Primary gastroduodenal tuberculosis presenting as gastric outlet obstruction:A case report and review of literature

BACKGROUND Mycobacterium tuberculosis(TB)is the causative agent of TB,a chronic granulo-matous illness.This disease is prevalent in low-income countries,posing a significant global health challenge.Gastrointestinal TB is one of the three forms.The disease can mimic other intra-abdominal conditions,leading to delayed diagnosis owing to the absence of specific symptoms.While gastric outlet obs-truction(GOO)remains a frequent complication,its incidence has declined with the advent of proton pump inhibitors and Helicobacter pylori eradication therapy.Gastroduodenal TB can cause upper gastrointestinal hemorrhage,obstruction,and malignancy-like tumors.CASE SUMMARY A 23-year-old male presented with recurrent epigastric pain,distension,nausea,vomiting,and weight loss,prompting a referral to a gastroenterologist clinic.Endoscopic examination revealed distorted gastric mucosa and signs of chronic inflammation.However,treatment was interrupted,possibly owing to vomiting or comorbidities such as human immunodeficiency virus infection or diabetes.Subsequent surgical intervention revealed a dilated stomach and diffuse thickening of the duodenal wall.Resection revealed gastric wall effacement with TB.CONCLUSION Primary gastric TB is rare,frequently leading to GOO.Given its rarity,suspicions should be promptly raised when encountering relevant symptoms,often requiring surgical intervention for diagnosis and treatment.

Endoscopic ultrasound-guided gastroenterostomy for gastric outlet obstruction in Mexico

BACKGROUND Endoscopic ultrasound-guided gastroenterostomy(EUS-GE)has recently emerged as an alternative treatment for gastric outlet obstruction(GOO)in selected patients.AIM To report the initial experience of EUS-GE in patients with GOO.METHODS This study was a retrospective,observational,multicenter study in which the data from 10 patients who underwent EUS-GE due to GOO between September 2021 and May 2023 were collected.We analyzed technical success,clinical success,adverse events,and survival.Technical success was defined as adequate positioning and deployment of the stent.Clinical success was defined as the patient’s ability to tolerate oral intake without vomiting 7 d after the procedure.Postprocedural adverse events were recorded.RESULTS Eleven procedures in 10 patients with GOO were included.The mean age of the patients was 67.5 years(range:56-77 years).Malignant GOO was present in 9 patients.Technical success was achieved in 9/11 procedures(82%).Among them,clinical success was achieved in 9 patients(100%).Adverse events occurred in 1 patient(9%).The median survival was 3 months(n=7;range:1-8 months).CONCLUSION EUS-GE is a feasible therapeutic option in the treatment of GOO.

Modified stomach-partitioning gastrojejunostomy for initially unresectable advanced gastric cancer with outlet obstruction: A case report

BACKGROUND Chemotherapy followed by gastrojejunostomy remains the main treatment for unresectable gastric cancer(GC)in the middle-or lower-third regions with gastric outlet obstruction(GOO).Radical surgery is performed as part of a multimodal treatment strategy for selected patients who respond well to chemotherapy.This study describes a case of successful radical resection with completely laparoscopic subtotal gastrectomy after a modified stomach-partitioning gastrojejunostomy(SPGJ)for obstruction relief,in a patient with GOO.CASE SUMMARY During the initial esophagogastroduodenoscopy,an advanced growth was detected in the lower part of the stomach,which caused an obstruction in the pyloric ring.Following this,a computed tomography(CT)scan revealed the presence of lymph node metastases and tumor invasion in the duodenum,but no evidence of distant metastasis was found.Consequently,we performed a modified SPGJ,a complete laparoscopic SPGJ combined with No.4sb lymph node dissection,for obstruction relief.Seven courses of adjuvant capecitabine plus oxaliplatin combined with Toripalimab(programmed death ligand-1 inhibitor)were administered thereafter.A preoperative CT showed partial response;therefore,completely laparoscopic radical subtotal gastrectomy with D2 lymphadenectomy was performed after conversion therapy,and pathological complete remission was achieved.CONCLUSION Laparoscopic SPGJ combined with No.4sb lymph node dissection was an effective surgical technique for initially unresectable GC with GOO.

