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Congenital antral web: rare cause of gastric outlet obstruction successfully managed with endoscopic balloon dilatation
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Upasana Ghosh, MD, DM
, Ujjal Poddar, MD, DNB, DM, Srinivas Srinidhi Vadlapudi, MD, DM, Moinak Sen Sarma, MD, DM, Anshu Srivastava, MD, DM
- Corresponding author: Ujjal Poddar. Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow 226014, Uttar Pradesh, India Email: ujjalpoddar@hotmail.com
- Received August 21, 2024 Revised November 22, 2024 Accepted November 22, 2024
- 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 [1]. A gastric antral web (GAW) is a congenital mucosal membrane present a few centimeters proximal to the normal pylorus, with varying aperture size [2,3] The diagnosis is established by an upper gastrointestinal endoscopy (UGIE). We report a 4-year-old boy, who presented with GOO, was diagnosed to have a GAW and was managed successfully with endoscopic balloon dilatation (EBD).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 (Fig. 1). EBD was done using a 10-mm controlled radial expansion (CRE) balloon (Boston Scientific Corp., Marlborough, MA, USA). Postdilatation, the pediatric endoscope (5.6-mm diameter) passed across and showed a normal pylorus and duodenum. While withdrawing the scope from the duodenum, the GAW was well appreciated (Fig. 2). Subsequently, dilatation (CRE, 12 mm) was done twice, 1 month apart, after which the child became asymptomatic. His weight, height, and BMI improved to 17 kg, 104 cm, and 15.5 kg/m2 respectively and he has been asymptomatic at 1 year of follow-up.A GAW is a rare cause of GOO. The duration from symptom onset to diagnosis ranges from immediate postpartum to 2 years [4,5]. Age of presentation depends on the aperture size of the web; newborns with small aperture (1–2 mm) present soon after birth. Late presentations in adulthood have been reported [6]. The majority of the patients present in infancy or early childhood [2,7]. This child presented with 1-month duration of symptoms, and he had acute malnutrition. Among other clinical features, Yeh et al. [8] have reported hematemesis due to web-related gastric ulcer in 48% (11 out of 23 children). Associated congenital anomalies include esophageal atresia, duodenal atresia, malrotation, cardiac defects such as ventricular septal defects, and coarctation of the aorta, may be seen in up to 28% of cases [5,8]. This child had a normal 2-dimensional echocardiography, and no other gastrointestinal anomaly.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 [3,7]. Some have combined electrocautery incisions with EBD and others have used EBD alone, both with good outcomes [3,7,8]. It is safe in expert hands and is feasible even in young children and has the advantage of early initiation of oral feeding [3,7]. This child was started on oral semisolid diet postdilatation, which he tolerated well. Endotherapy can be challenging at times. Firstly, it is difficult to perform EBD in infants, because of the small operating channel (2.0 mm) of the pediatric endoscope, through which the balloon (2.8 mm) cannot be introduced. Second, the procedure needs expertise and complications include bleeding, perforation [7]. Web excision or incision with or without pyloroplasty is the surgery of choice in neonates or infants. This child was managed successfully by EBD without any complications.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.
- Short question
- Short question
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.
- Conflicts of interest
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Conflicts of interest The author has no conflict of interest to declare.
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- Notes
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Funding
This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
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Fig. 2.
Normal pylorus beyond the antral web (postdilatation) on scope withdrawal from the duodenum.
- References
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