July 11, 2009 | In: PEDIATRIC SURGERY
82 HYPERTROPHIC PYLORIC STENOSIS
Denis D. Bensard M.D.
1. What is pyloric stenosis?
Show answer
Hypertrophic pyloric stenosis (HPS) is idiopathic thickening and elongation of the pylorus that produces gastric outlet obstruction. HPS is the most common surgical cause of nonbilious vomiting in infants. Offspring of an affected parent have an increased incidence of HPS (10%); the highest rate (20%) occurs in boys born to affected mothers.
2. Describe the typical presentation of HPS.
Show answer
The typical presentation is a healthy infant who initially fed normally but who presents at age 2-6 weeks with a history of “projectile” vomiting. The emesis is nonbilious. After vomiting, the infant appears hungry and will refeed immediately. With time, the infant becomes dehydrated and, if allowed to progress, malnutrition follows.
3. What are the physical findings?
Show answer
Affected infants suffer some degree of dehydration. The abdomen is nondistended and soft. A palpable pyloric tumor, known as the “olive,” confirms the diagnosis. An olive is palpable in 50% of patients. Associated findings are rare, but mild jaundice occurs in 5% of infants because of reduced glucuronyl transferase activity.
4. How is the diagnosis confirmed?
Show answer
Ultrasonographic criteria include pyloric diameter > 1.4 cm, wall width > 4 mm, and pyloric channel length > 1.6 cm. Alternatively, a barium upper gastrointestinal (UGI) examination may be used to confirm the diagnosis (gastric outlet obstruction, pyloric channel narrowing). Current analyses suggest that UGI is the most cost-effective initial radiologic diagnostic test because, unlike ultrasound, alternative causes of nonbilious vomiting (e.g., gastroesophageal reflux, malrotation, duodenal stenosis) can be identified.
5. Describe the likely electrolyte abnormalities.
Show answer
Electrolyte levels are often normal, but long-standing vomiting will eventually result in hypokalemic, hypochloremic metabolic alkalosis because of the loss of gastric acid (HCl). Earlier consideration of the diagnosis has led to a significant reduction in this classic electrolyte abnormality at presentation. Dehydration is corrected with either 0.9% NaCl or, in less severe cases, 0.5% NaCl with 30 mEq/L KCl. After dehydration and electrolytes are corrected, pyloromyotomy is performed.
6. What procedure is recommended for the correction of HPS?
Show answer
The Fredet-Ramstedt pyloromyotomy is recommended. A superficial incision is made longitudinally over the pyloric muscle in an avascular area, and the muscle fibers are fractured to expose the underlying mucosa. At the conclusion of the pyloromyotomy, the gastric mucosa should bulge upward into the cleft, and the pyloric muscle walls should move independently of one another. Air is injected into the stomach via the nasogastric tube to identify inadvertent mucosal perforation. Pyloromyotomy may be performed either via a transverse incision in the right upper quadrant (i.e., an open procedure) or via three small (3-mm) incisions in the epigastrium (i.e., a laparoscopic procedure). The results of open and laparoscopic pyloromyotomy appear equivalent.
7. What should be done if a perforation is identified?
Show answer
The mucosa should be closed with several fine sutures and covered with an omental patch. If the mucosal injury is too extensive, the myotomy should be closed with sutures and a second, parallel myotomy should be made at 45-180° from the original myotomy.
8. When can postoperative feeding begin?
Show answer
Small-volume feedings are started after the infant has recovered from anesthesia (2-3 hours) and advanced to goal. Small amounts of vomiting are common (20%), but most infants achieve full feeds within 24 hours postoperatively. Incomplete pyloromyotomy is uncommon (< 1%) and is not considered unless symptoms of gastric outlet obstruction persist for 7-10 days after surgery.
