CONGENITAL PYLORIC STENOSIS Harjasleen Sihota Roll # : 1016 MD4

INTRO Idiopathic HPS Infantile HPS Pediatric HPS Hirschsprung in 1888 3 /1000 babies Form of gastric outlet obstruction Affects gastrointestinal tract of an infant (mainly 1st born male) Obstruction of the pyloric lumen Pyloric muscular dystrophy Forceful vomiting, dehydration and salt and fluid imbalance Immediate treatment

SYMPTOMS 3 weeks of age VOMITING -1st symptom -NON BILIOUS -may be brown tinged with blood if gastritis develops CHANGES IN STOOL --fewer, smaller stool -constipation or mucus stool FAILURE TO GAIN WEIGHT & LETHARGY -fluid and salt abnormalities -dehydration *less active, sunken “soft spot” on head, sunken eyes, wrinkled skin *less urine (4 to 6 hours between a wet diaper) -increased stomach contractions after feeds. May make ripples, or WAVES OF PERISTALSIS Symptoms may be deceptive because the infant may seem uncomfortable, but may not appear in great pain or look ill

CAUSES Unknown Abnormal muscle innvervation, breast feeding and maternal stress in 3rd trimester Type B or O blood group May be genetic 3 out of 1000 births-firstborn male Whites of Northern European ancestry Less common in African Americans Rare in Asians

MANAGEMENT Fluid replacement Electrolyte abnormalities to stabilize patient 1960s oral atropine, surgery 1991 Pyloromyotomy -short transverse incision or laparoscopically

COMPLICATIONS Are rare, but include: -bleeding -hernia -infection In rare cases , initial operation may not resolve vomiting therefore, a reoperation may be necessary Small intestine may develop a leak and infant may become seriously ill Low incidence of morbidity and mortality Most infants go home from the hospital within one or two days after surgery Excellent results no increased risk of stomach or intestinal problems later in life The risk of dying from the procedure is extremely small and is often related to other severe medical conditions.

CASE STUDY This is a 3 week old male infant who presents to the emergency department with a chief complaint of vomiting x 3-4 days. His mother states that the vomiting has gotten progressively worse and now seems to "shoot out of his mouth." The emesis always occurs after feeding, sometimes vomiting the entire volume of his feed. The vomitus is non-bilious and non-bloody. After vomiting, the infant remains hungry and is still eager to feed. He is exclusively bottle fed with formula. There is no history of fever, URI symptoms, or diarrhea. He is less active than normal. He is making fewer wet diapers and less stool than usual. There is no history of trauma or recent travel. There are no ill contacts. Exam: VS T 37.0, P 170, R 50, BP 80/50, O2 saturation 99% on RA. Length is 54 cm (50th percentile) and weight is 3.6 kg (25th percentile; previously 50th) and head circumference is 37 cm (50th). He is a well-developed, well-nourished male in no distress. His skin is normal. HEENT exam is normal. His neck is supple. Heart auscultation reveals tachycardia and a regular rhythm. Lungs are clear. His abdomen is slightly distended with active bowel sounds. No hepatosplenomegaly is noted. Attempting to palpate an olive mass is inconclusive. He has no inguinal hernias. Genitalia are normal. Extremities are normal. Color, perfusion, and capillary refill are good. Neurologic examination is normal. CBC is unremarkable. Electrolytes: Na 131, K 3.2, Cl 95, bicarb 30. An IV fluid infusion is started. An abdominal series shows no obstruction, but the stomach is dilated.

CASE STUDY Diagnosis: An ultrasound study confirms the diagnosis of pyloric stenosis. The patient undergoes a pyloromyotomy and recovers without complications.

videos http://www.youtube.com/watch?v=JfG0VrSuV2Y http://www.youtube.com/watch?v=D3N3kgSSzHY

REFERENCES http://kidshealth.org/parent/medical/digestive/pyloric_stenosis.html# https://www.clinicalkey.com/topics/gastroenterology/pyloric-stenosis.html http://www.hawaii.edu/medicine/pediatrics/pedtext/s10c08.html http://www.amcresidents.com/Lectures/peds/CA2/pyloric%20stenosis.pdf https://www.surgery4children.com/diagnoses-and-treatment/abdomen/171-pyloromyotomy http://www.mayoclinic.org/diseases-conditions/pyloric-stenosis/multimedia/pyloromyotomy/img-20006399

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