pyloric stenosis 2

7/31/2019 Pyloric Stenosis 2

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Infants with vomiting

Prepared by.........Nuthapong Ukarapol , M

CC : Two infants were referred to the hospital because of vomiting.

Clinical presentations Case 1 Case 2

Age 3 weeks 4 weeks

Sex Female Male

Birth weight 2700 grams 2700 grams

Body weight on admission 3080 grams 2750 grams

Onset of symptoms 5 minutes after feeding 5- 30minutes after feeding

Characteristic of vomitus Digested milk Digested milk with bile

Abdominal mass Negative Negative

Abdominal distension Present PresentHistory of meconium passage within 24 hours within 24 hours

Feeding Formula Breast feeding

Initial investigations

Investigations Case 1 Case 2

Sodium 141 139

Potassium 5.3 5.3

Chloride 109 108

TCO219 18

Plain abdomen dilated stomach with small air in the

small intestine

dilated stomach with fair

amount of air in the smallintestine

What are the differential diagnosis for an infant with vomiting?

Group Diseases

GI obstruction Pyloric stenosis

Duodenal obstruction

Malrotation withintermittent volvulus

Hirschsprung's disease

GI disorders Gastroenteritis

Gastritis/duodenitis (CMA)

Eosinophilic/allergic

esophagitisGastroparesis

Achalasia


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Neurologic conditions HydrocephalusMass lesions

Infections Meningitis/sepsisUrinary tract infection

Metabolic/endocrine disorders Urea cycle defectCAH

Galactosemia

Organic acidemia

Toxic substances Iron

Vitamin A or D

What is/are the investigations for an infant with vomiting?

1. Ultrasound abdomen: to evaluate the presence of hypertrophic pyloric stenosis

2. UGIS: to evaluate mechanical obstruction e.g. achalasia, pyloric stenosis, duodenal web, duodenal stenosis,anular of pancreas, malrotation with ladd's band, volvulus, and jejunal or ileal atresia

3. Barium enema: to evaluate Hirshchsprung's disease

4. EGD: to evaluate mucosal diseases in the stomach e.g. cow's milk allergy, eosinophilic gastroenteritis, reflux

esophagitis

5. Metabolic screening e.g. electrolytes, LFT, urine reducing substances in suspected cases

6. Neuroimaging studies: to evaluate increased intracranial pressure in suspected cases

Discussion and disease progression

Case 1: This was a female newborn presenting with nonbillous vomiting. The initial diagnosis was gastric outlet

obstruction (hypertrophic pyloric stenosis). However, because there was neither physical finding (abdominal massnor electrolyte abnormality (hypochloremic hypokalemic metabolic alkalosis) characteristic of hypertrophic pytoristenosis, and because of the fact that the patient was a female other differential diagnoses should be considered. These include cow's milk allergy and eosinophilic gastroenteritis. An ultrasonography was performed and showedmild thickening of pyloric muscle (3.8 mm)(Fig. 1). During admission, the patient developed upper GI hemorrhagtherefore EGD was done to evaluate any feasible GI mucosal disorders. Reflux esophagitis and prolapse gastropath

were responsible for upper GI bleeding, The scope could be forcefully passed into the duodenum. There was a

pyloric obstruction noted during the procedure. The pathology revealed no evidence of cow's milk allergy or

eosinophilic gastroenteritis. An UGIS was finally confirmed the diagnosis of hypertrophic pyloric stenosis (Fig. 2)


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Figure 1 An ultrasonography scans pyloric region.

The markers are measuring the thickness of pyloric

muscle, which is 3.8 mm.

Figure 2 An upper GI series demonstrates pyloric

obstruction with a string sign. The findings are

consistent with pyloric stenosis.

Case 2: Because of billous vomiting, an UGIS was carried out first.The intestinal malrotation is demonstrated as

figure 3 and figure 4.

Fig 3 An upper GI series reveals a point of obstrution

at the fourth part of the duodenumFigure 4 An upper GI series demonstrates

malposition of the DJ junction, which is supposed

to be at the same level of the duodenal bulb. The

finding indicate intestinal malrotation.

Diagnosis: Case no. 1: Hypertrophic pyloric stenosis; Case no. 2: Intestinal malrotation with Ladd's band

Treatment:Case no.1: pyloromyotomy; Case no. 2: Lysis band

Points of discussion

1. Vomiting during newborn period should be considered as pathological condition until proved otherwise.

2. Poor weight gain is an important clinical clue to exclude overfeeding or problems in feeding techniques. As not


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in our cases, both of them had failure to thrive.3. Mode of inheritance in pyloric stenosis is multifactorial with male predominance (4-6:1). However, when femal

is affected, recurrence rate in all offspring is much higher than when male is affected (13% vs. 2.5-4%). Therefore

careful genetic counseling is very crucial.

4. A palpable abdominal mass in pyloric stenosis may be difficult to detect because of an overlying, dilated antrum

However, it can be more easily palpated after vomiting and gastric decompression. Overall, an experiencedexaminer could palpate a mass in only 60-80% of cases.

5. Electrolyte abnormality might not be present in all cases, particularly in a patient with short duration of thedisease.

6. Billous vomiting is an important history that leads us to investigate for small bowel obstruction rather than gastr

outlet obstruction. Therefore, the ultrasonography would not be useful in such case.

pyloric stenosis 2

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