Gastric outlet obstruction in children: an overview with report of Jodhpur disease and Sharma's classification

Nonhypertrophic Pyloric Stenosis in a Neonate: A Rare Presentation

Gastric outlet obstruction in neonates due to nonhypertrophic pyloric stenosis (NHPS) is a rare cause. We report the case of a 37-day-old baby boy who presented with complaints of vomiting for the last 2 weeks and an inconsolable cry over the last 2 days. He has been vomiting seven to eight times a day, a few hours after breastfeeding. On ultrasonography, the stomach was distended, while the pylorus was not hypertrophied. An upper gastrointestinal (GI) contrast study was done, which was suggestive of gastric volvulus. We performed a laparoscopy for the same. Intraoperatively, the volvulus was already resolved. We performed gastropexy. Postoperatively, he had persistent symptoms, for which an upper GI endoscopy was performed. It demonstrated a narrow pylorus, consistent with the NHPS. We performed a laparoscopic Heineke-Mikulicz pyloroplasty. The patient's symptoms had improved postoperatively. He was discharged after 5 days.

Pyloric stenosis secondary to peptic ulcer disease in pediatric patients: A case report and review of the literature

RATIONALE

Pediatric pyloric obstruction is a condition characterized by complete or incomplete obstruction of the distal stomach caused by obstructive lesions of the distal stomach, pyloric duct, or proximal duodenum. Congenital hypertrophic pyloric stenosis is the most common cause of pediatric pyloric obstruction, whereas acquired pyloric stenosis is comparatively rare, with peptic ulcer disease being the most common cause.

PATIENT CONCERNS

We describe a case of a 5-year-old girl who had peptic ulcer disease and developed scarring pyloric stenosis. We also give comprehensive details of the diagnosis and course of treatment.

DIAGNOSIS

Intraoperative findings revealed ulcerative, scarring pyloric obstruction.

INTERVENTIONS

Conservative treatment failed and surgery was subsequently performed.

OUTCOMES

No further vomiting symptoms occurred after surgery. And 3 months after surgery, the patient had gained weight on average and had no further complaints.

LESSONS

Although scarring pediatric pyloric blockage due to peptic ulcer is less common, emphasis should be placed on rapid diagnosis by accurate gastroscopy, barium meal of the gastrointestinal tract, or ultrasonography. Depending on the patient's condition, conservative treatment or surgery should be chosen carefully selected.

Hypertrophic Pyloric Stenosis in an Adolescent Girl: An Atypical Presentation of an Unexpected Disease

Hypertrophic pyloric stenosis is a common cause of vomiting in the first few weeks of life, but in rare cases, it may occur in older subjects with a major risk of delayed diagnosis and complications. We describe the case of a 12-year-and-8-month-old girl who presented to our department for epigastric pain, coffee-ground emesis, and melena, which arose after taking ketoprofen. An abdomen ultrasound showed thickening (1 cm) of the gastric pyloric antrum, while upper-GI endoscopy documented esophagitis and antral gastritis with a non-bleeding pyloric ulcer. During her hospital stay, she had no further episodes of vomiting and was therefore discharged with a diagnosis of "NSAIDs-induced acute upper gastrointestinal tract bleeding". After 14 days, following recurrence of abdominal pain and vomiting, she was hospitalized again. At endoscopy, pyloric sub-stenosis was found, abdominal CT showed thickening of large gastric curvature and pyloric walls, and an Rx barium study documented delayed gastric emptying. On suspicion of idiopathic hypertrophic pyloric stenosis, she underwent Heineke-Mikulicz pyloroplasty with resolution of symptoms and restoration of a regular caliber of the pylorus. Hypertrophic pyloric stenosis, although occurring rarely in older children, should be taken into account in the differential diagnosis of recurrent vomiting at any age.

Uncommon Cause of Chronic Vomiting in Children

Gastric outlet obstruction (GOO) is unusual and must be suspected in children with chronic vomiting and abnormal weight status. The treatment depends on etiology, and surgery is not always the first remedy. Diagnosis is easily confirmed by upper gastrointestinal fibroscopy.We report the case of an 11-year-old girl, who was presented with non-bilious emesis and weight loss. Abdominal computed tomography, ultrasound, and upper gastrointestinal fibroscopy showed dilated stomach with pyloric stenosis, which was confirmed by abdominal laparoscopic exploration and cured by Heineke-Mikulicz pyloroplasty. We also compare our study to previously reported cases.

Primary acquired cicatrizing gastric outlet obstruction in children

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Case report: Late-onset hypertrophic pyloric stenosis in a 3-year-old boy: It is never too late

Hypertrophic Pyloric Stenosis (HPS) represents a relatively rare occurrence beyond infancy. Here, we present the case of a barely 3-year-old boy diagnosed with late-onset HPS and successfully treated with extra-mucosal pyloromyotomy. We review the literature, challenging the principle that more aggressive surgical approaches should be preferred over less invasive ones.

