Infantile hypertrophic pyloric stenosis

Infantile Hypertrophic Pyloric Stenosis Without Metabolic Alkalosis: A Report of Two Cases

Infantile hypertrophic pyloric stenosis (IHPS) is a condition typically characterized by hypertrophy of the pylorus, leading to gastric outlet obstruction and forceful, nonbilious vomiting in young infants. This case series reports two infants with IHPS who exhibited metabolic acidosis, deviating from the classical biochemical presentation of hypochloremic, hypokalemic metabolic alkalosis. The unusual occurrence of metabolic acidosis in these cases suggests the possibility of alternative or additional pathophysiological mechanisms at play. Such deviations from the expected biochemical profile highlight the complexity of IHPS and the need for a broader diagnostic perspective.

The impact of high-frequency transducers on the sonographic measurements of the pyloric muscle thickness in infants

BACKGROUND

Ultrasound is the modality of choice for the diagnosis of hypertrophic pyloric stenosis (HPS). The evolution of high-frequency transducers in ultrasound has led to inconsistent ways of measuring the pylorus.

OBJECTIVE

To standardize the measurements and evaluate the appearance of the normal and hypertrophied pylorus with high-frequency transducers.

MATERIALS AND METHODS

We retrospectively analyzed abdominal ultrasounds of infants with suspected HPS from January 2019-December 2020. We classified the layers of the pylorus while assessing the stratified appearance. Two pediatric radiologists measured the muscle thickness of the pylorus independently by two methods for interrater agreement. Measurement (a) includes the muscularis propria and muscularis mucosa. Measurement (b) includes only the muscularis propria. We also evaluated the echogenicity of the muscularis propria. The interrater agreement, mean, range of the muscle thickness, and the diagnostic accuracy of the two sets of measurements were calculated.

RESULTS

We included 300 infants (114 F:186 M), 59 with HPS and 241 normal cases. There was a strong agreement between the readers assessed in the first 100 cases, and ICC was 0.99 (95% CI, 0.98-0.99). Measurement (a), median thickness is 2.4 mm in normal cases and 4.8 mm in HPS. Measurement (b), median thickness is 1.4 mm in normal cases and 4.0 mm in HPS. Measurement (a) has an accuracy of 89.7% (95% CI, 85.7-92.8%) with 98.3% sensitivity and 87.6% specificity. Measurement (b) has an accuracy of 98.0% (95% CI, 95.7-99.3%) with 89.8% sensitivity and 100.0% specificity. The pylorus stratification is preserved in all normal cases and 31/59 (52.5%) cases of HPS. There was complete/partial loss of stratification in 28/59 (47.5%) cases of HPS. In all HPS cases, the muscularis propria was echogenic.

CONCLUSION

Measuring the muscularis propria solely has a better diagnostic accuracy, decreasing the overlap of negative and positive cases. The loss of pyloric wall stratification and echogenic muscularis propria is only seen in HPS.

Congenital infantile hypertrophic pyloric stenosis in preterm dizygotic twins infants diagnosed early: A case report

INTRODUCTION AND IMPORTANCE

The association in the occurrence of hypertrophic pyloric stenosis (HPS) is 0.25 % to 0.44 % between monozygotic twins and 0.05 % to 0.10 % in dizygotic twins. A combination of genetic and environmental factors may have contributed to the occurrence of HPS. In view of the few related cases reported recently, we present two dizygotic twins who were diagnosed with HPS.

CASE PRESENTATION

This report describes a rare case of congenital infantile hypertrophic pyloric stenosis in preterm dizygotic twins diagnosed early, in which the first case presented with severe clinical features and managed surgically while the second presented with moderate features and hence managed non-operatively with atropine for 14 days. At 6 months of age, both twins continued to tolerate feeds, demonstrated satisfactory weight gain and had achieved appropriate developmental milestones. The postoperative course was uneventful in the twin A.

CLINICAL DISCUSSION

Congenital HPS in premature twins remains an underdiagnosed pathology due to its clinical picture mimicking digestive intolerance to feeds. The mean age at diagnosis is about 38 days, and only 0.4 % of all children suffering from HPS show symptoms in the first 3 days of life. Symptom relief is achieved after a classic pyloromyotomy is performed by a more preferable laparoscopic technique or using the open surgical technique.

CONCLUSION

If one of the dizygotic twins has HPS, the other baby should be evaluated for the same diagnosis as early as possible, to ensure timely management. HPS with moderate clinical features can be treated with atropine for 14 days while severe HPS should be treated by pyloromyotomy.

Imaging Features of Neonatal Bowel Obstruction

Radiologic evaluation of neonatal bowel obstruction is challenging owing to the overlapping clinical features and imaging appearances of the most common differential diagnoses. The key to providing an appropriate differential diagnosis comes from a combination of the patient's gestational age, clinical features, and imaging findings. While assessment of radiographs can confirm bowel obstruction and indicate whether it is likely proximal or distal, additional findings at upper or lower gastrointestinal contrast study together with use of US are important in providing an appropriate differential diagnosis. The authors provide an in-depth assessment of the appearances of the most common differential diagnoses of proximal and distal neonatal bowel obstruction at abdominal radiography and upper and lower gastrointestinal contrast studies. These are divided into imaging patterns and their associated differential diagnoses on the basis of abdominal radiographic findings. These findings include esophageal atresia variants including the "single bubble," "double bubble," and "triple bubble" and distal bowel obstruction involving the small and large bowel. Entities discussed include esophageal atresia, hypertrophic pyloric stenosis, pyloric atresia, duodenal atresia, duodenal web, malrotation with midgut volvulus, jejunal atresia, ileal atresia, meconium ileus, segmental volvulus, internal hernia, colonic atresia, Hirschsprung disease, and functional immaturity of the large bowel. The authors include the advantages of abdominal US in this algorithm, particularly for hypertrophic pyloric stenosis, duodenal web, malrotation with midgut volvulus, and segmental volvulus. ©RSNA, 2023 Online supplemental material is available for this article. Quiz questions for this article are available through the Online Learning Center.