9. Describe several hypotheses about the pathogenesis of HPS.
Show answer
Recent studies of the abnormal pyloric complex demonstrate improper innervation of pyloric smooth muscle, excessive contraction of circular pyloric smooth muscle (decreased nitric oxide synthase), increased extracellular matrix proteins (collagen), and increased expression or local synthesis of growth hormones (i.e., insulin-like growth factor-1, transforming growth factor beta-1, platelet derived growth factor).
References
BIBLIOGRAPHY
1. Campbell BT, McLean K, Barnhart DC, et al: A comparison of laparoscopic and open pyloromyotomy at a teaching hospital. J Pediatr Surg 37:1068-1071, 2002. Medline Similar articles Full article
2. Chen EA, Luks FI, Gilchrist BF, et al: Pyloric stenosis in the age of ultrasonography: Fading skills, better patients? J Pediatr Surg 31:829-830, 1996. Full article
3. Garza JJ, Morash D, Dzakovic A, et al: Ad libitum feeding decreases hospital stay for neonates after pyloromyotomy. J Pediatr Surg 37:493-495, 2002. Medline Similar articles Full article
4. Hulka F, Campbell JR, Harrison MW, et al: Cost-effectiveness in diagnosing infantile hypertrophic pyloric stenosis. J Pediatr Surg 32:1604-1608, 1997. Medline Similar articles Full article
5. Miozzari HH, Tonz M, von Vigier RO, et al: Fluid resuscitation in infantile hypertrophic pyloric stenosis. Acta Paediatr 90:511-514, 2001. Medline
6. Ohshiro K, Puri P: Pathogenesis of infantile hypertrophic pyloric stenosis: Recent progress. Pediatr Surg Int 13:243-252,1998. Medline Similar articles Full article
104 Responses to Hypertrophic Pyloric Stenosis
Habez
January 20th, 2012 at 11:22 pm
Related……
[...]just beneath, are numerous totally not related sites to ours, however, they are surely worth going over[...]……
Dallas Advertising
January 25th, 2012 at 4:20 pm
Blogs ou should be reading…
[...]Here is a Great Blog You Might Find Interesting that we Encourage You[...]……
Dallas Senior Portrait Photographer
January 25th, 2012 at 6:46 pm
Websites you should visit…
[...]below you’ll find the link to some sites that we think you should visit[...]……
Dallas Family Portrait Photographer
January 25th, 2012 at 7:29 pm
Links…
[...]Sites of interest we have a link to[...]……
Escort girl Paris
January 25th, 2012 at 10:27 pm
As I website {owner | possessor} I {think | believe | conceive} the {content | articles | content material | written content | subject material | subject matter} here is {very | really | real | rattling} {good | excellent | fantastic | great | supe…
Respect to article author , some fantastic selective information . “Consider that this day ne’er dawns again.” by Alighieri Dante….
pre workout supplements
January 25th, 2012 at 11:28 pm
Sites we Like……
[...] Every once in a while we choose blogs that we read. Listed below are the latest sites that we choose [...]……
Non-Lethal Weapons
January 26th, 2012 at 12:47 am
Recent Blogroll Additions…
[...]usually posts some very interesting stuff like this. If you’re new to this site[...]…
best post workout supplements
January 26th, 2012 at 8:24 am
Recent Blogroll Additions……
[...]usually posts some very interesting stuff like this. If you’re new to this site[...]……
webcam chat
January 26th, 2012 at 6:42 pm
Awesome website…
[...]the time to read or visit the content or sites we have linked to below the[...]……
scary
January 26th, 2012 at 8:24 pm
Recommeneded websites…
[...]Here are some of the sites we recommend for our visitors[...]……
Phil Cannella
January 26th, 2012 at 9:34 pm
Visitor recommendations…
[...]one of our visitors recently recommended the following website[...]……
Printable Hometown Buffet Coupons
January 26th, 2012 at 10:51 pm
Blogs ou should be reading…
[...]Here is a Great Blog You Might Find Interesting that we Encourage You[...]……
movie cast lists
January 26th, 2012 at 10:52 pm
Gems form the internet…
