Updated: 12/17/2019

Pyloric Stenosis

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Questions
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Topic
https://upload.medbullets.com/topic/120609/images/pyloric_stenosis.jpg
Snapshot
  • UltrasoundA 6-week-old first-born baby boy presents with projectile vomiting after feedings over the last 24 hours. Mom says that he enjoys feeding, and even after he vomits, he appears eager and hungry. On physical exam, you palpate an olive-shaped mass in the epigastric region. Labs show blood pH 7.47 and potassium of 3.2 mmol/L.
Overview
 
Introduction
  • Congenital hypertrophy of the pyloric sphincter 
  • Prevents stomach from emptying contents into intestinal tract 
    • "gastric outlet obstruction"
  • Risk factors
    • maternal history of pyloric stenosis
    • erythromycin use
  • Associated with transesophageal fistulas
  • Epidemiology
    • 1:500 births 
    • males > females
    • more common in first-borns
    • uncommon in children > 6 months old, most common within first 12 weeks of life
Presentation
  • Symptoms
    • infants feed well for first 2-3 weeks of life
    • presents with non-bilious vomiting after most or every feeding 
    • progresses to projectile vomiting at 2 weeks-2 months of life
    • can lead to severe malnutrition/dehydration
    • may experience other symptoms including
      • belching
      • abdominal pain
      • constant hunger
      • weight loss/failure to thrive
  • Physical exam
    • palpable epigastric olive-shaped mass
      • pathognomonic for the disorder
    • visible peristaltic waves over the gastrum
    • may have swollen abdomen indicated of starvation state

Evaluation
  • Electrolytes 
    • metabolic alkalosis
    • hypokalemia/hypochloremia
      • secondary to recurrent emesis
  • Barium studies
    • may show narrow pyloric channel
    • "string sign" or "pyloric beak"
  • Ultrasound
    • hypertrophic pylorus may be observed
Differential
  • Hiatal hernia, duodenal atresia, volvulus, meconium ileus, GERD, gastroenteritis, tracheoesophageal fistula

Treatment
  • Medical management
    • Hydration via IV fluids
      • indicated in all cases
    • Normalize acid-base/electrolyte abnormalities
      • potassium replacement is key
      • indicated in all cases
  • Surgical intervention
    • pyloromyotomy
      • indicated for surgical correction of defect
Prognosis, Prevention, and Complications
  • Prognosis
    • very good to excellent
    • surgery relieves symptoms and child is usually eating within hours of surgery
  • Prevention
    • there are no preventive measures available at this time
  • Complications
    • failure to thrive
High Yield
  • A newborn boy presents with projectile vomiting and is always hungry to eat more after vomiting.  The vomit is non-bilious, and an olive shaped mass is palpable in the patients abdomen.  The patient has been treated with erythromycin for an infection.
    • next best step in management: IV fluids and correct electrolytes (or order a complete metabolic panel)
    • best initial test: ultrasound with a target shape lesion
    • most accurate test: ultrasound
    • treatment: pyloromyotomy

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Questions (5)

(M2.PD.17.4688) A 5-week-old male infant is brought to the Emergency Department with the complaint of vomiting. His parents state he has been unable to keep normal feedings down for the past week and now has projectile non-bilious vomiting after each meal. He was given a short course of oral erythromycin at 4 days of life for suspected bacterial conjunctivitis. Physical examination is significant for sunken fontanelles and dry mucous membranes. A palpable, ball shaped mass is noted just to the right of the epigastrum. Which of the following conditions is most likely in this patient?

QID: 107551
1

Gastroesophageal reflux

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(0/7)

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Hypertrophic pyloric stenosis

86%

(6/7)

3

Milk-protein allergy

0%

(0/7)

4

Midgut volvulus

0%

(0/7)

5

Intussusception

14%

(1/7)

M 6 D

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(M2.PD.16.4694) A 3-week-old boy has non-bilious projectile vomiting that occurred after feeding. After vomiting, the infant is still hungry. The infant appears dehydrated and malnourished. A firm, “olive-like” mass of about 1.5 cm in diameter is palpated in the right upper quadrant, by the lateral edge of the rectus abdominus muscle. On laboratory testing, the infant is found to have a hypochloremic, hypokalemic metabolic alkalosis. Which of the following is most likely the cause of this patient’s symptoms?

QID: 107693
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Intussusception

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Duodenal atresia

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Hypertrophy of the pylorus muscle

100%

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Aganglionic colon segment

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Achalasia

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(M2.PD.14.13) A 5-week-old boy presents to the emergency department because of feeding problems. His parents inform the physician that their child has been vomiting after many of his feeds for the past week. They state that this is a new issue. His temperature is 97.6°F (36.4°C), blood pressure is 74/50 mmHg, pulse is 170/min, respirations are 15/min, and oxygen saturation is 99% on room air. Ultrasound of the abdomen is performed as seen in Figure A. Which of the following changes in Figure B is most likely to be seen in this patient?

QID: 104287
FIGURES:
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A

8%

(1/12)

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B

75%

(9/12)

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C

8%

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D

8%

(1/12)

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E

0%

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M 6 E

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Evidence (5)
VIDEOS & PODCASTS (1)
EXPERT COMMENTS (16)
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