Date:
Patient:
MRN:
Clincian: (Gastroenterologist, Surgeon)
Reason for Visit:
Evaluation for gastric outlet obstruction (GOO)
Assessment of symptoms and degree of obstruction
Review of imaging results
Treatment plan discussion
History of Present Illness:
Briefly describe the patient’s current status:
Onset and duration of symptoms (nausea, vomiting, early satiety – feeling full after eating a small amount, abdominal pain, weight loss)
Severity and frequency of vomiting (projectile vomiting may suggest more advanced obstruction)
History of intolerance to oral intake (may necessitate nasogastric tube placement)
Bowel habits (constipation may be present)
Past Medical History:
Underlying conditions that may cause GOO:
Peptic ulcer disease (gastric ulcer or duodenal ulcer)
Gastric malignancy (cancer of the stomach)
Gastroparesis (impaired stomach emptying due to nerve dysfunction)
Previous abdominal surgeries (adhesions)
History of hiatal hernia (may contribute to GOO)
Social History:
Smoking history (contributing factor to peptic ulcer disease)
Alcohol use (contributing factor to peptic ulcer disease)
Medications (certain medications can worsen gastroparesis)
Physical Exam:
Vital Signs: May be normal or abnormal depending on the severity of obstruction and dehydration.
Abdominal: Distention, succussion splash (rushing sound on palpation suggestive of fluid in the stomach), visible gastric peristalsis (strong contractions of the stomach wall).
Labs:
Electrolytes: May be deranged due to dehydration from vomiting (low potassium, sodium imbalances).
Complete Blood Count (CBC) – to assess for anemia or signs of infection.
Basic Metabolic Panel (BMP) – to assess kidney function and electrolytes.
Consider mentioning other labs ordered as needed based on suspicion of other conditions.
Imaging:
Upper endoscopy with biopsy: May be performed to visualize the upper GI tract, identify the cause of obstruction (e.g., peptic ulcer), and obtain tissue samples for diagnosis (if malignancy is suspected).
Upper GI series: X-ray examination of the upper gastrointestinal tract with barium contrast, may be used if endoscopy is contraindicated.
Abdominal CT scan: Can provide detailed images of the abdomen to assess for complications (bowel perforation) or evaluate for malignancy.
Assessment:
Summarize the suspected cause of GOO based on clinical presentation, physical exam, and imaging:
Confirmation of GOO diagnosis.
Identification of the underlying cause (peptic ulcer, malignancy, etc.).
Degree of obstruction (partial or complete).
Plan:
Outline the treatment plan based on the assessment:
Initial Management:
Nasogastric tube placement for decompression of the stomach and correction of dehydration.
Intravenous fluids for hydration and electrolyte replacement.
Definitive Treatment:
Medical management:
Medication to treat peptic ulcer disease (proton pump inhibitors).
Medications to improve gastric motility (prokinetic agents) for gastroparesis.
Endoscopic therapy:
Endoscopic balloon dilation for peptic ulcer strictures causing obstruction.
Stent placement for temporary relief of obstruction.
Surgery:
Surgical intervention (e.g., pyloromyotomy) for peptic ulcer disease causing severe obstruction.
Gastrectomy (partial or complete stomach removal) for malignancy or in cases where other treatments fail.
Prognosis:
Briefly discuss the prognosis. The prognosis depends on the underlying cause of GOO and the severity of obstruction. Early diagnosis and treatment can lead to a good outcome.
Untreated GOO can lead to complications like malnutrition, dehydration, and electrolyte imbalances.
Education:
Document any education provided to the patient regarding:
The nature of gastric outlet obstruction and its causes
The importance of dietary modifications (small frequent meals, avoidance of fatty or greasy foods) to manage symptoms.
The rationale for the chosen treatment approach and potential side effects.
The importance of following up with a healthcare professional to monitor progress and assess response to treatment.
Notes:
Include any additional relevant information not covered above, such as the patient’s understanding of the diagnosis and treatment plan, and any concerns they may have about their condition.
Consider mentioning the importance of seeking immediate medical attention if they experience worsening symptoms like severe abdominal pain or persistent vomiting