Intravenous atropine treatment in infantile hypertrophic pyloric stenosis

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.

Hypertrophic pyloric stenosis following persistent pulmonary hypertension of the newborn: a case report and literature review

BACKGROUND

Although persistent pulmonary hypertension of the newborn (PPHN) and infantile hypertrophic pyloric stenosis (HPS) are both well-known diseases that occur in early infancy, PPHN complicated by HPS is rare. As nitric oxide (NO) is an important mediator of biological functions, on both the vascular endothelium and smooth muscle cells, the decreased production of NO might play a role in the pathogenesis of both PPHN and HPS. We present the case of a neonate who developed HPS following PPHN, including a detailed review on research published to date, and we discuss the pathogenesis of PPHN and HPS.

CASE PRESENTATION

A female neonate born at 38 weeks of gestation, weighing 3140 g, developed PPHN due to meconium aspiration syndrome. Intensive treatment with high frequency oscillations and inhaled NO were initiated, and sildenafil and bosentan were added. She gradually recovered. At 15 days of age, the patient developed recurrent vomiting after feeding and the diagnosis of HPS was made. Intravenous atropine therapy was started at 20 days of age, but the efficacy was clinically unsatisfactory. The coadministration with transdermal nitroglycerin improved the symptoms, and oral feeding was successfully re-introduced.

CONCLUSIONS

Our patient recovered from both PPHN and HPS using NO-related medications. A decrease in NO synthesis is likely to be a common pathway for PPHN and HPS.

Efficacy of Medical Treatment for Infantile Hypertrophic Pyloric Stenosis: A Meta-analysis

BACKGROUND

Infantile hypertrophic pyloric stenosis (IHPS) is a common disease in infancy. Pyloromyotomy is universally considered the treatment for IHPS; however, oral or intravenous atropine has been reappraised for the treatment of IHPS in the past 20 years. We investigated the efficacy of atropine in the medical management of IHPS by using meta-analysis and investigated the sonographic changes of the pyloric canal, as well as the efficacy and adverse effects of atropine.

METHODS

Information was retrieved from PubMed, Ovid, and MEDLINE. The efficacy and adverse effects of atropine treatment for IHPS were reviewed using the standard process of meta-analysis.

RESULTS

Eleven articles were obtained. Five reports showed that 77 of 110 (70%) infants who were administered oral atropine benefitted by the induced remission of IHPS. Six reports showed that 288 of 345 (83.5%) patients who were treated initially with intravenous atropine then changed to oral atropine showed beneficial effects and had no serious side effects. Time to pyloric muscle normalization ranged from 5 weeks to 15 months.

CONCLUSION

The study results indicate that atropine is a possible alternative treatment for IHPS, particularly in infants with major concurrent disease, and is safe without obvious side effects.

Treating idiopathic hypertrophic pyloric stenosis with sequential therapy: A clinical study

AIM

The aim of this study was to explore the efficacy and safety of treating idiopathic hypertrophic pyloric stenosis with sequential therapy (ST).

METHODS

From January 2010 to June 2013, 49 children with idiopathic hypertrophic pyloric stenosis were divided into two groups to accept either atropine ST (ST group, n = 26) or laparoscopic surgery (operation group, n = 23). The remission rate of vomiting, complications, hospital stay and medical expenditure were compared between the two groups. The body weight and the thickness of the pyloric muscle at 6 months after the treatments were also compared.

RESULTS

The remission rate of vomiting was lower in the ST group (88.5%; 23/26) than in the operation group (100%, 23/23). The difference in the incidence rate of complications, body weight and pyloric muscle thickness was not statistically significant between the two groups. However, the hospital stay was significantly longer, while the medical expenditure was significantly lower in the ST group than in the operation group.

CONCLUSIONS

Atropine ST is safe, effective and cost-effective as compared with operation; however, the efficacy of ST is lower than operation.

Infantile hypertrophic pyloric stenosis at a tertiary care hospital in Tanzania: a surgical experience with 102 patients over a 5-year period

Background

Infantile hypertrophic pyloric stenosis (IHPS) is the most common cause of gastric outlet obstruction in infants. There is paucity of published data regarding this condition in our setting. This study describes the clinical presentation, mode of treatment and outcome of treatment of this disease and identifies factors responsible for poor outcome of these patients.

Methods

This was a descriptive retrospective study of infants with HPS admitted to Bugando Medical Centre and subsequently underwent surgery between February 2009 and January 2014.

Results

A total of 102 patients (M:F = 4.7:1) were studied. The median age at presentation was 5 weeks. The median duration of illness was 4 weeks. Fifty-four (52.9 %) patients occur in first-born children. Associated anomalies were reported in 7 (6.9 %) patients. Non-bilious vomiting was the most frequent symptom and it was described in all (100 %) patients. A palpable mass was found in 23.5 % of infants. The diagnosis of IHPS was made clinically in 86 (84.3 %) and by ultrasound in 16 (15.7 %) patients. The treatment was Ramstedt’s pyloromyotomy in all cases. There were 6 (5.9 %) intra-operative mucosal perforations which were repaired successively. Postoperative complication was 11.8 %. The median length of hospital stay was 12 days and it was significantly associated with prolonged pre-operative hospitalization (p = 0.001). The mortality rate was 4.9 %. Age below 2 weeks, late presentation (≥14 days), severe dehydration on admission, hypokalaemia on admission and surgical site infection were the main predictors of mortality (p < 0.001).

Conclusion

This study has shown that IHPS is a common condition in our setting. Age <2 weeks, delayed presentation, prolonged preoperative hospital stay, surgical site infection and high proportion of dehydration and electrolyte disturbance were the main predictors of poor outcome. A high index of suspicion is needed in infants with non-bilious vomiting to avoid delay in diagnosis.

