History

Fact Explanation
Age Age is important in the history to decide the origin of the illness whether it is congenital or acquired[2]. 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[3].
Abdominal Pain, heaviness, discomfort and vomiting occurs 30 mins to 2 hours after food, symptoms relieve with vomiting[1][2]. 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[4]
Haemoptysis and/ or malena[2] 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.
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. [2][5].
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[6].
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[1][2].
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[2][8].
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[9].
References
  1. BROOK WF. On Congenital Hour-Glass Stomach Br Med J [online] 1904 May 7, 1(2262):1073 [viewed 14 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2354057
  2. MOYNIHAN BG. On Hour-glass Stomach Med Chir Trans [online] 1904:143-162 [viewed 14 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2037073
  3. BLACKSTONE RP, RIVERA LA. Predicting Stricture in Morbidly Obese Patients Undergoing Laparoscopic Roux-en-Y Gastric Bypass: A Logistic Regression Analysis J Gastrointest Surg [online] 2007 Apr, 11(4):403-409 [viewed 14 August 2014] Available from: doi:10.1007/s11605-007-0135-x
  4. ARANZAMENDI RJ, BREITMAN F, ASCIUTTO C, DELGADO N, CASTAñOS C. [Dehydration and metabolic alkalosis: an unusual presentation of cystic fibrosis in an infant]. Arch Argent Pediatr [online] 2008 Oct, 106(5):443-6 [viewed 14 August 2014] Available from: doi:10.1590/S0325-00752008000500012
  5. SAID M, GAREL C, DE LAGAUSIE P, HASSAN M. [Imaging of meconium peritonitis of pseudotumor clinical presentation]. J Radiol [online] 1997 Dec, 78(12):1288-90 [viewed 14 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9499971
  6. GRAHAM DY, YAMAOKA Y. H. pylori and cagA: relationships with gastric cancer, duodenal ulcer, and reflux esophagitis and its complications. Helicobacter [online] 1998 Sep, 3(3):145-51 [viewed 14 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9731983
  7. STRUGATSKY D, MCNULTY R, MUNSON K, CHEN CK, SOLTIS SM, SACHS G, LUECKE H. Structure of the proton-gated urea channel from the gastric pathogen Helicobacter pylori Nature [online] 2013 Jan 10, 493(7431):255-258 [viewed 14 August 2014] Available from: doi:10.1038/nature11684
  8. PANDOLFINO JE, KRISHNAMOORTHY B, LEE TJ. Gastrointestinal Complications of Obesity Surgery MedGenMed [online] , 6(2):15 [viewed 14 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1395777
  9. FRIEDMAN GD, SIEGELAUB AB, SELTZER CC. Cigarettes, alcohol, coffee and peptic ulcer. N Engl J Med [online] 1974 Feb 28, 290(9):469-73 [viewed 14 August 2014] Available from: doi:10.1056/NEJM197402282900901

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[2] will lead to nutritional deficiency causing these features.
Dry skin, sunken eyes, reduced urine output These features of dehydration[3][4] associated with recurrent vomiting.
Vomitus examination[2]: 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[5]: 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[1] 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[6].
References
  1. MOYNIHAN BG. On Hour-glass Stomach Med Chir Trans [online] 1904:143-162 [viewed 14 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2037073
  2. SPITZ L. Vomiting after pyloromyotomy for infantile hypertrophic pyloric stenosis. Arch Dis Child [online] 1979 Nov, 54(11):886-889 [viewed 14 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1545582
  3. COLLER FA, MADDOCK WG. A STUDY OF DEHYDRATION IN HUMANS Ann Surg [online] 1935 Nov, 102(5):947-960 [viewed 15 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1390963
  4. LAVIZZO-MOUREY RJ. Dehydration in the Elderly: A Short Review J Natl Med Assoc [online] 1987 Oct, 79(10):1033-1038 [viewed 15 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2625510
  5. HAMZAOUI A, MELKI W, HARZALLAH O, NJIM L, KLII R, MAHJOUB S. Gastrointestinal involvement revealing Henoch Schonlein purpura in adults: Report of three cases and review of the literature Int Arch Med [online] :31 [viewed 14 August 2014] Available from: doi:10.1186/1755-7682-4-31
  6. SAID M, GAREL C, DE LAGAUSIE P, HASSAN M. [Imaging of meconium peritonitis of pseudotumor clinical presentation]. J Radiol [online] 1997 Dec, 78(12):1288-90 [viewed 14 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed

