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"Understanding Pyloric Stenosis: Symptoms, Treatment, and Management"

What is Pyloric Stenosis? 


Pyloric stenosis is a problem that affects babies between birth and 6 months of age and causes forceful vomiting that can lead to dehydration. It is the second most common problem requiring surgery in newborns.


The lower portion of the stomach that connects to the small intestine is known as the pylorus. In pyloric stenosis, the muscles in this part of the stomach enlarge, narrowing the opening of the pylorus and eventually preventing food from moving from the stomach to the intestine.




Which Babies are at Higher Risk for Pyloric Stenosis?


  • Caucasian babies seem to develop pyloric stenosis more frequently than babies of other races.

  • Boys develop pyloric stenosis more often than girls. That too first born male children. The condition occurs in approximately 1 to 3.5 per 1000 live births.

  • Pyloric stenosis may be inherited; several members of a family may have had this problem in infancy.

Why is Pyloric Stenosis of Concern?


Because the stomach opening becomes blocked and babies start vomiting, several problems can happen. The most serious problem is dehydration. When a baby vomits regularly, he or she will not get enough fluids to meet his or her nutritional needs. Babies have smaller bodies than adults and cannot tolerate losing fluid as easily as adults can. Minerals that the body needs to stay healthy, such as potassium and sodium, are also lost as the baby vomits. Babies who lack the right amount of water and minerals in their bodies can become very sick very quickly.

Another problem that occurs is weight loss. A baby who vomits most of (or all of) his or her feedings will not have adequate nutrition to gain weight and stay healthy.

 

What are the Symptoms of Pyloric Stenosis?


The most common symptoms noted in a baby with pyloric stenosis is forceful, projectile vomiting. This kind of vomiting is different from a "wet burp" that a baby may have at the end of a feeding. Large amounts of breast milk or formula are vomited, and may go several feet across a room. The baby is usually quite hungry and eats or nurses eagerly. The milk is sometimes curdled in appearance, because as the milk remains in the stomach and does not move forward to the small intestine, the stomach acid "curdles" it.


Other symptoms may include:


  • Weight loss

  • Ravenously hungry despite vomiting

  • Lack of energy

  • Fewer bowel movements

  • Constipation

  • Frequent, mucous stools

What Causes Pyloric Stenosis?

Pyloric stenosis is considered a multifactorial trait. Multifactorial inheritance means that many factors are involved in causing a birth defect. The factors are usually both genetic and environmental. Often one gender (either males or females) is affected more frequently than the other in multifactorial traits. There appears to be a different threshold of expression, which means that one gender is more likely to show the problem, over the other gender. For example, pyloric stenosis is four times more common in males than females. Once a child has been born with pyloric stenosis, the chance for it to happen again depends on the gender of the child already born with the condition, as well as the gender of the next child.





How is Pyloric Stenosis Diagnosed?


In addition to a complete medical history and physical examination, diagnostic procedures for pyloric stenosis may include:


  • Blood tests. These tests evaluate dehydration and mineral imbalances.

  • Abdominal X-rays. A diagnostic test that uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film.

  • Abdominal ultrasound. A diagnostic imaging technique that uses high-frequency sound waves and a computer to create images of blood vessels, tissues, and organs. Ultrasounds are used to view internal organs as they function, and to assess blood flow through various vessels.

  • Barium swallow/upper GI series. A diagnostic test that examines the organs of the upper part of the digestive system: the esophagus, stomach, and duodenum (the first section of the small intestine). A fluid called barium (a metallic, chemical, chalky, liquid used to coat the inside of organs so that they will show up on an X-ray) is swallowed. X-rays are then taken to evaluate the digestive organs.


Ultrasonography and upper gastrointestinal contrast studies of pyloric stenosis.(B from Goske MJ, Schlesinger AE. Hypertrophic pyloric stenosis. In Slovis TL, editor. Calley’s pediatric diagnostic imaging. St Louis: Mosby; 2008.)

