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DISPATCH
Year : 2019  |  Volume : 6  |  Issue : 2  |  Page : 74-76

Massive gastric dilatation in outlet obstruction – is it always benign?


1 Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
2 Department of Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

Date of Submission21-Oct-2019
Date of Acceptance28-Nov-2019
Date of Web Publication02-Jan-2020

Correspondence Address:
Dr. Vikram Kate
Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry - 605 006
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJAMR.IJAMR_126_19

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  Abstract 


Gastric outlet obstruction is one of the most common clinical presentations of carcinoma of the stomach, especially in South-West Asia. Although gross gastric dilatation is common in benign obstruction of the pylorus due to peptic ulcer disease, a hugely dilated and distended stomach can be a very rare presentation in a patient with malignancy. A 65-year-old female patient presented with recurrent episodes of vomiting immediately after food, ball-rolling movements in the abdomen, and loss of appetite and significant weight loss in the past 1 month. Upper gastrointestinal endoscopy revealed a dilated stomach and an ulceroproliferative growth in the antropyloric region. A biopsy of the growth revealed moderately differentiated adenocarcinoma of the stomach. Contrast-enhanced computed tomography of the abdomen and pelvis showed proliferative growth at antrum and the hugely dilated stomach reaching up to the pelvis. The patient underwent exploratory laparotomy. Intraoperative findings were that of a dilated and thickened stomach with growth at the antropyloric region of the stomach. Metastatic omental deposits were also seen, and thus, palliative gastrojejunostomy was carried out. This case is being reported to highlight that occasionally malignant gastric outlet obstruction may lead to a massive dilatation of the stomach.

Keywords: Carcinoma stomach, gastric outlet obstruction, massively dilated stomach


How to cite this article:
Sejal J, Pranavi A R, Mohsina S, Sureshkumar S, Naik D, Kate V. Massive gastric dilatation in outlet obstruction – is it always benign?. Int J Adv Med Health Res 2019;6:74-6

How to cite this URL:
Sejal J, Pranavi A R, Mohsina S, Sureshkumar S, Naik D, Kate V. Massive gastric dilatation in outlet obstruction – is it always benign?. Int J Adv Med Health Res [serial online] 2019 [cited 2020 Feb 27];6:74-6. Available from: http://www.ijamhrjournal.org/text.asp?2019/6/2/74/274623




  Introduction Top


Gastric outlet obstruction is a complete or incomplete obstruction of the distal stomach, pylorus, or proximal duodenum.[1] The incidence of gastric outlet obstruction due to peptic ulcer disease, which is the most common benign etiology, is 5%, whereas the incidence due to the most common malignant cause, i.e., peripancreatic malignancy is 15%–20%.[2] Malignant gastric outlet obstruction is a common presentation of locally advanced upper gastrointestinal tract malignancies such as pancreatic, gastric, and other carcinomas. Other common symptoms of carcinoma of the stomach include dyspepsia, early satiety, fullness after meals, loss of weight and appetite, and ball-rolling movements in the epigastrium. However, due to a short duration of obstruction, a hugely dilated stomach clinically or on imaging is unlikely.[3] The presence of a hugely distended and dilated stomach is most characteristically associated with a benign long-standing obstruction.[4] To the best of our knowledge, massive gastric dilatation associated with carcinoma stomach is exceedingly rare. Hence, here, we report a case of antral carcinoma leading to massive gastric dilatation.


  Case Report Top


A 65-year-old female patient presented with recurrent episodes of vomiting immediately after food, fullness after meals, and ball-rolling movements in the entire abdomen for 1 month. The patient also had a loss of appetite and significant weight loss in the past 1 month. There was no history suggestive of metastatic symptoms such as abdominal distension and swelling in other parts of the body.

On general examination, pallor was present. There was no icterus, generalized lymphadenopathy, pedal edema, clubbing, or cyanosis. On inspection, the abdomen was flat and flanks were not bulging, the umbilicus was in the center and all the quadrants moved with respiration. The patient had visible gastric peristalsis. There were no lumps, dilated veins, scars, or sinuses; hernial orifices were not bulging; and the external genitalia were normal. The abdomen was soft and nontender on palpation, and there was no palpable mass. There was no ascites. The liver span was 12 cm. Traube's space was resonant. Auscultoscraping revealed a hugely dilated stomach indicated by greater curvature going deep into the pelvis. Succussion splash was present, and bowel sounds were normal.