Is there a correlation between the outcome of transurethral resection of prostate and preoperative degree of bladder outlet obstruction？

To compare the impact of transurethral resection of prostate （TURP） on symptom scores and maximal flow rates （Qmax） in patients with equivocal bladder outlet obstruction （BOO） and definite BOO and to assess the relationship between the surgical outcomes and degree of preoperative BOO, we prospectively evaluated men with lower urinary tract symptoms and bladder outlet obstruction index （BOO1） greater than 20, who were refractory to conventional medical treatment and underwent TURP. Urodynamic evaluation, International Prostate Symptom Score （IPSS）, uroflowmetry, post-void residual volume （PVR） check and transrectal ultrasound were performed. 20〈B001〈40 was defined as equivocal BOO and BOO1 〉~40 as definite BOO. Changes of IPSS, Qmax, PVR and correlation analysis was performed between the degree of improvement of Qmax, subdomains of I PSS and BOO1. Fifty-four patients showed equivocal BOO and 80 patients showed definite BOO. Preoperatively equivocal BOO group and definite BOO group showed significant differences in maximal bladder capacity and prevalence of detrusor overactivity, whereas no difference was noted in prostate volume. Postoperatively both groups showed improvements in Qmax, obstructive （IPSSO） and irritative （IPSSI） subdomain of IPSS, but the degree of improvement in Qmax and IPSSI subdomain was statistically significantly greater in definite BOO group. The degree of improvement of Qmax and IPSSI showed weak correlation with preoperative BOO1. As a weak correlation was identified between preoperative degree of BOO and outcome of TURP, other factors other than BOO1 such as severity of patients＇ symptoms should be considered in deciding treatment modality.

Effect of preoperative nutrition therapy type and duration on short-time outcomes in gastric cancer patient with gastric outlet obstruction

Objective:To avoid perioperative complications caused malnutrition,nutrition therapy is necessary in gastric outlet obstruction(GOO)patients.Compared to parenteral nutrition(PN),enteral nutrition(EN)is associated with many advantages.This study aimed to investigate whether preoperative EN has beneficial clinical effects compared to preoperative PN in gastric cancer patients with GOO undergoing surgery.Methods:According to the methods of preoperative nutrition therapy,143 patients were divided into EN group(n=42)and PN group(n=101)between January 2013 and December 2017 at the Chinese People’s Liberation Army General Hospital.Multiple logistic regression models were used to assess the association between the methods of preoperative nutrition therapy and postoperative day of flatus passage.The generalized additive model and twopiecewise linear regression model were used to calculate the inflection point of the preoperative nutritional therapy time on the postoperative day of flatus passage in the PN group.Results:EN shortened the postoperative day of flatus passage in gastric cancer patients with GOO,which is a protective factor,especially in patients who underwent non-radical operations and the postoperative day of flatus passage reduced when the preoperative PN therapy was up to 3 d and a longer PN therapy(>3 d)did not accelerate the postoperative recovery of gastrointestinal functions.Conclusions:Preoperative EN therapy would benefit gastric cancer patients with GOO by accelerating postoperative recovery.For patients with absolute obstruction,no more than 3-day PN therapy is recommended if patients can tolerate general anesthesia and surgery.

