infantile HPS.pptx

infantile hypertrophic pyloric stenosis : features , diagnosis , and treatment.

1. infantile HYPERTROPHIC PYLORIC STENOSIS Dr Karrar Adil

2. It is hypertrophy of musculature of pyloric antrum , especially the circular muscle fibers , causing primary failure of pylorus to relax . Duodenum is normal . Incidence is 4 in 1000 births ; It is familial. Male : female ratio 4:1

3. Ethnic origin is important , highest incidence is found among whites of Scandinavian decent and lowest risk among African , Americans and Chinese . Familial association : Studies found higher rates among certain families. Pyloric stenosis develops in about 20% of male descendants and 10% of female descendants of mothers who had the condition . There is increased risk of developing the condition if newborn gets erythromycin or azithromycin in first 14 days after birth.

4. Clinical features : A first-born male child is the most commonly affected. Infant is normal at birth, symptomatic between the ages of 3–6 weeks. projectile nonbilious vomiting, after 2-3 days. The infants usually feed vigorously between episodes of vomiting.

5. Typical electrolyte abnormality: Hypochloremic , hypokalemic, metabolic alkalosis. Weight loss, emaciation and dehydration. Visible gastric peristalsis may be seen as a wave of contraction from the left upper quadrant to the epigastrium.

6. Diagnosis : Clinical examination : Palpation of the olive mass in the epigastrium or right upper quadrant by a skilled examiner is pathognomonic for the diagnosis of HPS.

7. Ultrasound abdomen : (preferred study) Pyloric muscle 4 mm or more in thickness. Length of pyloric canal > 14 mm. Cervix sign on long axis, target sign on short axis.

8. Ultrasound image of hypertrophic pyloric stenosis. Showing : Distended Stomach. hypertrophied pyloric muscle measuring (5mm). Elongated pyloric canal measuring about (16mm)in length.

9. cervix sign Target sign

10. Barium Meal : String sign: indicating a narrowed elongated pyloric canal that does not relax (most specific sign ). Shoulder sign: caused by hypertrophied muscle indenting the antrum . Double-track sign: caused by redundant mucosa separates barium into 2 columns in pyloric canal.

11. String sign Double tracking Shouldering sign

12. Differential Diagnosis : Duodenal atresia (Bilious vomiting is present). High intestinal obstruction. lntracranial haemorrhage . Gastro- oesophageal reflux . feeding problems.

13. Treatment : Pyloric stenosis is never a surgical emergency although dehydration and electrolyte abnormalities may present as medical emergency. Fluid resuscitation and correction of electrolyte abnormalities and metabolic alkalosis is essential before surgery. It is important that the underlying metabolic alkalosis is slowly corrected with normal saline.

14. Surgical treatment : Ramstedt's operation. Laparoscopic pyloromyotomy is becoming popular. Endoscopic pyloromyotomy is also tried (like POEM for achalasia). Balloon dilatation is tried but results are not optimum like surgery or myotomy .

15. Ramstedt's operation : The hypertrophied pylorus is delivered and rotated so that its superior surface comes into view. The least vascular portion is selected for incision which is made through the serosa only along the whole length of the pylorus and the distal antrum , followed by splitting the muscle coat by blunt dissection. On separating the edges with artery forceps the pyloric mucosa bulges into the cleft that is made in the muscle .

16. Great care is taken not to penetrate the mucosa. To be sure that there is no perforation, some air is squeezed from the stomach into the duodenum. If perforation has occurred, it is sutured horizontally using interrupted vicryl sutures and a piece of omentum placed over the closure.

17. Postoperative care : Postoperatively , the nasogastric tube can be removed and feeding commenced on the morning after. Vomiting after surgery occurs frequently but is usually self-limited. Complications : Incomplete myotomy , mucosal perforation (usually at the duodenal end), and wound infection. If the mucosa is inadvertently opened then feeding is delayed for 48 hours.

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