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 ?
Situs inversus abdominus in association with congenital duodenal obstruction: a report of two cases and review of the literature.
Although the cause of late presentation of malrotation symptoms (in older children and adults) has not been fully established, the severity of duodenal obstruction is thought to influence the clinical symptoms.
Giant Brunner's gland adenoma of the duodenal bulb presenting with ampullary and duodenal obstruction mimicking pancreatic malignancy.
However, 6.5% of patients may develop complications [11] which include common bile duct obstruction, acute or chronic recurrent pancreatitis, partial duodenal obstruction, diverticulitis, ulceration, hemorrhage, enterolith formation, malignant degeneration, and perforation [12].
We present a case of malignant duodenal obstruction with dilation of the biliary tract, with failed ERCP procedure.
18 years of age or older Information given and informed consent obtained Bilirubin > 50 umol/L (normal 26 umol/L) Typical radiological appearance of malignant common bile duct stenosis at ERCP Proximal margin of malignant bile duct stenosis > 2 cm from the hepatic confluence ECOG * performance status 0-2 Metastatic disease Resectable patients Previous gastric surgery or duodenal obstruction preventing ERCP Previous inclusion in the study Participation in another clinical trial in the preceding 90 days * ECOG Eastern Cooperative Oncology Group Table 2.
Congenital duodenal obstruction in neonates: a decade's experience from one center.
They may also be noted in newborns, and are usually associated with pyloric or duodenal obstruction. The patient may experience vague epigastric pain, fullness, dyspepsia, or vomiting.
Annular pancreas: a rare cause of duodenal obstruction in adults.
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.