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Pyloric Stenosis

Pyloric stenosis (or infantile hypertrophic pyloric stenosis) is a condition that causes severe projectile
non-bilious vomiting in the first few months of life. There is narrowing (stenosis) of the opening from the
stomach to the first part of the small intestine known as the duodenum, due to enlargement (hypertrophy) of the
muscle surrounding this opening (the pylorus, meaning "gate"), which spasms when the stomach empties. This
hypertrophy is felt classically as an olive-shaped mass in the middle upper part or right upper quadrant of the
infant's abdomen. In pyloric stenosis, it is uncertain whether there is a real congenital narrowing or whether
there is a functional hypertrophy of the pyloric sphincter muscle. This condition typically develops in male
babies in the first 26 weeks of life.

Pyloric stenosis also occurs in adults where the cause is usually a narrowed pylorus due to scarring from
chronic peptic ulceration. This is a different condition from the infantile form.

Signs and symptoms

Babies with this condition usually present any time in the first weeks to months of life with
progressively worsening vomiting. The vomiting is often described as non-bile stained ("non bilious") and
"projectile vomiting", because it is more forceful than the usual spittiness (gastroesophageal reflux) seen at this
age. Some infants present with poor feeding and weight loss, but others demonstrate normal weight gain.
Dehydration also can occur causing the baby to cry without having tears, and having less wet or dirty nappies
such as going hours or a couple days without having anything.

Constant hunger, belching, and colic are other
possible signs as the baby is not able to eat properly.

Diagnosis

Diagnosis is via a careful history and physical examination, often supplemented by radiographic studies.
There should be suspicion for pyloric stenosis in any young infant with severe vomiting. On exam, palpation of
the abdomen may reveal a mass in the epigastrium. This mass, which consists of the enlarged pylorus, is
referred to as the 'olive', and is sometimes evident after the infant is given formula to drink. It is an elusive
diagnostic skill requiring much patience and experience. There are often palpable (or even visible) peristaltic
waves due to the stomach trying to force its contents past the narrowed pyloric outlet.
Most cases of pyloric stenosis are diagnosed/confirmed with ultrasound, if available, showing the thickened
pylorus. Although somewhat less useful, an upper GI series (x-rays taken after the baby drinks a special contrast
agent) can be diagnostic by showing the narrowed pyloric outlet filled with a thin stream of contrast material; a
"string sign" or the "railroad track sign". For either type of study, there are specific measurement criteria used to
identify the abnormal results. Plain x-rays of the abdomen are not useful, except when needed to rule out other
problems.

Blood tests will reveal hypokalemic, hypochloremic metabolic alkalosis due to loss of gastric acid
(which contain hydrochloric acid and potassium) via persistent vomiting; these findings can be seen with severe
vomiting from any cause. The potassium is decreased further by the body's release of aldosterone, in an attempt
to compensate for the hypovolaemia due to the severe vomiting.




Pathophysiology

The gastric outlet obstruction due to the hypertrophic pylorus impairs emptying of gastric contents into
the duodenum. As a consequence, all ingested food and gastric secretions can only exit via vomiting, which can
be of a projectile nature. The exact cause of the hypertrophy remains unknown. The vomited material does not
contain bile because the pyloric obstruction prevents entry of duodenal contents (containing bile) into the
stomach. This results in loss of gastric acid (hydrochloric acid). The chloride loss results in hypochloremia
which impairs the kidney's ability to excrete bicarbonate. This is the significant factor that prevents correction
of the alkalosis. A secondary hyperaldosteronism develops due to the hypovolemia. The high aldosterone levels
causes the kidneys to avidly retain Na
+
(to correct the intravascular volume depletion), and excrete increased
amounts of K
+
into the urine (resulting in hypokalaemia). The body's compensatory response to the metabolic
alkalosis is hypoventilation resulting in an elevated arterial pCO
2
.

Treatment

Infantile pyloric stenosis is typically managed with surgery; very few cases are mild enough to be
treated medically.

The danger of pyloric stenosis comes from the dehydration and electrolyte disturbance rather than the
underlying problem itself. Therefore, the baby must be initially stabilized by correcting the dehydration and
hypochloremic alkalosis with IV fluids. This can usually be accomplished in about 2448 hours.
Intravenous and oral atropine may be used to treat pyloric stenosis. It has a success rate of 85-89% compared to
nearly 100% for pyloromyotomy, however it requires prolonged hospitalization, skilled nursing and careful
follow up during treatment. It might be an alternative to surgery in children who have contraindications for
anesthesia or surgery.

Surgery

The definitive treatment of pyloric stenosis is with surgical pyloromyotomy known as Ramstedt's
procedure (dividing the muscle of the pylorus to open up the gastric outlet). This is a relatively straightforward
surgery that can possibly be done through a single incision (usually 34 cm long) or laparoscopically (through
several tiny incisions), depending on the surgeon's experience and preference.

Today, the laparoscopic technique has largely supplanted the traditional open repairs which involved
either a tiny circular incision around the navel or the Ramstedt procedure. Compared to the older open
techniques, the complication rate is equivalent, except for a markedly lower risk of wound infection. This is
now considered the standard of care at the majority of Children Hospitals across the US, although some
surgeons still perform the open technique. Following repair, the small 3mm incisions are hard to see.

The vertical incision, pictured and listed above, is no longer usually required. Though many incisions
have been horizontal in the past years

Once the stomach can empty into the duodenum, feeding can commence. Some vomiting may be
expected during the first days after surgery as the gastro-intestinal tract settles. Very occasionally the myotomy
was incomplete and projectile vomiting continues, requiring repeat surgery. But the condition generally has no
long term side-effects or impact on the child's future.

Epidemiology

Males are more commonly affected than females, with firstborn males affected about four times as
often, and there is a genetic predisposition for the disease. It is commonly associated with people of Jewish
ancestry, and has multifactorial inheritance patterns. Pyloric stenosis is more common in Caucasians than
Hispanics, Blacks, or Asians. The incidence is 2.4 per 1000 live births in Caucasians, 1.8 in Hispanics, 0.7 in
Blacks, and 0.6 in Asians. It is also less common amongst children of mixed race parents. Caucasian babies
with blood type B or O are more likely than other types to be affected.
Infants exposed to erythromycin are at increased risk for developing hypertrophic pyloric stenosis,
especially when the drug is taken around two weeks of life.






Pines City Colleges
College of Nursing
Magsaysay Avenue, Baguio City














Pyloris Stenosis
Case Discussion


















Submitted By:
Sapon, Charmaine C.
BSN IV 1






Submitted To:
Mrs. Raquel Coloma
Clinical Instructor