Duodenal Ulcer Gastric Outlet Obstruction Diet For DiabetesPeptic Ulcers . If the ulcer is in your stomach, it is called a gastric ulcer. If the ulcer is in your duodenum, it is called a duodenal ulcer. Gastric outlet obstruction Sarika Rohatgi, MD, is a pediatric gastroenterology fellow at Children’s Hospital of Wisconsin and the Medical College of Wisconsin. Highly selective vagotomy and gastrojejunostomy in the treatment of peptic ulcer induced gastric outlet. Ulcers are fairly common. What causes peptic ulcers? In the past, experts thought lifestyle factors such as stress and diet caused ulcers. Duodenal Ulcer Gastric Outlet Obstruction DietaryToday we know that stomach acids and other digestive juices help create ulcers. These fluids burn the linings of your organs. Causes of peptic ulcers include: H. Gastric outlet obstruction, intractability. Duodenal Ulcers S&S. Peptic Ulcer Disease. Diet and nutrition news. Complications of stomach ulcer. Complications of stomach ulcers are relatively uncommon, but. This is known as gastric outlet obstruction. Gastric outlet obstruction is an. Patients With Postoperative Gastric Obstruction. Most ulcers are caused by an infection from a bacteria or germ called H. This bacteria hurts the mucus that protects the lining of your stomach and the first part of your small intestine (the duodenum). Stomach acid then gets through to the lining. NSAIDs (nonsteroidal anti- inflammatory drugs). These are over- the- counter pain and fever medicines such as aspirin, ibuprofen, and naproxen. Over time they can damage the mucus that protects the lining of your stomach. What are the symptoms of peptic ulcers? Each person’s symptoms may vary. In some cases ulcers don’t cause any symptoms. The most common ulcer symptom is a dull or burning pain in your belly between your breastbone and your belly button (navel). This pain often occurs around meal times and may wake you up at night. It can last from a few minutes to a few hours. Less common ulcer symptoms may include: Feeling full after eating a small amount of food. Burping. Nausea. Vomiting. Not feeling hungry. Losing weight without trying. Bloody or black stool. Vomiting blood. Peptic ulcer symptoms may look like other health problems. Always see your healthcare provider to be sure. How are peptic ulcers diagnosed? Your healthcare provider will look at your past health and give you a physical exam. You may also have some tests. Imaging tests used to diagnose ulcers include: Upper GI (gastrointestinal) series or barium swallow. This test looks at the organs of the top part of your digestive system. It checks your food pipe (esophagus), stomach, and the first part of the small intestine (the duodenum). You will swallow a metallic fluid called barium. Barium coats the organs so that they can be seen on an X- ray. Upper endoscopy or EGD (esophagogastroduodenoscopy). This test looks at the lining of your esophagus, stomach, and duodenum. It uses a thin lighted tube called an endoscope. The tube has a camera at one end. The tube is put into your mouth and throat. Then it goes into your esophagus, stomach, and duodenum. Your health care provider can see the inside of these organs. A small tissue sample (biopsy) can be taken. This can be checked for H. These check for infection- fighting cells (antibodies) that mean you have H. A small sample of your stool is collected and sent to a lab. In 2 or 3 days, the test will show if you have H. This checks to see how much carbon dioxide is in your breath when you exhale. You will swallow a urea pill that has carbon molecules. If you have H. You will have a sample taken of your breath by breathing into a bag. It will be sent to a lab. If your sample shows higher than normal amounts of carbon dioxide, you have H. Your healthcare provider will create a care plan for you based on what is causing your ulcer. Treatment can include making lifestyle changes, taking medicines, or in some cases having surgery. Lifestyle changes may include: Not eating certain foods. Avoid any foods that make your symptoms worse. Quitting smoking. Smoking can keep your ulcer from healing. It is also linked to ulcers coming back after treatment. Limiting alcohol and caffeine. They can make your symptoms worse. Not using NSAIDs (non- steroidal anti- inflammatory medicines). These include aspirin and ibuprofen. Medicines to treat ulcers may include: Antibiotics. These bacteria- fighting medicines are used to kill the H. Often a mix of antibiotics and other medicines is used to cure the ulcer and get rid of the infection. H2- blockers (histamine receptor blockers). These reduce the amount of acid your stomach makes by blocking the hormone histamine. Histamine helps to make acid. Proton pump inhibitors or PPIs. These lower stomach acid levels and