Pyloric Stenosis 08.03.2012

7/31/2019 Pyloric Stenosis 08.03.2012

1/17

Morning Report

Elisabeth Kaza, MD

August 3, 2012


2/17

You are in the ED...

2 mo old term female with severerecurrent vomiting and dehydration


3/17

HPI

3 wks ago (at 5 wks of life): first emesis Emesis:

Non bloody, non bilious

More forceful and frequent over time Seen by PCP numerous times, tried on:

Soy formula, Alimentum, Nutramigen

Anti-reflux meds

Would tolerate new formula for ~ 24hrs Past 2 days: not waking up, decreased

UOP, only smears of stool for past wk


4/17

PMH/SH/FH

Birth history: 39 wks to 30 y/o G3P2002 via NSVD

Resuscitation: dry & stim, Apgars 8/9

SH: UT Parents and 2 siblings (7 and 9 y/a)

FOB smokes at home

FH: not contributory

Medications: none currently

ROS: lethargy, decreased UOP, pallor


5/17

VS/PE

VS: T 37.1, HR 129, RR 28, BP 90/55, SaO2 92% on RAWeight: 3.6kg (Birth Weight: 3.054kg)

Height: 52.8 cm

Physical Exam:

Gen: no acute distress, appeared ill, slightly lethargic

HEENT: anterior fontanelle sunken, PERRL, drymucous membranes

Resp: clear to auscultation, no wheezing/crackles

CV: RRR, cap refill 3 sec, femoral pulses 2+

Abdomen: soft, mildly distended, NT, no HSM

Neuro: moves all extremities, Moro/suck wnl

Skin: cool, no rashes or jaundice


6/17

Differential Diagnosis ??

2 mo old term female with severerecurrent vomiting and dehydration


7/17

Vomiting in Children:

Reassurance, Red flag, Referral?

Gastrointestinal Neurologic Renal Endocrine

-Esophagus:

stricture, web, TEF, atresia

-Stomach:

pyloric stenosis, web, ulcer

GERD

-Intestine:

duodenal atresia, malrotation,

intussusception, volvulus,

duplication, NEC

-Colon:

Hirschsprung, imperforate anus

-Acute gastroenteritis

-H. pylori infection

-Parasitic infections-Appendicitis

-Celiac disease

-Milk/soy protein allergy

-Inflammatory bowel disease

-Pancreatitis

-Cholecystitis

-Hepatitis

-Peritonitis

-Trauma: duodenal hematoma

-Tumor

-Cyst

-Hematoma

-Cerebral edema

-Hydrocephalus

-Pseudotumor cerebri

-Migraine headache

-Abdominal migraine

-Seizure

-Meningitis

-Obstructive uropathy

-UPJ obstruction

-Nephrolithiasis

-Renal insufficiency

-GN

-UTI

-RTA

-Diabetic ketoacidosis

-Adrenal insufficiency

Metabolic Miscellaneous

-Galactosemia-Hereditary fructosemia

-Amino acidopathy

-Organic acidopathy

-Urea cycle defects

-Lactic acidosis

-Lysosomal storage

disorder

-Peroxisomal disorders

-Sepsis-Pregnancy

-Bulimia

-Psychogenic

-Cyclic vomiting

-Overfeeding

-Medication toxicity

-SMA syndrome

-Child abuse

-PNA


8/17

Age-related DD of Vomiting in

Children Younger Than 12 Mo

Age Common Causes Type of Vomiting Associated Features

Newborn - Intestinal atresia/web

- Meconium ileus

- Hirschsprungs

- NEC- Inborn errors of metabolism

Bilious, depending on lesion

Bilious

Bilious or nonbilious

Bilious or nonbiliousBilious or nonbilious

Esophagus, duodenum, jejunum

Ass with CF

Suction rectal surgery

KUB pneumatosisMay have acidosis/hypoglycemia

0-3 mo - Pyloric stenosis

- Malrotation, midgut volvulus

- Inborn errors of metabolism

- Milk/soy protein allergy

- GERD

- Child abuse

Nonbilious

Bilious


Bilious or nonbilious, bloody

Nonbilious, bloody

Nonbilious

Hypochloremic metabolic alkalosis

Emergent surgical consultation

Abnormal newborn screen

Hx extreme fussiness

Emesis within 30min of feeding

CNS imaging studies

3-12 mo - Gastroenteritis

- Intussusception

- Child Abuse

- Intracranial mass

Nonbilious initially

Bilious

Nonbilious

Nonbilious

Consider stool studies

Abdominal distention

Anterior fontanelle fullness

CNS imaging


9/17

Age-related DD of Vomiting in

Children Younger Than 12 Mo

Age Common Causes Type of Vomiting Associated Features

Newborn - Intestinal atresia/web

- Meconium ileus

- Hirschsprungs

- NEC- Inborn errors of metabolism

Bilious, depending on lesion

Bilious


Bilious or nonbiliousBilious or nonbilious

Esophagus, duodenum, jejunum

Ass with CF

Suction rectal surgery

KUB pneumatosisMay have acidosis/hypoglycemia

0-3 mo - Pyloric stenosis

- Malrotation, midgut volvulus

- Inborn errors of metabolism

- Milk/soy protein allergy

- GERD

- Child abuse

Nonbilious

Bilious


Bilious or nonbilious, bloody

Nonbilious, bloody

Nonbilious

Hypochloremic metabolic alkalosis

Emergent surgical consultation

Abnormal newborn screen

Hx extreme fussiness

Emesis within 30min of feeding

CNS imaging studies

3-12 mo - Gastroenteritis

- Intussusception

- Child Abuse

- Intracranial mass

Nonbilious initially

Bilious

Nonbilious

Nonbilious

Consider stool studies

Abdominal distention

Anterior fontanelle fullness

CNS imaging


10/17

PYLORIC STENOSIS

Hernanz-Schulman M Radiology 2003;227:319-331


11/17

Laboratory Evaluation

CBG: 7.59/62.2/58/59.7/BE unable toreport

BMP:

Anion Gap: 31

CBC:

CRP: 2.6

iCa: 1.17, Mg: 2.2, Phos: 3.9

124 53 40

2.6 >40 0.59104

11.7 488

39.3

9%B

36%N

33%L

22%MI/T: 0.19


12/17

Abdominal UltrasoundMarked thickening of pyloric mm and elongation of pyloric channel

Unilateral wall thickness: 5mm Channel length: 25mm


13/17

History

Harald Hirschsprung

(1830-1916)

German Pediatric

Congress inWiesbaden in 1887

2 infant girls with

pathologically

proven IHPS

Hernanz-Schulman M Radiology 2003;227:319-331


14/17

Symptoms

Persistent non-bilious vomitingAround 2-6 weeks of age

Usually forceful and projectile

Clear or curdled milk

Tends to occur within 30-60 min of feeding

Males, especially firstborn

Incidence: 3 per 1000 live births

Exact cause unclear Erythromycin interacts + motilin receptors

(gastric/pyloric contractions/hypertrophy)


15/17

Dx and Treatment

History, PE (palpable olive)

Laboratory:

hypochloremic hypokalemic metabolic

alkalosis

U/S of pyloric mm:

Sensitivity of 85-100%

Mm thickness of > 4mm Mm length of 14 mm

Surgical pyloromyotomy


16/17

Can you feel an olive?


17/17

Surgical Criteria

Good hydration status

Normalization of acid-base status and

electrolyte

Chloride > 100

Bicarb < 28 which she reached on day 3

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Pyloric Stenosis 08.03.2012