Predictive factors of negative outcome in initial atropine therapy for infantile hypertrophic pyloric stenosis

Atropine as an Adjunct in the Management of Pediatric Patients With Hypertrophic Pyloric Stenosis: A Single Institution Experience and Review of the Literature

Infantile hypertrophic pyloric stenosis (IHPS) is a condition whereby there is a thickening of the pyloric muscle, leading to obstruction of the gastric outflow. Typically present within three to five weeks of life, it presents as postprandial non-bilious projectile vomiting. Commonly, a pyloromyotomy is the gold standard to relieve the obstruction. However, in a subset of patients not amenable to undergo surgery or anesthesia, or for postoperative persistent or recurrent obstruction, atropine may offer an alternative treatment. A retrospective review was performed on pediatric patients with hypertrophic pyloric stenosis utilizing the electronic medical record. Data included were demographics, workup data, treatment, outcomes, and symptom resolution. Approval was obtained by the institutional review board of the host institution. Five pediatric patients, with an average age of 2.1 months, received atropine treatment for IHPS. The average time to reach full feeds since the initiation of atropine was approximately four days. Three of the five patients were successfully managed with IV atropine, which was then transitioned to oral atropine and tapered off as outpatients, leading to the resolution of symptoms. The remaining two patients were considered failures of medical management and subsequently required surgery. Atropine use as an alternative treatment for IHPS may be considered when patients are not able to undergo surgery or anesthesia or have recurrent or persistent obstructive symptoms postoperatively. In this limited study, atropine was found to be safe and effective. Randomized controlled studies may lend additional merit to this therapy in the future.

Risk factors for unsuccessful atropine therapy in hypertrophic pyloric stenosis

BACKGROUND

I.v. atropine (IA) for infantile hypertrophic pyloric stenosis (IHPS) is a good alternative to pyloromyotomy but has not been broadly accepted. The lower success rate is one of the greatest disadvantages of IA. We investigated the risk factors for unsuccessful results following IA for IHPS.

METHODS

Medical records of patients with IHPS who were admitted to Kimitsu Chuo Hospital between 2002 and 2016 and were initially given atropine sulfate were retrospectively reviewed. Atropine was given i.v. (0.1 mg/kg/day in eight divided doses). Oral feeding of milk was started with a small amount and increased in a stepwise fashion to full feed. IA therapy was defined as unsuccessful in the presence of projectile vomiting more than three times a day or intolerance to a predetermined amount of milk.

RESULTS

Of the 48 patients with IHPS, 33 patients were successfully treated with IA and 15 patients needed surgical intervention. On univariate analysis the risk factors for unsuccessful IA therapy were younger age, lower bodyweight, and shorter duration of symptoms before diagnosis. On multivariate analysis age at diagnosis < 30 days was the only significant risk factor for unsuccessful IA therapy (OR, 5.7 l P = 0.03).

CONCLUSIONS

Age at diagnosis < 30 days is a risk factor for unsuccessful IA therapy in IHPS. This might be considered when IA therapy is used for neonates with IHPS.

Operative outcomes of infantile hypertrophic pyloric stenosis in patients with congenital heart disease

PURPOSE

This study aims to compare the outcomes of pyloromyotomy for infantile hypertrophic pyloric stenosis (IHPS) in children with and without congenital heart disease (CHD).

METHODS

A retrospective, single pediatric center, case-control, matched cohort study was performed over 10years. A case of IHPS with CHD was paired with control patients of IHPS without CHD, matched by age and gender. Perioperative morbidity, 30-day mortality, length of hospital stay, and hospital cost were compared. Subgroups were analyzed based on the severity of CHD and the reason for admission.

RESULTS

Twenty-six patients who underwent pyloromyotomy for IHPS with CHD (CHD group) were matched with 78 patients with IHPS without CHD (Non-CHD group). No 30-day mortality was identified in either group. Overall perioperative complications were not significantly different between groups (11.5% vs 5.2%, p=0.163). However, postoperative length of stay was longer in CHD group (6 vs 1days, p<0.001) and any subgroups of CHD as compared to Non-CHD group. CHD group patients admitted only for IHPS had short postoperative LOS, whereas those who developed pyloric stenosis during a hospital admission stayed longer postoperatively (1.5 vs 26.5days, p<0.001). Mean hospital costs in patients admitted for IHPS were $16,270 and $3591 for CHD group and Non-CHD group, respectively (p<0.001).

CONCLUSIONS

IHPS patients with CHD have prolonged postpyloromyotomy course, especially when inpatients with CHD incidentally develop IHPS.

Contemporary management of pyloric stenosis

Hypertrophic pyloric stenosis is a common surgical cause of vomiting in infants. Following appropriate fluid resuscitation, the mainstay of treatment is pyloromyotomy. This article reviews the aetiology and pathophysiology of hypertrophic pyloric stenosis, its clinical presentation, the role of imaging, the preoperative and postoperative management, current surgical approaches and non-surgical treatment options. Contemporary postoperative feeding regimens, outcomes and complications are also discussed.