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PubMed1978

Peroperative grading of pyloric stenosis: a long term clinical and radiological follow-up of patients with severe pyloric stenosis treated by highly selective vagotomy and dilatation of the stricture.

Highly selective vagotomy (HSV) is now an accepted form of surgery for uncomplicated duodenal ulcer. Highly selective vagotomy and dilatation has been successfully used in some cases of pyloric stenosis, but many would regard severe pyloric stenosis as a contraindication to this procedure. Eleven patients with severe pyloric stenosis, measured objectively at operation, have been treated by HSV and dilatation of the stenosis and reviewed for periods of up to 3 years. The clinical results, immediate and long term, were good in all cases. Barium studies and histopathological findings were slower to return to normal. With intensive preoperative preparation to restore the tone of the dilated gastric muscle and gentle, controlled dilatation of the stricture, HSV in these patients should be as satisfactory as in those patients with uncomplicated duodenal ulcer.

Adult↗
PubMed1987

Infantile hypertrophic pyloric stenosis--diagnosis from the pyloric muscle index.

Measurements of pyloric length, diameter and muscle thickness were made from ultrasound images of 39 babies, 21 of whom were subsequently found at operation to have infantile hypertrophic pyloric stenosis. From these measurements, the volume of pyloric muscle in cm3 was estimated for each case and divided by the body weight in kilograms. The resulting pyloric muscle index proved to be a much more reliable guide to the diagnosis of pyloric stenosis than any of the individual measurements or the volume estimation alone.

Humans↗
PubMed1992

Nitric oxide synthase activity in infantile hypertrophic pyloric stenosis.

BACKGROUND: Hypertrophic pyloric stenosis is a common infantile disorder characterized by enlarged pyloric musculature and gastric-outlet obstruction. Its physiopathologic mechanism is not known, but a defect in pyloric relaxation (pylorospasm) has been postulated. Nitric oxide is a mediator of relaxation in the mammalian digestive tract, raising the possibility that pylorospasm could be caused by a defect in nitric oxide production. Since neuronal nitric oxide synthase and NADPH diaphorase are identical, we used the NADPH diaphorase histochemical reaction to study the distribution of nitric oxide synthase in pyloric tissue from patients with infantile hypertrophic pyloric stenosis. METHODS: We studied pyloric tissue from nine infants with infantile hypertrophic pyloric stenosis and seven control infants and children. Cryostat sections were processed for NADPH diaphorase histochemical analysis. A polyclonal tau antiserum was used to identify the enteric nervous system by immunohistochemical methods. RESULTS: NADPH diaphorase activity was restricted to the enteric nervous system and blood vessels. In the pyloric tissues from the control patients, intense diaphorase activity was present in the nerve fibers of the circular musculature, in the neurons and nerve bundles of the myenteric plexus, and in some nerve fibers of the longitudinal musculature. In the pyloric tissues from patients with infantile hypertrophic pyloric stenosis, the enteric nerve fibers in the hypertrophied circular musculature were enlarged and distorted and did not contain diaphorase activity, whereas the activity in the myenteric plexus and the longitudinal musculature was preserved. CONCLUSIONS: We suggest that a lack of nitric oxide synthase in pyloric tissue is responsible for pylorospasm in infantile hypertrophic pyloric stenosis.

Amino Acid Oxidoreductases↗
PubMed2007

Current management of hypertrophic pyloric stenosis.

Hypertrophic pyloric stenosis (HPS) is a common condition affecting infants that presents with progressive projectile nonbilious vomiting. The pyloric portion of the stomach becomes abnormally thickened and manifests as gastric outlet obstruction. The cause is unknown. Pyloromyotomy remains the standard of treatment and outcome is excellent. This article reviews the diagnostic work up and imaging, preoperative resuscitation, the various surgical approaches used, and the effect of subspecialty training on outcomes after pyloromyotomy. Postoperative care and the variety of postoperative feeding regimens applied after pyloromyotomy are reviewed, as well as intra- and postoperative complications. Finally, medical management, in lieu of surgery, is discussed.

Child↗
PubMedDate not supplied

[Ultrasonographic diagnosis of hypertrophic pyloric stenosis].