Differential Diagnoses

Fact Explanation
Pyloric stenosis This is a condition with a narrowing of the pylorus. Commonly it is congenital and presents with similar symptoms of projectile , non bilious vomiting. Vomiting usually starts around 3 weeks of age.[1]
Adrenal crisis and severe acute adrenocortical insufficiency[2] As this is an emergency and it also can present with recurrent vomiting this should be excluded. Adrenal crisis and severe acute adrenocortical insufficiency also have symptoms of weakness , pigmentation of skin, weight loss , abdominal pain, salt craving , diarrhea constipation and syncope .
Gastroenteritis[3] This gastroenteritis is a nonspecific term used for various pathologic states with gastrointestinal tract. The primary manifestation of this condition is diarrhea, accompanied by nausea, vomiting and abdominal pain.
References
  1. KAWAHARA H, TAKAMA Y, YOSHIDA H, NAKAI H, OKUYAMA H, KUBOTA A, YOSHIMURA N, IDA S, OKADA A. Medical treatment of infantile hypertrophic pyloric stenosis: should we always slice the "olive"? J Pediatr Surg [online] 2005 Dec, 40(12):1848-51 [viewed 15 August 2014] Available from: doi:10.1016/j.jpedsurg.2005.08.025
  2. REINGARDIENE D. [Acute adrenocortical insufficiency]. Medicina (Kaunas) [online] 2002, 38(7):769-75; quiz 776 [viewed 15 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12474663
  3. FEDOROWICZ Z, JAGANNATH VA, CARTER B. Antiemetics for reducing vomiting related to acute gastroenteritis in children and adolescents. Cochrane Database Syst Rev [online] 2011 Sep 7:CD005506 [viewed 15 August 2014] Available from: doi:10.1002/14651858.CD005506.pub5

Investigations - for Diagnosis

Fact Explanation
Full blood count(FBC) As anaemia can occur followed due to poor nutritional state and bleeding checking the hemoglobin is important[3].
Serum electrolytes- serum sodium, serum potassium, serum chloride With recurrent vomiting patient can develop electrolyte imbalances[4]- hypochloremia, hyponatremia, hypokaelemia.
Liver function test - AST, ALT This is helpful in suspected malignancy to check for liver metastasis[5]. Increased levels of AST and ALT may be seen with metastases.
Plain abdominal radiography[6] 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[6][7] 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[1] (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[8] This will shows the exact level of stricture and the extend of it.
Upper GI endoscopy and endoscopic biopsy[10] Upper GI endoscopy can help to visualize the gastric stricture an surrounding area, taking a tissue biopsy and histological examination will exclude gastric carcinoma.
References
  1. ROSS FG. Pyloric Stenosis and Fibrous Stricture of the Stomach Due to Ferrous Sulphate Poisoning Br Med J [online] 1953 Nov 28, 2(4847):1200-1202 [viewed 14 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2030186
  2. BARTH AD, BARBER SM, MCKENZIE NT. Pyloric Stenosis in a Foal Can Vet J [online] 1980 Aug, 21(8):234-236 [viewed 14 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1789725
  3. BANNERMAN RM, BEVERIDGE BR, WITTS LJ. Anaemia Associated with Unexplained Occult Blood Loss Br Med J [online] 1964 May 30, 1(5395):1417-1419 [viewed 14 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1814522
  4. LEUNG AK, ROBSON WL. In children with vomiting related to acute gastroenteritis, are antiemetic medications an effective adjunct to fluid and electrolyte therapy?: Part B: Clinical commentary Paediatr Child Health [online] 2008 May, 13(5):393-394 [viewed 14 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2532885
  5. TARTTER PI, SLATER G, GELERNT I, AUFSES AH JR. Screening for liver metastases from colorectal cancer with carcinoembryonic antigen and alkaline phosphatase. Ann Surg [online] 1981 Mar, 193(3):357-360 [viewed 14 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1345076
  6. DIALLO O, ZIEREISEN F, CHRISTOPHE C, KHéLIF K, AVNI EF. [Gastric pneumatosis as a sign of duodenal stenosis in a child with Down syndrome]. J Radiol [online] 2001 Aug, 82(8):924-6 [viewed 14 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11604690
  7. COSTA DIAS S, SWINSON S, TORRãO H, GONçALVES L, KUROCHKA S, VAZ CP, MENDES V. Hypertrophic pyloric stenosis: tips and tricks for ultrasound diagnosis Insights Imaging [online] , 3(3):247-250 [viewed 14 August 2014] Available from: doi:10.1007/s13244-012-0168-x
  8. NASTANSKI F, COHEN A, LUSH SP, DISTANTE A, THEUER CP. The role of oral contrast administration immediately prior to the computed tomographic evaluation of the blunt trauma victim. Injury [online] 2001 Sep, 32(7):545-9 [viewed 14 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11524086
  9. CHIU YC, LIANG CM, TAM W, WU KL, LU LS, HU ML, TAI WC, CHIU KW, CHUAH SK. The effects of endoscopic-guided balloon dilations in esophageal and gastric strictures caused by corrosive injuries BMC Gastroenterol [online] :99 [viewed 14 August 2014] Available from: doi:10.1186/1471-230X-13-99
  10. ADUFUL H, NAAEDER S, DARKO R, BAAKO B, CLEGG-LAMPTEY J, NKRUMAH K, ADU-ARYEE N, KYERE M. Upper Gastrointestinal Endoscopy at the Korle Bu Teaching Hospital, Accra, Ghana Ghana Med J [online] 2007 Mar, 41(1):12-16 [viewed 15 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1890535

