A rare case of gastric inlet and outlet obstruction in a perimenopausal woman

Abstract

A 42 year old lady presented with complaints of progressive dysphagia, vomiting and abdominal distension for five years. Patient was emaciated and anaemic on  presentation. Endoscopy showed stricture oesophagus at 34 cm. Barium study showed bird beak appearance of lower end of oesophagus with an air fluid level and gross dilatation of stomach with delayed emptying of contrast. CT abdomen showed a grossly distended stomach suggesting partial  obstruction due to growth or stricture. A diagnosis of achalasia cardia with partial gastric outlet obstruction was made. Patient underwent Hellers cardiomyotomy with Toupet fundoplication and a loop gastrojejunostomy with a                     jejunojejunostomy. Vagotomy was deferred as we were of the opinion that the gastric obstruction is due to dysmotility.    Postoperative recovery was uneventful. There have been very few case reports of combined gastric inlet and outlet                obstruction. Possibilities include achalasia cardia with antral web, distal carcinoma, obstruction due to chronic duodenal ulcer and adult onset hypertrophic stenosis. Lower  oesophageal growth associated with any of the above can also present in a similar fashion. In such cases the possibility of connective tissue disorders should also be kept in mind though they tend to affect the oesophagus more than other organs.