|Year : | Volume
| Issue : | Page :
Successful endoscopic treatment of an obstructing gastric antral web in a paediatric patient: A case report
Bing-Bing Ren1, Kui Jiang2, Tao Wang2, Da-Qing Sun1
1 Department of Pediatric Surgery, General Hospital, Tianjin Medical University, Tianjin, China
2 Department of Gastroenterology and Hepatology, General Hospital, Tianjin Medical University, Tianjin, China
|Date of Submission||02-Sep-2020|
|Date of Decision||18-Oct-2020|
|Date of Acceptance||26-Nov-2020|
|Date of Web Publication||06-May-2021|
Department of Pediatric Surgery, General Hospital, Tianjin Medical University, 154 An-Shan Road, Heping District, Tianjin 300052
Source of Support: None, Conflict of Interest: None
Gastric antral web (GAW) is a rare anomaly of the gastric antrum and can result in gastric outlet obstruction. Currently, endoscopic treatment of GAW is considered challenging due to high technical requirements and restenosis. Herein, we present a rare case of a paediatric patient with GAW cured by endoscopic transection and partial resection of the web. An 8-year-old boy was admitted because of a 9-month history of postprandial fullness and intermittent non-bilious vomiting of gastric contents. On performing upper gastrointestinal contrast and gastroscopy, the diagnosis of GAW was confirmed. Then, three electroincisions were performed in a radial fashion. Moreover, about a third of the web located in the larger curvature was resected. On follow-up for 6 months, the patient was completely relieved of the postprandial fullness and non-bilious vomiting. Hence, endoscopic treatment for GAW was considered safe and effective for this case. Furthermore, partial resection of the web contributed in avoiding restenosis.
Keywords: Case report, endoscopic treatment, gastric antral web, gastric outlet obstruction, paediatrics
|How to cite this URL:|
Ren BB, Jiang K, Wang T, Sun DQ. Successful endoscopic treatment of an obstructing gastric antral web in a paediatric patient: A case report. J Min Access Surg [Epub ahead of print] [cited 2021 Jun 14]. Available from: https://www.journalofmas.com/preprintarticle.asp?id=315527
| ¤ Introduction|| |
Gastric antral web (GAW) is a rare anomaly of the gastric antrum. The clinical symptoms of GAW are based on the size of the aperture within the web. Infants and children often present with persistent postprandial vomiting and failure to thrive or malnutrition. Currently, endoscopic treatment of GAW is considered challenging due to high technical requirements and restenosis. This report describes the case of a patient with GAW cured by endoscopic transection and partial resection of the web.
| ¤ Case Report|| |
An 8-year-old boy weighing 20 kg was admitted because of a 9-month history of postprandial fullness and intermittent non-bilious vomiting of gastric contents. During this time, he had lost about 8 kg in weight. During the last 2 weeks, the patient's symptoms had continuously aggravated. On examination, the abdomen was soft with no palpable masses. Laboratory examinations revealed no abnormal results concerning the blood routine index, liver and renal function or tumour markers. Upper gastrointestinal contrast study showed a partial gastric outlet obstruction due to a membranous structure at the antrum, which resulted in a 'double-bulb' appearance of the antrobulbar region [Figure 1]a. Gastroscopy demonstrated a 'circumferential stenosis' about 2–3 cm away from the pylorus, which confirmed a thickened mucosal membrane located at the antrum with an eccentric aperture measuring 4 mm in diameter [Figure 1]b. Endoscopic ultrasound revealed that the thickness of the gastric wall and mucosal layer was about 8.1 mm and 2.6 mm, respectively [Figure 1]c. However, the pylorus appeared normal. Biopsies were taken and were interpreted as mild mucosal chronic inflammation. A diagnosis of GAW was suggested. After consultation with a gastroenterologist, endoscopic treatment was performed under general anaesthesia. A GIF-Q260J gastroscopy (Olympus, Tokyo, Japan) was used. Normal saline with 1% methylene blue dye was injected into the submucosa to aid in visualisation and differentiation of tissue planes during the procedure. Then, three electroincisions were performed in a radial fashion through the web by using a triangle tip knife (Olympus, Tokyo, Japan) and an electrocautery. These electroincisions reached the surface of the muscularis propria. The web between the second and third incisions on the larger curvature was resected [Figure 2]a, [Figure 2]b, [Figure 2]c so that the endoscope could be passed through the second part of the duodenum. One week after surgery, upper gastrointestinal contrast was done again which showed that delayed gastric emptying was alleviated. He was discharged from the hospital tolerating a regular semi-liquid diet. During the 6-month follow-up, balloon dilatation was not performed. However, the aperture of the antral web had widened to a diameter of 10–12 mm as evaluated by an endoscope [Figure 2]d. The patient was completely relieved of the postprandial fullness and non-bilious vomiting during the subsequent 6-month period of observation while on a regular solid diet. In addition, his weight returned to 15 kg.