Congenital Hypertrophic Pyloric Stenosis in a Preterm Dizygotic Female Twin Infant: Case Report

Infants with hypertrophic pyloric stenosis are usually diagnosed at about 3 to 8 weeks of age. The clinical onset of symptoms in preterm babies is observed normally at a later age than in term or post-term newborns. This report describes a rare case of a 2-day old preterm twin girl presenting with drinking laziness and recurrent vomiting. Five days after the beginning of symptoms and after several studies, including an upper gastrointestinal contrast study, the diagnosis of hypertrophic pyloric stenosis was made and confirmed at surgery. The postoperative course was uneventful. Interestingly, the mother of the child herself had a history of postnatal surgery on her fifth day of life due to congenital hypertrophic pyloric stenosis. To our best knowledge, this is the first report in the literature describing congenital hypertrophic pyloric stenosis in a mother and her child.

Imaging of acute gastric emergencies: a case-based review

The stomach is one of the most frequently imaged organs in the body with dedicated and incidental inclusion in chest imaging modalities. Gastric emergencies often present clinically with non-specific abdominal, nausea, and vomiting. As such, imaging plays a critical role in early identification and treatment of a myriad of gastric emergencies. The goal of this paper is to showcase gastric emergencies as they appear on multimodality imaging.

The pediatric stomach - masses and mass-like pathology

Diagnostic imaging of pediatric gastric masses often provides a challenge for the practicing radiologist. Radiologists should be aware of this relatively unusual pathology, particularly in cross-sectional imaging findings. We will review pediatric gastric masses and mass-like lesions, focusing on neoplastic and inflammatory etiologies.

Predictive factors for time to full enteral feeding after pyloromyotomy for infantile hypertrophic pyloric stenosis

Background

The aim of the study was to evaluate how different parameters in the preoperative, perioperative, and postoperative period affect time to full enteral feeding (TFEF) in children undergoing pyloromyotomy.

Methods

A retrospective study of all children operated for infantile hypertrophic pyloric stenosis between 2001 and 2017 was conducted. Parameters in demographics and in the preoperative and postoperative period were evaluated against TFEF (hours) using linear regression models.

Results

In the whole cohort of 175 children, mean TFEF was 47 hours with Standard Deviation (SD) of ±35. In the multivariate model, TFEF decreased with age [beta (B): −0.62; 95% confidence interval (95% CI) −1.05 to −0.19; p=0.005) and increased with the presence of severe underlying disease (congenital heart defect or syndrome) (B: 26.5; 95% CI 3.3 to 49.7; p=0.026). Hence, for every day of age, the time to fully fed decreased by 0.6 hour, and the presence of an underlying disease increased the time to fully fed with over one day. TFEF did not seem to be affected by prematurity, weight loss, symptom duration, preoperative acid/base balance or electrolyte values, surgical method, or method of postoperative feeding.

Conclusions

TFEF decreased with higher age and increased in children with a severe underlying disease. These results may be useful in providing adequate parental information regarding what affects TFEF and the length of hospital stay.

Pediatric emergency gastrointestinal ultrasonography: pearls & pitfalls

Ultrasonography is an essential tool in pediatric imaging, particularly in the emergency setting. Although ultrasound is often the favored initial modality for abdominal imaging in children, it is highly operator-dependent and therefore prone to misinterpretation which can lead to false positive or negative exams, or even incorrect diagnoses. Conditions discussed in this series include ileocolic intussusception, hypertrophic pyloric stenosis, appendicitis, and ingested foreign bodies. We will review diagnostic criteria, highlight crucial findings, and illustrate commonly-encountered difficulties and mimics.

Are we performing ultrasound measurements of the wall thickness in hypertrophic pyloric stenosis studies the same way?

PURPOSE

To retrospectively review imaging planes, number of visible pyloric layers and location of measurements, in infants with suspected (HPS).

METHODS

103 pyloric ultrasound studies for suspected HPS were included. For each study, we recorded whether longitudinal or transverse views were performed, the layers visualized (a schematic was developed for two pediatric radiologists to categorize the interfaces of the anatomic layers a-e) and position of the internal measurement cursor. Categories for the anterior (superficial wall) layers were from external to internal: (a) internal aspect of the muscularis propria; (b) external aspect of the muscularis mucosa; (c) internal aspect of the muscularis mucosa; (d) internal aspect of the mucosa interfacing with a mucosal fold (e) deep aspect of the mucosal fold. Median differences between HPS groups were calculated and inter-reader agreement (kappa score) was performed between both readers.

RESULTS

In 100 studies (97 patients), longitudinal (99%) and transverse (69%) views of the pylorus were recorded. For longitudinal views, measurements included muscle thickness (95%), length (97%) and no pyloric diameter. For the transverse view, measurements included muscle thickness (16%) and the diameter (3%). Pyloric layer interfaces were visible: (a) in 64% (b) in 64% (c) in 66% (d) in 30% and (e) in 26%. The internal reference point of cursor placement for measuring the muscle wall thickness in the longitudinal view for one reader was as follows: (a) 46% (b) 27% (c) 30% (d) 1% and (e) 2% of studies. Surgically proven HPS group had a median thickness measurement 0.17 mm greater than the non-HPS studies (CI 95% 0.12-0.21, p < 0.05), and inter-reader agreement was considered as moderate (Kappa 0.5).

