Pyloric stenosis: Difference between revisions
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==Background== | ==Background== | ||
[[File:Gray1046.png |thumb|Outline of stomach, showing its anatomical landmarks, including the pylorus.]] | [[File:Gray1046.png |thumb|Outline of stomach, showing its anatomical landmarks, including the pylorus.]] | ||
*More common in males (5:1) & firstborn children (30%) | *More common in males (5:1) & firstborn children (30%) | ||
*Prematurity and macrolide use are also thought to be risk factors | *Prematurity and macrolide use are also thought to be risk factors | ||
*Most common surgical cause of vomiting in infants | *Most common surgical cause of vomiting in infants | ||
*The main diagnostic criterion is a measurement of more than 3 mm in thickness of the muscular layer.<ref>Dias, S et al Insights Imaging. 2012 Jun; 3(3): 247–250.</ref> | *The main diagnostic criterion is a measurement of more than 3 mm in thickness of the muscular layer on ultrasound.<ref>Dias, S et al Insights Imaging. 2012 Jun; 3(3): 247–250.</ref> | ||
*Abnormal elongation of the canal is characterised as greater than 17 mm in length .<ref>Teele RL, Smith EH. Ultrasound in the diagnosis of idiopathic hypertrophic pyloric stenosis. N Engl J Med. 1977 May 19. 296(20):1149-50.</ref><ref>Sargent SK, Foote SL, Mooney DP, Shorter NA. The posterior approach to pyloric sonography. Pediatr Radiol. 2000 Apr. 30(4):256-7</ref> | *Abnormal elongation of the canal is characterised as greater than 17 mm in length .<ref>Teele RL, Smith EH. Ultrasound in the diagnosis of idiopathic hypertrophic pyloric stenosis. N Engl J Med. 1977 May 19. 296(20):1149-50.</ref><ref>Sargent SK, Foote SL, Mooney DP, Shorter NA. The posterior approach to pyloric sonography. Pediatr Radiol. 2000 Apr. 30(4):256-7</ref> | ||
==Clinical Features== | ==Clinical Features== | ||
*Symptoms usually begin between 3-6 weeks of age, rarely after 12 weeks | *Symptoms usually begin between 3-6 weeks of age, rarely after 12 weeks | ||
*[[Nausea and vomiting (peds)|Vomiting]], immediately postprandial, nonbilious, often projectile, but desires to feed ("hungry vomiter") | *[[Special:MyLanguage/Nausea and vomiting (peds)|Vomiting]], immediately postprandial, nonbilious, often projectile, but desires to feed ("hungry vomiter") | ||
*Palpable mass in in RUQ to epigastric region after vomiting, occasionally may see reverse peristaltic fluid wave across abdomen | *Palpable mass in in RUQ to epigastric region after vomiting, occasionally may see reverse peristaltic fluid wave across abdomen | ||
*If untreated, will see signs of [[dehydration (peds)|dehydration]], weight loss, [[lethargy]], [[pediatric shock|shock]] | *If untreated, will see signs of [[Special:MyLanguage/dehydration (peds)|dehydration]], weight loss, [[Special:MyLanguage/lethargy|lethargy]], [[Special:MyLanguage/pediatric shock|shock]] | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
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{{Pediatric abdominal pain DDX}} | {{Pediatric abdominal pain DDX}} | ||
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==Evaluation== | ==Evaluation== | ||
[[File:Pyloric-stenosisLocal.jpg|thumb|Pyloric stenosis as seen on ultrasound in a 6 week old.]] | [[File:Pyloric-stenosisLocal.jpg|thumb|Pyloric stenosis as seen on ultrasound in a 6 week old.]] | ||
[[File:PS longitudinal Subramaniam.gif|thumbnail|Longitudinal view of thickened and elongated pylorus muscle<ref>http://www.thepocusatlas.com/pediatrics/</ref>]] | [[File:PS longitudinal Subramaniam.gif|thumbnail|Longitudinal view of thickened and elongated pylorus muscle<ref>http://www.thepocusatlas.com/pediatrics/</ref>]] | ||
*Labs may show [[hypokalemia]] and hypochloremic [[metabolic alkalosis]] | *Labs may show [[Special:MyLanguage/hypokalemia|hypokalemia]] and hypochloremic [[Special:MyLanguage/metabolic alkalosis|metabolic alkalosis]] | ||
===Imaging=== | ===Imaging=== | ||
''Primary test of choice'' | ''Primary test of choice'' | ||
*[[ultrasound: abdomen|Ultrasound]]: thickened (>3 mm) and elongated (>17 mm) pylorus ~ 95% Sn/Sp<ref>Rohrschneider WK, Mittnacht H, Darge K, Tröger J. Pyloric muscle in asymptomatic infants: sonographic evaluation and discrimination from idiopathic hypertrophic pyloric stenosis. Pediatr Radiol. 1998 Jun;28(6):429-34.</ref> | *[[ultrasound: abdomen|Ultrasound]]: thickened (>3 mm) and elongated (>17 mm) pylorus ~ 95% Sn/Sp<ref>Rohrschneider WK, Mittnacht H, Darge K, Tröger J. Pyloric muscle in asymptomatic infants: sonographic evaluation and discrimination from idiopathic hypertrophic pyloric stenosis. Pediatr Radiol. 1998 Jun;28(6):429-34.</ref> | ||
''Other tests that may show findings'' | ''Other tests that may show findings'' | ||
*[[Abdominal x-ray]]: may show large stomach bubble with absence of air in small bowel or colon | *[[Special:MyLanguage/Abdominal x-ray|Abdominal x-ray]]: may show large stomach bubble with absence of air in small bowel or colon | ||
