HYPERTROPHIC

PYLORIC
STENOSIS
 INTRODUCTION
 A condition characterised
by hypertrophy of the two
circular muscle layers of
the pylorus.
 Resulting in constriction
and obstruction of gastric
outlet.

 Described by
Hirschprung in 1888
 EPIDEMIOLOGY AND ETIOLOGY
 INCIDENCE - 1.5 to 4 per 1000 live births
 EPIDEMIOLOGY - Male : female ratio = 4:1
Increased risk in first born boys
 ETIOLOGY
 IDIOPATHIC
 GENETIC
 Rarely autosomal dominant
 FAMILIAL
 ETHNIC ORIGIN (more in whites): more
commonly seen in Caucasians
 ENVIRONMENTAL
 Erythromycin or azithromycin exposure
 Transpyloric feeding of premature
babies
 Associations

Turner syndrome
Tracheo-oesophageal fistula
Oesophageal atresia
Trisomy 18
CLINICAL PRESENTATION

 ONSET at 2 to 8 weeks of age

(commonly at around one
month of age)

 SYMPTOMS
 Projectile
,forcible, frequent
episodes of non- bilious
coffee ground vomiting
30 to 60 minutes after
feeding.
 Weight loss
 Persistent hunger
 Lethargy
 Constipation or
hunger diarrhoea
CLINICAL PRESENTATION(contd)

 SIGNS
 Palpable,oliveshaped,
mobile, smooth, firm
mass (1.5 to 2 cm)
with all borders well
made out, moves
with respiration, with
impaired resonance
on percussion to
right of epigastric
area.(95% cases)
CLINICAL PRESENTATION(contd)

SIGNS (contd.)

Visible gastric peristalsis from left upper

quadrant to epigastrium (golf ball waves)

Signs of dehydration

Jaundice (2%) (due to decreased hepatic

glucuronosyl transferase
associated with starvation)
DIAGNOSIS
 ABDOMEN X RAY (erect
posture)
upper abdominal gas
bubble in
the stomach.

 ABDOMINAL
ULTRASONOGRAPHY
(Gold standard at present)
Doughnut sign or cervical
pyloric sign
DIAGNOSIS (contd.)
 BARIUM MEAL/ Fluoroscopy
 Peristaltic waves (caterpillar sign)
 Delayed gastric emptying
 Elongated and narrow pyloric canal-
String sign / Railroad track sign
 The pylorus indents the contrast-filled
antrum (shoulder sign) or base of the
duodenal bulb (mushroom sign)
The barium may
Bulge in the distal
outline crowded
antrum with streak of
mucosal folds as barium pointing towards
parallel lines - DOUBLE pyloric canal- BEAK SIGN
TRACT SIGN

Double tract sign Beak sign

DIAGNOSIS ( contd.)
 BIOCHEMICAL CHANGES
 Dehydration
 Malnutrition
 Hypochloraemic hypokalaemic metabolic alkalosis
 Paradoxical aciduria
 Hyperbilirubinemia
 ARTERIAL BLOOD GAS ANALYSIS
 Low serum levels of potassium and chloride
 Increased blood pH and high blood bicarbonate level
MANAGEMENT
 Medical but not a surgical emergency
 RESUSCITATION
 MEDICAL TREATMENT –
Atropine methyl nitrate orally is tried to relax the
pylorus muscle.
 Surgery
 FREDET-RAMSTEDT’s PYLOROMYOTOMY>>>
conventional open procedure

 LAPARASCOPIC PYLOROMYOTOMY>

 DOUBLE –Y PYLOROMYOTOMY>
 PYLOROMYOTOMY
FREDET-RAMSTEDT’s
PYLOROMYOTOMY
 Division of pyloric muscle fibres
without opening of bowel lumen.
 Done via right upper
quadrant incision or
laparoscopically.
 Caution not to open mucosa
and avoid the prepyloric vein of
Mayo.
LAPARASCOPIC
PYLOROMYOTOMY
 Effective alternative
 Time to achieve full enteral feeding is
significantly shorter ( 18.5hrs) in those treated
laparoscopically vs those having open
pyloromyotomy(23.9 hrs)
 Better cosmesis
A, Laparoscopic
pyloromyotomy is
started using a
retractable blade.

B, A spreader with
grooves on the outer
surface is used to
complete the
pyloromyotomy. Intact
mucosal bulging along
with independent
muscular wall motion
is confirmed.
 The double-Y pyloromyotomy (Alayet's pyloromyotomy)
seems to be a good technique for the surgical
management of HPS.
 It offered a better functional outcome in terms of
postoperative vomiting during the first
postoperative week and weight gain during the
first 10 days in our initial series while having a
safety profile similar to Ramstedt's pyloromyotomy.
POST OPERATIVE
CARE
 Patient started on feedings of glucose and water or an
electrolyte infant formula ( eg - pedialyte) 4-6 hrs
after surgery.
Gradual increase in oral fluids till feeds are accepted
without emesis. Full feedings reached after 24 hrs
from surgery.
 Antibiotic prophylaxis not required.
 Postoperative monitoring for 12 hrs required in
patients with
 Hypoglycemia
 Hypothermia
 Respiratory depression and apnoea(due to CSF alkalosis
and intraoperative hyperventilation)
COMPLICATIONS
 Duodenal perforation – may go undetected especially
in laparoscopic RAMSTEDT’s.

 Continued postoperative bleeding

 Persistent vomiting (due to incomplete pyloromyotomy )

dehydration, weight loss and severe electrolyte
imbalance .
If persists >1 week, redo surgery.

 Foveolar cell hyperplasia (FCH), a rare cause of

persistent gastric outlet obstruction.(This requires an
extended pyloromyotomy) .
Sources:
• https://www.msdmanuals.com/home/children-s-health-issues/digestive-
disorders-in-children/hypertrophic-pyloric-stenosis#:~:text=Hypertrophic
%20pyloric%20stenosis%20is%20blockage,contents%20into%20the
%20small%20intestine

• https://emedicine.medscape.com/article/929829-overview

• https://radiopaedia.org/articles/pyloric-stenosis

• https://emedicine.medscape.com/article/803489-overview
Thank You
Thank You