Hypertrophic pyloric stenosis (HPS) is one of the most common causes of abdominal surgery during the first weeks of life. The primary cause of the muscular hypertrophy is unknown and the pathogenesis is obscure. Clinically, vomiting is always present and sometimes there is a palpable pyloric mass (olive). Upper gastrointestinal tract study with barium has been the most usual method for the diagnosis. Since the first report of the use of ultrasound (US) in the diagnosis of HPS in 1977, this technique has been widely used and accepted, being by now, the diagnostic imaging examination of choice for infants in whom this abnormality is suspected. This is our experience with the use of US in 27 infants with clinically suspected HPS. In 17 cases there was US evidence of HPS and in 10 patients results were negative. We did not have false positive neither false negative results. We strongly recommend this diagnostic method for all infants under clinical suspicion of HPS.

Female↗
PubMed1993

Hypertrophic pyloric stenosis.

Hypertrophic pyloric stenosis is a gastrointestinal tract disorder common in infancy. The disorder causes projectile vomiting, weight loss, and fluid and electrolyte abnormalities. The problem can usually be diagnosed by clinical symptoms and manual detection of an enlarged pylorus. When the diagnosis cannot be confirmed by these methods, however, imaging studies are relevant. Until recently, plain radiographs and upper gastrointestinal contrast studies have been used to make the diagnosis, but ultrasonography is becoming the method of choice because it is highly accurate and lacks the ionizing radiation inherent in a radiologic procedure. Surgery provides a safe and effective treatment.

Female↗
PubMed2005

The role of UGT1A1*28 mutation in jaundiced infants with hypertrophic pyloric stenosis.

Hypertrophic pyloric stenosis (HPS) may be accompanied by jaundice, a condition referred to as the icteropyloric syndrome (IPS). It has long been suspected that the etiology of IPS is an early manifestation of Gilbert's syndrome (GS). Clinical features common to both GS and IPS include jaundice precipitated by fasting and improved with feeding. Prevalence of jaundice in HPS is similar to that of clinically apparent GS in the general population. Discovery of a mutation in the promoter region of the bilirubin uridine diphosphate glucuronosyl transferase gene (UGT1A1*28) as the most common cause of GS has provided a tool to determine the role of GS in IPS. The aims of this study were to determine 1) the prevalence of IPS in a large group of infants with HPS, 2) whether disease severity contributed to the manifestation of IPS, and 3) whether GS played a role in IPS. Radioactive PCR and sequencing were used to determine the presence of UGT1A1*28 mutations. We determined a prevalence of IPS of 14.3% in HPS. Infants with IPS had significantly higher levels of alkalosis than infants with HPS alone. GS mutations were 4-fold higher in IPS (43.8%) than HPS (10.7%). In conclusion, the frequency of jaundice in HPS is similar to that of clinically apparent GS in the general population. Manifestation of IPS results from a more severe degree of metabolic disturbance and the presence of GS mutations.

Base Sequence↗
PubMed2001

Infantile hypertrophic pyloric stenosis: a comparative study of pyloric traumamyoplasty and Fredet-Ramstedt pyloromyotomy.

PURPOSE: The aim of this study was to compare the incidence of surgical complications (duodenal perforation, postoperative vomiting, wound infection or dehiscence, incisional hernia) between 2 different surgical techniques for the resolution of hypertrophic pyloric stenosis in children. METHODS: A clinically controlled, randomized study with follow-up from 24 to 36 months was conducted. One hundred children between 15 days and 2 months old, who underwent surgical resolution of hypertrophic pyloric stenosis, were put randomly into 2 groups: I, pyloric traumamyoplasty (n = 43); II, Fredet-Ramstedt pyloromyotomy (n = 57). Both groups were controlled for the main demographic variables. Postoperative follow-up was blind for the surgical team. Statistical analysis was done with simple frequencies, percentages, Student's t test, and chi(2). RESULTS: There was not a single case of duodenal perforation, incomplete pyloromyotomy, wound infection, dehiscence, or incisional hernia in any group (P value, not significant). Postoperative emesis was present in 8 patients, uniformly distributed between groups. The operating room time for traumamyoplasty was 39.3 +/- 16.4 minutes versus 54 +/- 16.4 minutes for pyloromyotomy (P =.0003). CONCLUSIONS: This controlled study proves that traumamyoplasty is a simple procedure, quicker to perform, and as safe as pyloromyotomy for the treatment of infantile hypertrophic pyloric stenosis in children. For these reasons, the authors believe it should be considered as an alternative.

