Early pyloric stenosis: a case control study

Congenital infantile hypertrophic pyloric stenosis in preterm dizygotic twins infants diagnosed early: A case report

INTRODUCTION AND IMPORTANCE

The association in the occurrence of hypertrophic pyloric stenosis (HPS) is 0.25 % to 0.44 % between monozygotic twins and 0.05 % to 0.10 % in dizygotic twins. A combination of genetic and environmental factors may have contributed to the occurrence of HPS. In view of the few related cases reported recently, we present two dizygotic twins who were diagnosed with HPS.

CASE PRESENTATION

This report describes a rare case of congenital infantile hypertrophic pyloric stenosis in preterm dizygotic twins diagnosed early, in which the first case presented with severe clinical features and managed surgically while the second presented with moderate features and hence managed non-operatively with atropine for 14 days. At 6 months of age, both twins continued to tolerate feeds, demonstrated satisfactory weight gain and had achieved appropriate developmental milestones. The postoperative course was uneventful in the twin A.

CLINICAL DISCUSSION

Congenital HPS in premature twins remains an underdiagnosed pathology due to its clinical picture mimicking digestive intolerance to feeds. The mean age at diagnosis is about 38 days, and only 0.4 % of all children suffering from HPS show symptoms in the first 3 days of life. Symptom relief is achieved after a classic pyloromyotomy is performed by a more preferable laparoscopic technique or using the open surgical technique.

CONCLUSION

If one of the dizygotic twins has HPS, the other baby should be evaluated for the same diagnosis as early as possible, to ensure timely management. HPS with moderate clinical features can be treated with atropine for 14 days while severe HPS should be treated by pyloromyotomy.

Subtotal pyloric obstruction by atypical hypertrophic pyloric muscle in a newborn

This is a case of a neonate with suspected duodenal atresia on prenatal imaging. However, distal bowel gas was identified postnatally on regular X-rays with a possible pyloric obstructing mass visualised on ultasound. No contrast was visualised passing through the stomach on fluoroscopic studies. Operative evaluation revealed an atypical asymmetric hypertrophic pylorus with exophytic lesions of ectopic glandular tissue. Longitudinal open pyloromyotomy was performed which relieved the gastric obstruction resulting in symptomatic relief without any anatomy altering procedure required.

An Unusual Presentation of Pyloric Stenosis: A Case Report

A full-term newborn female presented with non-bilious emesis immediately after feeding and abdominal distension on day one of life with neither palpable abdominal mass nor electrolyte derangements. The baby was initially admitted to rule out gastrointestinal obstruction versus sepsis as a cause of vomiting and abdominal distension. Initial imaging studies involving an upper gastrointestinal (GI) series showed obstruction at the level of the duodenum, but it was only during surgical exploration that the diagnosis of infantile hypertrophic pyloric stenosis was made. This case report highlights the atypical presentation of pyloric stenosis and the need to investigate cases of vomiting immediately after feeding in a newborn with ultrasonography at the least to minimize complications.

Transumbilical single-site two incision laparoscopic pyloromyotomy for pediatric hypertrophic pyloric stenosis

PURPOSE

A new novel technique for the treatment of pediatric hypertrophic pyloric stenosis (HPS), transumbilical single-site laparoscopic pyloromyotomy with a single instrument (TUSSLP), was introduced. TUSSLP was compared with the transabdominal three-site laparoscopic pyloromyotomy (TATSLP) procedure.

METHODS

Patients with HPS who underwent TUSSLP and TATSLP between January 2016 and September 2020 were assigned to group A and group B, respectively. The descriptive variables, perioperative clinical characteristics and postoperative follow-up results were retrospectively analyzed and compared between the 2 groups. The primary outcome of this study was the rate of switching to conventional pyloromyotomy.

RESULTS

Sixty-four patients were enrolled in this study. Of these patients, 29 (22 males, 7 females, 54.4 ± 22.6 days) who received TUSSLP were assigned to group A. The remaining 35 (28 males, 7 females, 54.5 ± 27.6 days) who received TATSLP were assigned to group B. The data of preoperative patient variables were comparable between the 2 groups (P > 0.05). The mean operative time (ORT) was 28.1 ± 5.6 min in group A, which was not significantly different from 25.8 ± 3.1 min in group B (P = 0.25). The other perioperative features were not significantly different between the 2 groups (P > 0.05). During follow-up (39.1 ± 14.7 m in group A and 35.4 ± 16.1 m in group B, P = 0.51), no significant difference was observed in the overall incidence of vomiting between the 2 groups (P = 0.26).

CONCLUSIONS

TUSSLP is a feasible and reliable minimally invasive method for HPS. It has the advantages of an improved cosmetic appearance. The postoperative follow-up results of TUSSLP are comparable with those of TATSLP.

