Gastric Outlet Obstruction (GOO) - Management

1. Definition and Causes

With decreasing peptic ulcer disease incidence, GOO should be considered malignant until proven otherwise. - Bailey and Love's Surgery, 28th ed.

2. Clinical Features

• Nausea and non-bilious vomiting (vomitus contains undigested food, no bile - pathognomonic)
• Progressive weight loss, early satiety, epigastric distension
• Succussion splash on abdominal auscultation (retained gastric contents)
• In benign GOO: long history of PUD; in malignant GOO: symptoms may be more acute

3. Metabolic Consequences

1. HCl loss -> primary metabolic alkalosis + hypochloraemia
2. Dehydration -> aldosterone activation -> Na+ retention, K+/H+ excretion
3. Paradoxical aciduria (kidney excretes H+ to conserve Na+)
4. Ionised calcium falls -> tetany possible

4. Diagnosis

Investigations

• Endoscopy (EGD) with biopsy - mandatory; stomach contents must be cleared first (NGT) to reduce aspiration risk; targeted biopsies to exclude malignancy
• CT scan (contrast-enhanced) - confirms obstruction, assesses resectability, looks for biliary obstruction, excludes distal obstruction
• Upper GI fluoroscopy with barium/contrast - confirms GOO; use with caution given aspiration risk
• Endoscopic ultrasound (EUS) - when deeper tissue sampling needed or malignancy strongly suspected

5. Initial Resuscitation (All Patients)

1. Wide-bore nasogastric (or orogastric) tube - decompress the stomach; may need lavage to clear thick contents
2. IV fluid resuscitation - isotonic saline (0.9% NaCl) with potassium supplementation; restoring NaCl/water allows kidneys to correct the acid-base abnormality
3. Electrolyte correction - serial monitoring of Na+, K+, Cl-, HCO3-; correct hypokalaemia aggressively
4. Antisecretory therapy - proton pump inhibitors (IV initially) for PUD-related cases
5. Nutritional support - enteral or parenteral nutrition in malnourished patients before intervention
6. Pre-endoscopy gastric emptying - prolonged fasting or NGT aspiration mandatory before EGD/SEMS placement to prevent aspiration

6. Management by Etiology

A. Benign GOO (PUD-related)

Medical treatment (first-line for acute/edematous obstruction)

• Aggressive H. pylori eradication + PPI therapy
• IV fluid/electrolyte correction + NGT decompression
• Early cases due to edema may resolve completely with conservative management as ulcer heals
• Serial saline load tests to assess response

Endoscopic balloon dilation

• First-line endoscopic intervention for benign pyloric stenosis
• Hydrostatic or pneumatic dilation (typically to 12-20 mm)
• May need to be repeated multiple times
• Can delay surgery for 1-2 years in ~50% of patients - Current Surgical Therapy, 14th ed.

Surgery (for failed medical/endoscopic therapy)

• Vagotomy + Antrectomy (V/A) - gold standard; lowest ulcer recurrence; Billroth II or Roux-en-Y reconstruction; operative mortality ~2%
• Vagotomy + Gastrojejunostomy (V/GJ) - lower operative mortality; can be done laparoscopically; reversible if dumping intolerable; risk of missing occult cancer
• Pyloroplasty - rarely used for GOO (preferred when pylorus can be used for drainage rather than bypassed)

V/A is the gold standard for obstructing duodenal ulcer but V/GJ is a good alternative, especially when laparoscopic approach is preferred. - Current Surgical Therapy, 14th ed.

