American Journal of Emergency Medicine 35 (2017) 1207.e1-1207.e2

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Case Report

Identification of gastric outlet obstruction using point-of-care ultrasound

Abstract

Gastric outlet obstruction is a rare diagnosis that can present with symptoms mimicking several other emergent diagnoses. Utilization of bedside ultrasound is a rapid and Non-invasive technique to differentiate this condition allowing for more rapid diagnosis and man- agement, while potentially reducing radiation. We present the case of a 56-year-old gentleman with no known past medical history who pre- sented with progressively worsening Epigastric pain associated with nausea and abdominal fullness. His abdomen was significantly tender and distended. A rapid bedside ultrasound demonstrated a lack of intra- peritoneal air, but the presence of a dilated stomach with decompressed intestines distally was identified, suggesting gastric outlet obstruction. This was subsequently confirmed by a computed tomogram of the ab- domen. The Underlying etiology was determined to be a duodenal ulcer with contained perforation that was managed conservatively in the hospital. To our knowledge, this is the first published case report de- scribing this technique in the adult population. This case provides a de- scription of the findings, techniques for differentiating gastric outlet obstruction from other forms of obstruction, and a basis for future study. Gastric outlet obstruction is typically due to the mechanical imped- ance of gastric contents into the duodenum. This can be caused by for- eign bodies, hypertrophic pyloric stenosis, Peptic ulcer disease, or malignancy [1,2]. The etiology of gastric outlet obstruction is most com- monly benign in younger patients, while malignancy is more commonly seen in older patients [3-5]. After the Initial diagnosis is made, Esophagogastroduodenoscopy is the preferred method to diag- nose and treat the ultimate cause of the obstruction, with surgery used in Refractory cases. Often, the initial diagnosis will be made with other imaging modalities, such as radiography, computed tomography, or magnetic resonance imaging. Ultrasound is well-described for Small bowel obstruction, but, to our knowledge, has not previously been de- scribed for gastric outlet obstruction in adults [6]. Thus, we present the first case report describing the identification of gastric outlet ob-

struction using point-of-care ultrasound.

A 56-year-old gentleman with no known past medical history pre- sented with epigastric pain for two weeks. He endorsed mild postpran- dial epigastric discomfort and fullness for the past two weeks, which became constant and severe over the preceding four days. He also en- dorsed three days of nausea with non-bloody, non-bilious emesis. He had no diarrhea, melena, or hematochezia. His vital signs were within normal limits. On examination, his abdomen was distended and diffuse- ly tender with hyperactive bowel sounds. The remainder of his exami- nation was unremarkable.

A bedside ultrasound was performed in the supine position (Fig. 1, Video), which demonstrated a dilated, fluid-filled structure with the ab- sence of peristalsis. There were no haustra or villi visualized. A

computed tomogram (CT) of the abdomen was subsequently obtained (Fig. 2), which confirmed the finding of a gastric outlet obstruction. The patient was admitted to the hospital where an EGD was performed, demonstrating a severe duodenal ulceration with a contained perfora- tion. The patient was managed conservatively with a proton pump in- hibitor and antibiotics for Helicobacter pylori. The patient improved during his hospital stay and was discharged with continued resolution of his symptoms at his two-week follow up visit.

Gastric outlet obstruction is a rare diagnosis in adults, presenting with symptoms that may mimic several other diagnoses. Common symptoms include epigastric pain, abdominal distension, early sati- ety, nausea, and vomiting [1,2,7]. However, many other intra-ab- dominal processes, as well as more distal forms of obstruction may mimic this. Diagnosis is typically made on abdominal CT, though this may result in a delay to diagnosis if the patient requires contrast or if there are other patients already awaiting CT. Additionally, not all locations may have access to CTs.

Ultrasound provides a rapid method to diagnose gastric outlet ob- struction. Additionally, ultrasound is non-invasive, low-cost, easily per- formed at the bedside, and is not associated with radiation. Furthermore, ultrasound can be easily repeated, allowing for serial as- sessments of resolution of the obstruction.

The ultrasound examination is performed by using a curviLinear probe and scanning across the upper abdomen, evaluating for a large, fluid-filled structure. This will typically be best visualized in the epigastrium and should not be visualized inferior to the umbilicus. One the structure is identified, it should be followed in both directions until it reaches its transition point or disappears at the diaphragm.

It is important to differentiate a gastric outlet obstruction from other forms of obstruction on point-of-care ultrasound. While both small bowel obstruction and gastric outlet obstruction will present with a large, fluid filled structure, gastric outlet obstruction can be differentiat- ed by its larger size, predominantly epigastric location, and lack of villi. Gastric outlet obstruction can be differentiated from a large bowel ob- struction by the lack of haustra and a transition point located in the epigastrium without extension to the left or right flank (i.e. descending or Ascending colon, respectively).

One should be aware of several potential limitations with this tech- nique. As with other ultrasound applications, there is operator variabil- ity in image acquisition, as well as interpretation. Therefore, it is important to maintain one’s ultrasound skills with practice and be aware of one’s limitations. Additionally, many specialists will still re- quire advanced imaging (e.g. CT or MRI) for confirming the presence of the gastric outlet obstruction and assessing for extrinsic etiology given the higher likelihood of malignancy in adults.

This case describes a novel Ultrasound technique for identifying gas- tric outlet obstruction, as well as techniques for differentiating this from

http://dx.doi.org/10.1016/j.ajem.2017.03.024

0735-6757/(C) 2017

1207.e2 M. Gottlieb, D. Nakitende / American Journal of Emergency Medicine 35 (2017) 1207.e1-1207.e2

Disclosures

None.

Meetings

None.

IRB

N/A.

Acknowledgements

None

Fig. 1. Ultrasound image demonstrating a significantly distended stomach.

Fig. 2. Computed tomogram demonstrating a significantly distended stomach.

Michael Gottlieb, MD* Damali Nakitende, MD

Department of Emergency Medicine, Rush University Medical Center,

Chicago, IL, United States

?Corresponding author at: 1750 West Harrison Street, Suite 108 Kellogg,

Chicago, IL 60612, United States.

E-mail address: [email protected] (M. Gottlieb).

References

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3. Shone DN, Nikoomanesh P, Smith-Meek MM, et al. Malignancy is the most common cause of gastric outlet obstruction in the era of H2 blockers. Am J Gastroenterol 1995 Oct;90(10):1769-70.
4. Misra SP, Dwivedi M, Misra V. Malignancy is the most common cause of gastric outlet obstruction even in a developing country. Endoscopy 1998 Jun;30(5):484-6.
5. Hyasinta J, Mabula M, Rambau P, et al. Gastric outlet obstruction at Bugando Medical Centre in Northwestern Tanzania: a prospective review of 184 cases. BMC Surg 2013 Sep 25;13:41.
6. Taylor M, Lalani N. Adult small bowel obstruction. Acad Emerg Med 2013;20(6): 528-44.
7. Kotisso R. Gastric outlet obstruction in Northwestern Ethiopia. East Centr Afr J Surg 2000;5:25-9.

   small or large bowel obstruction. Utilization of bedside ultrasound is a rapid and non-invasive technique to differentiate this condition allowing for more rapid diagnosis and management, while potential re- ducing radiation. This may also be valuable for serial assessments of res- olution of the obstruction.

   Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ajem.2017.03.024.