Pyloric Stenosis

What is pyloric
stenosis?
Also known as “Hypertrophic
Pyloric Stenosis”

narrowing or
obstruction of the
pyloric sphincter
One of the most
common disorders of
Affects infants early infancy
between 1 and 2
weeks and 3 or 4
months
Incidence: 5 in 1000 males
1 in 1000 females

Whites are more

affected often
than blacks or
Asians
Full-term infants are
affected more
frequently than
premature infants
 Anatomy
Mouth
of Digestive System
Pharynx

Esophagus

Stomach

Small Intestine

Liver and
Gallbladder

Pancreas

Large Intestine
Cardiac Region
Fundus
Body
Pylorus
 Pathophysiology of
UnknownPyloric
cause Stenosis
Predisposing
Factors
-Male
Food (chyme) in the -Heredity
stomach passes -Race
through

Thickening and narrowing -Hypertrophy

pyloric sphincter -hyperplasia
-Dehydration
-Lethargic
Leads to partial to complete -Malnourished
obstruction -Electrolyte
imbalance
Cannot pass through small
intestine (duodenum)

With no exit point, no Projectile

other choice but to vomiting
exit through the mouth
 Clinical Manifestations
❶Projectile Vomiting
❷No evidence of pain or discomfort except
that of chronic hunger
❸Weight loss
❹Signs of dehydration
❺Distended upper abdomen
❻Readily palpable olive-shaped tumor in the
epigastrium just to the right of the umbilicus
❼Visible gastric peristaltic waves that move
from left to right across the epigastrium
 Diagnostic Evaluation
a. History of Clinical Manifestations
Regurgitation Insatiable appetite
and non- with weight loss
projectile dehydration and
vomiting during constipation
the first few
weeks of life
Projectile vomiting beginning
at 2-3 weeks of age
 Visible peristaltic waves
b. Physical across the abdomen and an
Examination olive-sized mass in the left
upper quadrant are often
found.

Usually performed to
confirm the diagnosis c. Sonogram
and an upper GI series
may be performed as
well.

Reveals a swollen
d. Barium x-ray stomach and
narrowed pylorus
Longitudinal ultrasonogram of the pylorus in a patient with
surgically proven hypertrophic pyloric stenosis. Note the
thickened, circular muscle, elongated pylorus, and narrowed
pyloric channel.
e. Blood Test
Used to determine the
degree of dehydration,
electrolyte imbalance and
anemia.
f. Abdominal X-
raysUses invisible electromagnetic
energy beams to produce images of
internal tissues, bones, and organs
onto film.
 Treatment
a. Surgical Correction
Sometimes called Fredet-
Ramstedt
Pyloromyotomy
Treatment of choice
During surgery, the muscles
Laparoscopy of the pylorus are split and
separated.

The procedure can be

completed with an open
technique or with
laparoscopy.
 Laparoscopy
Has been found to be safe and
successful for infants

b. Intravenous Rehydration and Correction

of electrolyte and Acid-base imbalance
Feedings are usually begun 4-6 hours
postoperatively, beginning with small,
frequent feedings of glucose water or
electrolyte solutions.
Are given to relax the
pylorospasm.

c. Antispasmodic drugs
 Nursing Assessment
Observe the infant’s abdomen for the
presence of peristaltic waves. Bowel
sounds are hyperactive on auscultation.
Palpation reveals an olive-shaped mass in
the right upper quadrant of the abdomen.
Assess skin turgor, fontanels, urinary
output and mucous membranes to determine
whether hydration is adequate.
Measure vomitus and describe vomiting
episodes. Be alert for signs of an
electrolyte imbalance, particularly low
levels of serum chloride, sodium and
potassium and elevated pH.

Assess the parents’ level of anxiety

related to the child’s condition.
 Nursing
Management
Meet Fluid and Electrolyte Needs
Intravenous fluid therapy - administered to
correct fluid and electrolyte imbalances
and to maintain adequate hydration

Monitor intake and output (including

vomitus) and urine specific gravity.

