Transcript 4-PYLORIC STENOSIS ppt.ppt

PYLORIC STENOSIS
Pyloric stenosis is an acquired
condition caused by
hypertrophy and spasm of
the pyloric muscle, resulting
in gastric outlet obstruction.
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EPIDEMIOLOGY
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· Predominant age: Infancy; onset
usually at 2-4 weeks of age, rarely as
late as 5 months of age.
· Predominant sex: Male > Female
(4:1)
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ETIOLOGY
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Pylorospasm secondary to
reduced tissues nitric oxide
level(a mediator of relaxation)
may lead to hypertrophic P.S.
Erythromycine exposure
(early)
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RISK FACTORS
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· Incidence higher in 1stborn boys
· 40% of firstborns overall
· 5 times increased risk with
affected 1st-degree relative (1)[B]
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ASSOCIATED CONDITIONS
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· May be associated with
tracheoesophageal fistula
· Hirschsprung disease
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DIAGNOSIS
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SIGNS AND SYMPTOMS
History
· Nonbilious projectile vomiting after
feeding increasing frequency and
severity
(2nd -4th week of life)
· Emesis may become blood tinged from
vomiting-induced gastric irritation
· Hunger due to inadequate nutrition
· Diminished stools
· Weight loss
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Physical Exam
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· Palpable, firm, mobile mass ("olive"like) in right upper quadrant
· Palpable 70-90% of the time.
· Epigastric distention
· Visible gastric peristalsis after feeding
· Rarely, jaundice when starvation leads
to decreased glucuronyl transferase
activity resulting in indirect
hyperbilirubinemia. (1)[B]
· Late signs: Dehydration, weight loss
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Lab
· If prolonged vomiting
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- Hypokalemia
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- Hypochloremia
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- Metabolic alkalosis
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· Elevated unconjugated bilirubin level
(rare)
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· Paradoxical aciduria: The kidney
tubules excrete hydrogen to preserve
potassium in face of hypokalemic
alkalosis
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Imaging
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· Abdominal ultrasound is the study of
choice; shows thickened and
elongated pyloric muscle and
redundant mucosa
· Upper gastrointestinal series reveals
strong gastric contractions, elongated,
narrow pyloric canal (string sign),
parallel lines of barium in the narrow
channel (double tract sign or railroad
track sign).
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DIFFERENTIAL
DIAGNOSIS
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· Inexperienced or inappropriate
feeding
· Gastroesophageal reflux
· Gastritis
· Congenital adrenal hyperplasia, saltlosing
· Pylorospasm
· Gastric volvulus
· Antral or gastric web
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STABILIZATION
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· Prompt treatment to avoid dehydration and
malnutrition
· Correct acid-base and electrolyte
disturbances
· Needs high concentration of potassium in
preoperative fluids to correct alkalosis
· Patients need pre and post-op apnea
monitoring. They have a tendency toward apnea to
compensate with respiratory acidosis for their
metabolic alkalosis. Surgery should be delayed until
the alkalosis is corrected.
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SURGERY
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Ramstedt pyloromyotomy is
curative
· Entire length of hypertrophied
muscle is divided with preservation
of the underlying mucosa.
· May be performed using open or
laparoscopic techniques; no
randomized controlled trials have
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compared these 2 approaches.