Female↗
PubMed1989

Hypertrophic pyloric stenosis: use of the pyloric volume measurement in early US diagnosis.

The diagnosis of hypertrophic pyloric stenosis (HPS) with ultrasonography (US) is dependent on measurements of pyloric diameter (PD), pyloric length (PL), and muscle thickness. The authors were unable to confidently diagnose the condition with US in 45% of patients who underwent surgery for HPS because all three criteria were not fulfilled. An overall measurement of the "amount" of pyloric hypertrophy was introduced: pyloric volume (PV), which was equated to 1/4 pi x PD2 x PL. No overlap was found between patients with HPS (n = 22; PV = 3.13 mL; range, 1.4-5.1 mL) and asymptomatic control subjects (n = 28; PV = 0.65 mL; range, 0.2-1.3 mL) or symptomatic subjects without HPS (n = 25; PV = 0.86 mL; range, 0.4-1.3 mL). A positive correlation was found between age at diagnosis and PV, a finding reflecting that HPS is an acquired condition. In patients less than 4 weeks of age, the criterion of PV greater than or equal to 1.4 mL proved to aid in the identification of early HPS more accurately than any existing criteria.

Age Factors↗
PubMedDate not supplied

An uncommon association of H-type tracheoesophageal fistula with infantile hypertrophic pyloric stenosis.

Although infantile hypertrophic pyloric stenosis following esophageal atresia repair is known, infantile hypertrophic pyloric stenosis following H-type tracheoesophageal fistula has not been encountered previously. A case of H-type tracheoesophageal fistula and infantile hypertrophic pyloric stenosis is presented. The patient, operated on for H-type fistula, a rare congenital anomaly of the esophagus, on the tenth day of life was readmitted 19 days later because of continuous vomiting after every feeding. The clinical findings and physical and radiological examinations revealed infantile hypertrophic pyloric stenosis which required surgical treatment. It is suggested that the association of H-type tracheoesophageal fistula with infantile hypertrophic pyloric stenosis is coincidental, given the estimated incidence of one in every 84,375,000 males and 337,500,000 females.

Barium Sulfate↗
PubMed1989

Pyloric stenosis: congenital or acquired?

Pyloric muscle dimensions were measured in 1400 consecutive newborn infants. Nine of these subsequently developed pyloric stenosis. Their pyloric measurements at birth were all within the normal range. Congenital preformed muscular hypertrophy does not appear to be present in babies who later develop pyloric stenosis.

Humans↗
PubMed1979

Adult hypertrophic pyloric stenosis.

Adult hypertrophic pyloric stenosis is an unusual disease of obscure etiology which causes varying degrees of gastric outlet obstruction. Diagnosis by history, physical examination, and roentgenography is difficult but can be readily made with fiberoptic gastroscopy where a characteristic pyloric "cervix sign" is seen. All of the many operations for relief of gastric outlet obstruction have been tried with this lesion, with resection and Billroth I reanastomosis the accepted treatment. Two patients are reported with adult hypertrophic pyloric stenosis who had typical endoscopic findings. One was treated with distal gastrectomy, and the other was adequately treated by endoscopic dilatation alone. It is suggested that endoscopic dilatation is acceptable as primary therapy in suitable cases.

Dilatation↗
PubMed2001

Laparoscopic management of infantile hypertrophic pyloric stenosis.

Infantile hypertrophic pyloric stenosis is a common problem in pediatric surgery. Conventional management by the upper laparotomy was the method of choice over the last few decades. Advanced minimally invasive surgery allows successful endoscopic management of this entity too. We report on our initial experience with endoscopic surgery in the treatment of infantile hypertrophic pyloric stenosis with respect to some technical details. The operative procedure was well tolerated by the infant. After a short and uneventful postoperative course, the infant regained eating habits and was discharged from the hospital on the fifth postoperative day. Our favourable initial experience suggests that laparoscopic pyloromyotomy could be a safe and efficient alternative to the open surgery.

