Hour glass stricture and stenosis of stomach

Upper GI

Clinicals - History

Fact Explanation
Age Age is important in the history to decide the origin of the illness whether it is congenital or acquired.
Congenital hour glass stricture will present in the early life while acquired hour glass stricture and stenosis will present late.
Regarding acquired strictures, research evidence reveals that people in younger age(35 or younger) are more prone to get strictures than older age group.
Age
Age is important in the history to decide the origin of the illness whether it is congenital or acquired.
Congenital hour glass stricture will present in the early life while acquired hour glass stricture and stenosis will present late.
Regarding acquired strictures, research evidence reveals that people in younger age(35 or younger) are more prone to get strictures than older age group.
Abdominal Pain, heaviness, discomfort and vomiting occurs 30 mins to 2 hours after food, symptoms relieve with vomiting. In this condition stomach is divided into two portions by a stricture in the wall, this can occur at any point between the cardiac and pyloric orifices.Due to this obstruction to normal food flow in the stomach these symptoms occur.
Abdominal pain occurs as the upper part of the stomach tries to push the food particles through the barrier.
Heaviness and discomfort occurs due to the limited space available inside the stomach. So the stomach distends with small quantities of the food particles.
Vomiting occurs with the over distension of the stomach. As vomiting will reduce the food load symptoms will improve. the vomitus is non bilious. Occurrence of symptoms will depend on the degree of the stricture causing obstruction and the site of it. Also symptoms will be more prominent with solid food while less with fluids.
Abdominal Pain, heaviness, discomfort and vomiting occurs 30 mins to 2 hours after food, symptoms relieve with vomiting.
In this condition stomach is divided into two portions by a stricture in the wall, this can occur at any point between the cardiac and pyloric orifices.Due to this obstruction to normal food flow in the stomach these symptoms occur.
Abdominal pain occurs as the upper part of the stomach tries to push the food particles through the barrier.
Heaviness and discomfort occurs due to the limited space available inside the stomach. So the stomach distends with small quantities of the food particles.
Vomiting occurs with the over distension of the stomach. As vomiting will reduce the food load symptoms will improve. the vomitus is non bilious. Occurrence of symptoms will depend on the degree of the stricture causing obstruction and the site of it. Also symptoms will be more prominent with solid food while less with fluids.
Body weakness, excessive thirst, reduced urine out put, confusion Patients with recurrent vomiting will present with feature of dehydration (body weakness, excessive thirst, reduced urine out put) and electrolyte imbalances( confusion)- hypochloremic hyponatremia Body weakness, excessive thirst, reduced urine out put, confusion
Patients with recurrent vomiting will present with feature of dehydration (body weakness, excessive thirst, reduced urine out put) and electrolyte imbalances( confusion)- hypochloremic hyponatremia
Haemoptysis and/ or malena Either gastric erosion at the site of stricture or previous gastric ulcer which cause this stricture can cause bleeding this may present with haemoptysis and/ or malena Haemoptysis and/ or malena
Either gastric erosion at the site of stricture or previous gastric ulcer which cause this stricture can cause bleeding this may present with haemoptysis and/ or malena
Weight loss despite of increased appetite, easy fatiguability, lethargy, recurrent infection attacks Abdominal pain, heaviness, discomfort may limit the food uptake which leads to weight loss despite of increased appetite.Vomiting will again remove some quantity of food which ingested. This leads to malnutrition causing anaemia and other nutritional deficiency features. Weight loss despite of increased appetite, easy fatiguability, lethargy, recurrent infection attacks
Abdominal pain, heaviness, discomfort may limit the food uptake which leads to weight loss despite of increased appetite.Vomiting will again remove some quantity of food which ingested. This leads to malnutrition causing anaemia and other nutritional deficiency features.
Sudden onset generalized abdominal pain, fever, vomiting, ill health Strictures may lead to perforation of the stomach and release of the contents of the stomach will leads to peritonitis. . Sudden onset generalized abdominal pain, fever, vomiting, ill health
Strictures may lead to perforation of the stomach and release of the contents of the stomach will leads to peritonitis. .
Loss of weight, loss of appetite, easy fatiguability, gradually increasing obstructive features Long term gastric stricture can leads to gastric carcinoma which may present with those symptoms. Loss of weight, loss of appetite, easy fatiguability, gradually increasing obstructive features
Long term gastric stricture can leads to gastric carcinoma which may present with those symptoms.
Past medical history of recurrent attacks if gastritis Recurrent H. pylori infection causes recurrent attacks of gastritis this can lead to formation of hour glass strictures and stenosis. Gastric ulcer healing with fibrosis it self can lead to this condition. Past medical history of recurrent attacks if gastritis
Recurrent H. pylori infection causes recurrent attacks of gastritis this can lead to formation of hour glass strictures and stenosis. Gastric ulcer healing with fibrosis it self can lead to this condition.
Long term use of NSAIDs This is a risk factor in developing gastric ulcer which ultimately can result in formation of hour glass stricture and stenosis. Long term use of NSAIDs
This is a risk factor in developing gastric ulcer which ultimately can result in formation of hour glass stricture and stenosis.
Past surgical history of endoscopic examination This is associated with gastric srictures. As this is an invasive procedure it can damage stomach wall. Past surgical history of endoscopic examination
This is associated with gastric srictures. As this is an invasive procedure it can damage stomach wall.
Social history of stress, alcohol use, cigarette smoking These are risk factors of developing gastic ulcers. Social history of stress, alcohol use, cigarette smoking
These are risk factors of developing gastic ulcers.