CONCLUSIONS

We found a variety of thickness measurements performed predominantly in the longitudinal view and a largely abandoned diameter measurement. The latter might offer a solution as it is not defined by any internal interfaces.

Neonatal azithromycin administration to prevent infant mortality: study protocol for a randomised controlled trial

INTRODUCTION

Biannual mass azithromycin distribution to children aged 1-59 months has been shown to reduce all-cause mortality. Children under 28 days of age were not treated in studies evaluating mass azithromycin distribution for child mortality due to concerns related to infantile hypertrophic pyloric stenosis (IHPS). Here, we report the design of a randomised controlled trial to evaluate the efficacy and safety of administration of a single dose of oral azithromycin during the neonatal period.

METHODS AND ANALYSIS

The Nouveaux-nés et Azithromycine: une Innovation dans le Traitement des Enfants (NAITRE) study is a double-masked randomised placebo-controlled trial designed to evaluate the efficacy of a single dose of azithromycin (20 mg/kg) for the prevention of child mortality. Newborns (n=21 712) aged 8-27 days weighing at least 2500 g are 1:1 randomised to a single, directly observed, oral dose of azithromycin or matching placebo. Participants are followed weekly for 3 weeks after treatment to screen for adverse events, including IHPS. The primary outcome is all-cause mortality at the 6-month study visit.

ETHICS AND DISSEMINATION

This study was approved by the Institutional Review Boards at the University of California, San Francisco in San Francisco, USA (Protocol #18-25027) and the Comité National d'Ethique pour la Recherche in Ouagadougou, Burkina Faso (Protocol #2018-10-123). The findings of this trial will be presented at local, regional and international meetings and published in open access peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT03682653; Pre-results.

Is my baby normal? A review of seemingly worrisome but normal newborn signs, symptoms and behaviors

Infant patients are a unique challenge to emergency department (ED) physicians as the spectrum of normal infant signs, symptoms and behaviors are often difficult to differentiate from abnormal and potentially life-threatening conditions. In this article, we address some common chief complaints of neonates and young infants presenting to the ED, and contrast reassuring neonatal and young infant signs and symptoms against those that need further workup and intervention.

Impact of a multimedia teaching tool on parental anxiety and knowledge during the informed consent process

PURPOSE

Before performing a surgical procedure, informed consent (IC) is obtained. Parents may exhibit anxiety and/or a desire for more knowledge during the IC process for their child. The purpose of this study was to measure the impact of a multimedia intervention (MMI) versus conventional discussion on parental understanding and anxiety during the IC process for infants undergoing surgery for hypertrophic pyloric stenosis.

METHODS

A time-interrupted series design was employed over a 9-month period. In the first phase, conventional discussion for IC was performed. In the second phase, a MMI was utilized. In both phases, anxiety scores and post-consent knowledge tests were collected.

RESULTS

31 participants were included in the study, 17 in the conventional consent and 14 in the MMI phase. Parental anxiety around the IC discussion was measured. There was a significant decrease in anxiety noted with use of the MMI (p = 0.046) but no significant difference in knowledge (p = 0.84).

CONCLUSION

The MMI significantly reduced parental anxiety during the IC process. Providers may consider applying this type of MMI to other surgical procedures. Securing IC in a manner that improves knowledge and decreases anxiety may improve long-term understanding and parental satisfaction with the health care process.

Review of bedside surgeon-performed ultrasound in pediatric patients

PURPOSE

Pediatric surgeon performed bedside ultrasound (PSPBUS) is a targeted examination that is diagnostic or therapeutic. The aim of this paper is to review literature involving PSPBUS.

METHODS

PSPBUS practices reviewed in this paper include central venous catheter placement, physiologic assessment (volume status and echocardiography), hypertrophic pyloric stenosis diagnosis, appendicitis diagnosis, the Focused Assessment with Sonography for Trauma (FAST), thoracic evaluation, and soft tissue infection evaluation.

RESULTS

There are no standards for the practice of PSPBUS.

CONCLUSIONS

As the role of the pediatric surgeon continues to evolve, PSPBUS will influence practice patterns, disease diagnosis, and patient management.

TYPE OF STUDY

Review Article.

LEVEL OF EVIDENCE

Level III.

Hypertrophic pyloric stenosis following repair of oesophageal atresia and tracheo-oesophageal fistula in a neonate

Development of hypertrophic pyloric stenosis (HPS) after a few weeks of repair of an oesophageal atresia (OA) and tracheo-oesophageal fistula (TOF) is a rare condition in early infancy. Although vomiting or feeding intolerance in operated cases of OA+TOF are attributed to oesophageal stricture, gastro-oesophageal reflux and oesophageal dysmotility, it may also be caused by HPS. Herein, we report a newborn infant who had OA and TOF operation on day 2 of life and diagnosed to have HPS at 15th day of age. Even though it is a rare anomaly, HPS should be kept on mind in the presence of persistent vomiting following repair of OA.