Humans↗
PubMed1995

A new technique for laparoscopic repair of hypertrophic pyloric stenosis.

Since 1987, pyloric traumamyoplasty, a technique for the resolution of hypertrophic pyloric stenosis, has been used in 111 patients. Continuous prensile force is applied with Babcock intestinal clamps, with consequent rupture of the muscular layer, without disruption of the mucosa. Because this is a simple procedure that requires introduction of only one noncutting instrument, it has now been applied laparoscopically in 17 patients. Twelve were under 30 days of age; seven weighed less than 3.5 kg. The hospital stay averaged 1.8 days, and the average surgical time was less than 30 minutes. Only two trocar incisions were made in each case--one for the laparoscope video camera and lamp, the other for a modified Babcock clamp. There were no deaths and no complications related to the pyloric repair procedure. The authors conclude that laparoscopic pyloric traumamyoplasty is an attractive alternative for the management of hypertrophic pyloric stenosis.

Female↗
PubMed2003

Infantile hypertrophic pyloric stenosis.

Infantile hypertrophic pyloric stenosis is a common condition affecting young infants; despite its frequency, it has been recognized only for a little over a century, and its etiology remains unknown. Nevertheless, understanding of the condition and of effective treatment have undergone a remarkable evolution in the 20th century, reducing the mortality rate from over 50% to nearly 0%. The lesion is characterized by gastric outlet obstruction and multiple anatomic abnormalities of the pyloric antrum. The antropyloric muscle is abnormally thickened and innervated, and the intervening lumen is obstructed by crowded and redundant mucosa. Recognition of the obstructive role of the mucosa led to discovery of effective surgical treatment. Accurate clinical diagnosis in patients in whom a thickened antropyloric muscle is not readily palpable can be difficult, resulting in delayed diagnosis and can lead to emaciation and electrolyte imbalance, making the patient a suboptimal surgical candidate. Current imaging techniques, particularly sonography, are noninvasive and accurate for identification of infantile hypertrophic pyloric stenosis. Successful imaging requires understanding of anatomic changes that occur in patients with this condition and plays an integral role in patient care. Accurate, rapid, noninvasive imaging techniques facilitate rapid referral of vomiting infants and prompt surgical treatment of more suitable surgical candidates.

Algorithms↗
PubMed1984

Pyloric stenosis: diagnosis by real time sonography, the pyloric muscle length method.

Real time sonography was performed for identification of pyloric stenosis in 100 infants referred for vomiting. In nine patients, imaging did not identify the pylorus. One of nine had pyloric stenosis. In 91 imaged patients, 40 had pyloric stenosis and 51 did not. Each imaged patient had determinations of the three described diagnostic pyloric muscle measurements: pyloric muscle diameter, pyloric muscle thickness, and pyloric muscle length. The determination of pyloric muscle length was the most accurate (97.8%); it had two false negatives, but no false positive results. Erroneous surgery was thereby avoided. We conclude that real time sonographic determination of pyloric stenosis is reliable and practical, and that pyloric muscle length determination is the most accurate of the currently available techniques.

Humans↗
PubMed2000

Hunterian Lecture. The ontogeny of the peptide innervation of the human pylorus with special reference to understanding the aetiology and pathogenesis of infantile hypertrophic pyloric stenosis.

Infantile hypertrophic pyloric stenosis is the most common cause for urgent abdominal surgery in infancy. The aetiology of the condition is unknown. The ontogeny of the innervation and structure of the normal infant pylorus is unknown. A variety of differing histological features have been attributed to this condition and a number of animal models have been described. The histological changes in the human condition and those in the animal models have not been quantified and statistically verified. Thus, precise comparisons cannot be made. Immunohistochemistry was the principal technique employed in this study. Using this technique, the ontogeny and structure of the normal infant pylorus have been documented. The morphological and immunohistochemical changes underlying infantile hypertrophic pyloric stenosis have been quantified for the first time and compared with the quantified changes in natural and experimental animal models of this condition.

Animals↗