcinoid, lymphoma, gastric varices, and gastric outlet obstruction . Surg Clin North Am. 2011;91:1123-1130.
- KimJH, ShinJH, SongHY. Benign strictures of the esophagus and gastric outlet: Interventional management . Korean J Radiol. 2010;11(5);497-506.
- OtjenJP, IyerRS, PhillipsGS, et al. Usual and unusual causes of pediatric gastric outlet obstruction . Pediatr Radiol. 2012;42:728-737.
- ShoneDN, NikoomaneshP, Smith-MeekMM, et al. Malignancy is the most common cause of gastric outlet obstruction in the era of H2 blockers . Am J Gastroenterol. 1995;90:1769-1770.
See Also (Topic, Algorithm, Electronic Media Element)
ICD9
537.0 Acquired hypertrophic pyloric stenosis
ICD10
K31.1 Adult hypertrophic pyloric stenosis
SNOMED