Gastric partitioning for the treatment of malignant gastric outlet obstruction

BACKGROUND Gastric outlet obstruction(GOO)is one of the main complications in stage IV gastric cancer patients.This condition is usually managed by gastrojejunostomy(GJ).However,gastric partitioning(GP)has been described as an alternative to overcoming possible drawbacks of GJ,such as delayed gastric emptying and tumor bleeding.AIM To compare the outcomes of patients who underwent GP and GJ for malignant GOO.METHODS We retrospectively analyzed 60 patients who underwent palliative gastric bypass for unresectable distal gastric cancer with GOO from 2009 to 2018.Baseline clinicopathological characteristics including age,nutritional status,body mass index,and performance status were evaluated.Obstructive symptoms were graded according to GOO score(GOOS).Surgical outcomes evaluated included duration of the procedure,surgical complications,mortality,and length of hospital stay.Acceptance of oral diet after the procedure,weight gain,and overall survival were the long-term outcomes evaluated.RESULTS GP was performed in 30 patients and conventional GJ in the other 30 patients.The mean follow-up was 9.2 mo.Forty-nine(81.6%)patients died during that period.All variables were similar between groups,with the exception of worse performance status in GP patients.The mean operative time was higher in the GP group(161.2 vs 85.2 min,P<0.001).There were no differences in postoperative complications and surgical mortality between groups.The median overall survival was 7 and 8.4 mo for the GP and GJ groups,respectively(P=0.610).The oral acceptance of soft solids(GOOS 2)and low residue or full diet(GOOS 3)were reached by 28(93.3%)GP patients and 22(75.9%)GJ patients(P=0.080).Multivariate analysis demonstrated that GOOS 2 and GOOS 3 were the main prognostic factors for survival(hazard ratio:8.90,95%confidence interval:3.38-23.43,P<0.001).CONCLUSION GP is a safe and effective procedure to treat GOO.Compared to GJ,it provides similar surgical outcomes with a trend to better solid diet acceptance by patients.

Conservative management of malignant gastric outlet obstruction syndrome-evidence based evaluation of endoscopic ultrasoundguided gastroentero-anastomosis

Gastric outlet obstruction(GOO)is a clinical syndrome characterized by postprandial vomiting,abdominal pain,bloating and,in advanced cases,by weight loss secondary to inadequate oral intake.This clinical entity may be caused by mechanical obstruction,either benign or malignant,or by motility disorders.In this review we will focus on malignant GOO and on its endoscopic ultrasound(EUS)-guided palliative treatment.The most frequent malignant causes of this syndrome are gastric and locally advanced pancreatic carcinomas;other causes include duodenal or ampullary neoplasms,gastric lymphomas,retroperitoneal lymphadenopathies and,more infrequently,gallbladder and bile duct cancers.Surgery represents the treatment of choice when radical and curative resection is potentially feasible;if the malignant cause is not likely to be completely resected,palliative treatments should be proposed.Palliative treatments for malignant GOO are primarily based on surgical gastro-jejunostomy and endoscopic placement of an enteral self-expanding metal stent.Both treatments are effective;however,endoscopic stent placement is less invasive and it is associated with good short-term results,while surgery provides longer-lasting effects with a lower frequency of reintervention.In the last few years,EUS-guided gastroenterostomy(GE)has been proposed as palliative treatment for malignant GOO.This novel technique consists of the creation of an anastomosis between the gastric lumen and a small bowel loop distal to the malignant obstruction,through the deployment of a lumen-apposing metal stent under EUS-view.EUS-GE has the advantage of being as minimally invasive as enteral stent placement,and of guaranteeing long-term results similar to those of surgery.

Endoscopic ultrasound guided gastrojejunostomy for gastric outlet obstruction

Gastric outlet obstruction(GOO)is a clinical syndrome secondary to luminal obstruction at the level of the stomach and/or duodenum.GOO can be caused by either benign or malignant etiologies,often resulting in early satiety,nausea,vomiting and poor oral intake.GOO is associated with decreased quality of life and has been shown to significantly impact survival in patients with advanced malignancies.Traditional treatment options for GOO can be broadly divided into surgical[surgical gastrojejunostomy(GJ)]and endoscopic interventions(dilation and/or placement of luminal self-expanding metal stents).While surgical GJ has been shown to provide a more lasting relief of symptoms when compared to luminal stenting,it has also been associated with a higher rate of adverse events.Furthermore,many patients with advanced metastatic disease are not good surgical candidates.More recently,endoscopic ultrasound(EUS)-guided GJ has emerged as a potential alternative to traditional surgical and endoscopic approaches.This review focuses on the new advances and technical aspects of EUS-GJ and clinical outcomes in the management of both benign and malignant disease.