protect the lining of your stomach and duodenum. Mucosal protective agents. These medicines protect the stomach's mucus lining from acid damage so that it can heal. Antacids. These quickly weaken or neutralize stomach acid to ease your symptoms. In most cases, medicines can heal ulcers quickly. You may also need surgery if your ulcer causes other medical problems. What are the complications of peptic ulcers? Ulcers can cause serious problems if you don’t get treatment. The most common problems include: Bleeding. As an ulcer wears away the muscles of the stomach or duodenal wall, blood vessels may be hurt. This causes bleeding. Hole (perforation). Sometimes an ulcer makes a hole in the wall of your stomach or duodenum. When this happens, bacteria and partly digested food can get in. This causes infection and redness or swelling (inflammation). Narrowing and blockage (obstruction). Ulcers that are found where the duodenum joins the stomach can cause swelling and scarring. This can narrow or even block the opening to the duodenum. Food can’t leave your stomach and go into your small intestine. This causes vomiting. You can’t eat properly. When should I call my healthcare provider? See your healthcare provider right away if you have any of these symptoms: Vomiting blood or dark material that looks like coffee grounds. Extreme weakness or dizziness. Blood in your stools (your stools may look black or like tar)Nausea or vomiting that doesn’t get better, or gets worse. A sudden, severe pain that may spread to your back. Losing weight without even trying. Untreated peptic ulcers may cause other health problems. Sometimes they bleed. If they become too deep, they can break through your stomach. Ulcers can also keep food from going through your stomach. Key points. These ulcers are sores on the lining of your stomach or the first part of your small intestine (the duodenum). Stomach acids and other digestive juices help to make ulcers by burning the linings of these organs. Most ulcers are caused by infection from a bacteria or germ called H. In rare cases, surgery is needed. Next steps. Tips to help you get the most from a visit to your healthcare provider: Know the reason for your visit and what you want to happen. Before your visit, write down questions you want answered. Bring someone with you to help you ask questions and remember what your provider tells you. At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you. Know why a new medicine or treatment is prescribed, and how it will help you. Also know what the side effects are. Ask if your condition can be treated in other ways. Know why a test or procedure is recommended and what the results could mean. Know what to expect if you do not take the medicine or have the test or procedure. If you have a follow- up appointment, write down the date, time, and purpose for that visit. Know how you can contact your provider if you have questions. Gastric outlet obstruction . Ashai- Khan, MD, is a pediatric gastroenterologist at Children’s Hospital of Wisconsin. She also is an associate professor of Pediatric Gastroenterology at the Medical College of Wisconsin. INTRODUCTIONGastric outlet obstruction in the pediatric population, after the first few weeks of life, is an uncommon cause of persistent vomiting and most often requires surgical interventions. Our patient presented with a rare etiology of gastric outlet obstruction, with a possible etiology of drug- induced injury, which was amenable to successful nonsurgical management using advanced endoscopic procedures. CASEOur patient is a previously healthy, 3- year- old female who presented with three weeks of nausea, vomiting, abdominal. During this period, she was admitted twice for IV fluids for dehydration. These symptoms started acutely within two to three days after she began taking azithromycin and ibuprofen to treat walking pneumonia and had been worsening since. Due to reduced oral intake of initially solids and then liquids, she developed significant weight loss and constipation. She was admitted to another hospital for further workup. The hospital performed an abdominal ultrasound that showed hypertrophic pylorus, an esophagogastrogram that showed no passage of contrast through the stomach, and an unsuccessful upper endoscopy with evidence of gastric outlet obstruction. Here, we started her on IV nutrition, placed her nasogastric tube to suction and corrected her metabolic acidosis with intravenous fluids. Once stabilized, she was taken to the operating room for a repeat upper endoscopy, during which we found some ulcers, erythema and erosions in the esophagus and stomach, with complete occlusion of her pylorus. We carefully passed a guide wire through the possible small opening of the pylorus and confirmed the position by