HYPERTROPHIC PYLORIC

STENOSIS
The most common surgical cause of vomiting in infancy

1 to 4 per 1000 live births.

Male to female ratio is 4:1

 PATHOPHYSIOLOGY

Hypertrophy without hyperplasia

Genetic and environmental factors

Family history.
being a first-born infant.
 METABOLIC DERANGEMENT

Metabolic
Hypochloremic Hypokalemic
Alkalosis
CLINICAL FEATURES
 AGE

2-8 weeks in term infant

Slightly later in preterm

Only 4% after 3 months old

 VOMITING

Progressive\ every feeding

Non-bilious/ coffee-ground

Projectile

Hungry after vomiting, eager to eat, only to vomit once

again
Failure to thrive/ low weight

Constipation
Dehydration

Scaphoid abdomen

Visible peristaltic wave

Pyloric olive
DIFFERENTIAL
DIAGNOSIS
Pylorospasm.

GERD.

GE.

Raised ICP.

Metabolic disease.

Anatomic deformity.
IMAGING STUDIES
ULTRASONOGRAPHY
Thickness >=4 mm

length >=16 m
BARIUM MEAL
String sign
Double track sign
PREOPERATIVE PREPARATION
RESUSCITATION

RESUSCITATION

RESUSCITATION

THEN PYLOROMYOTOMY
HOW TO RESUSCITATE
 NGT

Severe gastric distension

Intraoperative

After contrast study

Perforation
OPERATIVE MANAGENENT
(Ramstedt`s, 1912)
PYLOROMYOTOMY
POSTOPERATIV COMPLICATIONS
Mucosal perforation

Wound infection and dehiscence

Postoperative emesis

Prolonged emesis
INTUSSUSCEPTION
PATHOGENESIS
Telescoping of one portion of the intestine (intussusceptum) into another
(intussuscepiens).
 Primary intussusception

Idiopathic

5-10 months

RTI OR GE

Peyer's patches
 Secondary intussusception

2-12%

Definite leading point

Meckel`s diverticulum
 TYPES

Ileocolic

Ileoileal

Cecocolic

Colocolic

Jejunojejunal
 NATURAL HISTORY

Intussusceptions > compressed bowel & mesentery >

venous obstruction > bowel wall oedema > arterial
insufficiency > bowel wall necrosis > sepsis > death, if not
treated
INCIDENCE
AGE

GENDER

HEALTHY

RTI or GE
PRESENTATION
ABDOMINAL PAIN

VOMITING

CURRANT JELLY STOOL

EXAMINATION
SIGN OF DANCE

ABDOMINAL MASS

BLOOD OR MASS/ PR EXAM

DELAYED > DEHYDRATION AND BACTEREMIA

PROTRUDE THROUGH ANUS > GRAVE

DIAGNOSTIC STUDIES
PLAIN X-RAY
U/S-Target sign
U/S-Pseudokidney sign
BARIUM ENEMA/claw sign
Barium enema/ spring sign
 NONOPERATIVE MANAGEMENT

Hydrostatic reduction

Pneumatic reduction
 OPERATIVE INDICATIONS

Evidence of peritonism or perforation, sepsis or possible gangrene.

Evidence of lead points e.g. filling defect on contrast enema.

Third time presentation.

Failure of non-operative management.

Perforation during non-operative reduction.

 RECURRENT
INTUSSUSCEPTION

The majority within 6 months.

Usually have no lead point.

Less with surgical resection.

 PO INTUSSUSCEPTION

Even thoracic surgery.

Usually within a month.

Ileoileal.
MECKEL`S DIVERTICULUM
The most common congenital malformation of the small
intestine.

The most common vitellointestinal anomalies.

True diverticulum on the antimesenteric border.

2% population.

2 years old.

2 feet from ileocecal valve.

2 inches length.

2 cm diameter.

2 types of heterotopic tissue.

CLINICAL FEATURES
 HAEMORRHAGE

Commonest.

Preschool child with painless rectal bleeding, episodic, ceases usually

spontaneously.

Iron deficiency anemia.

 OBSTRUCTION

Intussusception.

Band.

Volvulus.
 DIVERTICULITIS

Mimic acute appendicitis.

Less N/V.

Migratory tenderness.
DIAGNOSIS
History & examination.

NGT to exclude upper GI bleeding.

PR & occasionally lower endoscopies to exclude lower GI bleeding.

Radiology for complications .

Meckel`s scan (Technetium 99m pertechnetate).

Wireless capsule endoscopy.

laparoscopy.
TREATMENT
Stabilization.

Diverticulectomy.
ABDOMINAL WALL
DEFECT
EMBRYOLOGY
OMPHALOCELE
GASTROSCHISIS
Central at the umbilicus.

Large > 4 cm.

Sac.

Bowel ± liver.
Right of umbilicus.
Small < 4 cm.

No sac.

Bowel only.
Usually term.

High associated anomalies.

High mortality.

Early return of peristalsis

Preterm.

Low associated anomalies.

Low mortality.

Prolonged ileus.
 Preoperative care and
preparation

Avoid hypothermia.

Avoid hypovolemia.

Decompression.

Exclude associated anomalies.

Dressing.
 OPERATIVE PRINCIBLE

Primary closure.

Skin flap closure.

Stage closure.

Non-operative in giant omphalocele.

PEDIATRIC AND NOENATAL

INGUINAL HERNIA
DEFINITIONS
HERNIA.

PROCESSUS VAGINALIS.

TUNICA VAGINALIS.

CANAL OF NUCK

SLIDING RICHTER LITTER

CLASSIFICATION
REDUCIBLE.

IRREDUCIBLE.

OBSTRUCTED.

STRANGULATED.

INFLAMED.
DIFFERENYIAL
DIAGNOSIS
HYDROCELE.

HEMATOCELE.

UDT.

LN.

FEMORAL HERNIA.
HYDROCELE
 TYPES

Communicating hydrocele.

Non communicating.

encysted.
UMBILICAL HERNIA
Common.

Not congenital.

Blacks and preterm.

Hypothyroidism and Down syndrome.

Surgical indications
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