[...]very few websites that happen to be detailed below, from our point of view are undoubtedly well worth checking out[...]……
flights to pakistan
January 26th, 2012 at 11:46 pm
Recommeneded websites…
[...]Here are some of the sites we recommend for our visitors[...]……
LED Lights
January 26th, 2012 at 11:56 pm
Recent Blogroll Additions……
[...]usually posts some very interesting stuff like this. If you’re new to this site[...]……
paranormal activities
January 27th, 2012 at 1:41 am
Superb website…
[...]always a big fan of linking to bloggers that I love but don’t get a lot of link love from[...]……
noclegi zakopane
January 27th, 2012 at 1:43 am
Visitor recommendations…
[...]one of our visitors recently recommended the following website[...]……
Beata Geralds
January 27th, 2012 at 4:19 am
Related……
[...]just beneath, are numerous totally not related sites to ours, however, they are surely worth going over[...]……
inkjet cartridges
January 27th, 2012 at 6:38 pm
Recommeneded websites…
[...]Here are some of the sites we recommend for our visitors[...]……
cleaning business
January 27th, 2012 at 6:38 pm
Visitor recommendations…
[...]one of our visitors recently recommended the following website[...]……
free apple ipad 3
January 27th, 2012 at 10:09 pm
Recent Blogroll Additions……
[...]usually posts some very interesting stuff like this. If you’re new to this site[...]……
gain Twitter followers
January 27th, 2012 at 10:48 pm
Websites worth visiting…
[...]here are some links to sites that we link to because we think they are worth visiting[...]……
Bee Pollen
January 28th, 2012 at 2:12 pm
Related……
[...]just beneath, are numerous totally not related sites to ours, however, they are surely worth going over[...]……
article
January 28th, 2012 at 3:49 pm
Recent Blogroll Additions……
[...]usually posts some very interesting stuff like this. If you’re new to this site[...]……
Alin Ophy
January 28th, 2012 at 9:40 pm
Great website…
[...]we like to honor many other internet sites on the web, even if they aren’t linked to us, by linking to them. Under are some webpages worth checking out[...]……
black hair
January 28th, 2012 at 9:42 pm
Links…
[...]Sites of interest we have a link to[...]……
http://11.016.scripts.mit.edu/www/laura/time/
January 28th, 2012 at 11:11 pm
Visitor recommendations…
[...]one of our visitors recently recommended the following website[...]……
suplimente
January 29th, 2012 at 3:46 pm
Recent Blogroll Additions……
[...]usually posts some very interesting stuff like this. If you’re new to this site[...]……
Jesse V.
January 29th, 2012 at 5:00 pm
Blog PR and Resources…
[...]!Important! I really like your website, it’s very well built and the material is very good so I’d like to ask you a quick question: As a website owner, have you ever wanted to make money off of your website? Not just a few bucks a month, but hundr…
website design
January 29th, 2012 at 5:02 pm
Cool sites…
[...]we came across a cool site that you might enjoy. Take a look if you want[...]……
Cures For Psoriasis
January 29th, 2012 at 6:31 pm
Visitor recommendations…
[...]one of our visitors recently recommended the following website[...]……
App
January 29th, 2012 at 6:37 pm
Websites worth visiting…
[...]here are some links to sites that we link to because we think they are worth visiting[...]……
Merchant Services
January 29th, 2012 at 7:53 pm
Websites we think you should visit…
[...]although websites we backlink to below are considerably not related to ours, we feel they are actually worth a go through, so have a look[...]……
Organo Gold
January 29th, 2012 at 8:00 pm
Links…
[...]Sites of interest we have a link to[...]……
best wefted Indian hair
January 29th, 2012 at 9:35 pm
Visitor recommendations…
[...]one of our visitors recently recommended the following website[...]……
project payday scam
January 29th, 2012 at 9:46 pm
You should check this out…
[...] Wonderful story, reckoned we could combine a few unrelated data, nevertheless really worth taking a look, whoa did one learn about Mid East has got more problerms as well [...]……
