pyloric stenosis.ppt

1)Nitrous oxide synthase deficiency (most accepted )

2)Nerve cell theory ( ganglion cell theory)

3)Increased child & maternal gastrin

3/1000 live birth Definite familial incidence Male:Female = 4:1 Commonly in the first born male child Most common cause for laparotomy

before 1 year Age: 3 weeks - 3 months

Circular muscle hypertrophy

Contraction to overcomeobstruction

Stagnation gastritis

Gastric dilataion

1. Vomiting Non-bilious Progressive Projectile or forcible Persistent Immediately after meals Child is hungry and eager to eat after Sometimes, coffee ground due to gastrits2. Constipation3. Failure to thrive & loss of weight

1. General signs of dehydration Wasting Sunken eyes Depressed fontanel

2. General signs of vitamin deficiency

Test feeding revealed visible peristalsis from the left to the right in the upper abdomen.

Olive shaped mass “pyloric tumor” at the angle between right rectus muscle and the liver.

1. Complete blood count2. Blood Chemistry Serum electrolytes ( sodium,

potassium, chloride) → diminished Urea → elevated Blood glucose → diminished3. Arterial blood gases (ABG) Metabolic alkalosis

1. Abdominal X-ray

2. Barium meal

3. Ultrasonography

Dilated stomach with single bubble sign Scanty gases distal to the obstruction

Dilated stomach Delayed gastric emptying Hypertrophic gastric rugae “String sign”: Narrow & elongated pyloric canal “Beak sign”: Narrow pyloric lumen/channel to a

point “Shoulder sign”: impression on the antrum and

the duodenal cap by the thick muscle “Double track sign”: when the narrow pyloric

channel is lined on opposing luminal surface with contrast

Diagnosis is confirmed when: Pyloric muscle thickness (serosa→mucosa)

≥4mm Pyloric thickness (serosa→serosa) ≥ 15mm Pyloric channel length ≥ 17mm Circumferential muscular thickening

surrounding the central channel and filled with mucosa( “target sign”.

Causes of non-bilious vomiting

SurgicalPyloric atresiaAntral webPylorospasmGastro-oesophageal refluxGastric volvolusPreampular duodenal stenosisEctopic pancreas within the pyloric muscle

MedicalGastroenteritisIncreased intracranial pressureMetabolic diseases

Hospitalization NG suction Correction of fluid,electrolytes & pH

disturbances Maintenance fluid with 5% dextrose in 0.45%

normal saline containing 20-40 mEq/l KCl.

Fred-Ramstedt’s pyloromyotomy

Right upper quadrant transverse or umbilical fold incision

Delivery of the hypertrophied pylorus Splitting of the pyloric muscle till mucosal

bulge

Fred-Ramstedt’s pyloromyotomy

Fred-Ramstedt’s pyloromyotomy

Crystalloid resuscitation is continued postoperatively until the patient returns to full feeding.

1. Wound infection2. Incisional hernia3. Persistent vomiting due to: Stagnation gastritis Inadequate pyloromyotomy4. Mucosal perforation

Pyloric stenosis

Age

Sex

Clinical

Investigation

Treatment

3weeks – 3 months

Male predominance

Non-bilious vomitingOlive mass

U/S

Surgical

A 3-week-old, first-born male develops forceful, non- bilious emesis. Which of these findings establishes the diagnosis?

(A) ultrasonographic pyloric muscle thickness of 2.5 mm

(B) ultrasonographic pyloric thickness greater than 1.5 cm

(C) ultrasonographic pyloric diameter of 1.0 cm or less(D) an UGI series showing a classic "double bubble"

sign (E) palpable pyloric mass (olive) midline of the

abdomen

Which of the following is most consistent with pyloric stenosis?

A. Na 140 Cl 110 K 3.2 HCO3 26

B. Na l42 Cl 90 K 5.2 HCO3 39

C. Na 139 Cl 85 K 3.2 HCO3 36

D. Na l40 Cl 95 K 4.0 HCO3 38 

A 4-week-old breast-fed boy was completely well untill 2 days earlier, when he began vomiting all feeds. He was otherwise well, and keen to feed the persistent vomiting.

(a)What is the significant thing to ask about regarding vomiting?

(b)What physical sign would you wish to find to confirm the diagnosis you suspect?

(c) If you were unable to demonstrate this sign, what would you do if you still suspect?

(d)What initial investigations would you perform to assist you in resuscitation?