A 54-year-old gentleman with good past health presents with a 2-month history of progressive weight loss, poor appetite and malaise. He has also noted increasing epigastric distension and pain with recurrent vomiting of coffee ground materials. He denies any recent use of non-steroidal anti-inflammatory drugs.
•Afebrile, pulse 70 bpm, BP 125/60mmHg, SaO2 98-100% on RA.
•Pallor, hydration on the dry side.
•Examination of the hands reveals no clubbing and normal-appearing palmar creases.
•Head and neck examination is unremarkable.
•Cardiovascular: HS dual, no murmur.
•His chest is clear on auscultation.
•Abdominal examination reveals a soft abdomen, with a large mass in the epigastrium, associated with succussion splash.
•No signs of oedema.
–WBC 6.9 x 109/L;
–haemoglobin 6.9g/dL (microcytic hypochromic);
–platelets 299 x 109/L.
•Liver function tests are grossly normal.
•Iron profile: Fe 2μmol/L, TIBC 72μmol/L, Fe saturation <5%.
What is your clinical diagnosis?
Given the clinical history and examination findings, gastric outlet obstruction (GOO) is suspected. The differential diagnosis would include intestinal obstruction.
What further investigations would you request?
In view of the history of epigastric pain and vomiting, an erect chest X-ray and abdominal X-ray are useful screening tests. The chest X-ray shows no free gas under the diaphragm. The abdominal X-ray is shown below (Figure 19.1).
Please describe what you see
There is a large, dilated gastric shadow, likely filled with food contents. This is consistent with a diagnosis of gastric outlet obstruction.
What would be your next step?
The patient should be kept nil per oral, with insertion of a Ryle’s tube connected to a bedside bag for gastric decompression, intravenous fluids initiated, and electrolytes corrected.
How would you proceed?