querty phone
January 29th, 2012 at 10:54 pm
Blogs ou should be reading…
[...]Here is a Great Blog You Might Find Interesting that we Encourage You[...]……
how to play bingo
January 29th, 2012 at 11:05 pm
Blogs ou should be reading…
[...]Here is a Great Blog You Might Find Interesting that we Encourage You[...]……
barmixerschule
January 30th, 2012 at 8:06 am
Recommeneded websites…
[...]Here are some of the sites we recommend for our visitors[...]……
are omega 3 fish oil supplements expensive
January 30th, 2012 at 10:11 am
Websites worth visiting…
[...]here are some links to sites that we link to because we think they are worth visiting[...]……
Jennifer Ellison wallpapers
January 30th, 2012 at 12:16 pm
Recommeneded websites…
[...]Here are some of the sites we recommend for our visitors[...]……
Meet and Greet Parking Gatwick Airport
January 30th, 2012 at 12:19 pm
Websites worth visiting…
[...]here are some links to sites that we link to because we think they are worth visiting[...]……
Montage Photo Gratuit
January 30th, 2012 at 12:33 pm
Awesome website…
[...]the time to read or visit the content or sites we have linked to below the[...]……
Wholesale Clothing
January 30th, 2012 at 2:18 pm
Cool sites…
[...]we came across a cool site that you might enjoy. Take a look if you want[...]……
Cheap Payday Loans
January 30th, 2012 at 2:27 pm
Gems form the internet…
[...]very few websites that happen to be detailed below, from our point of view are undoubtedly well worth checking out[...]……
gynexin
January 30th, 2012 at 9:45 pm
Recent Blogroll Additions……
[...]usually posts some very interesting stuff like this. If you’re new to this site[...]……
what is serotonin
January 31st, 2012 at 7:39 am
Recommeneded websites…
[...]Here are some of the sites we recommend for our visitors[...]……
how to work from home
January 31st, 2012 at 10:53 am
Read was interesting, stay in touch……
[...]please visit the sites we follow, including this one, as it represents our picks from the web[...]……
Stenography Info
January 31st, 2012 at 1:56 pm
Links…
[...]Sites of interest we have a link to[...]……
icf wall bracing
January 31st, 2012 at 2:01 pm
Visitor recommendations…
[...]one of our visitors recently recommended the following website[...]……
coleman roadtrip grill light
January 31st, 2012 at 3:09 pm
Sources…
[...]check below, are some totally unrelated websites to ours, however, they are most trustworthy sources that we use[...]……
scrunch hair overnight
January 31st, 2012 at 8:15 pm
Read was interesting, stay in touch……
[...]please visit the sites we follow, including this one, as it represents our picks from the web[...]……
best way to get blood out of clothes
January 31st, 2012 at 8:32 pm
Check this out…
[...] that is the end of this article. Here you’ll find some sites that we think you’ll appreciate, just click the links over[...]……
commercial inspections
February 1st, 2012 at 9:31 am
You should check this out…
[...] Wonderful story, reckoned we could combine a few unrelated data, nevertheless really worth taking a look, whoa did one learn about Mid East has got more problerms as well [...]……
cholesterol
February 1st, 2012 at 10:30 am
Blogs ou should be reading…
[...]Here is a Great Blog You Might Find Interesting that we Encourage You[...]……
tone butt
February 1st, 2012 at 11:05 am
Related……
[...]just beneath, are numerous totally not related sites to ours, however, they are surely worth going over[...]……
bartschneider test
February 1st, 2012 at 1:46 pm
Recent Blogroll Additions……
[...]usually posts some very interesting stuff like this. If you’re new to this site[...]……
Scott Tucker Payday Loans
February 1st, 2012 at 3:28 pm
Cool sites…
[...]we came across a cool site that you might enjoy. Take a look if you want[...]……
senior citizen travel insurance
February 1st, 2012 at 8:57 pm
Read was interesting, stay in touch……
