PYLORIC STENOSIS

Pyloric stenosis is an acquired

condition caused by
hypertrophy and spasm of
the pyloric muscle, resulting
.in gastric outlet obstruction

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 EPIDEMIOLOGY
 · Predominant age: Infancy; onset
usually at 2-4 weeks of age, rarely as
late as 5 months of age.

 · Predominant sex: Male > Female

(4:1)

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ETIOLOGY
 Pylorospasm secondary to
reduced tissues nitric oxide
level(a mediator of relaxation)
may lead to hypertrophic P.S.

 Erythromycine exposure
(early)

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RISK FACTORS

 · Incidence higher in 1stborn boys

 · 40% of firstborns overall
 · 5 times increased risk with
affected 1st-degree relative (1)[B]

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ASSOCIATED CONDITIONS
 · May be associated with
tracheoesophageal fistula

 · Hirschsprung disease

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DIAGNOSIS
 SIGNS AND SYMPTOMS
 History
 · Nonbilious projectile vomiting after
feeding increasing frequency and severity
 (2nd -4th week of life)
 · Emesis may become blood tinged from
vomiting-induced gastric irritation
 · Hunger due to inadequate nutrition
 · Diminished stools
 · Weight loss

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Physical Exam
 · Palpable, firm, mobile mass ("olive"-like)
in right upper quadrant
 · Palpable 70-90% of the time.
 · Epigastric distention
 · Visible gastric peristalsis after feeding
 · Rarely, jaundice when starvation leads to
decreased glucuronyl transferase activity
resulting in indirect hyperbilirubinemia. (1)
[B]
 · Late signs: Dehydration, weight loss
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Lab

· If prolonged vomiting

   - Hypokalemia
   - Hypochloremia
   - Metabolic alkalosis
 · Elevated unconjugated bilirubin level
(rare)
 · Paradoxical aciduria: The kidney tubules
excrete hydrogen to preserve potassium
in face of hypokalemic alkalosis

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Imaging

1. · Abdominal ultrasound is the study of

choice; shows thickened and elongated
pyloric muscle and redundant mucosa

2. · Upper gastrointestinal series reveals

strong gastric contractions, elongated,
narrow pyloric canal (string sign),
parallel lines of barium in the narrow
channel (double tract sign or railroad
track sign).
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11
DIFFERENTIAL
DIAGNOSIS

1. · Inexperienced or inappropriate feeding

2. · Gastroesophageal reflux
3. · Gastritis
4. · Congenital adrenal hyperplasia, salt-
losing
5. · Pylorospasm
6. · Gastric volvulus
7. · Antral or gastric web

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STABILIZATION

1. · Prompt treatment to avoid dehydration and

malnutrition
2. · Correct acid-base and electrolyte
disturbances
3. · Needs high concentration of potassium in
preoperative fluids to correct alkalosis
4. · Patients need pre and post-op apnea
monitoring. They have a tendency toward apnea to
compensate with respiratory acidosis for their
metabolic alkalosis. Surgery should be delayed until
the alkalosis is corrected.

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SURGERY

 Ramstedt pyloromyotomy is curative

 · Entire length of hypertrophied
muscle is divided with preservation of
the underlying mucosa.
 · May be performed using open or
laparoscopic techniques; no
randomized controlled trials have
compared these 2 approaches.
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