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Pyloric stenosis
Dr Behrang Amini et al.

Hypertrophic pyloric stenosis (HPS) refers to the idiopathic thickening of gastric pyloric

musculature which then results in progressive gastric outlet obstruction.

Epidemiology
Pyloric stenosis is relatively common and has a male predilection (M:F ~4:1), and is more
commonly seen in Caucasians 4. It typically occurs between the first week to 3 months of age.
There may be a positive family history. 
Incidence of hypertrophic pyloric stenosis is approximately 2-5 per 1,000 births per year in
most white populations. HPS is less common in India and among black and other Asian
populations.

Clinical presentation
Clinical presentation is typical with non-bilious projectile vomiting. The hypertrophied pylorus
can be palpated as an olive-sized mass in the right upper quadrant. A succussion splash may
be audible, and although common, is only relevant if heard hours after the last meal 6. 

Risk factors
 maternal history of pyloric stenosis 10

Pathology
HPS is the result of both hyperplasia and hypertrophy of the pyloric circular muscles
fibres. The pathogenesis of this is not understood. There are four main theories 9:
 immunohistochemical abnormalities
 genetic abnormalities
 infectious cause
 hyperacidity theory

Radiographic features
Plain radiograph
Abdominal x-ray findings are non-specific but may show a distended stomach with minimal
distal intestinal bowel gas.

Fluoroscopy
An upper gastrointestinal series (barium meal) excludes other, more serious causes of
pathology, but the findings of a UGI series infer rather than directly visualise the hypertrophied
muscle. On upper gastrointestinal fluoroscopy:
 delayed gastric emptying
 peristaltic waves (caterpillar sign) 
 elongated  pylorus with a narrow lumen (string sign) which may appear duplicated
due to puckering of the mucosa (double-track sign)
 the pylorus indents the contrast-filled antrum (shoulder sign) or base of the duodenal
bulb (mushroom sign)
 the entrance to the pylorus may be beak-shaped (beak sign)
Ultrasound
Ultrasound is the modality of choice in the right clinical setting because of its advantages over
a barium meal are that it directly visualises the pyloric muscle and does not use ionising
radiation. Unfortunately, it is incapable of excluding other diagnoses such as midgut volvulus.
Easy ultrasound technique is to find gallbladder then turn the probe obliquely sagittal to the
body in an attempt to find pylorus longitudinally 7.

The hypertrophied muscle is hypoechoic, and the central mucosa is hyperechoic. Diagnostic
measurements include (mnemonic "number pi"):

 pyloric muscle thickness, i.e. diameter of a single muscular wall on a transverse

image: >3 mm (most accurate 3)
 length, i.e. longitudinal measurement: >15-17 mm
 pyloric volume: >1.5 cc
 pyloric transverse diameter: >13 mm
With the patient right side down the pylorus should be watched and should not be seen to
open.

Treatment and prognosis

Initial medical management is essential with rehydration and correction of electrolyte
imbalances. This should be completed prior to surgical intervention.
Treatment is surgical with a pyloromyotomy in which the pyloric muscle is divided down to the
submucosa. This can be performed both open and laparoscopically. The operation is curative
and has very low morbidity 4-5.

Differential diagnosis
There is usually little differential when imaging findings are appropriate. Of course, clinically it
is important to consider other causes of vomiting in infancy.

A degree of pylorospasm is common in infancy and is responsible for some delay in gastric
emptying. The pylorus, however, appears sonographically normal. In cases where the doubts
persist, fluid gastric distention can be performed to "open" a tapered pylorus. 

Gastro-oesophageal reflux which represents the cause of vomiting in two-thirds of infants

referred to radiology 8.

Other causes of proximal gastrointestinal obstruction can be considered 8:

 midgut volvulus
 gastric antral web
 duodenal web/stenosis
 annular pancreas
 bezoar
Article Information
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Cases and Figures


Figure 1. pyloric stenosis measurements Figure 2.



Case 1.


Case 2


Case 2 with antral nipple sign



Case 4


Case 5


Case 6


Case & 7 : With mushroom sign



Case 8

Case 9 case 10


Case 11


Case 12 :antral nipple and cervix sign


Case 13 : with target
sign

Case 14

Case 15 : with
target sign