Congenital pyloric-stenosis

pediatrics

1. Congenital Pyloric Stenosis
Made by : Esam muhsin
: Ameer
azeez
21/03/2017

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 3
rd
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 1
st
week and
as late as the 5
th
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

9. Diagnosis

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

14. Thank you