Upper GI series in infants and children with vomiting: insights into ACR appropriateness criteria

Background

Although upper gastrointestinal series (UGI) series are frequently requested in pediatric radiology department, there are few articles investigating its value in children with vomiting. The purpose of this study was to review imaging findings perceived during UGI series in infants and children presented with vomiting in correlation to their symptoms based on the ACR appropriateness criteria. This was to identify clinical scenarios with higher diagnostic yield.

Results

A cross-sectional study including UGI series of 76 patients presented with vomiting (1 month–17 years) was performed. Patients were grouped according to their age into 5 groups and stratified according to the type of vomiting into 3 groups (bilious vomiting, new-onset nonbilious vomiting, intermittent nonbilious vomiting since birth). Associated symptoms were described with calculation of a novel clinical score. Radiological abnormalities in different age groups were described in relation to the type of vomiting. All patients with bilious vomiting or nonbilious vomiting associated with melena or dysphagia had abnormal findings. Gastroesophageal reflux was detected in 25% of cases. Patients with normal and abnormal study were compared according to their clinical score. The clinical score was significantly higher in the group of patients with abnormal findings (p < .001). Patients with recurrent chest symptoms and loss of weight had significantly higher rate of abnormal findings.

Conclusion

UGI series had a higher diagnostic yield in patients with bilious vomiting, children with nonbilious vomiting with higher clinical scores when associated with recurrent chest symptoms, loss of weight, dysphagia, or GIT bleeding especially melena.

Primary acquired gastric outlet obstruction in children: A retrospective single center study

BACKGROUND/ PURPOSE

Idiopathic hypertrophic pyloric stenosis is by far the most common cause of gastric outlet obstruction (GOO) in young infants, with more than 90% of cases presenting between 3 and 10 weeks after birth. While cases of late onset pyloric stenosis beyond infancy have been reported, the etiology is poorly understood. We report our experience of 5 cases, describing the similarities and differences in management of our patient population which happens to be the second largest reported in literature.

METHODS

From July 2014 to June 2018 (4 years) a total of five patients of primary acquired GOO were encountered at our center.

RESULTS

The age range was 3 to 6 years and only one of them was a female. All presented with characteristic nonbilious vomiting that was recurrent and episodic. Upper GI (gastrointestinal) contrast study series revealed a dilated stomach and delayed gastric emptying. Upper GI endoscopy also demonstrated a dilated stomach without any intraluminal polyp, ulcer or any other pathology. Intraoperatively the pylorus had no evidence of scarring, inflammation, external compression or any mass in and around the pylorus. A retrocolic gastrojejunostomy was curative in all patients.

CONCLUSION

Though rare, one must maintain a high index of suspicion for primary acquired GOO in the differential diagnosis of older children with nonbilious vomiting and failure to thrive. Following appropriate diagnostic workup, surgical interventions should be performed expeditiously because adequate nutrition is key to proper physical and mental development of the child. Further research will hopefully elucidate the underlying pathophysiology in order to guide clinical options for both prevention and treatment.

TYPE OF STUDY

Retrospective single center study.

LEVEL OF EVIDENCE

Level 4.

An unusual surgical cause of pyloric stenosis in an 8-month-old infant

Infantile hypertrophic pyloric stenosis (IHPS) is the most common surgical cause of nonbilious, projectile vomiting in children. Its incidence is estimated to be 2-5/1000 live births and has been noted to be quite rare in African-Americans, Asians, and Indians. It is more common in infants under 6 months of age and is quite rare in older infants. While IHPS is invariably intrinsic in nature, extrinsic pyloric stenosis is very rare. Children who present with nonbilious, projectile vomiting after the age of 6 months should, therefore, be thoroughly investigated for causes other than IHPS. This is a case report of an 8-month-old child who had a band of tissue constricting the pylorus which mimicked IHPS.

Update on endoscopic management of gastric outlet obstruction in children

Endoscopic balloon dilatation (EBD) and surgical intervention are two most common and effective treatments for gastric outlet obstruction. Correction of gastric outlet obstruction without the need for surgery is an issue that has been tried to be resolved in these decades; this management has developed with EBD, advanced treatments like local steroid injection, electrocauterization, and stent have been added recently. The most common causes of pediatric gastric outlet obstruction are idiopathic hypertrophic pyloric stenosis, peptic ulcer disease followed by the ingestion of caustic substances, stenosis secondary to surgical anastomosis; antral web, duplication cyst, ectopic pancreas, and other rare conditions. A complete clinical, radiological and endoscopic evaluation of the patient is required to make the diagnosis, with complimentary histopathologic studies. EBD are used in exceptional cases, some with advantages over surgical intervention depending on each patient in particular and on the characteristics and etiology of the gastric outlet obstruction. Local steroid injection and electrocauterization can augment the effect of EBD. The future of endoscopic treatment seems to be aimed at the use of endoscopic electrocauterization and balloon dilatations.