**Characteristic caterpillar sign (gastric contractions against hypertrophied pylorus) | **Characteristic caterpillar sign (gastric contractions against hypertrophied pylorus) | ||
*Upper GI: string sign (narrowed pyloric lumen), double track sign (duplicated mucosa), beak sign (abnormality of pyloric opening) | *Upper GI: string sign (narrowed pyloric lumen), double track sign (duplicated mucosa), beak sign (abnormality of pyloric opening) | ||
==Management== | ==Management== | ||
*[[IVF]] | |||
*[[Special:MyLanguage/IVF|IVF]] | |||
**Normal electrolytes and no evidence of dehydration | **Normal electrolytes and no evidence of dehydration | ||
***5% dextrose with 0.25% NaCl and 2 meq KCl per 100 mL | ***5% dextrose with 0.25% NaCl and 2 meq KCl per 100 mL | ||
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***Higher NaCl concentrations (0.5% to normal saline) and higher rates of administration (1.5 to 2 times maintenance) | ***Higher NaCl concentrations (0.5% to normal saline) and higher rates of administration (1.5 to 2 times maintenance) | ||
**Ensure correction of bicarbonate level, as it may be a hypoventilation risk | **Ensure correction of bicarbonate level, as it may be a hypoventilation risk | ||
*[[Nasogastric tube]] | *[[Special:MyLanguage/Nasogastric tube|Nasogastric tube]] | ||
*Surgery | *Surgery | ||
**Can be delayed 24-36 hr to rehydrate infant and correct electrolytes | **Can be delayed 24-36 hr to rehydrate infant and correct electrolytes | ||
===Precautions=== | ===Precautions=== | ||
*Ensure that kidneys are functional prior to giving [[potassium]] | |||
*Ensure that kidneys are functional prior to giving [[Special:MyLanguage/potassium|potassium]] | |||
*Do not give lactated ringers | *Do not give lactated ringers | ||
**May lead to worsening alkalosis > apnea in infants | **May lead to worsening alkalosis > apnea in infants | ||
==Disposition== | ==Disposition== | ||
*Admission | *Admission | ||
==See Also== | ==See Also== | ||
*[[Abdominal Pain (Peds)]] | |||
*[[Special:MyLanguage/Abdominal Pain (Peds)|Abdominal Pain (Peds)]] | |||
==References== | ==References== | ||
<references/> | <references/> | ||
[[Category:Pediatrics]] | [[Category:Pediatrics]] | ||
[[Category:GI]] | [[Category:GI]] | ||
[[Category:Surgery]] | [[Category:Surgery]] | ||
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Latest revision as of 23:55, 4 January 2026
Background
- More common in males (5:1) & firstborn children (30%)
- Prematurity and macrolide use are also thought to be risk factors
- Most common surgical cause of vomiting in infants
- The main diagnostic criterion is a measurement of more than 3 mm in thickness of the muscular layer on ultrasound.[1]
- Abnormal elongation of the canal is characterised as greater than 17 mm in length .[2][3]
Clinical Features
- Symptoms usually begin between 3-6 weeks of age, rarely after 12 weeks
- Vomiting, immediately postprandial, nonbilious, often projectile, but desires to feed ("hungry vomiter")
- Palpable mass in in RUQ to epigastric region after vomiting, occasionally may see reverse peristaltic fluid wave across abdomen
- If untreated, will see signs of dehydration, weight loss, lethargy, shock
Differential Diagnosis
Pediatric Abdominal Pain
0–3 Months Old
- Emergent
- Nonemergent
3 mo–3 y old
- Emergent
- Nonemergent
3 y old–adolescence
- Emergent
- Nonemergent
Evaluation
Longitudinal view of thickened and elongated pylorus muscle[4]
- Labs may show hypokalemia and hypochloremic metabolic alkalosis
Imaging
Primary test of choice
- Ultrasound: thickened (>3 mm) and elongated (>17 mm) pylorus ~ 95% Sn/Sp[5]
Other tests that may show findings
- Abdominal x-ray: may show large stomach bubble with absence of air in small bowel or colon
- Characteristic caterpillar sign (gastric contractions against hypertrophied pylorus)
- Upper GI: string sign (narrowed pyloric lumen), double track sign (duplicated mucosa), beak sign (abnormality of pyloric opening)
Management
- IVF
- Normal electrolytes and no evidence of dehydration
- 5% dextrose with 0.25% NaCl and 2 meq KCl per 100 mL
- Moderate or severe dehydration
- Higher NaCl concentrations (0.5% to normal saline) and higher rates of administration (1.5 to 2 times maintenance)
- Ensure correction of bicarbonate level, as it may be a hypoventilation risk
- Normal electrolytes and no evidence of dehydration
- Nasogastric tube
- Surgery
- Can be delayed 24-36 hr to rehydrate infant and correct electrolytes
Precautions
- Ensure that kidneys are functional prior to giving potassium
- Do not give lactated ringers
- May lead to worsening alkalosis > apnea in infants
Disposition
- Admission
See Also
References
- ↑ Dias, S et al Insights Imaging. 2012 Jun; 3(3): 247–250.
- ↑ Teele RL, Smith EH. Ultrasound in the diagnosis of idiopathic hypertrophic pyloric stenosis. N Engl J Med. 1977 May 19. 296(20):1149-50.
- ↑ Sargent SK, Foote SL, Mooney DP, Shorter NA. The posterior approach to pyloric sonography. Pediatr Radiol. 2000 Apr. 30(4):256-7
- ↑ http://www.thepocusatlas.com/pediatrics/
- ↑ Rohrschneider WK, Mittnacht H, Darge K, Tröger J. Pyloric muscle in asymptomatic infants: sonographic evaluation and discrimination from idiopathic hypertrophic pyloric stenosis. Pediatr Radiol. 1998 Jun;28(6):429-34.