Introduction: Idiopathic pyloric stenosis is an uncommon finding in adults with only 200-300 case reports in the literature and is often mistaken for malignancy which causes majority of gastric outlet obstruction (GOO) in adults.
Surgical resection is invasive and entails antrectomy. Endoscopic intervention is less invasive but may require repeat balloon dilatations with increasing risk of adverse events (perforation and bleeding) with each subsequent dilation. Novel prosthesis like lumen apposing metal stent (LAMS) developed in the last five years have offered alternate interventions.
Case Description/Methods: We report the case of a 39 year old female who visited her primary care physician with persistent symptoms of abdominal pain, occasional vomiting and nausea, and weight loss for the past two years. There is no history of nonsteroidal anti-inflammatory drugs abuse. On physical examination abdomen was soft with mild epigastric discomfort on deep palpation. Bowel sounds were normal with no masses.
Gastroenterology team was consulted and patient underwent an esophagogastroduodenoscopy (EGD) revealing severe gastric stenosis at the pylorus. Stomach biopsy was negative for helicobacter pylori or dysplasia. Endoscopic ultrasound with EDG was done the following month to rule out malignancy which was negative. After failure of repeat dilations a 15mm fully covered LAMS was inserted. To secure this stent three sutures were applied to the stent which in turn were anchored to the gastric body with endoclips (Image 1). Without securing the stent, there would be a high risk of stent migration.
Discussion: While the stent was in place patient experienced no GOO symptoms. A few days after stent removal EGD showed a patent pylorus. However, 1 week after stent removal patient experiences similar symptoms of GOO with multiple hospital admissions for inability to tolerate oral intake. EGD done 1 month after stent removal showed restenosis of pylorus. PEG tube failed due to inability to perform jejunal extension. As such, a Hickman’s line was inserted for total parental nutrition with outpatient surgical planning.
More research is needed to ascertain if novel techniques like LAMS secured with sutures and endoclips to prevent migration can successfully treat this benign entity, while leaving more invasive surgical procedures for malignant processes. The secured LAMS in our patient did not migrate while in situ and keeping it in for longer periods of time or indefinitely may save the patient a surgery and maintain patency.
Disclosures: Tarini Gunaratne indicated no relevant financial relationships. Henry Ng indicated no relevant financial relationships. Hassan Siddiki indicated no relevant financial relationships.
Tarini Gunaratne, MD1, Henry Ng, MD2, Hassan Siddiki, MD3. P1744 - Conservative vs Surgical Management of Benign Idiopathic Pyloric Stenosis in Adults: An Atypical Entity, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.
