IHPS if you want take will info then download it with animation

1. ‫الرحیم‬ ‫الرحمن‬ ‫هللا‬ ‫بسم‬
2/8/2021 1

2. Nangarhar University Teaching Hospital
Surgery ward
Topic to be presented
Infantile Hypertrophic Pyloric Stenosis
( IHPS )
Presenter
Dr. Abdullah Ihsaas 3rd Year TMO of GS
Guidance
Associate prof Dr. Gul aqa sadat
Date
1399/11/16
2/8/2021 2

3. Anatomy of stomach
• Stomach is most dilated part of gastrointestinal tract and has a J-like shape
• Positioned between the abdominal esophagus and the small intestine
• Located in epigastrium, Umbilical and lift hypochondrium regions of the
abdomen
Divided into four regions
1. Cardia
2. Fundus
3. Body
4. Pyloric part: which is divided into
 Pyloric antrum
 Pyloric canal
• Pylorus contained thick circular muscle the pyloric sphincter  symphatitic and ganglion
innervation
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4. The GI tract contains four layers:
1. Mucosa (the innermost layer)  epithelium , lamina propria , muscularis mucosa
2. sub mucosa
3. muscularis propria ( smooth muscle layer ) : There are usually two layers
 the inner layer is circular
 the outer layer is longitudinal are used for peristalsis (rhythmic waves of
contraction)
4. adventitia Or serosa ( the outermost layer ): of loose connective tissue - covered by the
visceral peritoneum. Contains
 blood vessels,
 lymphatic's and nerves.
Layers of the Gastrointestinal Tract
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6. Function of pylorus
Food from the stomach, as chyme, passes through the pylorus to the duodenum . The
pylorus, through the pyloric sphincter, regulates entry of food from the stomach into the
duodenum.
Gastric Juice :
Hydrochloric acid
Mucus
pepsin
Lipase
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7. Innervation
innervated by intrinsic neurons of the enteric nervous system (ENS)
and by the axons of extrinsic sympathetic, parasympathetic
and visceral afferent neurons.
Both the intrinsic and the extrinsic innervation, to different degrees, are affected by age
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8. History
• Hildanus in 1627 the first auter who described case of IHPS, how ever the history dos not fit,
child recover spontaneously it is likely a case of overfeeding
• Patrick Blair in 1717 described a more typical clinical and postmortem finding of IHPS
• first complete description was by Herald Hirsch sprung in 1888 and named it angeborener
pylorus stenosis ( congenital pyloric stenosis )
• Cordua  jejunostomy 1892
• Lobker  gastroenterostomy 1898
• Nicolle tried  pyloric dilatation via gastrostomy
• Pyloroplasty and external mucosal pyloroplasty  nicool, Dent, fredet and weber
• On 23 august 1911 Wilhelm Conrad Ramstad firs performed his pyloromyotomy without
transversal suture
• On 18 June 1912 he repeated his new technique on another male patient and reported these two
canes to the national science assembly at Munster, Ramstad operation is nowadays a stander
surgical technique for the IHPS.
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9. Infantile hypertrophic pyloric stenosis
• One of the most common surgical condition of the newborn
• A condition characterised by concentric hypertrophy of the muscle involving the internal
circular layer of pylorus on gastric side
• Produces a gastric outlet obstruction
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10. Epidemiology
Incidence
• It occurs at a rate of 1 to 4 per 1000 live births
• Commonly occur in causation in ( whites ) but is less common in ( Africans and
Asians)
• Males are affected more often with a 4:1 male to female ratio.
• Present in infants between 3 and 8 weeks of age
• First born
• Preterm infants
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11. Etiology and risk factors
but Genetic and environmental factors appear to play a large role in
pathophysiology
Environmental factors associated with HPS include
 The method of feeding
 Seasonal variability
 Exposure to erythromycin in first 2 weeks of age has been reported
There has been lot of research on this subject and various factors
Several gastro intestinal peptides or growth factors that may facilitate pyloric
hypertrophy some of these include
Substance p – decreased neurotrophins, deficient nitric oxide synthase and gastrin
hyper secretion
Ultrastructure abnormalities of enteric nerves and the interstitial cells of cajal have
been implicated
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12. Cont.
 A cohort study found that treatment of young infants with macrolide antibiotics was
strongly associated with infantile hypertrophic pyloric stenosis (IHPS).
 Maternal use of macrolides during the first 2 weeks after birth was also associated
with an increased risk of IHPS.
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13. Risk factors including
Family history
Maternal
 Younger maternal age <25y
 Maternal smoking during pregnancy
Fatal
 Gender
 Being a first born infant
 Premature infants are diagnosed with HPS
later than term or post term infants
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14. Associated anomaly's
Golden role in children's
I. Some is Genetically x linked described by spicer
 esophageal atresia and neuronal dysfunction
 Turner syndrome
 Trisomy 18
II. Other Non Genetic Malformations
 Inguinoscrotal pathology
 Encephalocele
 Hydrocephalus
 Cardiac malformation
 Gastro esophageal reflux
 Hiatus hernia
 Jaundice described with IHPs usually resolves after pyloromyotomy
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15. Clinical manifestation
Often start with Vomiting at 3 - 8 week of life, and some time earlier
 Post prandial – always Forceful – non bilious
 Remain hunger
 The vomit contains milk or curds
 It can have a brownish discoloration or have ‘’Coffee ground” appearance
caused by chronic gastritis
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16. Physical examination
Physical examination mad diagnosis 75 %
Start by a feeding of formula or breast feed if the infant state allows it
( alert, active )
Inspection:
 Visible gastric peristaltic waves that progress successively from the
upper left to the mid right of the abdomen. ( golf ball waves )
