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Infantile hypertrophic pyloric stenosis

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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.
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.
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%)
Infantile hypertrophic pyloric stenosis
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
Investigations
• Biochemical investigation-
CBC,KFT,LFT,SE.
• ABG
• X ray abdomen-Erect
• USG abdomen

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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
  • 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
  • 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
  • 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