[Clinical and therapeutical considerations regarding a rare case of pre-pyloric stenosis]. / Consideratii clinico-terapeutice privind un caz rar de stenoza prepilorica.

The neonatal obstacle caused by a pre-pyloric diaphragm represent a rare cause of high oclusion in new-born. We present the case of a 6 days old new-born admitted in our department for nonbilious vomiting and feeding intolerance in which the clinical exam and the imagistic explorations (plain and contrast abdominal X-Rays, and ultrasound) could not reveal an evident cause for the oclusion. The surgical intervention imposed by the simptoms revealed the existece of a complete diaphragm in the prepyloric region. The initial excision of the diaphragm was not sufficient, the patient undergoing a second surgical intervention of gastrojejunal anastromosis with favorable evolution this time. The authors are presenting diagnosis and theraputical management peculiarities of this rare condition.

Penile agenesis and congenital hypertrophic pyloric stenosis: an association or a random coexistence?

A neonate with penile agenesis and congenital hypertrophic pyloric stenosis is presented. The patterns of associated anomalies with penile agenesis, and those of congenital hypertrophic pyloric stenosis are discussed.

Clinical presentation of pyloric stenosis: the change is in our hands.

BACKGROUND: Hypertrophic pyloric stenosis classically presents as projectile vomiting during the third to fourth week of life, associated with good appetite. Additional classical presenting findings include palpation of the pyloric tumor, described as olive-shaped; a visible gastric peristaltic wave after feeding; and hypochloremic, hypokalemic metabolic alkalosis. It was recently claimed that this presentation has changed due to the easier access to gastrointestinal imaging. OBJECTIVE: To validate this contention and discuss possible reasons. METHODS: We conducted a retrospective chart review of all patients who underwent pyloromyotomy for HPS between 1990 and 2000. Only patients with confirmed HPS at the time of surgery were included. We also performed a comprehensive review of older studies for comparison. RESULTS: Seventy patients underwent pyloromyotomy over the 10 year period. Overall, 81% of patients were male infants and the mean age at diagnosis was 40 days. The mean duration of symptoms was 8 days. A firstborn child was noted in 43% of the cases. The classical symptom of projectile vomiting was absent in one-third of the patients, a pyloric tumor was not palpated in one-half of the cases, bicarbonate was higher than 28 mEq/L in 20%, and a pH of above 7.45 was present in 25% of patients. Hypochloremia was noted in about one-third. We found a good correlation between ultrasonographic width and length of the pylorus and the intraoperative findings. Pylorus length +/- 24 mm correlated with significantly longer duration of symptoms. When compared with previous studies, the main findings were not significantly different; namely, mean age at diagnosis, percentage of male gender, and duration to diagnosis. The decrease in the number of pyloric tumors palpated paralleled the increase in the use of upper gastrointestinal series and ultrasonography in particular. CONCLUSIONS: The clinical presentation of HPS has not actually changed despite the easier accessibility of GI imaging studies. However, the one significant change is the low percentage of pyloric tumors palpated, probably due to declining clinical skills accompanied by earlier utilization of imaging studies. The use of imaging and laboratory studies did not change the age at diagnosis but may have shortened the time for diagnosis and reduced the postoperative stay. Imaging and laboratory studies may be helpful for the subgroup with a non-classical clinical presentation.

Comparison of the incidence of complications in open and laparoscopic pyloromyotomy: a concurrent single institution series.

PURPOSE: The purpose of this study was to compare the incidence and type of technical complications seen in a concurrent series of pyloromyotomies done open and laparoscopically. METHODS: The medical records of all patients who underwent pyloromyotomy for congenital hypertrophic pyloric stenosis over a 66-month period were reviewed (n = 457). Information obtained included age, sex, weight, operating time, and intraoperative and postoperative complications. RESULTS: Four hundred fifty-seven pyloromyotomies were equivalently divided between the 2 techniques (232 laparoscopic, 225 open). Demographic characteristics and operating times were similar. There were no deaths in the series. The overall incidences of complications were similar in the 2 groups (open, 4.4%; laparoscopic, 5.6%). There was a greater rate of perforation with the open technique and a higher rate of postoperative problems including incomplete pyloromyotomy in the laparoscopic group. CONCLUSIONS: The open and laparoscopic approaches have similar overall complication rates. The distribution and the type of complications differ, however.

Idiopathic hypertrophic pyloric stenosis in identical twins.

Idiopathic hypertrophic pyloric stenosis (IHPS) was thought to be a congenital disease traditionally, even though several published reports assumed IHPS was an acquired disease. The pathogenesis and inheritance patterns of IHPS are not fully understood. Except for the familial recurrence of IHPS, concordance of IHPS in monozygotic or dizygotic twins was also noted, but occurrence in female twins is rare. From July 1992 through June 2000, 130 patients were diagnosed with IHPS in our hospital including one pair of female twins. We present the finding in the twins and review the associated articles about the pathogenesis and inheritance patterns of IHPS.

A quantitative study of the neural changes underlying pyloric stenosis in dogs.

