Duodenal Obstruction

Duodenal Obstruction

 

Definition

Duodenal obstruction is a failure of food to pass out of the stomach either from a complete or partial obstruction.

Description

The duodenum is the first part of the intestine, into which the stomach, the gall bladder, and the pancreas empty their contents. The pylorus connects the duodenum with the stomach and contains the valve that regulates stomach emptying. Obstruction usually occurs right at this outlet, so that the gall bladder and pancreas are unable to drain their secretions without hindrance.

Causes and symptoms

Obstruction of the duodenum occurs in adults and infants, each for a different set of reasons. In adults, the usual cause is a peptic ulcer of such antiquity that repeated cycles of injury and scarring have narrowed the passageway. Medical treatment of ulcers has progressed to the point where such obstinate ulcer disease is rarely seen any more. In infants, the conditions are congenital—either the channel is underdeveloped or the pylorus is overdeveloped. The first type is called duodenal hypoplasia and the second is termed hypertrophic pyloric stenosis. In rare cases, the channel may be missing altogether, a condition called duodenal atresia. To say that these anomalies are congenital is not to say their cause is understood. As with most birth defects, the specific cause is not known.
Food that cannot exit the stomach in the forward direction will return whence it came. Vomiting is the constant symptom of duodenal obstruction. It may be preceded by indigestion and nausea as the stomach attempts to squeeze its contents through an ever narrowing outlet.
Hypertrophic pyloric stenosis appears soon after birth. The infant will vomit feedings, lose weight, and be restless and irritable.

Diagnosis

X rays taken with contrast material in the stomach readily demonstrate the site of the blockage and often the ulcer that caused it. Gastroscopy is another way to evaluate the problem. In infants, x rays may not be necessary to detect pyloric stenosis. It is often possible to feel the enlarged pylorus, like an olive, deep under the ribs and see the stomach rippling as it labors to force food through.

Treatment

Bowel obstruction requires a surgeon, sometimes immediately. Newer surgical techniques constantly improve the outcome, but obstruction is a mechanical problem that needs a mechanical solution. Most adults who come to surgery for obstruction have suffered for years from peptic ulcer disease. They will usually benefit from ulcer surgery at the same time their obstruction is relieved. The surgeon will therefore select a procedure that combines relief of obstruction with remedy for ulcer disease. There are many choices. In fact, even without obstruction, functional considerations require ulcer surgery to include enhancement of stomach emptying.
To treat an infant with hypertrophic pyloric stenosis, some surgeons have had success with forceful balloon dilation of the pylorus done through a gastroscope, but the standard procedure is to cut across the overdeveloped circular muscle that is constricting the stomach outlet. There are reports of infant hypertrophic pyloric stenosis remitting without surgery following a very careful feeding schedule, but mortality is unacceptably high.

Prognosis

A functioning and unrestricted intestine is a prerequisite for living independent of the most advanced and continuous medical care available. Achieving this desirable goal is the rule with surgery for duodenal obstructions of all types. The bowel is so malleable that there is a rearrangement to suit every occasion. The variety of possible configurations is limited only by the surgeon's imagination.

Prevention

Prompt and effective treatment of peptic ulcers will prevent chronic scarring and narrowing. Drugs developed over the past few decades have all but eliminated the need for ulcer surgery.

Key terms

Atresia — Failure to develop; complete absence.
Contrast agent — A substance that produces shadows on an x ray so that hollow structures can be more easily seen.
Gastroscopy — Looking into the stomach with a flexible viewing instrument called a gastroscope.
Hypoplasia — Incomplete development.
Peptic ulcer — A wound in the lower stomach and duodenum caused by stomach acid and a newly discovered germ called Helicobacter pylori.

Resources

Books

Redel, Carol A., and R. Jeff Zeiwner. "Anatomy and Anomalies of the Stomach and Duodenum." In Sleisenger & Fordtran's Gastrointestinal and Liver Disease, edited by Mark Feldman, et al. Philadelphia: W. B. Saunders Co., 1997.
References in periodicals archive ?
Concomitant obstruction is seen particularly in patients with pancreatic cancer, which causes biliary obstruction in 70%-90% and duodenal obstruction in 15%-20% of patients (16).
Endoscopic management of a pregnant lady with duodenal obstruction due to malrotation with midgut volvulus.
Treatment of gastric outlet and duodenal obstruction with uncovered expandable metal stents.
10) other complications reported with duodenal trauma include intra-abdominal abscess, pancreatitis, duodenal obstruction and bile duct fistula.
Additional diagnostic imaging criteria include duodenal obstruction with abrupt cut-off in the third portion in setting of active peristalsis, and/or anatomic abnormalities such as high fixation of duodenum by the ligament of Treitz and anomaly of SMA.
Manama, July 19 (BNA): A newborn Bahraini baby suffering from congenital duodenal obstruction has undergone a successful surgery at the Salmaniya Medical Complex (SMC).
Combination of partial situs inversus, polysplenia and annular pancreas with duodenal obstruction and intestinal malrotation.
This edition has chapters on cholangioscopy, videocholangioscopy, echoendoscopy, combined biliary and duodenal obstruction, endoscopic ultrasound (EUS) access of the pancreatobiliary tree for diagnosis and transluminal and rendezvous therapy, and the history of ERCP, as well as a section on radiation safety.
Congenital causes of duodenal obstruction require surgery which can relieve the obstruction and is commonly successful without complication.
He said, "Congenital causes of duodenal obstruction require surgery, but to perform the surgery on a day-old baby was a tough call.
Palliative surgical biliary drainage is also effective and has the advantage of allowing the addition of a gastrojejunostomy if duodenal obstruction is present or imminent.
Duodenal obstruction by gallstones (Bouveret's syndrome): a review of the literature.