Gastric outlet obstruction (GOO) in children can have various etiologies such as idiopathic hypertrophic pyloric stenosis, gastric volvulus, gastric duplication cysts, and antral web, etc [
A 4-year-old boy presented with recurrent episodes of large-volume, nonbilious vomiting containing stale food for 1 month, along with visible gastric peristalsis, intermittent abdominal pain, and 1-kg weight loss. There was no history of corrosive or foreign body ingestion or nonsteroidal anti-inflammatory drug intake. His weight and height were 13 kg and 102 cm respectively, and his body mass index (BMI) was 12.5 kg/m2 (below the 3rd percentile as per World Health Organization Child Growth Standards, 2006). Abdominal examination revealed an epigastric lump with visible gastric peristalsis and succussion splash. Laboratory investigations revealed serum sodium 131 mmol/L (hyponatremia), potassium 2.9 mmol/L (hypokalemia), chloride 95 mmol/L, pH 7.50, and bicarbonate 34 mmol/L (hypochloremic metabolic alkalosis), urea 24mg/dL, creatinine 0.6mg/dL. All the parameters normalized after fluid resuscitation. An erect x-ray of the abdomen showed an overdistended stomach. Abdominal ultrasound ruled out idiopathic hypertrophic pyloric stenosis. Contrast-enhanced computed tomography (CECT) of the abdomen showed an overdistended stomach with a transition point near the pylorus and a normal duodenum but the presence of a web could not be ascertained. Computed tomography ruled out any extramural compression. UGIE showed a pinpoint, eccentric pylorus (pseudo pylorus) without any ulcer (
A GAW is a rare cause of GOO. The duration from symptom onset to diagnosis ranges from immediate postpartum to 2 years [
Radiographic studies have poor yield in infants compared to adults. Other than barium studies and ultrasound abdomen, CECT abdomen can demonstrate the antral web. In our patient, the ultrasound could not identify the web. CECT abdomen showed a transition point near the supposed pylorus. The diagnosis was made on UGIE which showed a normal pyloric opening beyond the GAW. One should remember that the antral web may be mistaken as the normal pylorus on UGIE. Sometimes, the eccentric aperture of a partial web may be misinterpreted as a gastric fold.
Treatment can be offered by surgery or therapeutic endoscopy. As the web usually does not have a muscle layer, EBD is effective. Therapeutic endoscopy can be in the form of EBD, needle knife incision or multiple electroincisions of the web [
A GAW is a rare cause of GOO and should be kept in mind in children presenting with nonbilious vomiting. A careful endoscopy clinches the diagnosis. EBD is curative and can abate the need for surgery.
Which of the following regarding a gastric antral web is wrong?
i. It presents in infants only.
ii. It does not have a muscular layer.
iii. It can be managed either by surgery or therapeutic endoscopy.
iv. The clinical presentation is gastric outlet obstruction.
Answer: i. It presents in infants only.
The author has no conflict of interest to declare.
This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Pinpoint aperture of the gastric antral web.
Normal pylorus beyond the antral web (postdilatation) on scope withdrawal from the duodenum.