Late-onset hypertrophic pyloric stenosis with gastric outlet obstruction: case report and review of the literature

We report late-onset hypertrophic pyloric stenosis in a 17-year-old female. She presented with abdominal pain and an episode of upper gastrointestinal hemorrhage and subsequently developed gastric outlet obstruction. Work-up revealed circumferential pyloric thickening, delayed gastric emptying, and a stenotic, elongated pyloric channel. Biopsies showed benign gastropathy, negative for Helicobacter pylori, without eosinophilic infiltrates. Botulinum toxin injection provided limited relief. Diagnostic laparoscopy confirmed the hypertrophic pylorus and we performed laparoscopic pyloromyotomy. The patient tolerated the procedure well and had complete symptom resolution at 1-year follow-up. Hypertrophic pyloric stenosis is a rare cause of gastric outlet obstruction in adolescents and may be managed successfully with laparoscopic pyloromyotomy.

Efficiency of upper gastrointestinal endoscopy in pediatric surgical practice

After the introduction of flexible fiber optic endoscopy to pediatric gastroenterology in the 1970s, upper gastrointestinal (UGI) endoscopy can be performed for the diagnosis and treatment of all age groups of children. We review indications, contraindications, preparation of patients for the procedure, and details of diagnostic and therapeutic UGI endoscopy used in pediatric surgery. We also discuss potential complications of endoscopy.

Laparoscopic pyloroplasty for idiopathic non-hypertrophic pyloric stenosis in a child

Acquired gastric outlet obstruction (GOO) during infancy and childhood represents an uncommon event. We describe a 6-year-old boy with GOO who did not respond to medical treatment or to endoscopic pyloric balloon dilatations. The stenosis was successfully treated with laparoscopic pyloroplasty which relieved the obstruction.

Usual and unusual causes of pediatric gastric outlet obstruction

Gastric outlet obstruction in children encompasses a spectrum of disorders that extends beyond hypertrophic pyloric stenosis. Each condition can result in the clinical syndrome of persistent nonbilious vomiting, which can progress to dehydration and electrolyte imbalances. This paper reviews the spectrum of both the common and uncommon entities that cause partial or complete gastric outlet obstruction and their imaging appearances. The correct diagnosis of those with gastric outlet obstruction can be achieved by combining clinical presentation with appropriate imaging, leading to optimal and timely patient management.

Management of pyloric stricture in children: endoscopic balloon dilatation and surgery

BACKGROUND

Surgical correction is the most preferred treatment modality in pyloric stricture (PS). Recently a few studies reported the experience of balloon dilation in children with PS. This study was designed to present our experiences of the management of the patients with PS with balloon dilation and corrective surgery.

METHODS

The records of 14 patients who were treated with the diagnosis of PS between August 2003 and August 2011 were reviewed retrospectively.

RESULTS

There were nine boys and five girls (mean age, 3.4 ± 1.7 years). The history of caustic ingestion was detected in eight patients; six of them were admitted on the day of ingestion. Two patients were admitted with nonbilious vomiting more than 2 weeks after ingestion. Four patients did not have a remarkable medical history, including caustic ingestion. They admitted with the complaint of nonbilious vomiting. PS was detected during endoscopy in two patients who had a diagnosis of peptic ulcer disease. PS was shown by barium meal study in all patients. Endoscopy was performed in all patients. Endoscopic balloon dilation was tried in 12 patients. Overall eight patients required surgical procedures for PS. The complaints were resolved by endoscopic balloon dilation of pylorus in the remaining six patients.

CONCLUSIONS

Although endoscopic balloon dilatation for benign PS in adults is a generally accepted method of treatment, there is less experience with endoscopic balloon dilatation for PS in children. PS due to benign disorders can be effectively and successfully treated through endoscopic balloon dilatation in suitable patients. In patients with successful pyloric balloon dilatation, surgery can be avoided.

