Malignant Gastric Outlet Obstruction
Common gastrointestinal symptoms experienced by patients with cancer can vary widely and determining an underlying malignancy can prove difficult.
Patients with an underlying malignancy can clinically present in a variety of ways. Common gastrointestinal symptoms experienced by patients with cancer can vary widely and include nausea, vomiting, diarrhea, constipation, weight loss, decreased appetite, and abdominal pain.
When a patient presents with any of these non-specific symptoms, a previously undiagnosed malignancy is not typically the leading diagnosis.
However, a detailed history and physical can lead to the correct diagnosis in 70% to 90% of cases.1 One such diagnosis that may be the key to an underlying malignancy is that of a gastric outlet obstruction (GOO).
GOO occurs when there is a mechanical obstruction impeding gastric emptying. GOO has both benign and malignant etiologies, however the history and physical exam findings are similar.
Patients with GOO can present with nausea, post-prandial vomiting, early satiety, dehydration, abdominal bloating, weight loss, and epigastric tenderness. The duration of symptoms can vary between an acute or chronic presentation.2
When examining a patient with GOO, they may have a “succussion splash” which occurs when you auscultate the patient's epigastric/left upper quadrant and then move their hips back and forth. If several hours after eating you can hear a “splash-like” noise, it suggests delayed gastric emptying which may be due to GOO.
Although the succussion splash is an interesting physical exam maneuver to be familiar with, it is not entirely specific or sensitive to identifying GOO.
If there is a high clinical suspicion for GOO, then benign and malignant etiologies should be considered. Malignancy is the underlying etiology in up to 80% of patients with GOO.2,3
Malignancies that lead to GOO include gastric (adenocarcinoma, lymphoma or carcinoid), metastatic pancreatic, small bowel, and metastatic cholangiocarcinoma.2,4
Benign causes of GOO include peptic ulcer disease, inflammatory bowel disease (Crohn's Disease), gallstones (Bouveret syndrome), and pancreatitis. Although formally not a GOO, gastroparesis should be considered on the differential diagnosis as well since impaired gastric motility can cause similar symptoms.
When evaluating a patient for GOO, there are several tests that can be used. Most laboratory tests are non-specific to GOO and may be consistent with dehydration secondary to poor oral intake. Gastrin levels may be elevated but are not specific for GOO.
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Patients with GOO may also be anemic from a multitude of reasons and is not specific. In addition, there are no specific tumor markers to indicate that a GOO is of malignant etiology.
Abdominal X-rays (including dedicated obstruction series) may show excessive fluid within the stomach and reduced air within the small bowel. If the initial X-rays are unrevealing or inconclusive, the patient can undergo a barium swallow or upper gastrointestinal series (+/- with small bowel follow-through).