[...]please visit the sites we follow, including this one, as it represents our picks from the web[...]……
best electric shaver
February 1st, 2012 at 10:53 pm
Websites you should visit…
[...]below you’ll find the link to some sites that we think you should visit[...]……
body by vi reviews
February 2nd, 2012 at 12:07 am
Read was interesting, stay in touch……
[...]please visit the sites we follow, including this one, as it represents our picks from the web[...]……
Scott Tucker Racing
February 2nd, 2012 at 8:00 am
Superb website…
[...]always a big fan of linking to bloggers that I love but don’t get a lot of link love from[...]……
Scott Tucker Racing
February 2nd, 2012 at 9:04 am
Awesome website…
[...]the time to read or visit the content or sites we have linked to below the[...]……
Scott Tucker Racing
February 2nd, 2012 at 9:06 am
Websites you should visit…
[...]below you’ll find the link to some sites that we think you should visit[...]……
Scott Tucker CBS
February 2nd, 2012 at 9:35 am
Recent Blogroll Additions……
[...]usually posts some very interesting stuff like this. If you’re new to this site[...]……
Scott Tucker Racing
February 2nd, 2012 at 10:25 am
You should check this out…
[...] Wonderful story, reckoned we could combine a few unrelated data, nevertheless really worth taking a look, whoa did one learn about Mid East has got more problerms as well [...]……
the best site on the net
February 3rd, 2012 at 7:52 am
Sites we Like……
[...] Every once in a while we choose blogs that we read. Listed below are the latest sites that we choose [...]……
Bank Owned Homes
February 3rd, 2012 at 5:31 pm
Links worth visiting…
[...]Sites of interest we have a link to[...]…
BPO Companies
February 4th, 2012 at 2:08 am
Check this out…
[...] that is the end of this article. Here you’ll find some sites that we think you’ll appreciate, just click the links over[...]…
bpo software
February 4th, 2012 at 5:22 am
Surfing around…
While I was surfing yesterday I noticed a excellent post about…
rack card printing
February 4th, 2012 at 9:58 pm
You should check this out……
[...] Wonderful story, reckoned we could combine a few unrelated data, nevertheless really worth taking a look, whoa did one learn about Mid East has got more problerms as well [...]………
motorcycle jackets
February 5th, 2012 at 3:05 am
Cool sites…
[...]we came across a cool site that you might enjoy. Take a look if you want[...]……
spinach health benefits
February 5th, 2012 at 4:14 am
Recommeneded websites…
[...]Here are some of the sites we recommend for our visitors[...]……
natural remedies for cold sores
February 5th, 2012 at 4:40 am
Awesome website…
[...]the time to read or visit the content or sites we have linked to below the[...]……
athletes acceleration speed training
February 5th, 2012 at 1:42 pm
Recommeneded websites…
[...]Here are some of the sites we recommend for our visitors[...]……
football speed
February 5th, 2012 at 1:51 pm
Check this out…
[...] that is the end of this article. Here you’ll find some sites that we think you’ll appreciate, just click the links over[...]……
new technology trends for future
February 5th, 2012 at 2:39 pm
Awesome website…
[...]the time to read or visit the content or sites we have linked to below the[...]…
aquaponic
February 6th, 2012 at 2:19 am
Related……
[...]just beneath, are numerous totally not related sites to ours, however, they are surely worth going over[...]……
Credit Rating
February 6th, 2012 at 3:14 am
Check this out…
[...] that is the end of this article. Here you’ll find some sites that we think you’ll appreciate, just click the links over[...]……
tarot gratis
February 6th, 2012 at 4:40 pm
Great website…
[...]we like to honor many other internet sites on the web, even if they aren’t linked to us, by linking to them. Under are some webpages worth checking out[...]……
recensioni giochi da tavolo
February 6th, 2012 at 4:48 pm
Awesome website…
[...]the time to read or visit the content or sites we have linked to below the[...]…