Inform parents that all diapers will be

weighed to measure the infant’s output of
urine and stool.
Minimize Weight Loss

Monitor weight daily both preoperatively

and postoperatively. Small frequent
feedings consisting of clear liquids are
begun within 4-6 hours postoperatively.
Promote Rest and Comfort

The infant is swaddled to maintain warmth and

provide comfort. Postoperatively the infant is
uncomfortable because of the surgical incision.

Instruct parents to avoid pressure on the incision.

Acetaminophen or other analgesics can be

administered to relieve discomfort as ordered.
Prevent Infection

Postoperatively the incision is covered with

collodion or Steri-Strips and should be kept
clean and dry.

Check the incision site for redness, swelling or

discharge.

Monitor the infant’s temperature every 4

hours.
Provide Supportive Care

Encourage them to participate in the infant’s

care and to discuss their fears ad concerns.

Provide simple and clear explanations about

the infant’s condition and care.

Advise parents that occasional vomiting after

surgery may occur.
Discharge Planning and Home Care
Teaching

Instruct parents to observe the incision for

redness, swelling or discharge and to notify
the physician immediately if these occur or if
the infant’s temperature is higher than 38.5°C
(101°F).
Common Medications
Generic Name: Cetirizine

Brand name: Virlix

Classification: histamine 1-
receptor antagonist

Indication: For allergic rhinitis and

urticaria
 Action:
Antagonize histamine effects at histamine1-
receptor sites, preventing allergic response.
Also has mild bronchodilatory effects and
blocks histamine-induced bronchoconstriction
in asthma.

Side Effects/Adverse Reactions:

CNS: dizziness, drowsiness, fatigue
CV: palpitations, edema
EENT: pharyngitis
GI: nausea, vomiting, abdominal distress, dry mouth
Musculoskeletal: myalgia, joint pain
Respiratory: bronchospasm
Skin: photosensitivity, rash, angioedema
Other: fever
Dosage:
• Older than age 6: 5
Contraindications:
to 10mg PO daily Hypersensitivity
• Children ages 2 – 5: to drug or
2.5 to 5mg PO daily hydroxyzine
Acute asthma
attacks
Pyloroduodenal
obstruction
Breastfeeding
 Nursing
Responsibilities
Patient monitoring:
• Monitor creatinine levels in patients with renal
dysfunction
• Assess hepatic enzyme levels in patients with
hepatic disease

Patient teaching:
•Tell patient to take with full glass of water
•Inform patient that drug may impair alertness and
that alcohol may exaggerate this effect
•Caution patient to avoid driving and other
hazardous activities until he knows how drug
affects concentration and alertness
Generic name: Metronidazole hydrochloride

Brand name: Flagyl, Flagyl-ER, MetroGel,

Protostat

Classification: Antiinfective

Indication: For treatment of intestinal

amebiasis, trichomoniasis, inflammatory bowel
disease, H. pylori infection causing peptic
ulcers, bacterial vaginosis, and anaerobic
infections and perioperative prophylaxis in
colorectal surgery.
Side Effects/Adverse effects:
• Dizziness
• Headache
• Confusion
• Depression
• Irritability
• Weakness
• Insomnia
• May develop dark or reddish brown urine

Contraindications:
Hypersensitivity to drug, other
nitroimidazole derivatives, or parabens
(topical form only)
First trimester pregnancy in patietns with
trichomoniasis
Dosage:
Amebiasis:
A: PO: 500-750 mg t.i.d for 5-10 d
C: PO: 35-50 mg/kg/d in 3 divided doses
Anaerobic infections:
A: PO: 7.5 mg/kg q6h; max: 4 g/d
A: IV 15 mg/kg loading dose, then 7.5 mg/kg q6h
Bacterial vaginosis:
A: PO: ER preparation: 750 mg/d x 7d
Perioperative prophylaxis:
A: IV: 1 g, 1 h before surgery; 500 mg, 6 and 12 h after
first dose
Rosacea:
Thin application twice per day to affected areas
Available in vaginal and topical gel
 Nursing
Responsibilities
Patient Monitoring:
• Monitor IV site. Avoid prolonged use of
indwelling catheter
• Evaluate hematologic studies, especially in
patients with history of blood dyscrasias