Gastrojejunostomy followed by induction chemotherapy for incurable gastric cancer with outlet obstruction

A 72-year-old male gastric cancer patient with outlet obstruction underwent laparoscopic exploration. The examination disclosed intraperitoneal free cancer cells with no overt peritoneal, lymphatic, or hepatic metastasis. The patient underwent laparoscopy-assisted gastroje-junostomy (LAGJ) and started chemotherapy with S-1 plus cisplatin on postoperative day 13. Three course of the chemotherapy shrank the tumor markedly. Then, the patient underwent gastrectomy with a curative intent. Laparotomy revealed no intraperitoneal free cancer cells, and microscopically complete resection was achieved. The patient received S-1 chemotherapy as postoperative adjuvant treatment for 1 year, and is still alive with no evidence of peritoneal recurrence. LAGJ followed by S-1 plus cisplatin is one of the optional treatments that should be considered for patients with outlet obstruction as it may widen opportunities for potentially curative resection.

Endoscopic approach to gastric remnant outlet obstruction after gastric bypass:A case report

BACKGROUND Acute gastric remnant bleeding is a rare complication of bariatric surgery.Furthermore,acute bleeding from the gastric remnant resulting in gastric remnant outlet obstruction has not been described previously.Endoscopic management of gastric remnant bleed has been challenging due to difficulty accessing the excluded stomach.Traditionally,this necessitates surgical intervention.Recently,however,the adoption of endoscopic ultrasound-directed transgastric intervention provides an alternative approach to management.CASE SUMMARY A 65-year-old male with a prior gastric bypass presented with the sudden onset of progressive abdominal distension,nausea,and melena of two days duration.His imaging illustrated a massively distended stomach.A nasogastric tube did not result in drainage of fluid or decompression of his abdomen.His endoscopy revealed a normal-appearing gastro-jejunal anastomosis and confirmed the distended"fluid"-filled gastric remnant.An endoscopic ultrasound-directed gastrogastrostomy was created to decompress the gastric remnant.Two liters of blood was suctioned before a large adherent clot was visualized in the gastric antrum.The patient underwent emergent angiography with embolization of the gastroduodenal artery.He was discharged with a stable hemoglobin level and resolution of symptoms.Healing superficial gastric ulcers were visualized on a follow-up endoscopy.Gastric biopsies were consistent with Helicobacter pylori infection for which the patient was treated,and successful eradication was achieved.CONCLUSION This patient benefited from a timely diagnosis and effective therapy of an acute gastric remnant obstruction from a bleeding ulcer with endoscopic ultrasound directed transgastric intervention.

Management of gastric outlet obstruction:Focusing on endoscopic approach

Gastric outlet obstruction(GOO)is a medical condition characterized by epigastric pain and postprandial vomiting due to mechanical obstruction.The obstructions typically involved in GOO can be benign or malignant.Peptic ulcer disease is the most common cause of benign GOO,and malignant causes include gastric cancer,lymphoma,and gastrointestinal stromal tumor.With the eradication of Helicobacter pylori(H.pylori)and the use of proton pump inhibitors,the predominant causes have changed from benign to malignant diseases.Treatment of GOO depends on the underlying cause:Proton pump inhibitors,H.pylori eradication,endoscopic treatments including balloon dilatation or the placement of self-expandable stents,or surgery.

Gastric Outlet Obstruction by a Hydrocholecyst. A Very Rare Variant of Bouveret Syndrome: A Case Report

It is estimated that between 0.3% - 0.5% of patients with cholelithiasis have biliary ileus, of this small proportion, only between 1% - 3% is complicated by the syndrome described in 1896 by Leon Bouveret. Bouveret syndrome refers to the obstruction of the gastric outlet tract secondary to the passage and impactation of a gallstone in the duodenum, through a cholecystoduodenal fistula. It is most common in women, between the ages of 74 - 77 and is clinically characterized by pain, bloating, incoercible vomiting and anorexia.

