2. Gastric Outlet Obstruction
• is non-bilious vomiting
• Other signs include abdominal distention
and bleeding from secondary inflammation
• Most common cause of non-bilious
vomiting is infantile hypertrophic pyloric
stenosis
3. Pyloric Stenosis
• First described by Hirschsprung in 1888
• Ramstedt described an operative
procedure to alleviate the condition in
1907 – the procedure used to this day to
treat pyloric stenosis
4. Pyloric Stenosis
• 3/1000 live births – frequency may be increasing
• Most common in whites of Northern European
ancestry, less common in African Americans
and rare in Asians
• Four times more common in males – especially
firstborn
• Increased in infants with type B or O blood
groups
5. Etiology
• Cause is unknown, but abnormal muscle
innervation, breast feeding and maternal
stress in the 3rd
trimester have been
implicated
• Elevated serum PG’s, reduced levels of
pyloric nitric oxide synthase and infant
hypergastrinemia have been found
6. Clinical Manifestations
• Non-bilious vomiting is the initial symptom
• May or may not be projectile initially
• Usually progressive, occurs immediately
after a feeding
• Vomiting usually starts after 3 wks of age,
but may develop as early as 1st
week and
as late as the 5th
month
7. Clinical Manifestations
• After vomiting, infant is hungry and wants
to feed again
• Progressive loss of fluid, hydrogen ion and
chloride leads to a hypochloremic
metabolic alkalosis.
• Serum K levels are maintained
• Greater awareness has led to earlier
diagnosis
8. Clinical Manifestations
• Jaundice occurs in 5% of infants with
pyloric stenosis – associated with a
decreased level of glucuronyl transferase
10. Diagnosis
• Diagnosis traditionally made by palpation of
mass
• Firm, movable, approx 2 cm in length, olive
shaped and best palpated from the left
Mass located above and to the right of the
umbilicus in the midepigastrum beneath the liver
edge
• Peristaltic wave may be present prior to emesis
11. Treatment
• Preoperative treatment is directed toward
correcting the fluid/acid-base and
electrolyte imbalances.
• Correction of the alkalosis is essential to
prevent postoperative apnea
• Surgery is the treatment of choice –
Ramstedt pyloromyotomy
12. Treatment
• Ramstedt pyloromyotomy – performed through a
short transverse incision or laparoscopically
• Underlying pyloric mass is split without cutting
the mucosa and the incision is closed
• Post-op vomiting occurs in ½ the patients and
thought to be due to edema of the pylorus
• Feedings can usually be initiated within 12-24
hours
13. Treatment
• Persistent vomiting suggests an
incomplete pyloromyotomy, gastritis,
GERD.
• Surgical treatment is curative with a low
mortality rate