Patient teaching:
• Advise patient to take drug with food if it
causes GI upset.
• Tell patient with trichomoniasis to refrain
from sexual intercourse or to have a male
partner wear a condom to prevent re-infection.
• Advise patient to report fever, sore throat,
bleeding, or bruising
• Inform patient using topical form to clean
area thoroughly with mild cleanser before
use and then wait 15 to 20 minutes before
applying.

• Tell female patient to consult prescriber if

she is pregnant or plans to become pregnant.

• As appropriate, review all other significant

and life-threatening adverse reactions and
interactions, especially those related to
the drugs, tests, and behaviors mentioned
above.
 Related Articles
Bottle-feeding and the Risk of Pyloric Stenosis
Biggar, J., Krogh, C., Fischer, T., et al. (2012). Bottle-feeding and the risk
of pyloric stenosis. Pediatrics. Retrieved from
http://pediatrics.aappublications.org/content/pediatrics/early/2012/08/28/p
eds.2011-2785.full.pdf
Pyloric stenosis is the most common condition requiring surgery in infants. It
is typically not present at birth but develops within the first weeks after
birth. The etiology is largely unknown, but bottle-feeding has been
suggested as a risk factor.
RESULTS: Among 70 148 singleton infants, 65 infants had surgery for PS, of
which 29 were bottle-fed before PS diagnosis. The overall HR of PS for
bottle-fed infants compared with not bottle-fed infants was 4.62 (95%
confidence interval [CI]: 2.78–7.65). Among bottle-fed infants, risk
increases were similar for infants both breast and bottle-fed (HR: 3.36
[95% CI: 1.60–7.03]), formerly breastfed (HR: 5.38 [95% CI: 2.88–10.06]),
and never breastfed (HR: 6.32 [95% CI: 2.45–16.26]) (P = .76). The
increased risk of PS among bottle-fed infants was observed even after 30
days since first exposure to bottle-feeding and did not vary with age at
first exposure to bottle-feeding.
CONCLUSIONS: Bottle-fed infants experienced a 4.6-fold higher risk of PS
compared with infants who were not bottle-fed. The result adds to the
evidence supporting the advantage of exclusive breastfeeding in the first
months after birth.
New insights on the pathogenesis of pyloric stenosis of infancy.
A review with emphasis on the hyperacidity theory.
Rogers, I. (2012) New insights on the pathogenesis of pyloric
stenosis of infancy. A review with emphasis on the hyperacidity
theory. Open Journal of Pediatrics, 2, 97-105.
doi: 10.4236/ojped.2012.22017.

A review is presented on the theories concerning the cause of

pyloric stenosis with emphasis on the primary position of
inherited hyperacidity in pathogenesis. Existing theories are
critically analyzed and the hyperacidity theory is precisely
defined in the light of recent physiological insights into the
gastrointestinal hormone motilin. The progressive fixed fasting
hypergastrinaemia within the first few weeks of life will, in
the baby who inherits acid secretion at the top of the normal
range, produce hyperacidity of sufficient severity to trigger
the process of acid-induced work hypertrophy of the pylorus.
The potential contribution of motilin is discussed. The baby
who inherits a normal gastric acidity will not reach acid
levels severe enough to trigger sphincter hypertrophy despite
the early gastrin stimulus. The potential threat will cease
when gastrin naturally declines with age and the pyloric canal
becomes wider. Genetic factors clearly must also be involved
and these are separately discussed.
Thank you for
listening!
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