B. Malignant GOO (MGOO)

Resectable disease

• Curative resection (Whipple/pancreaticoduodenectomy, gastrectomy) - preferred when feasible
• If neoadjuvant therapy planned: laparoscopic/robotic gastrojejunostomy preferred over duodenal stent (stent makes subsequent resection more difficult)

Unresectable/palliative disease - two main approaches:

• Performed endoscopically (fluoroscopy + endoscopy)
• ~90% of patients can tolerate soft/regular diet after successful placement
• Advantages: outpatient/short stay, faster recovery of oral intake, lower cost
• Disadvantages: stent dysfunction (tumour ingrowth/overgrowth), shorter durability
• Preferred for: poor performance status, life expectancy weeks to 2-3 months
• Tumour ingrowth into uncovered SEMS can often be managed with a covered SEMS placed inside
• If biliary obstruction coexists: biliary stenting MUST be done FIRST - placing a biliary stent after duodenal SEMS is technically very difficult

• Open or laparoscopic retrocolic side-to-side GJ to posterior wall of distal stomach
• Better long-term outcomes: less symptom recurrence, fewer reinterventions
• Advantages: durable, no stent-related complications
• Disadvantages: higher short-term morbidity, longer hospital stay
• Preferred for: better performance status, expected survival >2-3 months

• Endoscopic creation of a gastrojejunal anastomosis using lumen-apposing metal stents (LAMS)
• Recent meta-analyses (2024-2026) show comparable or superior results to surgical GJ with fewer complications - see PMID 39465748

1. Operable tumor + neoadjuvant therapy planned → laparoscopic/robotic GJ
2. Advanced unresectable disease → duodenal SEMS (outpatient)
3. Combined biliary + duodenal obstruction → PTC for biliary decompression first, then laparoscopic GJ
4. Goal in neoadjuvant candidates: normalize bilirubin + ensure enteral nutrition to start systemic therapy ASAP

Drainage PEG (venting gastrostomy)

• For patients unfit for surgery or stenting
• Gastrostomy tube used to drain stomach (not feed) - palliation of vomiting
• Technically challenging if stomach wall is thickened

Medical palliation

• Prokinetics (metoclopramide, domperidone) - modest benefit in malignant gastroparesis component, but become less effective with disease progression
• Corticosteroids - may reduce peritumoral oedema transiently

7. Special Situations

8. Summary Algorithm

GOO Confirmed
     |
Resuscitate: NGT + IV 0.9% NaCl + K+ + PPI
     |
EGD + biopsy + CT scan
     |
   /     \
Benign    Malignant
  |           |
PPI +      Resectable?
H.pylori Rx    /    \
  |          Yes    No
Balloon      |      |
dilation  Resect  SEMS vs Surgical GJ
  |               (based on PS + prognosis)
Fails              |
  |           Poor PS/short life → SEMS
Surgery       Good PS/longer life → GJ
(V/A or V/GJ)  Neoadjuvant planned → Lap GJ

Recent Evidence (2024-2026)

• EUS-GE vs duodenal SEMS: A 2024 meta-analysis (PMID 39465748) found EUS-guided gastroenterostomy and duodenal stenting have comparable technical success; EUS-GE may offer lower reintervention rates.
• EUS-GE for benign GOO: A 2026 meta-analysis (PMID 39761155) shows EUS-GE is effective and safe in benign GOO - an expanding indication.
• Pancreatic cancer palliation: A 2026 meta-analysis (PMID 41241872) comparing palliative approaches (stent vs surgical bypass vs EUS-GE) in locally advanced pancreatic cancer found no clear winner - choice remains individualized.
• Gastric partitioning vs gastrojejunostomy: A 2026 meta-analysis (PMID 41530728) - gastric partitioning may reduce delayed gastric emptying compared to conventional GJ.
• EUS-GJ vs surgical GE: A 2026 meta-analysis (PMID 42034575) found EUS-guided gastrojejunostomy had comparable efficacy to surgical gastroenterostomy with potentially fewer complications.

• Sleisenger and Fordtran's Gastrointestinal and Liver Disease
• Current Surgical Therapy, 14th ed.
• Bailey and Love's Short Practice of Surgery, 28th ed.
• Yamada's Textbook of Gastroenterology, 7th ed.
• Clinical Gastrointestinal Endoscopy, 3rd ed.