1. Morning Report July 6, 2012 Good Morning!

2. Symptoms Acute /subacuteChronic LocalizedDiffuse SingleMultiple StaticProgressive ConstantIntermittent Single EpisodeRecurrent AbruptGradual SevereMild PainfulNonpainful BiliousNonbilious Sharp/StabbingDull/Vague Problem Characteristics Ill-appearing/ Toxic Well-appearing/ Non-toxic Localized problemSystemic problem AcquiredCongenital New problem Recurrence of old problem Semantic Qualifiers

3. Illness Script Predisposing Conditions  Age, gender, preceding events (trauma, viral illness, etc), medication use, past medical history (diagnoses, surgeries, etc) Pathophysiological Insult  What is physically happening in the body, organisms involved, etc. Clinical Manifestations  Signs and symptoms  Labs and imaging

4. Ultrasound

5. Predisposing Conditions 5:1 Male predominance More common is 1 st born (30% of cases) Caucasian Typically between the age of 2 weeks – 6 weeks Family clustering Erythromycin exposure in 1 st 2 weeks of life

6. Pathophysiology True etiology unknown Hypertrophy of the pyloric muscle that leads to gastric outlet constriction Exposure to erythromycin (less so with other macrolides)  Increases risk 8-fold  Erythromycin interacts with smooth muscle motilin receptors  This causes strong gastric and pyloric contractions  Subsequent hypertrophy of the pyloric muscle

7. Anatomy Hypertrophy of the pylorus Elongation and thickening Progresses to near- complete obstruction

8. Clinical Manifestations* Vomiting  Non-bilious  Forceful/projectile  Progressive (increasing frequency) Progression  Ravenously hungry   Dehydrated/weight loss   Lethargic FTT Jaundice Palpable “olive” (up to 90%) Peristaltic wave after eating Electrolyte abnormalities

9. Electrolytes Metabolic alkalosis**  Decreased excretion into small intestine (increase in serum)  Decreased total body K+ leads to shift of K+ outside of cell in exchange for H+  Increased re-absorption by kidney for fluid retentions (due to dehydration) Hypochloremia* Hypokalemia* (late finding) Correction of electrolytes before surgery…  Correct dehydration (often with NS bolus)  If mild-moderate dehydration…  D5 ½ NS at correction rate, KCl once voids

10. Diagnosis** Primarily a clinical diagnosis Ultrasound  Pyloric muscle thickness > 4mm  Pyloric muscle length > 14mm  85-100% sensitivity and specificity UGI  89%-100% sensitive/specific  “string sign”, “double track”

11. UGI

12. Pyloromyotomy

13. Thanks! ! Noon Conference… Respiratory Failure by Costa