Congenital Hypertrophic Pyloric Stenosis in a Preterm Dizygotic Female Twin Infant: Case Report

Infants with hypertrophic pyloric stenosis are usually diagnosed at about 3 to 8 weeks of age. The clinical onset of symptoms in preterm babies is observed normally at a later age than in term or post-term newborns. This report describes a rare case of a 2-day old preterm twin girl presenting with drinking laziness and recurrent vomiting. Five days after the beginning of symptoms and after several studies, including an upper gastrointestinal contrast study, the diagnosis of hypertrophic pyloric stenosis was made and confirmed at surgery. The postoperative course was uneventful. Interestingly, the mother of the child herself had a history of postnatal surgery on her fifth day of life due to congenital hypertrophic pyloric stenosis. To our best knowledge, this is the first report in the literature describing congenital hypertrophic pyloric stenosis in a mother and her child.

Low socioeconomic status and formula feeding directly correlate with increased incidence of hypertrophic pyloric stenosis

PURPOSE

The purpose of this analysis was to determine if a correlation exists between socioeconomic status (SES) and pyloric stenosis (PS) as well as between PS and feeding method.

METHODS

Data was collected retrospectively from the electronic medical record. Patients were included if they resided in a county in Illinois where our institution maintains >10% visit share, were < 1 year in age, and received a pyloromyotomy from January 2011 to May 2018. Patient addresses were geocoded and merged with county and tract-level census data. A control group was matched on gender, race, tract level, median household income (MHI), and age. Feeding method for each group was collected. Univariate analysis and multivariate analyses were employed.

RESULTS

SES was explored using MHI. After controlling for gender, age, race, and institution adjusted tract size, the association between MHI and pyloromyotomy remained significant. As MHI decreased, the odds of having a PS case increased. Additionally, the PS incidence rate increased as MHI decreased. Patients who were exclusively formula fed were more likely to have PS.

CONCLUSION

Pyloric stenosis had a direct correlation with SES as defined by MHI. As MHI decreased, the rates of PS increased. In addition, breastfeeding was protective, independent of MHI.

TYPE OF STUDY

Prognosis study.

LEVEL OF EVIDENCE

Level II.

Pediatric emergency medicine point-of-care ultrasound: summary of the evidence

The utility of point-of-care ultrasound is well supported by the medical literature. Consequently, pediatric emergency medicine providers have embraced this technology in everyday practice. Recently, the American Academy of Pediatrics published a policy statement endorsing the use of point-of-care ultrasound by pediatric emergency medicine providers.  To date, there is no standard guideline for the practice of point-of-care ultrasound for this specialty. This document serves as an initial step in the detailed "how to" and description of individual point-of-care ultrasound examinations.  Pediatric emergency medicine providers should refer to this paper as reference for published research, objectives for learners, and standardized reporting guidelines.

Single-site umbilical laparoscopic pyloromyotomy in neonates less than 21-day old

PURPOSE

Single-site umbilical laparoscopic pyloromyotomy for hypertrophic pyloric stenosis in neonates <3-week old has rarely been reported in the literature. This article reports our initial experience with this procedure.

METHODS

Overall, 13 cases of hypertrophic pyloric stenosis occurred in neonates <3-week old from January 2010 to April 2013 in our hospital. All neonates were treated by a single-site laparoscopic procedure. A 5-mm trocar and endoscope were introduced through an incision in the center of the umbilicus, and two 3-mm working instruments were inserted directly into the abdomen via separate lateral fascial stab incisions in the umbilical fold, and a single-site umbilical laparoscopic pyloromyotomy was then performed.

RESULTS

The procedure was performed in 13 infants (12 male) with mean age of 17.3 days. The average length of the operation was 26 min. The mean postoperative hospital stay was 4.5 days. All patients were discharged home on full feeds. Follow-up examinations were scheduled 2 to 6 weeks after discharge, and no postoperative complications were noted in any of the patients.

CONCLUSION

These cases had shorter and thinner pylori than their older counterparts. However, the laparoscopic procedure was safe and feasible, with good postoperative results and excellent cosmesis. Surgeons should have a firm foundation of advanced minimal access surgical skills prior to attempting the procedure.

Evaluation of hypertrophic pyloric stenosis by pediatric emergency physician sonography

OBJECTIVES

The objective was to evaluate the accuracy of pediatric emergency physician (EP) sonography for infants with suspected hypertrophic pyloric stenosis (HPS).

METHODS

This was a prospective observational pilot study in an urban academic pediatric emergency department (PED). Patients were selected if the treating physician ordered an ultrasound (US) in the department of radiology for the evaluation of suspected HPS.

RESULTS

Sixty-seven patients were enrolled from August 2009 through April 2012. When identifying the pylorus, pediatric EPs correctly identified all 10 positive cases, with a sensitivity of 100% (95% confidence interval [CI] = 62% to 100%) and specificity of 100% (95% CI = 92% to 100%). There was no statistical difference between the measurements obtained by pediatric EPs and radiology staff for pyloric muscle width or length (p = 0.5 and p = 0.79, respectively).

CONCLUSIONS

Trained pediatric EPs can accurately assess the pylorus with US in the evaluation of HPS with good specificity.