Gastric Outlet Obstruction : Is "Early" Surgical Repair Harmful
K Adivarekar, Gaurav Baheti, Dharmendra Singh, Sanjay B Raut
Gastric outlet obstruction
due to accidental corrosive acid ingestion is as well known as it is discouraging.
We present here three cases of corrosive prepyloric strictures and our management
modalities. Having burnt our fingers in the first case we were wiser in planning
a staged procedure for the next two patients with satisfying results and thus
questioning the rationale of an early surgical intervention in these cases.
Corrosive acid ingestion still remains a major health hazard in children and
there is an urgent need for public awareness, proper and effective legislation,
ensuring correct labelling and safe packaging. Because of the greater use of
alkali in the household caustic injury caused by acids is relatively uncommon.
Tendency of the acids to “lick the oesophagus and bite the pyloric antrum”1
is known, but recently gastric burns caused by alkali corrosives have been reported.2
We present here our experience in the management of patients with corrosive
gastric outlet obstruction.
A three and half year old boy presented to us with history suggestive of gastric
outlet obstruction since 5 days. Barium study revealed a abrupt cut off at the
pylorus. Scopy done showed an inflamed pylorus with a non-passable stricture
at the pre-pyloric region. Patient was explored and a Heinecke-Mickuliz pyloroplasty
was done. Post-op was uneventful and the patient was discharged. A week after
the discharge patient was brought with similar complaints. On careful probing,
history of accidental ingestion of battery fluid was obtained. Repeat dye study
showed abrupt cut off at the pyloric region. A feeding jejunostomy was done.
Patient was discharged and was followed up after 8 weeks at which time a gastro-jejunostomy
was done. Post-op was uneventful. Patient is asymptomatic and is thriving well.
A seven year old girl had history of haematemesis following accidental ingestion
of battery fluid for which she was treated at a private nursing home. Patient
was referred to us for persistent vomiting with significant weight loss. Barium
study showed dilatation of the stomach with abrupt cut off at the pylorus.
OGD scopy showed the pylorus to be inflamed and oedematous and the scope could
not be negotiated across. (Fig. 2)
A feeding jejunostomy was done and the patient was discharged to allow for the
complete healing process to take place. After two months a repeat barium study
showed complete gastric outlet obstruction. The patient was explored. A tight
prepyloric stricture was evident. A finneys type pyloroplasty was done. Post-op
was uneventful. After 6 weeks the patient is asymptomatic, is gaining weight
and barium study shows dye passing easily across into the duodenum. (Fig. 3)
A seven year old girl was referred to us with history of corrosive ingestion
2 weeks back. OGD scopy done showed the presence of circumferential corrosive
ulcer with pyloric obstruction. Patient had complaints of persistent vomiting
with significant weight loss. A feeding jejunostomy was done and the patient
was discharged, with the reparative surgery to be done after 6-8 weeks, to allow
for the complete healing process to take place. Repeat Barium study showed abrupt
cut off at the pyloric region, with the finding confirmed on gastroscopy. Patient
underwent an explorative laparotomy 8 weeks after the initial insult which showed
the presence of a prepyloric stricture. A finneys type pyloroplasty was done.
At 6 weeks follow-up the patient is asymptomatic and is thriving well.
The first description of gastric burn without the involvement of the oesophagus
was in 1828, which was a case of sulphuric acid ingestion.3,4 Viscosity and
specific gravity of corrosive acids is lower than that of liquid alkalis, hence
acids are associated with rapid transit through the oesophagus and the damage
primarily occurs in the antrum of the stomach.5 Also the related antral spasm
causes pooling of the corrosive at the antrum leading to burns at the antrum.6,7
Another reason for the greater susceptibility of the stomach is its columnar
epithelium, whereas the oesophagus has a more resilient squamous epithelium.3
Some investigators have also reported cases of corrosive prepyloric strictures
after alkali products instead of the solid or crystalline forms.2,4 The degree
of mucosal injury depends on the nature of the agent, the amount and the concentration
ingested, the amount of food in the stomach at the time of ingestion and the
mode of ingestion.8-10
The management of gastric outlet obstruction is operative, but there is still
some controversies especially in the timing of the surgery. In the first case
we burnt our fingers, by an early intervention, for want of a proper history
of corrosive ingestion. Once the history was confirmed we waited for the complete
healing process to take place after which we went ahead with the reparative
surgery. Hence reparative surgery is to be done after complete healing process
is over. During this phase if any insult is added it will cause more extensive
The guidelines propagated by us are as follows:
Initial resuscitation with airway management and cardiovascular stability.
Fibreoptic endoscopy within 24-48 hours for grading the severity of injury.
In the early cases supportive medical therapy in the form of intravenous antibiotics,
H2 receptor blockers and steroids which interfere with the inflammation, collagen
synthesis, fibrosis and chronic scarring are advocated.
Drugs used : steroids (prednisolone or recently dexamethasone). Antacids, proton
A feeding jejunostomy is done for the maintenance of enteral nutrition and the
patient is discharged.
Patient followed up after 6-7 weeks. Investigated with repeat barium study and
endoscopy and accordingly the reparative surgery is planned.
Process of Healing
First 24 hours : Haemorrhage, thrombosis and marked inflammation.
After 48 hours : Thrombosis of the submucosal vessels, hence local necrosis
Till 3rd week : Necrotic tissue is sloughed, oedema decreases and neovascularisation
3-6th week : Scar formation with fibroblast proliferation and commencement of
stricture formation, mucosal re-epithelisation begins by the 4th week and is
usually complete by the 6th week.
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Double-blind trial in patients from 32 countries to assess whether budesonide
is useful in the treatment of early onset mild persistent asthma. Their results
showed that the drug was effective in reducing the likelihood of a severe asthma-related
event, as well as increasing the number of symptom-free days.
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