Two Cases of Helicobacter pylori-Negative Gastric Outlet Obstruction in Children

Gastric outlet obstruction (GOO) in children is most commonly caused by idiopathic hypertrophic pyloric stenosis. Prior to proton pump inhibitors and H2 blockers, peptic ulcer disease (PUD) secondary to H. pylori was a cause of GOO. Both patients presented with a history of weight loss, vomiting, and abdominal pain. Their diagnosis of PUD and GOO was made by EGD and UGI. H. pylori testing was negative for both on multiple occasions but still received H. pylori eradication therapy. Patient 1 after failing pharmaceutical management underwent surgery for definitive treatment. Patient 2 underwent six therapeutic pyloric dilations before undergoing surgery as definitive treatment. These cases suggest that GOO secondary to PUD occurs in the absence of H. pylori infection and surgical management can provide definitive therapy.

Ventral longitudinal stricturotomy and transversal closure: the Heineke-Mikulicz principle in urethroplasty

OBJECTIVES

To describe the Heineke-Mikulicz principle in urethral surgery and to evaluate preliminary surgical and functional outcomes of this technique.

METHODS

Ten patients (of a cohort of more than 400 patients treated with urethroplasty during a 7-year period) with a urethral stricture were treated using the Heineke-Mikulicz principle: a ventral longitudinal stricturotomy was performed with transversal closure of the urethra. Only patients with a short (<1 cm), not too narrow or fibrotic stricture at the bulbar urethra or fossa navicularis were considered as appropriate candidates. At closure of the study, all patients were sent a questionnaire about the functional outcome of the procedures. This included questions about postoperative shortening, chordee, postvoid dribbling, ejaculatory disturbances, erectile dysfunction, and penile sensitivity.

RESULTS

Mean follow-up was 46.6 months (range: 15-79 months). There were no immediate or early postoperative complications. Nine of 10 patients (90%) were successfully treated. On the questionnaire, 1 patient reported mild postoperative chordee and shortening, and 1 patient complained of postvoid dribbling. None of the sexually active patients reported ejaculatory disturbances, erectile dysfunction, or diminished penile sensitivity.

CONCLUSIONS

The preliminary surgical and functional results with the Heineke-Mikulicz principle are promising. Larger cohorts of patients are needed for further evaluation.

Late-onset hypertrophic pyloric stenosis: definition of diagnostic criteria and algorithm for the management

BACKGROUND AND PURPOSE

Gastric outlet obstruction (GOO) may be caused by various congenital and acquired conditions in children. The authors report 11 cases of GOO caused by muscular hypertrophy of the pylorus, which was proven histologically in 7. They describe this entity as "late-onset hypertrophic pyloric stenosis (HPS)," define the diagnostic criteria of the disease, and produce an algorithm for its management.

MATERIALS AND METHODS

The medical records of patients with GOO treated from 1999 and 2009 were retrospectively reviewed. Patients with infantile HPS and GOO secondary to corrosive ingestion or neoplasm were not included. Age, sex, family history, presenting symptoms and signs, radiologic methods and findings, type of management, histopathologic features, and outcome were noted for each patient.

RESULTS

Eleven patients (4 male, 7 female) ranging in age from 2 to 8 years (mean, 3.6 years) were included in the study. The symptoms were nonbilious vomiting (n = 11), abdominal pain (n = 4), and weight loss (n = 2). Abdominal ultrasound (n = 6) and upper gastrointestinal contrast studies were obtained (n = 11). Gastroscopy revealed complete (n = 6) or partial (n = 5) obstruction of the pylorus. Balloon dilatation of the pylorus was performed in 5 cases and repeated in 3 cases. Conservative treatment was initially attempted in 11 patients. Two patients with chronic gastritis and Helicobacter pylori (n = 2) were treated with amoxicillin-clavulanic acid, clarithromycin, and lansoprazole. A Billroth I procedure was performed in 7 cases. Hypertrophied pyloric muscle was noted in 7 patients and chronic gastritis in 2. The postoperative course was uneventful.

CONCLUSION

Hypertrophic pyloric stenosis is rarely seen after infancy. Analysis of our results and review of the literature prompted us to redescribe this entity as "late-onset HPS" and define the diagnostic criteria. Late-onset HPS is probably an acquired disease of unknown etiology. The management of late-onset HPS has been summarized in an algorithm, which will also be useful in the treatment of GOO in children caused by etiologies other than classical infantile HPS.

Delayed presentation of hypertrophic pyloric stenosis: a rare case

Hypertrophic pyloric stenosis (HPS) is the most common cause of gastric outlet obstruction in infants, with an incidence of 1.5 to 3 per 1000 live births, and classically presents at 3 to 4 weeks of age. Delayed presentation of HPS is an extremely rare occurrence after early infancy. With the exclusion of congenital HPS, gastric outlet obstruction in childhood is a rare condition (1:100,000). We report a case of delayed presentation of HPS in a 4 1/2-year-old child in whom the pylorus was hypertrophied and appeared like an "olive," and for which pyloromyotomy was curative.