Comparison of Combination Treatments of Distigmine and either Mirabegron or Solifenacin for Rats with Partial Bladder Outlet Obstruction

Objective: Detrusor hyperactivity with impaired contractility (DHIC) is not an uncommon bladder disorder, and is often difficult to treat. Therefore, using a rat model featuring both urinary frequency and residual urine, we investigated whether an anticholinergic agent (solifenacin) or a &#946;3-agonist (mirabegron) is more suitable to combine with distigmine to treat DHIC. Methods: The partial bladder outlet obstruction (BOO) rat model was used. Rats were treated for 2 weeks: BOO/Solifenacin group was treated with 0.1 mg/kg solifenacin (n = 8), BOO/Mirabegron group was treated with 1 mg/kg mirabegron (n = 8), BOO/- group was not drug-treated but was given distilled water (n = 8), and the control group was also given distilled water (n = 8). Then the urethral ligature was removed under urethane anesthesia, and continuous cystometry was performed to evaluate bladder function. Baseline measurements were taken, then distigmine was administered to all groups, and cystometry was performed again to measure changes in bladder function. Results: Residual volumes increased in the BOO/- group, and the detrusor contractions were more frequent than that of the control group. Solifenacin treatment did not influence changes, except for threshold pressure, to any cystometric measurements. However, mirabegron treatment decreased the residual volume and residual volume rate;it also decreased detrusor contraction frequency similar to measurements obtained from the control group. Distigmine treatment enhanced detrusor contractions, which resulted in less residual volume, and decreased detrusor contraction frequency in the BOO model. Conclusions: The combination of distigmine and mirabegron was determined to be a better treatment than the combination of distigmine and solifenacin for DHIC.

Primary Presentation of Ovarian Cancer with Bladder Outlet Obstruction/Chronic Urinary Retention in a 12-Year Old Female

Urinary retention in women is rare and is more frequently described as case reports or small case series. The female/male ratio is 1:13 with about 3 cases per 100,000 women every year We report a case of a 12-year old female student. She presented with progressive weight loss, worsening lower urinary tract symptoms with distended lower abdomen of 10 weeks duration. Physical examination revealed a mobile tender firm pelvic mass, 18 centimeters (cm) × 16 cm in size. Laboratory and imaging studies showed obstructive nephropathy and uropathy respectively. She was worked up and had uneventful exploratory laparotomy with right salpingo-oophorectomy, urinary bladder diverticulectomy and pelvic lymphadenectomy. Histopathology of the pelvic mass showed ovarian dysgerminoma with lymph node metastasis. She responded very well to chemotherapy and resumed her school activities. Bladder outlet obstruction is relatively rare in females and in the index patient, ovarian dysgerminoma is the cause leading to obstructive nephropathy and uropathy.

Effect of doxazosin on rabbit bladder compliance after partial bladder outlet obstruction

Objective To explore the effect of doxazosin on rabbit bladder compliance after partial bladder outlet ob- struction. Methods A total of 40 male New Zealand white rabbits were randomized into 4 groups,with 10 rabbits in each group. Partial bladder outlet

Palliative Therapy for Gastric Outlet Obstruction Caused by Unresectable Gastric Cancer： A Meta-analysis Comparison of Gastrojejunostomy with Endoscopic Stenting

