Infantile Hypertrophic Pyloric Stenosis- An Overview

Infantile Hypertrophic Pyloric

Stenosis (IHPS)

Infantile Hypertrophic Pyloric

Stenosis (IHPS)

AN OVERVIEW AN OVERVIEW

Dr.B.SELVARAJ,MS;Mch;FICS; 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 Peristalsis����VGP

• 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 Peristalsis����VGP

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 Rail

road 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 length����1.5 to 2 cms

(Normal 1.2cms)

• Pyloric channel diameter����1.3 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 withD5W 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

• Postop����Progressive 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

Etiology

Preop prep

Imaging

• Hypertrophied muscle

• G O Obstruction

• Non bilious vomiting

• Gastric fluid loss

• Hypochloremic alkalosis

• Paradoxical aciduria

• Idiopathic

• Milk curd Theory

• Familial

• AXR- dilated stomach

• Ba Meal- String sign

• USG Abd- dilated &

elongated pyloric muscles

Tt &

Complica

tions

Pathology

IHPS

H & P

• 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

• Fredet-Ramstedt’s

Pyloromyotomy

• Unrecognised perforation with

peritonitis

• Occasional bleeding

• Persistent vomiting

• Wound infn & dehiscence

P

M

Stenosis

Infantile Hypertrophic Pyloric

Stenosis

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