Infantile Hypertrophic Pyloric Stenosis: An Epidemiological Review

Infantile hypertrophic pyloric stenosis (IHPS) is the most common gastrointestinal disease among infants. IHPS occurs as an isolated condition or together with other congenital anomalies. Association with genetic and environmental factors, bottle feeding, younger maternal age, maternal smoking, and erythromycin administration in the first two weeks of life has been shown. Familial aggregation has been described and a family history is seen in 47.9 percent of siblings. Infants typically present with projectile vomiting associated with symptoms of failure to thrive. An olive-like mass palpable in the right upper abdominal quadrant is being reported less frequently because of earlier diagnosis by ultrasound. IHPS is generally corrected through laparoscopic pyloromyotomy. Endoscopic pyloric balloon dilation is a novel alternative. Further studies on different populations, the general population, and familial segregation to determine the prevalence, influence, and mode of familial aggregation and correlation with environmental factors are needed to determine the etiology of IHPS.

Adult idiopathic hypertrophic pyloric stenosis - a common presentation with an uncommon diagnosis

Background and Objectives: Adult Idiopathic hypertrophic pyloric stenosis (AIHPS) is a rare but well-defined entity in adults with only 200-300 cases reported so far in the literature.We describe a case of AIHPS and the relevant literature review.

Methods and Results: The patient presented with acute onset upper abdominal pain associated with nausea, vomiting, foul-smelling black tarry stools, and anorexia. On the Esophagogastroduodenoscopy (EGD), pylorus demonstrated a unique “cervix sign.” The patient had multiple endoscopic dilations with minimal relief. She then underwent a distal partial gastrectomy with a Billroth 1 gastroduodenostomy with considerable  improvement in her symptoms on follow up.

Conclusion: Adult Idiopathic hypertrophic pyloric stenosis (AIHPS) is a rare disease which is also underreported due to a difficulty in diagnosis. The most common symptoms of AIHPS are postprandial nausea, vomiting, early satiety, and epigastric pain as seen in our patient. Endoscopy usually shows ?Cervix sign? a unique sign showing a fixed, markedly narrowed pylorus with a smooth border. Multiple treatments have been proposed for AIHPS, including endoscopic dilation, pyloromyotomy with or without pyloroplasty, gastrectomy with a Billroth 1 gastroduodenostomy. Currently, there is no evidence of one surgical technique being superior to another. Further research needs to be done on AIHPS before one technique can be standardized as the standard of care.

The treatment of pyloric stenosis: Evolution in practice

Over the last hundred years, idiopathic hypertrophic pyloric stenosis has undergone an evolution in treatment, with subsequent improvements in outcome. Initially, it was treated by physicians with antispasmodics and various alternative feeding and resuscitation modalities. The evolution of surgical approaches led to a revolution in outcome, from almost certain death to complete cure. The progression of surgical and medical treatments is reviewed in this article until, ultimately, Ramstedt's pyloromyotomy is reached. This distilled operation has remained the gold-standard procedure for over a century.

An unusual surgical cause of pyloric stenosis in an 8-month-old infant

Infantile hypertrophic pyloric stenosis (IHPS) is the most common surgical cause of nonbilious, projectile vomiting in children. Its incidence is estimated to be 2-5/1000 live births and has been noted to be quite rare in African-Americans, Asians, and Indians. It is more common in infants under 6 months of age and is quite rare in older infants. While IHPS is invariably intrinsic in nature, extrinsic pyloric stenosis is very rare. Children who present with nonbilious, projectile vomiting after the age of 6 months should, therefore, be thoroughly investigated for causes other than IHPS. This is a case report of an 8-month-old child who had a band of tissue constricting the pylorus which mimicked IHPS.

Application of color Doppler ultrasound combined with Doppler imaging artifacts in the diagnosis and estimate of congenital hypertrophic pyloric stenosis

Congenital Hypertrophic Pyloric Stenosis (CHPS) is a disease condition that is caused as a result of pylorus wall hypertrophy and hyperplasia. In this study, we used color Doppler flow imaging (CDFI) and Doppler artifacts technique to observe the blood flow of hypertrophic pylorus tissue and the dynamic imaging of liquid passing through the pyloric canal in CHPS infants. 65 cases of CHPS infants and 50 infants without CHPS served as control group. We found that there were statistically significant differences between the blood flow grade of muscular layer and mucosal layer between CHPS and control infants, but no significant differences were observed in the same group. Doppler artifacts technique demonstrated the whole process of contrast agent flow through pyloric canal was directly observed in 35 of 65 subjects, and the internal diameter of the pyloric canal was 1.93 ± 0.33mm.Conclusion that CDFI combined with color Doppler artifacts technique was proved to be effective to observe the distribution feature and blood flow grade in each layer of pyloric canal in CHPS patients. This method provides the evidence for judging the degree of pyloric stenosis clinically, and furnishes the basis of therapy along with its clinical significance and good application value.

Pediatric Abdominal Pain: An Emergency Medicine Perspective

Abdominal pain is a common complaint that leads to pediatric patients seeking emergency care. The emergency care provider has the arduous task of determining which child likely has a benign cause and not missing the devastating condition that needs emergent attention. This article reviews common benign causes of abdominal pain as well as some of the cannot-miss emergent causes.

Emergency ultrasonography of the gastrointestinal tract of children

Ultrasonography (US) is widely used to evaluate most body parts in pediatric patients because it is simple, noninvasive, easy to use, and applicable in a wide variety of clinical situations. US is the modality of choice for the initial evaluation of acute abdominal pain in pediatric patients because of their small body habitus and the presence of less fat tissue in the abdominal wall and peritoneal cavity. The most important factor in performing pediatric emergency US is the graded compression technique and selection of the proper transducer. The careful evaluation of bowel wall thickening combined with ancillary findings such as fluid collection, increased echogenicity of the mesenteric fat tissue, enlarged lymph nodes, hyperemic bowel changes, and abnormal bowel peristalsis can increase the diagnostic capability of US.

