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Infantile Hypertrophic Pyloric Stenosis- An Overview
Infantile Hypertrophic Pyloric Stenosis (IHPS) An Overview
2. Dr.B.SELVARAJ,MS;MCh;FICS; Neonatal & Pediatric Surgeon Associate Professor Melaka Manipal Medical College Melaka- 75150 Malaysia
OBJECTIVES •To discuss the etiology, clinical features, and pathophysiology of IHPS •To discuss workup to clinch the correct diagnosis •To discuss the various treatment options •To make you confident in managing an infant with IHPS
PLAN • Etiology • Pathophysiology • History & Physical • Differential Diagnosis • Workup • Preop preparation • Management • Complications
History • 1646-Sabricus Hildanus-1st described • 1888-Hirschsprung-Pathology • 1908-Fredet-Longitudinal incision closed transversely • 1912- Ramstedt- omitted transverse closure • 1986- Tan&Bianchi- Periumbilical incision • 1992- Lap Pyloromyotomy
Etiology • Hypertrophy of muscles surrounding pyloric channel • Idiopathic • Various Hypothesis: Milk curd theory& theory of Aganglionosis • Male: Female 4:1 • Female parent with the disorder four times more chances of having affected offspring • Increased incidence within families
Pathology • Hypertrophied muscles • Gastric outlet obstruction • Nonbilious projectile vomiting • Gastric fluid loss • Hypochloremic Hypokalemic Alkalosis • Paradoxical Aciduria
History&Physical • Cyclical Nonbilious projectile vomiting at 2wks to 2 months of age • Usually first-born male child • Failure to thrive • Loss of weight & Dehydration • Visible Gastric PeristalsisVGP • Olive tumor • Occasional jaundice
History Physical • Nonbilious projectile vomiting at 3 to 6 weeks of age • Usually first born male child • Failure to thrive • Loss of weight Dehydration • Visible Gastric PeristalsisVGP Olive tumor – Occasional jaundice
IHPS- Paradoxical Aciduria
Differential Diagnosis • GE Reflux • Faulty feeding techniques • Indirect marker of illness like UTI, ICP, and Congenital adrenal hyperplasia • Pyloric Atresia • Pyloric Membrane Neonatal only • Antral Atresia • Antral Membrane
Workup • AXR- Erect: Dilated Stomach • Barium meal series: String sign and Railroad track sign • USG Abdomen: Dilated and elongated pyloric channel muscles • Serum electrolytes • Arterial blood gas analysis
Plain AXR Barium Meal
USG Abdomen
USG Diagnostic criteria IHPS • Pyloric channel length1.5 to 2 cms (Normal 1.2cms) • Pyloric channel diameter1.3 to 1.5cms (Normal 1 cms) • Circular muscle thickness 4 to 5 mms (Normal 2mms)
Preop Preparation • NPO • NGT Decompression and gastric lavage • Correction of dehydration and alkalosis with D5W with 1/2 normal saline • Serum bicarbonate should be 28 meq/ ltr and Serum chloride should be 100 meq/ltr before taking up the child for surgery
Management • Fredet- Ramstedt’s Pyloromyotomy conventional open procedure • Laparoscopic Pyloromyotomy • PostopProgressive increase in feeding from 8 hrs onwards • D/C IVF if child tolerates 60ml Q3H
Fredet- Ramstedt’s Pyloromyotomy
Fredet- Ramstedt’s Pyloromyotomy
Laparoscopic Pyloromyotomy
Laparoscopic Pyloromyotomy
Complications • Unrecognised Duodenal perforation • Occasional intraabdominal bleeding • Postop persistent vomiting: If 1Wk Redo Surgery Torgerson’s muscle incision • Wound infection/ Wound dehiscence
Infantile Hypertrophic Pyloric Etiology Tt Complications • Fredet-Ramstedt’s Pyloromyotomy • Unrecognised perforation with peritonitis • Occasional bleeding • Persistent vomiting • Wound infection and dehiscence P Preop prep IHPS Imaging • Hypertrophied muscle • G O Obstruction • Non-bilious vomiting • Gastric fluid loss • Hypochloremic alkalosis • Paradoxical aciduria • Idiopathic • Milk curd Theory • Familial Pathology H P • AXR- dilated stomach • Ba Meal- String sign • USG Abd- dilated elongated pyloric muscles • 1st born male child • Cyclical non-bilious projectile vomiting • Dehydration loss of weight • Olive tumor • NPO • NGT aspiration gastric lavage • Correction of dehydration Electrolytes imbalance M Stenosis
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