Clinicals - Examination

Fact Explanation
Emaciated, ill patient with features of nutritional deficiencies( pallor, angular stomatitis, glossitis) Difficulty in eating due to the discomfort associated with meals and recurrent vomiting will lead to nutritional deficiency causing these features. Emaciated, ill patient with features of nutritional deficiencies( pallor, angular stomatitis, glossitis)
Difficulty in eating due to the discomfort associated with meals and recurrent vomiting will lead to nutritional deficiency causing these features.
Dry skin, sunken eyes, reduced urine output These features of dehydration associated with recurrent vomiting. Dry skin, sunken eyes, reduced urine output
These features of dehydration associated with recurrent vomiting.
Vomitus examination: blood stained, undigested food, non bilious Due to bleeding from erosion/ gastric ulcer and undigested food as stricture is in the stomach, there is no time to digest the food. Non bilious as the obstruction is above the second part of the duodenum bile will not come out with the vomiting. Vomitus examination: blood stained, undigested food, non bilious
Due to bleeding from erosion/ gastric ulcer and undigested food as stricture is in the stomach, there is no time to digest the food. Non bilious as the obstruction is above the second part of the duodenum bile will not come out with the vomiting.
Stool examination: dark coloured stools, may be tar like Malena will cause dark coloured/ tar like stools depending on the degree of bleeding. If the bleeding is mild it may be microscopic. Stool examination: dark coloured stools, may be tar like
Malena will cause dark coloured/ tar like stools depending on the degree of bleeding. If the bleeding is mild it may be microscopic.
Mass in the epigastric/ left upper quadrant area. Proximal part of the stricture of the stomach can dilate and may feel as a mass in the epigastric area and/or left upper quadrant. Mass in the epigastric/ left upper quadrant area.
Proximal part of the stricture of the stomach can dilate and may feel as a mass in the epigastric area and/or left upper quadrant.
Febrile, ill looking patient with generalized abdominal tenderness, guarding, rigidity These are the examination findings in patients with peritonitis. Febrile, ill looking patient with generalized abdominal tenderness, guarding, rigidity
These are the examination findings in patients with peritonitis.

Investigations - Diagnosis

Fact Explanation
Full blood count(FBC) As anaemia can occur followed due to poor nutritional state and bleeding checking the hemoglobin is important. Full blood count(FBC)
As anaemia can occur followed due to poor nutritional state and bleeding checking the hemoglobin is important.
Serum electrolytes- serum sodium, serum potassium, serum chloride With recurrent vomiting patient can develop electrolyte imbalances- hypochloremia, hyponatremia, hypokaelemia. Serum electrolytes- serum sodium, serum potassium, serum chloride
With recurrent vomiting patient can develop electrolyte imbalances- hypochloremia, hyponatremia, hypokaelemia.
Liver function test - AST, ALT This is helpful in suspected malignancy to check for liver metastasis. Increased levels of AST and ALT may be seen with metastases. Liver function test - AST, ALT
This is helpful in suspected malignancy to check for liver metastasis. Increased levels of AST and ALT may be seen with metastases.
Plain abdominal radiography X ray of an abdomen will show a radiolucent rim within the gastric wall and a dilated stomach. In obstruction a series of X rays (eg; supine abdomen, upright abdomen, chest postero-anterior) will helpful in demonstrating the presence of gastric dilatation.
In a case of gastric perforation, gas under the diaphragm will show in a up right chest x ray.
Plain abdominal radiography
X ray of an abdomen will show a radiolucent rim within the gastric wall and a dilated stomach. In obstruction a series of X rays (eg; supine abdomen, upright abdomen, chest postero-anterior) will helpful in demonstrating the presence of gastric dilatation.
In a case of gastric perforation, gas under the diaphragm will show in a up right chest x ray.
Ultra sound scan abdomen Thickness of the stomach wall, gastric dilatation, site of stricture will give and idea about the condition.
In a suspected case of malignancy can look for liver metastases as well.
Ultra sound scan abdomen
Thickness of the stomach wall, gastric dilatation, site of stricture will give and idea about the condition.
In a suspected case of malignancy can look for liver metastases as well.
Contrast upper GI studies (Gastrografin or barium meal and follow through) This will show the enlargement of the proximal stomach and the hour glass appearance with middle narrowing( as a filling defect) Contrast upper GI studies (Gastrografin or barium meal and follow through)
This will show the enlargement of the proximal stomach and the hour glass appearance with middle narrowing( as a filling defect)
CT scans with oral contrast This will shows the exact level of stricture and the extend of it. CT scans with oral contrast
This will shows the exact level of stricture and the extend of it.
Upper GI endoscopy and endoscopic biopsy Upper GI endoscopy can help to visualize the gastric stricture an surrounding area, taking a tissue biopsy and histological examination will exclude gastric carcinoma. Upper GI endoscopy and endoscopic biopsy
Upper GI endoscopy can help to visualize the gastric stricture an surrounding area, taking a tissue biopsy and histological examination will exclude gastric carcinoma.

