S3264 Post-Pancreatitis Gastric Outlet Obstruction: A Narrow Escape

Introduction: Gastric outlet obstruction (GOO) is a rare complication in acute pancreatitis, occurring in about 5.7% of cases. Risk factors include severe or necrotizing pancreatitis, duct disruption, and peripancreatic collections. We present a case of GOO following a first episode of acute pancreatitis, emphasizing the condition’s morbidity and the importance of close follow-up when unusual findings are present. Case Description/Methods: A 40-year-old man presented with nausea, vomiting, and abdominal pain. His abdomen was distended and diffusely tender. Notably, he had been hospitalized for acute pancreatitis 3 weeks prior, during which magnetic resonance cholangiopancreatography (MRCP) showed common bile duct (CBD) dilation up to 1.3 cm without stones and mass effect from an edematous pancreatic head. A follow-up endoscopic ultrasound was scheduled but not yet completed. Computed tomography abdomen revealed a large, ill-defined mass involving the second part of the duodenum and pancreatic head, causing GOO. A nasogastric (NG) tube was placed for gastric decompression. The patient underwent esophagogastroduodenoscopy with duodenal dilation, which showed pancreatic enlargement but no discrete mass. His NG tube was removed, and he was started on a clear liquid diet, which he initially tolerated. However, due to pain, he underwent repeat computed tomography which showed persistent GOO. Abdominal magnetic resonance imaging showed abrupt termination of the distal CBD by a 4.8 × 4.0 cm irregular, enhancing mass, likely arising from the pancreatic head or ampulla. An endoscopic ultrasound-guided biopsy was performed, and the patient ultimately underwent a surgical gastrojejunostomy, resulting in relief of his obstruction. Discussion: Post-pancreatitis GOO can pose significant complications. Although imaging raised concern for malignancy, biopsy revealed only fibrous tissue and minimal duodenal mucosa, likely contaminant. Initial management of GOO includes nasogastric decompression, intravenous fluid hydration, and gradual reintroduction of diet, with the hope that obstruction resolves as inflammation subsides. In this case, due to persistent symptoms, longer-term options included endoscopic versus surgical gastrojejunostomy. Given the patient’s young age, surgical bypass was favored for its durability and the potential for a larger, more lasting anastomosis. Follow-up imaging was recommended in 2 months for reassessment.