Upper gastrointestinal endoscopy showed a dilated stomach with minimal food residue and ulceroproliferative growth in the antropyloric region. The scope could not be negotiated beyond into the duodenum. A biopsy of the growth revealed moderately differentiated adenocarcinoma of the stomach. Contrast-enhanced computed tomography (CECT) of the abdomen and pelvis showed proliferative growth at antrum completely obstructing pyloric lumen with maintained fat planes with surrounding structures (T3) and heterogeneously enhancing perigastric nodes, largest 9 mm in diameter (N1) with no evidence of distant metastasis [Figure 1]. Sagittal view CECT of the abdomen showed proliferative growth obstructing the pylorus suggestive of carcinoma of the stomach T3N1M0 and the hugely distended stomach reaching up to the pelvis [Figure 2]. The patient underwent exploratory laparotomy. Intraoperative findings were that of a dilated and thickened stomach with growth at the antropyloric region [Figure 3]. Metastatic omental deposits were noted indicating disseminated disease which changed the stage of the disease to T3N1M1. Thus, a palliative gastrojejunostomy was carried out. The patient recovered from the procedure, and the postoperative course was uneventful.
Figure 1: Contrast-enhanced computed tomography of the abdomen showing a proliferative growth at antrum (blue arrow) and perigastric nodes (yellow arrow)

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Figure 2: Contrast-enhanced computed tomography (coronal reconstruction) of the abdomen showing proliferative growth obstructing the pylorus (blue arrow) and hugely dilated stomach (yellow arrow)

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Figure 3: Intraoperative picture of the dilated and thickened stomach

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  Discussion Top


Gastric outlet obstruction is the consequence of any disease process that produces a mechanical impediment to gastric emptying. Sir James Walton described the gastric outlet obstruction because of benign obstruction as the “stomach one can hear, the stomach one can see, and the stomach one can feel.“[3] Owing to the long duration of symptoms in a benign obstruction, the stomach wall hypertrophies and dilates, whereas a malignant obstruction develops over a much shorter period of time and does not produce dilatation or distension of the stomach.

Kreel and Ellis reported succussion splash indicative of a dilated stomach was heard in 36 (64%) patients of the ulcer group and only 5 (14%) patients of the carcinoma group.[5] In addition, visible gastric paralysis was present in 9 (16%) duodenal ulcer patients and only 1 (3%) carcinoma stomach patient. These are indicators of the presence of massive gastric dilatation in cases of gastric outlet obstruction because of peptic ulcer disease.

In the present case, the history was suggestive of malignancy because of the short duration, elderly patient, and presence of constitutional symptoms. However, examination findings such as succussion splash, visible gastric peristalsis, and auscultatory percussion revealing greater curvature beyond pelvic brim were pointers to a dilated stomach indicative of a benign cause. The unusual finding on the CECT abdomen was a hugely dilated and distended stomach extending deep into the pelvis along with a growth in the stomach suggestive of a long-standing obstruction. This could have been because of a slow-growing tumor which led to obstruction over a long period and remained asymptomatic. The patient underwent laparotomy which showed omental tumor deposits indicating disseminated disease. Palliative gastrojejunostomy was carried out for gastric outlet obstruction. The patient tolerated the surgery well, and the postoperative period was uneventful. The patient is currently on follow-up.

This case report highlights that the surgeon should have an index of suspicion of carcinoma stomach in a patient presenting gastric outlet obstruction with a hugely dilated stomach as an atypical presentation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.



Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Samad A, Whanzada TW, Shoukat I. Gastric outlet obstruction: Change in etiology. Pak J Surg 2007;23:29-32.  Back to cited text no. 1
    
2.
Jaka H, Mchembe MD, Rambau PF, Chalya PL. Gastric outlet obstruction at bugando medical centre in Northwestern Tanzania: A prospective review of 184 cases. BMC Surg 2013;13:41.  Back to cited text no. 2
    
3.
Hallinan JT, Venkatesh SK. Gastric carcinoma: Imaging diagnosis, staging and assessment of treatment response. Cancer Imaging 2013;13:212-27.  Back to cited text no. 3
    
4.
Horton KM, Fishman EK. Current role of CT in imaging of the stomach. Radiographics 2003;23:75-87.  Back to cited text no. 4
    
5.
Kreel L, Ellis H. Pyloric stenosis in adults: A clinical and radiological study of 100 consecutive patients. Gut 1965;6:253-61.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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