Pediatric emergency medicine point-of-care ultrasound: summary of the evidence

The utility of point-of-care ultrasound is well supported by the medical literature. Consequently, pediatric emergency medicine providers have embraced this technology in everyday practice. Recently, the American Academy of Pediatrics published a policy statement endorsing the use of point-of-care ultrasound by pediatric emergency medicine providers.  To date, there is no standard guideline for the practice of point-of-care ultrasound for this specialty. This document serves as an initial step in the detailed "how to" and description of individual point-of-care ultrasound examinations.  Pediatric emergency medicine providers should refer to this paper as reference for published research, objectives for learners, and standardized reporting guidelines.

Non-laparoscopic minimal surgical approach to pyloromyotomy: An experience from a challenged resource setting

BACKGROUND

The aim of the study is to review the experience with the classic Ramstedt's pyloromyotomy through the RUQ approach and the circumlinear supraumbilical fold approach (circumumbilical [CU]) pyloromyotomy (an approach that combines the ease and safety of the open pyloromyotomy with the advantages of minimal invasiveness).

PATIENTS AND METHODS

A single centre review in a period of 12 years from January 2001 to December 2013 with the institutional ethical committee's approval, evaluating 316 pyloromyotomies based on surgical approach: RUQ (171); and CU (145). Patients' demographics, acid-base/electrolyte status on presentation, mean operative time (MOT), postoperative length of stay (LOS) at hospital, and complications were recorded.

RESULTS

Patients demographics, acid - base/electrolyte status on presentation; and MOT were not significantly different. The median LOS was 33 and 30 minutes for CU and RUQ, respectively, with no statistical significant difference between the two groups. One patient in the CU group had a late adhesive bowel obstruction requiring laparotomy and bowel resection. Moreover, wound infection rates did not differ significantly between the two groups (CU 3; and RUQ; 3; P = 0.15).

CONCLUSIONS

Pyloromyotomy is associated with a low complication rate. Cosmetically, CU is superior to the RUQ approach. Its short learning curve and the feasibility to examine the integrity of the duodenal mucosa intraoperatively may make CU a safer alternative in case of surgeons who are still practicing the RUQ approach in countries with a challenged resource settings.

Ultrasonography: Applications in Pediatric Abdomen

Ultrasonography (US) is a valuable imaging tool for evaluation of different clinical conditions in children, in general and abdominal conditions, in particular. The interest in US derives primarily from the lack of ionizing radiation exposure, low cost, portability, real-time imaging and Doppler capabilities. In addition, US application requires no preparation or sedation, making it particularly attractive in the pediatric population. Because of these advantages, US has been adopted as the primary imaging tool for evaluation of a number of pediatric abdominal conditions that would have involved the use of ionising radiation in the past, e.g., pyloric stenosis, intussusception and various renal and bladder abnormalities, to name a few. Certain limitations, however, are inherent to US including large body habitus, excessive bowel gas, postoperative state and the learning curve. In addition, pediatric US is particularly challenging as the children are frequently unable to co-operate for breath holding and many of them are crying during the scanning. In the present review, the authors discuss the various applications of US in the evaluation of pediatric abdomen.

Is there any correlation between radiologic findings and eradication of symptoms after pyloromyotomy in hypertrophic pyloric stenosis?

BACKGROUND

Hypertrophic pyloric stenosis (HPS) is one of the most common gastrointestinal disorders during early infancy, with an incidence of 1-2:1000 live births in the world. In this study, we aimed to investigate the correlation between radiologic findings and eradication of symptoms after pyloromyotomy in HPS.

MATERIALS AND METHODS

One hundred and twenty-five (102 boys and 23 girls) patients with suspected infantile HPS were treated surgically by Ramstedt pyloromyotomy between March 21, 2004 and March 20, 2014 at paediatric surgery ward of Tabriz Children's Hospital, Iran. The demographic features, clinical findings, diagnostic work-up, operation type and postoperative specifications of the patients were studied retrospectively.

RESULTS

Male to female ratio was 4:1. The patients were 16-90 days of old and the mean age was 39 ± 1.42 days. The range of pyloric canal length was 7.60-29.00 mm and the mean length was 19.54 ± 3.42 mm. Pyloric muscle diameter was 2.70-9.00 mm, and the mean diameter was 4.86 ± 1.14 mm. Seventy-two percent of patients had episodes of vomiting after operation. Mean time of persistence of vomiting after pyloromyotomy was 15.73 ± 0.15 h. Mean discharge time was 55.22 ± 0.08 h. Radiologic findings did not show any significant correlation with persistence of vomiting or discharge time.

CONCLUSION

The present study revealed that radiographic findings could not predict postoperative symptom eradication after pyloromyotomy in HPS.

Infantile hypertrophic pyloric stenosis at a tertiary care hospital in Tanzania: a surgical experience with 102 patients over a 5-year period

Background

Infantile hypertrophic pyloric stenosis (IHPS) is the most common cause of gastric outlet obstruction in infants. There is paucity of published data regarding this condition in our setting. This study describes the clinical presentation, mode of treatment and outcome of treatment of this disease and identifies factors responsible for poor outcome of these patients.

Methods

This was a descriptive retrospective study of infants with HPS admitted to Bugando Medical Centre and subsequently underwent surgery between February 2009 and January 2014.