Investigations - Fitness for Management

Fact Explanation
Full blood count(FBC) As anaemia can occur followed by poor nutritional state and bleeding check the hemoglobin is important[1]. 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[2]- hypochloremia, hyponatremia and hypokalemia will be the electrolyte abnormalities.
References
  1. BANNERMAN RM, BEVERIDGE BR, WITTS LJ. Anaemia Associated with Unexplained Occult Blood Loss Br Med J [online] 1964 May 30, 1(5395):1417-1419 [viewed 14 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1814522
  2. LEUNG AK, ROBSON WL. In children with vomiting related to acute gastroenteritis, are antiemetic medications an effective adjunct to fluid and electrolyte therapy?: Part B: Clinical commentary Paediatr Child Health [online] 2008 May, 13(5):393-394 [viewed 14 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2532885

Investigations - Followup

Fact Explanation
Upper GI endoscopy and endoscopic biopsy[1] 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[2] (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[3] Similar to contrast upper GI studies this is useful in assessing the progress of the disease and the response to the treatment.
References
  1. ADUFUL H, NAAEDER S, DARKO R, BAAKO B, CLEGG-LAMPTEY J, NKRUMAH K, ADU-ARYEE N, KYERE M. Upper Gastrointestinal Endoscopy at the Korle Bu Teaching Hospital, Accra, Ghana Ghana Med J [online] 2007 Mar, 41(1):12-16 [viewed 15 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1890535
  2. ROSS FG. Pyloric Stenosis and Fibrous Stricture of the Stomach Due to Ferrous Sulphate Poisoning Br Med J [online] 1953 Nov 28, 2(4847):1200-1202 [viewed 14 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2030186
  3. NASTANSKI F, COHEN A, LUSH SP, DISTANTE A, THEUER CP. The role of oral contrast administration immediately prior to the computed tomographic evaluation of the blunt trauma victim. Injury [online] 2001 Sep, 32(7):545-9 [viewed 14 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11524086

Investigations - Screening/Staging

Fact Explanation
Upper GI endoscopy and endoscopic biopsy[1] 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.
References
  1. ADUFUL H, NAAEDER S, DARKO R, BAAKO B, CLEGG-LAMPTEY J, NKRUMAH K, ADU-ARYEE N, KYERE M. Upper Gastrointestinal Endoscopy at the Korle Bu Teaching Hospital, Accra, Ghana Ghana Med J [online] 2007 Mar, 41(1):12-16 [viewed 15 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1890535

Management - General Measures

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.
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[2].
References
  1. FRIEDMAN JN. Enterostomy tube feeding: The ins and outs Paediatr Child Health [online] 2004 Dec, 9(10):695-699 [viewed 15 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2724142
  2. THOMAS DR, COTE TR, LAWHORNE L, LEVENSON SA, RUBENSTEIN LZ, SMITH DA, STEFANACCI RG, TANGALOS EG, MORLEY JE, DEHYDRATION COUNCIL. Understanding clinical dehydration and its treatment. J Am Med Dir Assoc [online] 2008 Jun, 9(5):292-301 [viewed 15 August 2014] Available from: doi:10.1016/j.jamda.2008.03.006

Management - Specific Treatments

Fact Explanation
Gastro enterostomy[1][2][4] 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[3] 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.
References
  1. GIBSON CL. TREATMENT OF HOUR-GLASS STOMACH BY DOUBLE GASTRO-ENTEROSTOMY Ann Surg [online] 1923 Nov, 78(5):587-593 [viewed 15 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1400518
  2. WEBB RC. OPERATIVE TREATMENT OF HOUR-GLASS STOMACH: WITH REPORT OF A CASE TREATED BY DOUBLE POSTERIOR GASTRO-ENTEROSTOMY Ann Surg [online] 1917 Oct, 66(4):418-420 [viewed 15 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1426633
  3. KIM JH, SHIN JH, SONG HY. Benign Strictures of the Esophagus and Gastric Outlet: Interventional Management Korean J Radiol [online] 2010, 11(5):497-506 [viewed 15 August 2014] Available from: doi:10.3348/kjr.2010.11.5.497
  4. ROWLANDS RP. Hour-glass Stomach with Pyloric Stenosis, treated by Gastro-jejunostomy, followed by Gastro-gastrostomy Proc R Soc Med [online] 1921, 14(Clin Sect):8-9 [viewed 15 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2153197