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GASTRIC OUTLET OBSTRUCTION Name:Kwaku Agyeman Age:74yrs Sex:male Religion:Christian[catholic] Residence: Agona Ashanti arrital status: married with

7 children PC-a!dominal "ain#4wks #$omiting #%wk HPC &atient was well until 4wks ago when he started ex"eriencing an incedious onset o' a!dominal "ain locali(ed at the e"igastric region) !urning in nature*it is aggra$ated !y hunger and relie$ed on eating*+he "ain has !een increasing in intensity and !ecame associated with no !ilous "ro,ectile $omiting that contains 'ood "articles and a!out -..mls in $olume*/e re"orted to the Agona go$0t hos"ital where he was gi$en some antacids and other medication gi$en some medications unknowned to him and re'erred to KA+/ 'or ex"ert management ODQ 1e$er2 3eight loss2 A!domenal "ain2 4i((iness2 &al"itations2 5omiting2 Consti"ation2 6uandice#$e Chronic NSA74 use#$e /aemo"tysis#$e alena#$e PM&SH 8ne "re$ious hos"ital admission 9yrs ago at S4A hos"ital wherehe was treated 'or a 'e!rile ilness No known hx o' &:4 Chronic medical illnesses 4 /+N SC4 +; <"ile"sy )surgical o"#$e /aemotrans'usion#$e DRUG HX Currently on medications unknown to him* No known drug allergies* FAMILY HX No known 'amily hx o' chronic medical illnesses[4 /+N +; SC4 Asthma)<"ile"sy]

SOCIAL HISTORY =i$es at Agona Ashanti with his 'amily*/e is a retired teacher*/e does not drink alcohol nor smoke cigarette* SUMMARY 7 "resent a 74yr old man who "resented with a 4wk history o' !urning e"igastric "ain that has !een increasing in intensity !ecame associated "ro,ectile non !ilous $omitus >wks later*

DIFFERENCIAL DIAGNOSIS ?astric outlet o!struction -ndary to &:4 ?astric carcinoma &ancreatic ca 8thers %* Benign#gastric "oly" #"yloric stenosis #congenital duodenal we!s #gall stone o!struction #"ancreatic "seudocyst #+; -* Malignant#"ancreatic ca #duodenal ca #cholangiocarcinoma #gastric ca #metastases to gastric outlet* OE 7ll looking elderly man)he is thin)"ale)anicteric)a'e!rile with sunken eyes)"oor skin turgor[dehydrated] and no lym"hadeno"athy*there is an o!$ious !ulge in the a!domen s"aning 'rom the le't hy"ochondrium to the right hy"ochondrium with "eristalsis seen in the same location* C!S &ulse @-!"m#regular)weak $olume ;& %%.AB. mm o' /g S% 2 S- 2 . RS RR#%Bc"m Air entry adeCuate !ilaterally !reath sounds $ersicular with no added !reath sounds* A"#$%en 8!$ious !ulge in the a!domen extending 'rom the le't hy"ochondriac region to the rt hy"ochodriac region*was tym"anitic to "ercussion* Seccussion s"lash was "ositi$e*Rest o' a!domen was so't non#tender)no guarding*Rt D =t kidneys)li$er)s"leen not "al"a!le Shi'ting dullness#$e ;owel sounds "resent !ut scanty* /ernial ori'ices clear* DRE &erianal area healthy Anal tags#$e S"hincter tone normal Am"ulla is em"ty &rostate is "al"a!le) measures >*EcmF-*Ecm) sur'ace is smooth )median sulcus is "al"a!le) symmetrical in sha"e non tender)edge is de'ined) 'irm in consistency)rectal mucosa mo!ile o$er "rostate* <xamining 'inger is stained with 'aeces* MSS +here was no tenderness the lum!osacral s"ine

CNS &atient is concious and alert and well oriented in "erson "lace and time* +one)"ower and re'lexes a""ear intact* DIAGNOSIS ?astric outlet o!struction -ndary to &:4 ?astric carcinoma IN!ESTIGATIONS Diagn$&ti' %* &lain erect a!domenal x#ray -* ?astric as"iration o' 4..cc or more[a'ter Bam#B"m 'ast] >* :""er ?7 endosco"y 4* ;arium meal E* A!domenal :S? S())$*ti+e %* 1;C -* ;:N Createnine and electrolytes >* =1+ 4* +est 'or / "ylori E* Chest x#ray B* <C? 7* 1;S and Sickling* T*eat%ent Initial *e&(&'itati$n P*e-$) 'a*e O)e*ati+e )*in'i)le& P$&t $) 'a*e &ast wide !ore N? tu!e to decom"ress the stomach) this im"ro$es gastric tone) / "ylori is eradicated with tri"le thera"y[ome"ra(ole)metronida(ole and amoxycillin] 7' this does not work then $agotomy with gastro,e,unostomy is done* 8ther o"tions are# $agotomy and antrectomy #$agotomy2"yloro"lasty #truncal $agotomy and gastro,e,unostomy C$%)li'ati$n& Ea*l, -haemorrhage #haematoma 'ormation #anastomotic leak #surgical site in'ection #"ost $agotomy diarrhoea -post gastrectomy syndromes Dumping Bile gastritis Afferent loop syndrome Anaemia Late

Recurrence &ost o" adhessions leading to intestinal o!struction /y"ertro"hic scars keloids

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