fluoroscopy. We then threaded a balloon dilation catheter over the guide wire into the duodenum under fluoroscopic guidance. The balloon was gradually inflated with increasing pressures to dilate the pylorus successfully. After dilation, we injected Botox around the pylorus. When we then passed the endoscope into the duodenum with extensive manipulation, the area appeared normal. She went home two days after the procedure on sucralfate and proton pump inhibitors with diet advanced to high- calorie oral liquids. She did well for a week or so until she was readmitted for recurrence of similar symptoms. She underwent a repeat upper endoscopy and dilation two weeks after the first procedure. The endoscopy showed a significantly improved esophagus and stomach. Next, we passed a guide wire under fluoroscopy, followed by the dilation catheter. We performed serial dilations at a pressure and diameter greater than the previous dilations. We noted a porous transparent vascular membrane with extensive surrounding granulation tissue beyond the dilated area. Despite extensive manipulation, we were unsuccessful in passing the scope into the duodenum. To assess the obstruction, we performed a contrast study, which showed dilated stomach and small amounts of contrast flowing into the duodenum. During this third dilation procedure we were able to enter the duodenum using a neonatal scope. Due to persistent narrowing of the pylorus, we repeated serial dilations under direct fluoroscopy in conjunction with the Interventional Radiology team. Biopsies taken from the pylorus were consistent with drug- induced injury to the strictured area. We continued her on a high- calorie liquid diet and allowed gradual advancement as tolerated. Now, five months after her last dilation, she is completely asymptomatic, on a regular diet, off all medications and growing well. DISCUSSIONIn the pediatric population, gastric outlet obstruction can have two possible etiologies, mechanical and functional. Mechanical obstruction happens when the exit to the stomach is narrowed but the gastric nervous and muscular systems are intact. The causes of mechanical obstruction can be perinatal or postnatal. The perinatal causes mainly include anatomical abnormalities as antral webs, congenital gastric atresias, pyloric stenosis, annular pancreas or gastric duplication cysts or hypertrophic pyloric stenosis, though most of these present at a later age. On the other hand, postnatal causes range from more common peptic ulcer disease or drug- induced gastric ulcers and healing burns from caustic ingestion to more uncommon causes as eosinophilic gastroenteritis or Crohn’s disease and other granulomatous diseases, both infectious and noninfectious. The commonly implicated drugs include non- steroidal anti- inflammatory drugs, macrolides, fluoxetine in pregnancy, opium/opiates and Lipitor. The common causes of luminal obstruction include gastric bezoar, percutaneous endoscopic gastrostomy tube migration or prolapse, malrotation or volvulus, gastric polyps, diaphragmatic hernia, acute or chronic pancreatitis causing external compression or adhesions, pancreatic pseudocyst, hematomas (traumatic or Henoch- Sch. Functional causes of gastroparesis include neurological causes that could be acute, secondary to viral infections, electrolyte abnormalities and surrounding tissue inflammation, or chronic as seen in uncontrolled diabetes; and intrinsic muscular diseases as seen in mitochondrial disorders and cerebral palsy. Management of gastric outlet obstruction depends primarily on the identified etiology. A patient’s workup starts with an abdominal X- ray, which can identify an enlarged stomach and possible bezoar or migrated percutaneous endoscopic gastrostomy tube. Other investigations include esophago- gastro- duodenogram or upper gastrointestinal series, abdominal ultrasound, and CT or MRI as required. Most patients also need an endoscopy, which may be diagnostic and/or therapeutic. In a pediatric population, we attempt to manage most cases conservatively. The majority of these patients present with significant esophageal and gastric irritation due to obstruction of flow and acid reflux and hence require adjunct medical therapy with proton pump inhibitors, sucralfate or steroids. With an advanced endoscopic approach we can do pneumatic dilations, place stents, ablate antral webs or inject Botox, but most children ultimately require surgical interventions with antral web resection, partial gastrectomy, antrectomy or Billroth II operation. CONCLUSIONWith advanced endoscopic therapeutic procedures we may be able to completely avoid the need for surgical interventions and it should always be considered in appropriate cases prior to surgery.
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