What is the Treatment for Pyloric Stenosis?


Specific treatment for pyloric stenosis will be determined by your baby's doctor based on:


  • The baby's gestational age, overall health, and medical history

  • The extent of the problem

  • The baby's tolerance for specific medications, procedures, or therapies

  • Expectation for the course of the problem

  • Your opinion and preference

Pyloric stenosis must be repaired with an operation. However, doctors may need to treat your baby's dehydration and mineral imbalances first. Water and minerals can be replaced through intravenous (IV) fluid.


Once your baby is no longer dehydrated, surgery can be performed. Under anesthesia, a small incision is made above the navel and the tight pyloric muscle is repaired.





What are the Major Complications of Pyloric Stenosis Surgery?


The major complications of pyloromyotomy include mucosal perforation, wound infection, incisional hernia, prolonged postoperative emesis, incomplete myotomy, and duodenal injury.

  • Mucosal perforation occurs in 1% to 2% of cases. If the disruption occurs at the duodenopyloric junction, a simple interrupted absorbable suture can be placed to close the defect and a patch of omentum can be used to bolster the repair. This can be accomplished laparoscopically depending on the experience of the surgeon. Otherwise, the laparoscopic case should be converted to open. If the perforation is large or in the middle of the myotomy, then the myotomy should be closed with absorbable suture. A new myotomy can then be made 90 to 180 degrees from the original incision. Repairing this injury would be difficult to perform laparoscopically. Feedings should be held for 24 hours and then restarted. A water-soluble contrast study can be performed if desired.

  • Duodenal injuries also can occur with either the laparoscopic or open approach.

  • Infantile Hypertrophic pyloric stenosis (PS) has been suggested as a high-risk disease for the development of Incisional Hernia Studies report varying rates of incisional hernia after pyloromyotomy, ranging from 2.5% to 7%. It's important to note that incisional hernias are less common in children compared to adults undergoing abdominal surgery. Possible reasons for incisional hernia after pyloromyotomy:

    • Age: Since the surgery is performed on very young infants (usually under 3 months), their abdominal wall tissues are still developing and might be weaker, making them more susceptible to tears or strain during surgery.

    • Healing process: Any disruption in the healing process at the incision site, like infection, can increase the risk of hernia formation.

    • Surgical technique: While pyloromyotomy is a minimally invasive procedure, there's still a chance of slight muscle damage during surgery, which could contribute to a future hernia.

  • Wound infections also occur in 1% to 2% of cases.There are no data to support the use of prophylactic perioperative antibiotics because a pyloromyotomy is considered a clean procedure. Local wound care is usually sufficient to treat these infections.

  • Postoperative emesis is common, occurring in up to 80% of patients at some point. Prolonged emesis is less common and ranges in incidence from 2% to 26%. Most commonly, this is due to gastroesophageal reflux (24%-31%) but can be secondary to incomplete myotomy (0-6%).

  • There have been retrospective studies that do not show any difference in complication rates between the laparoscopic and open techniques.

What is the Recovery Time for Pyloric Stenosis Surgery?


Babies can often begin drinking small amounts of clear liquids in the first 24 hours. Generally, clear liquids, such as an electrolyte drink, will be given to your baby first. However, babies may still vomit for several days after surgery due to swelling of the surgical site of the pyloric muscle. The swelling goes away within a few days.

Most babies will be taking their normal feedings by the time they go home. Babies are usually able to go home within two to three days after the operation.


What is the Long-Term Prognosis for Pyloric Stenosis?


Recurrent pyloric stenosis is rare. Recurrent pyloric stenosis is a rare entity, with an incidence of less than 2% of all children who undergo successful surgery. True recurrent pyloric stenosis includes complete resolution of symptoms for three or more weeks before recurrence of emesis, weight gain, and evidence of re-stenosis on sonographic or operative confirmation.


In most cases, the problem is unlikely to reoccur. Babies who have undergone the surgery should have no long-term effects from it.

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