21 day old baby boy, with non-bilious projectile vomiting.
Small nodular mass is palpated in mid upper abdomen, on physical exam
â€¢ Plain Radiograph: distended stomach bubble with little distal gas.
â€¢ Ultrasound: thickened and elongated pylorus which persisted for and did not relax following feeds.
â€¢ Fluoroscopy: contrast material did not move past the pylorus of the stomach, despite multiple positional maneuvers over the course of 15 minutes.
â€¢ Hypertrophic pyloric stenosis
â€¢ Antral gastric ulcer with scarring
â€¢ Ectopic pancreas
Surgical Pyloromyotomy to relieve the obstruction
Radiography is seldom useful; however, massive distention of the stomach, little small bowel or colonic air, and visible gastric peristaltic waves are highly suggestive.
At UGI, all babies with HPS should show delayed gastric emptying and hyper-peristaltic waves - that stop at the pylorus. If contrast passes through the pylorus, you would see the hypertrophied pylorus, producing indentation on the gastric antrum and the duodenal bulb along, with a "string sign" of a thin contrast stream within the narrow pyloric channel.
Treatment for HPS is the Ramstedt pyloromyotomy. This is a relatively safe procedure, with little if any morbidity or mortality; and, it is almost always effective.
Kirks, Donald. Practical Pediatric Imaging. Diagnostic Radiology of Infants and Children. 3rd ed. Philadelphia: Lippincott-Raven, 1998:899-904.
Hypertrophic pyloric stenosis is a narrowing of the pyloric channel secondary to muscle thickening to the point where emptying of the stomach is prevented. Pyloric stenosis is fairly common as it affects about 3 out of 1,000 babies in the United States. Pyloric stenosis is about four times more likely to occur in firstborn male infants. Pyloric stenosis occurs more commonly in Caucasian infants than in babies of other ethnic backgrounds, and affected infants are more likely to have blood type B or O. Symptoms include progressive, non-bilious projectile vomiting, decreased stooling and no weight gain. Sonography is the imaging modality of choice as the muscles of the pylorus are seen in both the transverse and longitudinal planes, with the additional benefit of realtime visualization of gastric peristalsis. The threshold value of the thickness in the transverse plane from the mucosal margin to the exterior confines of the pyloric musculature is 3mm and the upper limit of normal for channel length is roughly 14 mm. Surgical treatment with pyloroplasty is commonly performed in the United States while medical management is often utilized in Europe.
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