for more information and get download version visit drarjunpawar.com Infantile hypertrophic pyloric stenosis

1. Infantile Hypertrophic Pyloric
Stenosis
• Most common cause of gastric outlet
obstruction in infants.
• prevalence - 1.5 to 4.0 per 1000 live
births
• more common in boys than girls,
ratio of approximately 2:1 to 5:1.

2. Etiology of IHPS
No definitive causative factors have been
identified.
• Top Feeding (breast-feeding versus formula
feeding), seasonal variability,
• erythromycin exposure,
• transpyloric feeding of premature infants.
• alterations in relaxation of the pyloric muscle.
• Immature ganglion cells in pylorus.
• Lack of Nitric Oxide Synthase in pyloric
tissue might be responsible for
pylorospasm and lead to IHPS.

3. Symptoms & signs
• Vomiting after feeding- forceful, projectile,
nonbilious vomiting
• More common in 3 to 6 wks of age
Sometimes Coffee ground due to gastritis
• Persistent hunger( want to feed soon after
vomiting).
• Decreased urine output,
• Diarrhea (Starvation Stool)
• Failure to thrive, weight loss,
O/E: Dehydration, Lethargic
• Epigastric Fullness & Visible gastric peristalsis)
• Palpable “olive” in epigastrium
• Ictero-pyloric syndrome(5%)

5. Differential diagnosis
Medical:
• High grade reflux
• Viral GE
• Adrenal crisis(Hyperkalemic acidosis)
• ICH
Surgical:
• Duodenal atresia/Stenosis(Annular Pancreas)
• Antral web/ Atresia
• Antro-pyloric duplication

6. Investigations
• Biochemical investigation-
CBC,KFT,LFT,SE.
• ABG
• X ray abdomen-Erect
• USG abdomen

7. Biochemical Investigations
• Hypochloremic, hypokalemic metabolic
alkalosis with paradoxical aciduria in
advanced cases.
• Hypocalcemia
• with or without renal failure- Increased BUN
& Creatinine
• Jaundice(Ictero-pyloric syndrome)

8. ABG

9. X ray abdomen-Erect & dye study

10. USG Criteria
• Pyloric muscle thickness
-3.5 (in premature infants) to 4 mm or
more
- Pylorus Diameter > 1.4 cm
• Pyloric channel length - 16 mm or greater

12. Treatment
• Correction of dehydration and Sr. electrolytes
• 0.45% DNS + KCL
• Fluid requirement – 1.5 times
• Repeat ABG before surgery

13. Surgery
• Ramstedt Pyloromyotomy
• Laparoscopic Pyloromyotomy
• Non operative management

16. Ramstedt Pyloromyotomy

18. Ramstedt Pyloromyotomy

19. Laparoscopic Pyloromyotomy

20. 2 Port technique
A 5mm, 30o telescope
Insufflation pressures : 6
to 8 mm of Hg
Flow rate : 1 to 2 l/min
Electrocautery hook
Surgical Steps

21. Laparoscopic Pyloromyotomy

23. Immediate post op 6 weeks post op

24. Post op Feeding
Post pyloromyotomy Feeding Schedule*
• Pedialyte, 30 mL orally every 3 hr 1
• Full-strength formula, 30 mL orally every 3 hr 1
• Full-strength formula, 45 mL orally every 3 hr 2
• Full-strength formula, 60 mL orally every 3 hr 1
• Full-strength formula, 75 mL orally every 3 hr 1
• Full-strength formula as desired

25. Complications
• Persistent vomiting- incomplete
pyloromyotomy
• Mucosal perforation
• Anaesthesia related – Unable to extubate,
apnoea

26. Non operative management

27. Dose of atropine
I.V. Atropine –
0.01mg/kg /dose
6 times/ day
10 minutes before each feed
For initial 3 to 5 days
Oral Atropine-
0.02mg/kg/dose
6 times/day for
2wks

28. Thank you