You are on page 1of 46

Infantile hypertrophic pyloric stenosis

Infantile hypertrophic pyloric stenosis

1)

Nitrous oxide synthase deficiency (most accepted ) Nerve cell theory ( ganglion cell theory)

2)

3)

Increased child & maternal gastrin

3/1000 live birth Definite familial incidence Male:Female = 4:1 Commonly in the first born male child Most common cause for laparotomy before 1 year Age: 3 weeks - 3 months

Circular muscle hypertrophy

Contraction to overcome obstruction

Gastric dilataion

Stagnation gastritis

1. Vomiting

2. Constipation 3. Failure to thrive & loss of weight

Non-bilious Progressive Projectile or forcible Persistent Immediately after meals Child is hungry and eager to eat after Sometimes, coffee ground due to gastrits

1. General signs of dehydration


Wasting Sunken eyes Depressed fontanel

2. General signs of vitamin deficiency

Test feeding revealed visible peristalsis from the left to the right in the upper abdomen.

Olive shaped mass pyloric tumor at the angle between right rectus muscle and the liver.

1.
2.

Complete blood count Blood Chemistry

Serum electrolytes ( sodium, potassium, chloride) diminished Urea elevated Blood glucose diminished
3. Arterial blood gases (ABG)

Metabolic alkalosis

1.
2. 3.

Abdominal X-ray Barium meal


Ultrasonography

Dilated stomach with single bubble sign Scanty gases distal to the obstruction

Dilated stomach Delayed gastric emptying Hypertrophic gastric rugae String sign: Narrow & elongated pyloric canal Beak sign: Narrow pyloric lumen/channel to a point Shoulder sign: impression on the antrum and the duodenal cap by the thick muscle Double track sign: when the narrow pyloric channel is lined on opposing luminal surface with contrast

Diagnosis is confirmed when: Pyloric muscle thickness (serosamucosa) 4mm Pyloric thickness (serosaserosa) 15mm Pyloric channel length 17mm Circumferential muscular thickening surrounding the central channel and filled with mucosa( target sign.

Causes of non-bilious vomiting Surgical

Pyloric atresia Antral web Pylorospasm Gastro-oesophageal reflux Gastric volvolus Preampular duodenal stenosis Ectopic pancreas within the pyloric muscle

Medical

Gastroenteritis Increased intracranial pressure Metabolic diseases

Hospitalization NG suction Correction of fluid,electrolytes & pH disturbances Maintenance fluid with 5% dextrose in 0.45% normal saline containing 20-40 mEq/l KCl.

Fred-Ramstedts pyloromyotomy
Right upper quadrant transverse or umbilical fold incision Delivery of the hypertrophied pylorus Splitting of the pyloric muscle till mucosal bulge

Fred-Ramstedts pyloromyotomy

Fred-Ramstedts pyloromyotomy

Crystalloid resuscitation is continued postoperatively until the patient returns to full feeding.

1.
2. 3.

Wound infection Incisional hernia Persistent vomiting due to:

Stagnation gastritis Inadequate pyloromyotomy


4. Mucosal perforation

Pyloric stenosis

Age
Sex

3weeks 3 months

Male predominance

Clinical
Investigation

Non-bilious vomiting Olive mass U/S

Treatment

Surgical

A 3-week-old, first-born male develops forceful, nonbilious emesis. Which of these findings establishes the diagnosis? (A) ultrasonographic pyloric muscle thickness of 2.5 mm (B) ultrasonographic pyloric thickness greater than 1.5 cm (C) ultrasonographic pyloric diameter of 1.0 cm or less (D) an UGI series showing a classic "double bubble" sign (E) palpable pyloric mass (olive) midline of the abdomen

Which of the following is most consistent with pyloric stenosis?


A. Na B. Na C. Na D. Na 140 l42 139 l40 Cl 110 Cl 90 Cl 85 Cl 95 K K K K 3.2 5.2 3.2 4.0 HCO3 26 HCO3 39 HCO3 36 HCO3 38

A 4-week-old breast-fed boy was completely well untill 2 days earlier, when he began vomiting all feeds. He was otherwise well, and keen to feed the persistent vomiting.
(a) (b) (c) (d)

What is the significant thing to ask about regarding vomiting? What physical sign would you wish to find to confirm the diagnosis you suspect? If you were unable to demonstrate this sign, what would you do if you still suspect? What initial investigations would you perform to assist you in resuscitation?

You might also like