This study aimed to quantify the neural changes in congenital pyloric stenosis in dogs and to study the comparative anatomy between this condition in dogs and that in infantile hypertrophic pyloric stenosis. Eight specimens from the pylorus of dogs with pyloric stenosis and six control specimens were examined using conventional histology and immunohistochemistry for a range of neural antigens. The changes in the proportion of nerves immunoreactive for each antigen were quantified and analysed statistically. The morphology of the nerves in the diseased dogs was similar to that in controls. Only vasoactive intestinal peptide was reduced in expression in dogs (median proportion in control dogs 0.57, in diseased dogs 0.17; P = 0.065). This study demonstrates both morphological similarities and significant differences between closely related conditions in dogs, humans and other species.

Intermittent 'double bubble' sign in a case of congenital pyloric atresia.

We report a case of congenital pyloric atresia in which two cystic masses in the fetal upper abdomen and polyhydramnios were observed from 24 weeks' gestation to term. The two cystic masses were thought to indicate the 'double bubble' sign in utero, leading to a misdiagnosis of congenital duodenal obstruction. At 33 weeks' gestation, continuous ultrasound observation of the two cystic masses was made for 60 min. During the periods when gastric peristalsis was absent, the 'double bubble' sign was observed. However, during the periods when gastric peristalsis was present, the 'double bubble' sign disappeared. In retrospect, both cystic masses were stomach and the 'double bubble' sign disappeared with peristalsis of the antrum. In order to differentiate from congenital duodenal obstruction, whole stomach configuration should be delineated by continuous observation covering periods when gastric peristalsis is active as well as quiet.

Congenital hypertrophic pyloric stenosis.

Congenital hypertrophic pyloric stenosis, an important cause of intractable vomiting in infants is diagnosed clinically and confirmed ultrasonographically. Other useful interventions are plain radiography and barium study. Differential diagnosis includes pylorospasm and gastroesophageal reflux. Management protocol includes correction of dehydration and electrolyte imbalance and either Fredet Ramstedt pyloromyotomy or medical treatment with atropine sulphate. Atropine is initially given intravenously till vomiting is controlled and then orally at double the effective i.v. done for another 3 weeks. Atropine sulphate is generally well tolerated and side effects are few like tachycardia, raised SGPT and hyperthermia. Atropine sulphate is very effective, cheap, safe and perhaps more acceptable treatment option for CHPS.

[Emesis after pyloromyotomy in congenital hypertrophic pyloric stenosis: incomplete pyloromyotomy, recurring pyloric stenosis or gastric outlet obstruction?]. / Pyloromyotomia utáni hányás congenitalis hypertrophiás pylorusstenosisban: inkomplett pyloromyotomia, visszatéró pylorusstenosis vagy gyomorkimeneti obstructio?

The authors present a case of an infant who was treated for recurrent vomiting following pyloromyotomy. Gastroscopic examination showed a polypoid tumour of 4-5 mm in diameter located at the antral region. The patient recovered following re-pyloromyotomy.

Does dehydration affect thickness of the pyloric muscle? An experimental study.

Congenital hypertrophic pyloric stenosis (CHPS) is a common condition in infancy associated with smooth muscle hypertrophy and resulting in pyloric outlet obstruction. The final diagnosis of CHPS is based on precise ultrasonographic measurements of length and width of the pyloric muscle. Based on our clinical and sonographic experience, we observed that smaller measurements of the pyloric muscle were obtained in dehydrated infants than in children examined after proper fluid restoration. The clinical importance of these observations was evident because false-negative results could be obtained. An experimental animal work followed, proving our clinical observation to be true. A significant difference of about 30% to 50% was found between measurements of the muscle thickness of the gastric and pyloric muscles in a state of water deprivation, as compared with a state of full hydration (p < 0.05). Based on our preliminary results, we suggest that children with suspected CHPS should be well hydrated before the ultrasound (US) examination is performed, to avoid false-negative results and a consequent delay in treatment.

Caudal block with 4 mg x kg-1 (1.6 ml x kg-1) of bupivacaine 0.25% in children undergoing surgical correction of congenital pyloric stenosis.

BACKGROUND: Since 1970, bupivacaine 0.25% in a dose of 4 mg x kg-1 (1.6 ml x kg-1) has been used at the Hospital Infantil de México for caudal block in children undergoing surgical correction of congenital pyloric stenosis (CPS). Although this dose is considered unsafe, in our experience, it has been associated with a high success rate and a low incidence of adverse events. This experience has not been previously documented. METHODS: A retrospective cohort of patients undergoing surgical correction of CPS was studied. Nineteen patients received general anaesthesia while 223 received caudal block. The latter were then grouped according to the sedation technique. The rate of successful caudal blocks and complications were considered the major outcomes of the study, whereas the postsurgical fasting period and hospital stay were considered secondary outcomes. RESULTS: The rate of success of caudal block was 96%. Anaesthetic complications related to bupivacaine were present in 1.3%. Mortality occurred in the postoperatory period in one septic patient who also was suffering from gastroschisis that required general anaesthesia. Postoperatory fasting period and hospital stay tended to be higher with general anaesthesia than caudal block. However, of the 19 patients receiving general anaesthesia, five suffered serious comorbidity and nine were failed caudal blocks. CONCLUSIONS: Caudal block with bupivacaine 0.25% (4 mg x kg-1) was associated with a low rate of anaesthetic complications. Further prospective studies to clarify the risks and benefits are required.