Overview
Definition:
Gastrojejunal anastomosis stricture refers to the narrowing of the connection between the stomach and the jejunum, typically following surgical reconstruction like in gastric bypass or gastrectomy
This obstruction impedes the passage of food and fluids, leading to significant upper gastrointestinal symptoms.
Epidemiology:
The incidence of gastrojejunal strictures varies widely depending on the surgical technique, patient factors, and post-operative care, ranging from 1-15% in some series of gastric bypass procedures
Risk factors include poor surgical technique, ischemia, infection, and early oral intake.
Clinical Significance:
Strictures can lead to severe malnutrition, dehydration, vomiting, pain, and weight loss, significantly impacting patient quality of life and requiring prompt intervention
Accurate diagnosis and appropriate management are crucial for successful patient outcomes and to prevent long-term complications.
Clinical Presentation
Symptoms:
Progressive postprandial nausea and vomiting, often projectile
Early satiety
Abdominal pain, typically epigastric
Weight loss and failure to thrive
Regurgitation of undigested food
Abdominal distension.
Signs:
Dehydration and electrolyte imbalances
Epigastric tenderness on palpation
Visible peristalsis in severe cases
Decreased bowel sounds may indicate ileus secondary to obstruction.
Diagnostic Criteria:
Diagnosis is primarily based on clinical suspicion confirmed by imaging
There are no formal criteria, but a history of upper GI surgery followed by progressive obstructive symptoms is highly suggestive
Endoscopic visualization and biopsy can also confirm the diagnosis and rule out other pathology.
Diagnostic Approach
History Taking:
Detailed history of previous gastrointestinal surgery, including the type and date of procedure
Onset, character, and timing of symptoms relative to meals
Episodes of vomiting, their content, and relief
Nutritional intake and weight changes
Previous complications or interventions.
Physical Examination:
General assessment for hydration status and nutritional deficits
Abdominal examination for distension, tenderness, masses, and bowel sounds
Assessment for stigmata of chronic liver disease or malnutrition.
Investigations:
Upper gastrointestinal contrast study (barium swallow): Essential for visualizing the anatomy and the site/severity of the stricture
Endoscopy (EGD): Allows direct visualization, biopsy for histology (to rule out malignancy or inflammation), and often therapeutic intervention (dilation)
CT scan: Useful for assessing extraluminal complications like abscesses or fistulae and for pre-operative planning if revision surgery is considered
Laboratory tests: Complete blood count, electrolytes, renal function tests, liver function tests, albumin to assess nutritional status and identify complications.
Differential Diagnosis:
Peptic ulcer disease recurrence
Gastric outlet obstruction from other causes (e.g., malignancy, inflammation)
Internal herniation
Stomal stenosis not related to anastomosis
Dumping syndrome symptoms mimicking obstruction.
Management
Initial Management:
Bowel rest and nasogastric decompression to relieve vomiting and distension
Intravenous fluid resuscitation and electrolyte correction
Nutritional support, often via parenteral nutrition if oral intake is severely compromised
Pain management.
Endoscopic Management:
Endoscopic dilation: The primary minimally invasive treatment
Balloon dilators (e.g., Savary-Gillard, CRE balloons) or hydrostatic dilators are used to gradually open the stricture under direct endoscopic visualization
Multiple sessions may be required
Dilations are typically performed incrementally, with increasing balloon sizes over successive sessions
Success rates vary but are generally good for benign strictures.
Surgical Management:
Indications for surgical revision include failure of endoscopic dilation, recurrent strictures, complete obstruction, or suspicion of malignancy
Revision surgery typically involves resecting the stenotic segment and performing a new gastrojejunal anastomosis, often with modifications to the original procedure (e.g., widening the stoma, altering the limb lengths in bypass procedures)
Techniques include hand-sewn or stapled reconstructions.
Supportive Care:
Aggressive nutritional support is vital, especially for patients undergoing multiple dilations or revision surgery
Close monitoring for signs of leaks, bleeding, or infection
Psychosocial support for patients dealing with chronic GI issues.
Complications
Early Complications:
Perforation of the gastrojejunal anastomosis during dilation or surgery
Bleeding from the site of dilation or anastomosis
Leakage from the anastomosis post-revision
Prolonged ileus
Aspiration pneumonia due to vomiting.
Late Complications:
Recurrent stricture formation after dilation or surgery
Chronic malnutrition and weight loss
Dumping syndrome
Internal herniation
Stomal ulceration
Incisional hernias if open surgery is performed.
Prevention Strategies:
Meticulous surgical technique to ensure adequate blood supply to the anastomosed ends
Avoidance of tension on the anastomosis
Proper timing of oral intake post-operatively
Aggressive management of post-operative infections
Diligent follow-up for early detection of symptoms.
Prognosis
Factors Affecting Prognosis:
The etiology of the stricture (benign vs malignant)
The severity and length of the stricture
The patient's nutritional status
The success of the initial treatment (dilation or surgery)
The presence of other co-morbidities.
Outcomes:
Endoscopic dilation can achieve successful long-term relief in a significant proportion of patients with benign strictures
Surgical revision generally offers a more definitive solution but carries higher risks
Patients with recurrent strictures may have a poorer prognosis.
Follow Up:
Regular clinical and nutritional assessment
Endoscopic surveillance may be necessary for patients with a history of strictures or specific risk factors
Patients should be educated on warning signs of recurrence and advised to seek medical attention promptly.
Key Points
Exam Focus:
Differentiate between dilation and revision indications
Understand the complications of both
Recall imaging modalities and their interpretation for diagnosing strictures
Know the surgical techniques for revision and associated risks.
Clinical Pearls:
Always consider a gastrojejunal stricture in a patient with a history of gastric surgery presenting with intractable vomiting
Barium swallow is your first-line imaging
Endoscopy is often diagnostic and therapeutic
Be aggressive with nutritional support.
Common Mistakes:
Underestimating the severity of symptoms and delaying diagnosis
Attempting dilation in cases suspicious for malignancy
Insufficient nutritional support post-intervention
Not considering recurrent stricture as a possibility.