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Annular pancreas
5%
5/111
Duodenal artresia
3%
3/111
Hirschprung's disease
2%
2/111
Necrotizing enterocolitis
0%
0/111
Pyloric stenosis
89%
99/111
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This infant with forceful, non-bloody, non-bilious vomiting likely has pyloric stenosis.Pyloric stenosis presents with non-bilious, "projectile" vomiting in the first few weeks of life. It presents most commonly in infants between the ages of 3-6 weeks, and is more common in males. The condition also has a predilection for first-born males. Classically, an olive-shaped mass is palpated in the abdomen in physical exam. Pyloric stenosis causes a hypochloremic, hypokalemic metabolic alkalosis due to electrolyte loss from frequent vomiting. Pyloric stenosis is diagnosed with abdominal ultrasound that will show a thickened, obstructed pylorus. Patients are typically managed first with fluid resuscitation and electrolyte repletion. Infants with hypokalemic, hypochloremic metabolic alkalosis are at particularly increased risk for apnea if these derangements are not corrected. Once resuscitated, patients are managed with surgical intervention. Van den Bunder et. al review the association of perioperative apnea with pyloric stenosis. They note that this often occurs in patients with a hypochloremic, hypokalemic metabolic alkalosis. They recommend repletion of fluids and electrolytes prior to surgery.Illustration A shows a longitudinal ultrasound of pyloric stenosis with the arrow denoting a long and thick pyloric channel.Incorrect Answers:Answer 1: Annular pancreas is a congenital malformation that results in obstruction of the duodenum due to compression by the pancreas. However, obstruction occurs distal to the ampulla of Vater, therefore vomiting is bilious. Answer 2: Duodenal artresia is a congenital cause of duodenal obstruction that is commonly associated with Down syndrome. It is commonly discovered at birth with failure to pass meconium. Answer 3: Hirschprung's disease is a congenital condition that results in inability to pass stool. Exam characteristically reveals an empty rectal vault. It is typically diagnosed shortly after birth. Answer 4: Necrotizing enterocolitis is an infection of the bowel wall. It is most common in premature neonates. It presents with abdominal distention and sepsis.Bullet Summary:Pyloric stenosis commonly affects males between the ages of 3 and 6 weeks and presents with forceful, non-bloody, non-bilious emesis.
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