Results

A total of 102 patients (M:F = 4.7:1) were studied. The median age at presentation was 5 weeks. The median duration of illness was 4 weeks. Fifty-four (52.9 %) patients occur in first-born children. Associated anomalies were reported in 7 (6.9 %) patients. Non-bilious vomiting was the most frequent symptom and it was described in all (100 %) patients. A palpable mass was found in 23.5 % of infants. The diagnosis of IHPS was made clinically in 86 (84.3 %) and by ultrasound in 16 (15.7 %) patients. The treatment was Ramstedt’s pyloromyotomy in all cases. There were 6 (5.9 %) intra-operative mucosal perforations which were repaired successively. Postoperative complication was 11.8 %. The median length of hospital stay was 12 days and it was significantly associated with prolonged pre-operative hospitalization (p = 0.001). The mortality rate was 4.9 %. Age below 2 weeks, late presentation (≥14 days), severe dehydration on admission, hypokalaemia on admission and surgical site infection were the main predictors of mortality (p < 0.001).

Conclusion

This study has shown that IHPS is a common condition in our setting. Age <2 weeks, delayed presentation, prolonged preoperative hospital stay, surgical site infection and high proportion of dehydration and electrolyte disturbance were the main predictors of poor outcome. A high index of suspicion is needed in infants with non-bilious vomiting to avoid delay in diagnosis.

Sonography of the pediatric gastrointestinal system

Sonography is a commonly used modality for the investigation of abdominal symptoms in the pediatric population. It is a highly sensitive, readily available imaging modality that does not require ionizing radiation, iodinated contrast material, or anesthesia and can be performed at the bedside if necessary. Abdominal ultrasound is therefore often the first examination performed. This article presents an overview of the ultrasound characteristics of some of the most frequently encountered pathologies as well as some more rarely encountered entities. Our aim was to present a series of characteristic images of a wide gamut of pediatric abdominal conditions. The goal was to familiarize the reader with key sonographic features of both congenital and acquired gastrointestinal pathologies in children, making them more easily recognizable.

An infant with poor weight gain and hypochloremic metabolic alkalosis: a case report

Bartter syndrome is an autosomal recessive disease manifested by a defect in chloride transport in the thick loop of Henle, with different genetic origins and molecular pathophysiology. Children with Bartter syndrome generally present in early infancy with persistent polyuria and associated dehydration, electrolyte imbalance, and failure to thrive. Although early diagnosis and appropriate treatment of Bartter syndrome may improve the outcome, some children will progress to renal failure. We report a case of an 8-week-old infant who was admitted for electrolyte imbalance and failure to thrive. Laboratory studies revealed hypochloremic metabolic alkalosis with severe hypokalemia. Health care providers should consider Bartter syndrome when excessive chloride losses appear to be renal in origin and the patient has normal blood pressure and high levels of serum renin and aldosterone. Treatments, including indomethacin, spironolactone, and aggressive fluid and electrolyte replacement, may prevent renal failure in children with Bartter syndrome. Molecular genetics studies are indicated to identify the primary genetic defect.

The ins and outs of pyloromyotomy: what we have learned in 35 years

PURPOSE/BACKGROUND

The aim of the study is to evaluate a large series of infantile hypertrophic pyloric stenosis (IHPS) patients treated by one pediatric surgeon focusing on their diagnostic difficulties and complications.

METHODS

From July 1969 to December 2003 (inclusive), the charts of 791 infants with IHPS were retrospectively reviewed.

RESULTS

There were 647 (82%) males and 144 (18%) females; mean age was 38 days, median 51 (range 7 days-10 months). When ultrasonography (US) was routinely used (1990), the age at diagnosis decreased to <40 days. The mean weight before and after routine US was 3.2 kg, median 3 (range 1.5-6). Twenty-five (3.1%) were premature at diagnosis, mean age 49 days, median 56, (range 1-3 months) and mean weight 2.5 kg, median 2.3 (range 1.5-3.2). Eighty-one (10%) had a positive family history. Forty-four (5%) were non-Caucasians. Seventy-five (9 %) had other medical conditions, anomalies and/or associated findings. Sixty (7%) patients had abnormal preoperative electrolytes. Ten (1.2%) pylorics occurred after newborn operations. Of the entire total (791) who were treated, there were 13 (1.7%) not operated on. All operations were done open initially through one of two right upper quadrant incisions, and then through an upper midline incision under general endotracheal anesthesia; 14 (1.7 %) had concomitant procedures. Prophylactic antibiotics (from 1982) decreased the wound infection rate to 3.9%. There were a total of 87 (10%) complications which included 9 (1.1%) intraoperative, (including mistaken diagnoses) 78 (9%) postoperative: 59 (2%) early (<1 month) and 19 (2.4%) late (>1 month). The 13 (1.6%) postoperative transfers (12 from non-pediatric surgeons) had 16 (18%) complications (including 1 death); five (33%) requiring reoperation (4 incomplete, 1 perforation). There were two deaths.

CONCLUSIONS

IHPS should be considered in any vomiting infant. US allows earlier diagnosis. Serious complications are uncommon and avoidable, but recognizable and easily corrected. Higher surgeon volume of pyloromyotomies (>14 per year) is associated with fewer complications.

The clinical features of infantile hypertrophic pyloric stenosis in Chinese Han population: analysis from 1998 to 2010

Objective

To investigate clinical features of infantile hypertrophic pyloric stenosis (IHPS) in Chinese Han population.

Methods

Three hundred and sixteen hospitalized patients with IHPS from January 1998 to February 2010 were retrospectively reviewed, and data including patient's sex, onset age, other coexisting congenital defects, pyloric circular muscle thickness evaluated by ultrasonograph, serum electrolytes concentration, and results of arterial blood gas analysis on admission were collected. The patients were divided into two groups: the duration between first onset and admission less than or equal to 10 days (early onset group), and more than 10 days (late onset group). The results of arterial blood gas and serum electrolyte concentration were compared between the two groups.