Investigations - Management

Fact Explanation
Upper GI endoscopy and endoscopic biopsy Upper GI endoscopy can help to visualize the gastric stricture an surrounding area, taking a tissue biopsy and histological examination will exclude gastric carcinoma at presentation as well as during follow up. Upper GI endoscopy and endoscopic biopsy
Upper GI endoscopy can help to visualize the gastric stricture an surrounding area, taking a tissue biopsy and histological examination will exclude gastric carcinoma at presentation as well as during follow up.
Contrast upper GI studies (Gastrografin or barium meal and follow through) This will helpful in assessing the patients condition/ improvement with the treatment( surgery). Contrast upper GI studies (Gastrografin or barium meal and follow through)
This will helpful in assessing the patients condition/ improvement with the treatment( surgery).
CT scans with oral contrast Similar to contrast upper GI studies this is useful in assessing the progress of the disease and the response to the treatment. CT scans with oral contrast
Similar to contrast upper GI studies this is useful in assessing the progress of the disease and the response to the treatment.
Full blood count(FBC) As anaemia can occur followed by poor nutritional state and bleeding check the hemoglobin is important. In assessing the fitness nutritional state this takes an important role. Full blood count(FBC)
As anaemia can occur followed by poor nutritional state and bleeding check the hemoglobin is important. In assessing the fitness nutritional state this takes an important role.
Serum electrolytes- serum sodium, serum potassium, serum chloride With recurrent vomiting patient can develop electrolyte imbalances- hypochloremia, hyponatremia and hypokalemia will be the electrolyte abnormalities. Serum electrolytes- serum sodium, serum potassium, serum chloride
With recurrent vomiting patient can develop electrolyte imbalances- hypochloremia, hyponatremia and hypokalemia will be the electrolyte abnormalities.
Upper GI endoscopy and endoscopic biopsy As hour glass strictures and stenosis of the stomach can end up in gastric cancer screening for it is useful in long term follow up. Upper GI endoscopy with multiple biopsies will help in excluding gastric carcinoma. Upper GI endoscopy and endoscopic biopsy
As hour glass strictures and stenosis of the stomach can end up in gastric cancer screening for it is useful in long term follow up. Upper GI endoscopy with multiple biopsies will help in excluding gastric carcinoma.

Management - Supportive

Fact Explanation
Improve the patient's nutritional state External supplementation of the vitamins, iron will help to improve nutritional deficiency to a certain extent. If the stricture is very severe, aduodenostomy or jejunostomy can be used in feeding until surgical correction. Improve the patient's nutritional state
External supplementation of the vitamins, iron will help to improve nutritional deficiency to a certain extent. If the stricture is very severe, aduodenostomy or jejunostomy can be used in feeding until surgical correction.
Manage acute state of severe vomiting if the patient present with severe vomiting, assess the level of dehydration clinically and adequate re hydration is needed. If severe, Intravenous fluid replacement will be needed. Manage acute state of severe vomiting
if the patient present with severe vomiting, assess the level of dehydration clinically and adequate re hydration is needed. If severe, Intravenous fluid replacement will be needed.

Management - Specific

Fact Explanation
Gastro enterostomy This is the surgical treatment option. In this surgery, all or part of the stomach is surgically removed and reconnected to small intestine. Gastro enterostomy
This is the surgical treatment option. In this surgery, all or part of the stomach is surgically removed and reconnected to small intestine.
Endoscopically/ fluoroscopically guided balloon dilation Endoscopically or fluoroscopically guided balloon dilation is a safe and effective alternative to surgery for patients with benign strictures of the stomach. Balloon dilation has been widely used to treat peptic ulcer-related gastric outlet obstruction. Endoscopically/ fluoroscopically guided balloon dilation
Endoscopically or fluoroscopically guided balloon dilation is a safe and effective alternative to surgery for patients with benign strictures of the stomach. Balloon dilation has been widely used to treat peptic ulcer-related gastric outlet obstruction.

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