Rapid correction of metabolic alkalosis in hypertrophic pyloric stenosis with intravenous cimetidine: preliminary results

Is there any benefit with pantoprazole treatment in infantile hypertrophic pyloric stenosis?

CONTEXT

Previous studies demonstrated faster correction of metabolic derangement associated with hypertrophic pyloric stenosis with pre-operative intravenous (IV) histamine-2 receptor antagonists.

AIMS

We investigated if similar outcomes are achieved with IV pantoprazole, a proton-pump inhibitor (PPI), including the subgroup of delayed presenters in the South African setting.

SETTINGS AND DESIGN

A 5-year retrospective record review (January 2014-December 2018) compared the rate of metabolic correction in patients with hypertrophic pyloric stenosis at two tertiary centres.

SUBJECTS AND METHODS

One centre routinely administers IV pantoprazole (1 mg/kg daily) preoperatively (PPI group) and the other does not (non-PPI group). Fluid administration, chloride supplementation and post-operative emesis were evaluated.

STATISTICAL ANALYSIS

Spearman's rank correlation coefficient was used to calculate statistical significance for discrete dependent variables. Continuous variables were compared between the groups using the Student t-test. Fisher's exact contingency tables were used to classify categorical data and to assess the significance of outcome between two treatment options. P < 0.05 was considered statistically significant.

RESULTS

Forty-two patients received IV pantoprazole and 24 did not. The mean time of metabolic correction was 8 h shorter in the PPI group (P = 0.067). Total pre-operative chloride administration correlated to the rate of metabolic correction in both cohorts (P < 0.0001). Profound hypochloraemia (chloride <85 mmol/l) was corrected 23 h faster in the PPI group (P < 0.004). Post-operative emesis was noted: 0.45 episodes/patient in the PPI group and 0.75 episodes/patient in the non-PPI group (P = 0.01).

CONCLUSIONS

Pre-operative IV pantoprazole administration showed a faster correction of metabolic derangements, and in profound hypochloraemia, the correction occurred substantially faster in the PPI group. Post-operative emesis was significantly less frequent in the PPI group.

Brief Overview and Updates on Infantile Hypertrophic Pyloric Stenosis: Focus on Perioperative Management

Infantile hypertrophic pyloric stenosis is the most common surgical cause of vomiting in infancy. After adequate resuscitation, surgical pyloromyotomy is the standard of care for infants with pyloric stenosis. This article provides a brief overview and updates on hypertrophic pyloric stenosis in infants, with a focus on the surgical approach as well as perioperative management of this pathology. The most controversial aspect of the management of infants with pyloric stenosis is post-pyloromyotomy feeding, as there is no clear consensus in the literature on the best regimen. More randomized controlled trials are needed to establish the optimal resuscitation protocol in the preoperative phase and the ideal feeding regimen in the postoperative phase for infants with hypertrophic pyloric stenosis. [Pediatr Ann. 2021;50:(3):e136-e141.].

A Delphi Analysis to Reach Consensus on Preoperative Care in Infants with Hypertrophic Pyloric Stenosis

INTRODUCTION

 Infantile hypertrophic pyloric stenosis (IHPS) is a common gastrointestinal condition that can lead to metabolic alkalosis and, if uncorrected, to respiratory complications. A standardized approach to correct metabolic derangements and dehydration may reduce time until pyloromyotomy while preventing potential respiratory complications. Such an evidence-based policy regarding preoperative care is absent. We aim to formulate a recommendation about preoperative care for infants with IHPS using the Delphi technique.

MATERIALS AND METHODS

 The RAND/UCLA appropriateness method was used to reach international consensus in a panel of pediatric surgeons, pediatric anesthetists, and pediatricians. Statements on type and frequency of blood sampling, required serum concentrations before pyloromyotomy and intravenous fluid therapy, were rated online using a 9-point Likert scale. Consensus was present if the panel rated the statement appropriate/obligatory (panel median: 7-9) or inappropriate/unnecessary (panel median: 1-3) without disagreement according to the interpercentile range adjusted for symmetry formula.

RESULTS

 Thirty-three and twenty-nine panel members completed the first and second round, respectively. Consensus was reached in 54/74 statements (73%). The panel recommended the following laboratory tests and corresponding cutoff values prior to pyloromyotomy: pH ≤7.45, base excess ≤3.5, bicarbonate <26 mmol/L, sodium ≥132 mmol/L, potassium ≥3.5 mmol/L, chloride ≥100 mmol/L, and glucose ≥4.0 mmol/L. Isotonic crystalloid with 5% dextrose and 10 to 20 mEq/L potassium should be used for fluid resuscitation.

CONCLUSION

 Consensus is reached in an expert panel about assessment of metabolic derangements at admission, cutoff serum concentrations to be achieved prior to pyloromyotomy, and appropriate intravenous fluid regime for the correction of dehydration and metabolic derangements in infants with IHPS.

Guidelines of the Italian Society of Videosurgery (SIVI) in Infancy for the minimally invasive treatment of Hypertrophic Pyloric Stenosis in neonates and infants

The most appropriate treatment for the infantile Hypertrophic Pyloric Stenosis (HPS) is still debated. The non-surgical conservative treatment with oral or intravenous administration of atropine does not enjoy a widespread appreciation for several factors (...).

Pyloric stenosis of Infancy, primary hyperacidity and Occam's razor

An account is given of the process by which the Primary Hyperacidity pathogenesis of Pyloric Stenosis of Infancy (PS) evolved. The initial discovery that fasting gastrins were high at birth and continued to rise within the first 4 days was the starting point. Since acidity was also rising at the same time it was proposed that the usual negative feed-back between gastrin and stomach acidity was not mature in the first few weeks of life. The gastrin model for producing PS in puppy dogs was a further incentive to believe that relatively high gastrins, and secondary high acidity would thereby repeatedly cause sphincter contraction and lead to hypertrophy. When gastrin was found to be normal in PS babies we considered and accepted, the less complicated hypothesis that a Primary Inherited Hyperacidity itself was the driving force. Such a theory explained nearly all the clinical features. When we further considered the expected consequences of an initially ineffective negative feed -back and its later maturation, the known peak acidity in neonatal development was explained. This phenomenon also provided an explanation for the remaining previously unexplained time sensitive features of the condition.

Hypertrophic pyloric stenosis: predicting the resolution of biochemical abnormalities

PURPOSE

Hypertrophic pyloric stenosis (HPS) is a common condition of infancy, often presenting with marked biochemical derangement, requiring correction. Previous studies have looked at the relationship between serum electrolytes and acid-base balance in HPS but not at the relationship between the degree of biochemical derangement and time taken to resolve the biochemical abnormality.

METHODS

Retrospective analysis was performed on all 151 infants undergoing pyloromyotomy over a 3 year period. Of these, 105 met the inclusion criteria of: compliance with the unit HPS fluid protocol, and the documentation of at least three serial biochemical investigations. The rate of correction for each biochemical marker (sodium, potassium, chloride, urea, pCO2, hydrogen ion concentration, bicarbonate and the base excess) was plotted against the degree of disturbance and then against time.

RESULTS

A significant relationship (P < 0.01) was found between the rate of correction of an abnormal chloride, urea or base excess and the degree of initial derangement. This enables the prediction of the time taken for the required correction of biochemical abnormalities prior to theatre.

CONCLUSION

This method of analysis may be of value in comparing the effectiveness of different fluid regimes in use for the correction of biochemical abnormalities in infants with IHPS.