Results

There were 271 males and 45 females in 316 patients; the onset age ranged between 1 and 351 (26.5±26.6) days. The birth weight ranged between 1.6 and 4.5 (3.23±0.44) kilograms; coexisting congenital defects were found in 65 cases (20.6%). Pyloric circular muscle thickness was 4–8 (5.4±1.0) millimetres (mm). For the early onset group, the rates of hypokalemia, hypochloraemia and hypercapnia were significantly lower than those in the late onset group (18.67% VS 50%, P<0.0001; 46.03% VS 71.01%, P = 0.003; 56.58% VS 83.44%, P = 2.17×10⁻⁵; respectively).

Conclusions

The symptom duration in Chinese Han population was longer than that in other populations. And as the prolongation of symptom duration, the incidence of acid-base imbalance increased significantly. Infants with persistent vomiting at the age of 3∼5 weeks after birth should be considered IHPS, and go to hospital as soon as possible in order to reduce the incidence of hypokalemia, hypochloraemia and hypercapnia, and avoid deterioration.

Olive without a cause: the story of infantile hypertrophic pyloric stenosis

For many diseases and medical conditions the clinical recognition and the development of accurate diagnostic methods and the etiological cause precede effective treatment. In the case of infantile hypertrophic pyloric stenosis (HPS), this sequence of events did not happen. Clinical recognition of the entity proceeded directly to the development of curative treatment. Reliable diagnostic imaging methods followed, but a definitive etiology has not been elucidated. This paper reviews the historical aspects of hypertrophic pyloric stenosis, discusses how and why it took so long for this not uncommon disease to be recognized, and highlights the physicians who changed an often fatal disease into an easily diagnosed and treated minor affliction.

Tales from previous times: important eponyms in pediatric surgery

The use of eponyms in medicine has a long and captivating tradition, which applies to pediatric surgery as well. Unfortunately, even though these eponyms are widely used, oftentimes the fascinating personalities and lives behind these names remain unrecognized or underappreciated, especially among residents, fellows and younger-generation pediatric surgeons. Therefore, in this article, we review 15 names that are frequently used as eponyms in modern pediatric surgery and hereby enlighten the personalities behind them. Given their particular frequency, we choose the following eponyms: Ramstedt pylorotomy, Nissen fundoplication, Murphy's sign and sequence, McBurney's sign and incision, Meckel's diverticulum, Kasai portoenterostomy, Ladd's procedure, Morgagni and Bochdalek hernia, Ravitch operation, Nuss procedure, Hirschsprung disease, Swenson pullthrough, Peña procedure and Wilms tumor. A detailed description of the historical importance of these personalities and their contribution to our field is given. Without the appropriate historical background, it is difficult for the current younger and next generation pediatric surgeons to grasp the full spectrum of the ongoing progress in our field. Therefore, our article conveys not only important insight into the past, but also provides young surgeons with an important historical perspective essential to understand the current and future developments in modern pediatric surgery.

Predictive factors of negative outcome in initial atropine therapy for infantile hypertrophic pyloric stenosis

BACKGROUND

The predictive factors of negative outcome in initial i.v. atropine (IA) therapy of infantile hypertrophic pyloric stenosis (IHPS) are unknown. Conservative therapy for IHPS is useful for infants because it does not have the risk of surgical and anesthetic stress, but some cases of atropine therapy result in failure. This study clarified the predictive markers of negative outcome in initial atropine therapy for IHPS.

METHODS

Seventy-six patients with IHPS admitted from 1998 to 2011 were included in this study. The predictive risk factors of negative outcome in initial atropine therapy for IHPS were evaluated.

RESULTS

Thirty-one patients initially underwent non-operative therapy for IHPS during the study period. Of the 31 patients, 18 (58%) ceased projectile vomiting (PV) with IA and subsequent oral atropine. Univariate analysis showed that lack of bodyweight gain before treatment, elevated urine potassium at admission, and PV occurring ≥5 times (PV ≥5) in total for 3 days from IA initiation were predictive risk factors for negative outcome in IHPS. Multivariate analysis identified only PV ≥5 in total for 3 days after IA initiation as independently associated with failure of atropine for IHPS.

CONCLUSIONS

PV ≥5 in total for 3 days after IA initiation is a potential indicator of negative outcome of IA in IHPS patients. The present results provide valuable information for determining whether early surgical intervention for IHPS or initial atropine therapy is the best option.

Pyloromyotomy versus i.v. atropine therapy for the treatment of infantile pyloric stenosis: nationwide hospital discharge database analysis

BACKGROUND

Several studies have suggested that i.v. atropine has a potential role in treating infantile hypertrophic pyloric stenosis (IHPS). It remains unclear, however, whether surgery can be replaced by i.v. therapy.

METHODS

Data were extracted on infants with IHPS who were treated with atropine and/or surgery, from a nationwide administrative database through 2006-2008. Patient demographic data, treatment effects and length of hospital stay were analyzed in each treatment group.

RESULTS

A total of 585 infants met the criteria for IHPS; 188 patients (32%) were initially treated with atropine (i.v. form, n = 180; oral form, n = 8), while 397 were treated with surgery as a first-line therapy. Of the 180 infants receiving i.v. atropine, 38 were withdrawn from medical management and subsequently underwent surgery. Thus, the overall success rate of i.v. atropine was 78.9% (142/180). Surgery had a success rate of 100%, and postoperative complications were found in 2.8% of patients (12/435). Medical management required longer hospital stay than surgery (mean, 13.5 days vs 8.0 days; P < 0.001).

