Gastric outlet obstruction possibly secondary to ulceration in a 2-year-old girl: a case report
© Okawada et al; licensee BioMed Central Ltd. 2009
Received: 06 November 2008
Accepted: 05 January 2009
Published: 05 January 2009
Gastric outlet obstruction due to ulceration is extremely rare in childhood. We report a case of gastric outlet obstruction possibly secondary to peptic ulceration and our surgical management. Our approach, without vagotomy or antrectomy, would appear to be a safe and effective.
Gastric outlet obstruction (GOO) may be caused by peptic ulceration, caustic ingestion, tumor, chronic granulomatous disease, or eosinophilic gastroenteritis [1–6], but peptic ulceration is extremely rare in childhood with an incidence of only 1 in 100,000 live births [1, 2, 7].
The introduction of histamine-2 (H2) receptor blockers, proton pump inhibitors (PPI), and treatment for Helicobacter pylori (H pylori) has revolutionized the non-surgical management of peptic ulcer disease, with most patients now being treated conservatively [8, 9].
Herein, we present a case of severe GOO possibly secondary to peptic ulceration despite intravenous administration of H2 receptor blockers who required surgical intervention.
GOO is extremely rare in children and its management is not established . There are some reports of children with GOO secondary to peptic ulceration being treated successfully with vagotomy combined with pyloroplasty, anterectomy, or gastrojejunostomy [1, 10, 11] and Billroth I, Billroth II, or pyloroplasty have also been used to treat GOO with good results. In these reports, peptic ulceration did not recur and failure to thrive was not seen in any of these cases in childhood. However, anterectomy is relatively invasive in children, and gastrojejunostomy has a risk for peptic ulceration on the anastomotic site. Pyloroplasty may change the angle of the pyloric canal which may disrupt the smooth passage of stomach contents into the duodenum postoperatively. We experienced such complications in patients who had pyloroplasty elsewhere. Some authors have advocated balloon dilatation of the pylorus in adults, but its long-term efficacy has not been proven in children . In adults, the short-term failure and long-term recurrence rates for balloon dilatation have been reported to be as high as 30–84% [13–15]. In our case, balloon dilatation was not effective, and we perform the procedure described here for GOO in children.
In the present case, we did not perform vagotomy because serum gastrin was normal and H pylori was negative. Surprisingly, the mucosa of the antral stricture was normal and no mucosal scar was identified on preoperative endoscopy or intraoperatively, although mucosal scarring is usually present after treatment of peptic ulceration according to other reports in the literature [1, 13–15]. Our procedure is simple and does not cause any anatomic or physiologic changes.
We believe our procedure is suitable for patients with GOO secondary to peptic ulceration and should be considered as one of the indications for surgical intervention in children with GOO with normal serum gastrin.
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
Gastric outlet obstruction
Proton Pump Inhibitors
- H pylori:
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