|Figure 1: (a) Upper gastrointestinal contrast showing delayed gastric emptying, typical ‘double-bulb’ sign. (b) Gastroscopy demonstrating a ‘circumferential stenosis’ about 2–3 cm away from the pylorus. (c) Ultrasound gastroscopy revealing the thickness of the gastric wall and mucosal layer to be about 8.1 mm and 2.6 mm, respectively (empty arrow indicates the gastric wall and solid arrow indicates the mucosal layer)|
Click here to view
|Figure 2: (a and b) Three electroincisions performed in a radial fashion through the web. (c) The appearance of about a third of the web resected. (d) At 6 months' endoscopic therapy, gastroscopy showing no circumferential stenosis|
Click here to view
| ¤ Discussion|| |
GAW is a rare cause of gastric outlet obstruction. Due to non-specific clinical manifestations, the diagnosis of GAW is fairly difficult. Before receiving appropriate treatment, patients often undergo unsuccessful medical therapy. For accurate diagnosis, we must rely on careful history, as well as both upper gastrointestinal contrast and gastroduodenoscopy. An upper gastrointestinal contrast can show delayed gastric emptying, a thin radiolucent linear 'knife-like' septum or the typical 'double-bulb' appearance. Endoscopic features of GAW mainly include circumferential stenosis with a central aperture through which the true pylorus is seen.
Endoscopic treatment of GAW was first reported in 1985. Three radial incisions were performed which relieved symptoms of a partially obstructing GAW in a 14-year-old female. In 1988, Al-Kawas reported that in his case 6 weeks after laser treatment, restenosis of GAW was found. Then, the patient underwent gastrotomy and antral web resection. To avoid restenosis, a part of the antral web located in the larger curvature was resected in combination with electroincision in our case.
In addition, Salah and Baron suggested that endoscopic treatment for GAW can be used as first-line treatment in selected patients. The endoscopic treatment modality for GAW is either balloon dilation or needle-knife incisions. Balloon dilation has proven to be less invasive and effective, but did not always provide long-term symptom alleviation. In recent years, several cases have shown that balloon dilatation combined with needle-knife incisions had low risk of perforation or significant bleeding and hence could also be a sufficient treatment modality.,,
Endoscopic treatment for GAW is technically challenging which requires a high level of experience and suitable equipment. From our experience, to demonstrate the size of apertures and the location of web and confirm the thickness of the web, it is recommended that gastroscopy and Endoscopic ultrasound be performed before endoscopic treatments. These radial incisions made in the diaphragm should not be more than 5 mm deep. Moreover, in the present case, normal saline with 1% methylene blue dye was injected into the submucosa, which contributed to control of the incision depth and lowered the risk of perforation. Because the web is closer to the pylorus, we should pay more attention to the distance between the incision and the pylorus to avoid damaging the pylorus.
In this case, balloon dilatation was not performed following needle-knife incision. To our knowledge, ours is the first reported case of resection of a part of antral web to avoid restenosis. Our patient was asymptomatic during a 6-month follow-up period. Therefore, we conclude that electroincision combination with a resected part of antral web is an effective endoscopic treatment.
Consent for publication
Written informed consent was obtained from the patient who participated in this study, for publishing the photographs.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that name and initial will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
This study was funded by the Project of the National Natural Science Foundation of China (grant no. 81770537).
Conflicts of interest
There are no conflicts of interest.
| ¤ References|| |
Amin R, Martinez AM, Arca MJ. Diagnosis and treatment of gastric antral webs in pediatric patients. Surg Endosc 2019;33:745-9.
Fritz J, Martinez A, Arca M, Lerner D. Endoscopic diagnosis of antral webs in children. Endoscopy 2017;49:E18-20.
Berr F, Rienmueller R, Sauerbruch T. Successful endoscopic transection of a partially obstructing antral diaphragm. Gastroenterology 1985;89:1147-51.
Al-Kawas FH. Endoscopic laser treatment of an obstructing antral web. Gastrointest Endosc 1988;34:349-51.
Salah W, Baron TH Sr. Gastric antral web: A rare cause of gastric outlet obstruction treated with endoscopic therapy. Gastrointest Endosc 2013;78:450.
Peck J, Khalaf R, Marth R, Phen C, Sosa R, Cordero FB, et al
. Endoscopic balloon dilation for treatment of congenital Antral Web. Pediatr Gastroenterol Hepatol Nutr 2018;21:351-4.
Morales SJ, Nigam N, Chalhoub WM, Abdelaziz DI, Lewis JH, Benjamin SB. Gastric antral webs in adults: A case series characterizing their clinical presentation and management in the modern endoscopic Era. World J Gastrointest Endosc 2017;9:19-25.
Gehwolf P, Hechenleitner P, Sanal M, Profanter C, Häussler B, Härter B. Treatment of congenital gastric outlet obstruction due to a web: A retrospective single-center review. Surg Laparosc Endosc Percutan Tech 2019;29:207-11.
[Figure 1], [Figure 2]