CONCLUSION

Surgery remains the suitable standard management option for IHPS, with its high success rate, minimal complications and shorter hospital stay compared with i.v. atropine therapy.

Evaluation of hypertrophic pyloric stenosis by pediatric emergency physician sonography

OBJECTIVES

The objective was to evaluate the accuracy of pediatric emergency physician (EP) sonography for infants with suspected hypertrophic pyloric stenosis (HPS).

METHODS

This was a prospective observational pilot study in an urban academic pediatric emergency department (PED). Patients were selected if the treating physician ordered an ultrasound (US) in the department of radiology for the evaluation of suspected HPS.

RESULTS

Sixty-seven patients were enrolled from August 2009 through April 2012. When identifying the pylorus, pediatric EPs correctly identified all 10 positive cases, with a sensitivity of 100% (95% confidence interval [CI] = 62% to 100%) and specificity of 100% (95% CI = 92% to 100%). There was no statistical difference between the measurements obtained by pediatric EPs and radiology staff for pyloric muscle width or length (p = 0.5 and p = 0.79, respectively).

CONCLUSIONS

Trained pediatric EPs can accurately assess the pylorus with US in the evaluation of HPS with good specificity.

Prolonged prostaglandin E1 therapy in a neonate with pulmonary atresia and ventricular septal defect and the development of antral foveolar hyperplasia and hypertrophic pyloric stenosis

Prostaglandin E1 (alprostadil) is widely used for maintaining the patency of ductus arteriosus in ductus-dependent congenital heart defects in neonates to improve oxygenation. Among more common side effects are fever, rash, apnoea, diarrhoea, jitteriness, and flushing. More severe side effects are brown fat necrosis, cortical hyperostosis, and gastric outlet obstruction, most commonly the result of antral foveolar hyperplasia or hypertrophic pyloric stenosis. We report on an infant with a ductus-dependent congenital heart defect who developed symptoms and sonographic evidence of focal foveolar hyperplasia and hypertrophic pyloric stenosis after prolonged treatment with prostaglandin E1. Gastrointestinal symptoms persisted after corrective cardiac surgery, and pyloromyotomy was required. Study of the case and of available literature showed an association between the total dose of prostaglandin E1 administered and duration of treatment and the development of gastric outlet obstruction. We conclude that if patients are treated with a prostaglandin E1 infusion, careful monitoring for symptoms and signs of gastric outlet obstruction is required.

Transmural pressure loading enhances gastric mucosal cell proliferation

AIM

Although increased intraluminal pressure in the stomach due to gastric outlet obstruction or functional gastric motor dysfunction, including gastroparesis, may affect gastric mucosal integrity, the direct effect of mechanical pressure on gastric mucosal cells has not yet been fully investigated. The aims of this study were to determine whether exposure to transmural pressure would affect the proliferation of gastric mucosal cells and to elucidate the intracellular signaling pathways involved.

METHODS

Cellular proliferation and DNA synthesis were evaluated in rat gastric epithelial cells exposed to high transmural pressures. The levels of activation of 3 MAP kinases, ERK, JNK, and p38, were assessed, and the induction of immediate early gene expression was examined. The activation of nuclear factor activator protein-1 (AP-1) was evaluated by an electrophoretic mobility shift assay.

RESULTS

Exposure to high transmural pressure significantly increased DNA synthesis within 24 h, with the most marked increase observed after exposure to a pressure of 80 mmHg, and this increase was inhibited by the MEK1 inhibitor PD98059. Early activation of ERK kinase, but not of JNK or p38 kinase, was detected after pressure loading. Early induction of the c-fos and c-myc genes and activation of the AP-1 transcription factor were also demonstrated within 3 h of exposure to 80 mmHg of pressure.

CONCLUSION

Gastric mucosal cell proliferation induced by exposure to high transmural pressure may be related to early activation of ERK, the induction of c-fos and c-myc, and the activation of AP-1.

Usual and unusual causes of pediatric gastric outlet obstruction

Gastric outlet obstruction in children encompasses a spectrum of disorders that extends beyond hypertrophic pyloric stenosis. Each condition can result in the clinical syndrome of persistent nonbilious vomiting, which can progress to dehydration and electrolyte imbalances. This paper reviews the spectrum of both the common and uncommon entities that cause partial or complete gastric outlet obstruction and their imaging appearances. The correct diagnosis of those with gastric outlet obstruction can be achieved by combining clinical presentation with appropriate imaging, leading to optimal and timely patient management.

Emergent pediatric US: what every radiologist should know

Appendicitis, intussusception, and hypertrophic pyloric stenosis (HPS) are three of the most common reasons for emergent abdominal imaging in pediatric patients. Although the use of computed tomography has risen dramatically over the past 2 decades, children are particularly at risk for the adverse effects of ionizing radiation, and even low-dose radiation is associated with a small but significant increase in lifetime risk of fatal cancer. In most emergency departments, the use of magnetic resonance (MR) imaging as a primary modality for the evaluation of a child with abdominal pain remains impractical due to its high cost, its limited availability, and the frequent need for sedation. Ultrasonography (US) does not involve ionizing radiation and, unlike MR imaging, is relatively inexpensive, is widely available, and does not require sedation. Another major advantage of US in abdominal imaging is that it allows dynamic assessment of bowel peristalsis and compressibility. Delayed diagnosis of any of the aforementioned disease processes can lead to serious morbidity and, in some cases, death. The ability to diagnose or exclude disease with US should be part of a core radiology skill set for any practice that includes a pediatric population.