Palpation:
The examiner should stay on the left of the patient while baby is supine
in mothers arms, relaxed, warmed reassured
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17. Physical examination
 The left hand is placed are the epigastrium with the mid finger tip just above
and to the right of the umbilicus.
 The right hand is beneath the infant for support, giving a slight extension to the
back in order to ease the palpation of the ( olive ) which is pushed forward by
the vertebrae.
 If it is not palpated , then the test is repeated just after an episode of vomiting
or decompression of stomach via NGT 10fr, 12fr
 Jaundice 2 % cases
 Dehydration and malnutrition such as poor weight gain, weight loss, marasmus,
decreased urinary output, lethargy, and shock
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19. Assessment and Diagnostic Findings
Diagnosis is usually made on the clinical evidence.
 Laboratory studies:
Electrolytes, pH, BUN, and creatinine levels should be
obtained at the same time as intravenous access in patients with pyloric stenosis.
 Ultrasonography.
 If the clinical presentation is typical and an olive is felt, the diagnosis is almost
certain
 however formal ultrasonography is still recommended to confirm the diagnosis.
 Sensitivity and specificity approach 100%
 Diagnostic criteria  pyloric muscle thickness of 4mm or more and pyloric channel
length of 16mm or more
 Radiography:
 Barium swallow show an abnormal retention of barium in the stomach and increased peristalsis.
• String sign  contrast within the narrow lumen
• Shoulders  bulging of the pyloric muscle protruding into the antrum
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21. Differential Diagnosis
DDx for nonbiloius vomiting should be considered
This include medical and surgical conditions
Medical
 Pylorospasm
 Gastric atony
 GERD
 Gastroenteritis
 Increased intracranial pressure
 And metabolic disorders
Surgical or Anatomic causes
 Gastric Antral web
 Pyloric atresia
 Foregut duplication cyst
 Gastric tumors or a tumor causing extrinsic gastric compression
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22. Pathophysiology
• Child with uncorrected metabolic alkalosis will hypo ventilate to normalize serum PH ( compensatory
respiratory acidosis ) clinically this translates to an inability to wean from mechanical ventilation post
operatively.
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23. Pre operative management
Correction of dehydration and electrolyte abnormalities is obligatory before
bringing the infant to operating room
Pre operative fluid resuscitation
 Type of fluid : 5% Dextrose with 0.45% saline.
 Add 2mmol of KCl in each 100 of fluid
 Volume: 150 ml/kg of body Wight /24 hr.
 Correct hypovolaemia with 10ml /kg 0.9% saline
 The most important factor is serum HCO3 level 25 – 28 mEq/L
• Close attention is paid to urinary output ,over all perfusion, repeat lab
investigation
• All enteral feedings are held prior to surgery (NPO)
• There is no need for nasogastric decompression for long time if there was any
radiopaque
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24. Management
I. Medical
II. Operative management
 Open approach
 Laparoscopic approach
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25. 1. Medical
 Reports of medical treatment with
 atropine and pyloric dilation
 but require long periods and are often not effective
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26. 2. Operative management
The mainstay of therapy is typically resuscitation followed by
pyloromyotomy.
1. The open approach
 Several incisions have been described for the open approach
 The typical right upper quadrant transverse incision seems to be commonly
 More cosmetically pleasing incision is Omega – shaped incision around the superior portion of the
umbilicus
 Pylorus is delivered through the incision
 A longitudinal serosal incision is made in the pylorus approximately 2 mm proximal to the junction of the
duodenum an is carried onto the anterior gastric wall for approximately 5 mm.
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28. Cont..
 Blunt dissection  divided the firm pyloric fibers using the handle
of a scalpel.
 Until the pyloric sub mucosal layer is seen and slightly protruded
 Care must be exercised when dividing fibers
 Ensure independent movement of mucosa in edges
 The mucosal integrity can be checked by installing air through the
NG tube if there are no leakage air should suctioned
 If there was perforation then close it with omental patch
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29. 2. Laparoscopic pyloromyotomy
Alain et al first describe extra mucosal pyloromyotomy
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30. Laparoscopic vs open approach
• The large randomized controlled series comparing open vs
laparoscopic pyloromyotomies showed less post operative pain, and
emesis, and fewer complications in the laparoscopic group but no
difference in length of hospital stay or operating time
• Laparoscopic surgery need great deal of experience
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31. Post operative care
• Rapid resolution of emesis
• Short duration of analgesic requirement
• Significant improvement in feeding tolerance  start 15 -30 ml per
feed several hour after the conclusion of the operation
some other ( 18 – 24 hr. )
• Persistent emesis while in the hospital giving H2 blocker or PPI
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32. Complications
• Mucosal perforation
• Wound infection
• Emesis
• Incisional hernia
• Dehiscence
• Recurrent pyloric stenosis
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33. Outcomes
• In the past, the mortality from pyloric stenosis was considerable and
approached 50%.
• Today, however, mortality is nearly zero with improvement in neonatal
resuscitation and anesthesia as well as surgical techniques.
• Morbidity is also significantly lower than in the past
• an overall complication rate between 1–2%. Additionally,
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35. Reference
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