Background： Gastrojejunostomy （G J J） and endoscopic stenting （ES） are palliative treatments for gastric outlet obstruction （GO0） caused by gastric cancer. We compared the outcomes of GJJ with ES by performing a meta-analysis. Methods： Clinical trials that compared GJJ with ES for the treatment of GOO in gastric cancer were included in the meta-analysis. Procedure time, time to resumption of oral intake, duration of hospital stay, patency duration, and overall survival days were compared using weighted mean differences （WMDs）. Technical success, clinical success, procedure-related mortality, complications, the rate of re-obstruction, postoperative chemotherapy, and reintervention were compared using odds ratios （ORs）.Results： Nine studies were included in the analysis. Technical success and clinical success were not significantly different between the ES and GJJ groups. The ES group had a shorter procedure time （WMD = -80.89 min, 95% confidence interval [CI] = -93.99 to -67.78, P 〈 0.001）, faster resumption of oral intake （WMD = -3.45 days, 95% CI = -5.25 to -1.65, P 〈 0.001）, and shorter duration of hospital stay （WMD = -7.67 days, 95% CI = -11.02 to -4.33, P 〈 0.001）. The rate of minor complications was significantly higher in the GJJ group （OR = 0.13, 95% CI = 0.04-0.40, P 〈 0.001）. However, the rates of major complications （OR = 6.91, 95% CI = 3.90-12.25, P 〈 0.001）, re-obstruction （OR = 7.75, 95% CI = 4.06-14.78, P 〈 0.001）, and reintervention （OR = 6.27, 95% CI = 3.36-11.68, P 〈 0.001） were significantly lower in the GJJ group than that in the E S group. Moreover, GJJ was significantly associated with a longer patency duration （WMD = -167.16 days, 95% CI = -254.01 to -89.31, P 〈 0.001） and overall survival （WMD = -103.20 days, 95% CI = -161.49 to -44.91, P = 0.001）. Conclusions： Both GJJ and ES are effective procedures for the treatment of GOO caused by gastric cancer. ES is associated with better short-term outcomes. GJJ is preferable to ES in terms of its lower rate of stent-related complications, re-obstruction, and reintervention. GJJ should be considered a treatment option for patients with a long life expectancy and good performance status.

Individual flexible endoscopic procedure for treatment of obstruction of fourth ventricle outlet

Objective To summarize the indication,method and effect of individual flexible endoscopic procedure for treatment of obstruction of fourth ventricle outlet. Methods The clinical data of 32 cases of obstruction of fourth ventricle outlet treated by individual flexible endoscopic

Endoscopic ultrasound guided gastroenterostomy:Technical details updates,clinical outcomes,and adverse events

Endoscopic ultrasound-guided gastroenterostomy(EUS-GE)has been transformed from an innovative technique,into a viable alternative to enteral stenting and surgical gastrointestinal anastomosis for patients with gastric outlet obstruction.Even EUS-GE guided ERCP and EUS-guided gastrointestinal anastomosis for the treatment of afferent loop syndrome have been performed,giving patients more less invasive options.However,EUS-GE is still a technically challenging procedure.In order to improve EUS-GE,several techniques have been reported to improve the technical details.With EUS-GE widely performed,more data about EUS-GE’s clinical outcomes have been reported.The aim of the current review is to describe technical details updates,clinical outcomes,and adverse events of EUS-GE.

Underactive bladder:Pathophysiology and clinical significance

Underactive bladder(UAB)is a voiding disorder which generates disabling lower urinary tract symptoms(LUTS)due to the inability to produce an effective voiding contraction sufficient to empty the bladder.The underlying abnormality,that is usually appreciated when performing urodynamic studies,has been defined by the International Continence Society(ICS)as detrusor underactivity(DUA).DUA is a common yet under-researched bladder dysfunction.The prevalence of DUA in different patient groups suggests that multiple aetiologies are implicated.Currently there is no effective therapeutic approach to treat this condition.An improved understanding of the underlying mechanisms is needed to facilitate the development of new advances in treatment.The purpose of this review is to discuss the epidemiology,pathophysiology,common causes and risk factors potentially leading to DUA;to aid in the appropriate diagnosis of DUA to potentially improve treatment outcomes.

Non-invasive evaluation of lower urinary tract symptoms(LUTS)in men

Lower urinary tract symptoms(LUTS)are common in males over the age of 40 years old and are likely to increase with an aging population.Currently urodynamic studies are the gold standard to determine the aetiology of voiding dysfunction and LUTS.However,due to its invasive nature,a great number of non-invasive ultrasound based investigations have been developed to assess patients with symptomatic LUTS.The clinical application of noninvasive tests could potentially stratify patients who would require more invasive investigations and allow more precise patient directed treatment.A PubMed literature review was performed and we will discuss the non-invasive investigations that have been developed thus far,focusing on bladder wall and detrusor wall thickness(BWT&DWT),ultrasound estimated bladder weight(UEBW)and intravesical prostatic protrusion(IPP).