maryland short sale attorney
February 6th, 2012 at 6:54 pm
Cool sites…
[...]we came across a cool site that you might enjoy. Take a look if you want[...]……
remedies for psoriasis
February 6th, 2012 at 10:32 pm
Blogs ou should be reading…
[...]Here is a Great Blog You Might Find Interesting that we Encourage You[...]……
Air Conditioning Repairs
February 7th, 2012 at 1:49 am
Check this out…
[...] that is the end of this article. Here you’ll find some sites that we think you’ll appreciate, just click the links over[...]……
Mass Income Multiplier
February 7th, 2012 at 7:59 am
Recommeneded websites…
[...]Here are some of the sites we recommend for our visitors[...]……
track cell phone
February 7th, 2012 at 9:04 am
Awesome website…
[...]the time to read or visit the content or sites we have linked to below the[...]……
Darryl Keesee
February 7th, 2012 at 11:01 am
Gems form the internet…
[...]very few websites that happen to be detailed below, from our point of view are undoubtedly well worth checking out[...]……
Keyword doesn't matter
February 7th, 2012 at 12:19 pm
Sites we Like……
[...] Every once in a while we choose blogs that we read. Listed below are the latest sites that we choose [...]……
Cambridge Life Solutions
February 7th, 2012 at 12:25 pm
Blogs ou should be reading…
[...]Here is a Great Blog You Might Find Interesting that we Encourage You[...]……
windows and doors
February 7th, 2012 at 12:43 pm
Read was interesting, stay in touch……
[...]please visit the sites we follow, including this one, as it represents our picks from the web[...]……
Montreal photography wedding
February 7th, 2012 at 1:03 pm
Related……
[...]just beneath, are numerous totally not related sites to ours, however, they are surely worth going over[...]……
best protein powder for women
February 7th, 2012 at 2:53 pm
Superb website…
[...]always a big fan of linking to bloggers that I love but don’t get a lot of link love from[...]……
Sex Show
February 7th, 2012 at 3:43 pm
Recommeneded websites…
[...]Here are some of the sites we recommend for our visitors[...]……
free novels
February 7th, 2012 at 4:02 pm
Visitor recommendations…
[...]one of our visitors recently recommended the following website[...]……
Biscuit Beetle, Carpet Beetle, Beetle Treatment, Hertfordshire
February 7th, 2012 at 6:00 pm
Read was interesting, stay in touch……
[...]please visit the sites we follow, including this one, as it represents our picks from the web[...]……
tanie noclegi zakopane
February 7th, 2012 at 9:24 pm
Related……
[...]just beneath, are numerous totally not related sites to ours, however, they are surely worth going over[...]……
goals goals goals
February 7th, 2012 at 11:54 pm
Links…
[...]Sites of interest we have a link to[...]……
resume
February 8th, 2012 at 12:50 am
Great website…
[...]we like to honor many other internet sites on the web, even if they aren’t linked to us, by linking to them. Under are some webpages worth checking out[...]……
Tony Ortega
February 8th, 2012 at 1:40 am
Great website…
[...]we like to honor many other internet sites on the web, even if they aren’t linked to us, by linking to them. Under are some webpages worth checking out[...]……
waxless skis
February 8th, 2012 at 2:32 am
Websites worth visiting…
[...]here are some links to sites that we link to because we think they are worth visiting[...]……
dissolve kidney stones
February 8th, 2012 at 11:09 am
Visitor recommendations…
[...]one of our visitors recently recommended the following website[...]……
Scott Tucker Racing
February 8th, 2012 at 4:30 pm
Recent Blogroll Additions……
[...]usually posts some very interesting stuff like this. If you’re new to this site[...]……
Scott Tucker Racing
February 8th, 2012 at 6:24 pm
Links…
[...]Sites of interest we have a link to[...]……
Scott Tucker Racing
February 8th, 2012 at 6:55 pm
Sources…
[...]check below, are some totally unrelated websites to ours, however, they are most trustworthy sources that we use[...]……