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

BACKGROUND

The predictive factors of negative outcome in initial i.v. atropine (IA) therapy of infantile hypertrophic pyloric stenosis (IHPS) are unknown. Conservative therapy for IHPS is useful for infants because it does not have the risk of surgical and anesthetic stress, but some cases of atropine therapy result in failure. This study clarified the predictive markers of negative outcome in initial atropine therapy for IHPS.

METHODS

Seventy-six patients with IHPS admitted from 1998 to 2011 were included in this study. The predictive risk factors of negative outcome in initial atropine therapy for IHPS were evaluated.

RESULTS

Thirty-one patients initially underwent non-operative therapy for IHPS during the study period. Of the 31 patients, 18 (58%) ceased projectile vomiting (PV) with IA and subsequent oral atropine. Univariate analysis showed that lack of bodyweight gain before treatment, elevated urine potassium at admission, and PV occurring ≥5 times (PV ≥5) in total for 3 days from IA initiation were predictive risk factors for negative outcome in IHPS. Multivariate analysis identified only PV ≥5 in total for 3 days after IA initiation as independently associated with failure of atropine for IHPS.

CONCLUSIONS

PV ≥5 in total for 3 days after IA initiation is a potential indicator of negative outcome of IA in IHPS patients. The present results provide valuable information for determining whether early surgical intervention for IHPS or initial atropine therapy is the best option.

Pyloromyotomy versus i.v. atropine therapy for the treatment of infantile pyloric stenosis: nationwide hospital discharge database analysis

BACKGROUND

Several studies have suggested that i.v. atropine has a potential role in treating infantile hypertrophic pyloric stenosis (IHPS). It remains unclear, however, whether surgery can be replaced by i.v. therapy.

METHODS

Data were extracted on infants with IHPS who were treated with atropine and/or surgery, from a nationwide administrative database through 2006-2008. Patient demographic data, treatment effects and length of hospital stay were analyzed in each treatment group.

RESULTS

A total of 585 infants met the criteria for IHPS; 188 patients (32%) were initially treated with atropine (i.v. form, n = 180; oral form, n = 8), while 397 were treated with surgery as a first-line therapy. Of the 180 infants receiving i.v. atropine, 38 were withdrawn from medical management and subsequently underwent surgery. Thus, the overall success rate of i.v. atropine was 78.9% (142/180). Surgery had a success rate of 100%, and postoperative complications were found in 2.8% of patients (12/435). Medical management required longer hospital stay than surgery (mean, 13.5 days vs 8.0 days; P < 0.001).

CONCLUSION

Surgery remains the suitable standard management option for IHPS, with its high success rate, minimal complications and shorter hospital stay compared with i.v. atropine therapy.

Ultrasonographic serial measurements of the morphologic resolution of the pylorus after Ramstedt pyloromyotomy for infantile hypertrophic pyloric stenosis

OBJECTIVE

The purposes of this study were to evaluate the accuracy of the ultrasonographic measurements used during diagnosis of hypertrophic pyloric stenosis (HPS), to examine the relationship between the palpability and the morphologic features of the pyloric mass, and to show the morphologic resolution of the pylorus after pyloromyotomy.

METHODS

One hundred three infants with the diagnosis of HPS by clinical findings and ultrasonographic measurements were treated surgically by Ramstedt pyloromyotomy. The measurement parameters were the muscle thickness, diameter, and channel length of the pylorus. The serial measurements were performed postoperatively for 1 year after surgery.

RESULTS

The preoperative ultrasonographic measurements of the pylorus were significantly correlated with the actual measurements obtained by surgery (P<.05). The diameter correlated most significantly with the palpability of the pylorus. In contrast to the prompt improvement of clinical symptoms, the muscle thickness did not reach the normal range (approximately 2 mm) until 8 months after surgery. The diameter had not decreased to its normal range (approximately 10 mm) by the end of the 1-year postoperative follow up period. The channel length decreased more rapidly than the other 2 parameters.

CONCLUSIONS

The preoperative ultrasonographic measurements of the pylorus reliably evaluated the pyloric muscle thickness and diameter in HPS. The actual pyloric diameter correlated with the palpability of the pyloric mass. The morphologic resolution of the pylorus after surgery did not correlate with the prompt improvement of symptoms.

Current management of hypertrophic pyloric stenosis

Hypertrophic pyloric stenosis (HPS) is a common condition affecting infants that presents with progressive projectile nonbilious vomiting. The pyloric portion of the stomach becomes abnormally thickened and manifests as gastric outlet obstruction. The cause is unknown. Pyloromyotomy remains the standard of treatment and outcome is excellent. This article reviews the diagnostic work up and imaging, preoperative resuscitation, the various surgical approaches used, and the effect of subspecialty training on outcomes after pyloromyotomy. Postoperative care and the variety of postoperative feeding regimens applied after pyloromyotomy are reviewed, as well as intra- and postoperative complications. Finally, medical management, in lieu of surgery, is discussed.

Intravenous Atropine Treatment in Hypertrophic Pyloric Stenosis: Evaluation by Clinical Course and Imaging

Hypertrophic pyloric stenosis (HPS) is the principal disease to consider in neonates presenting with frequent projectile vomiting and poor weight gain. Ramstedt pyloromyotomy is commonly used for the surgical treatment of HPS. The present study investigated the efficacy of nonsurgical medical treatment using intravenous administration of atropine and the examined the clinical course and results of ultrasonography and a contrast upper gastrointestinal series. A 34-day-old girl was admitted with chief complaints of projectile vomiting and poor weight gain. HPS was diagnosed on the basis of the clinical course and results of imaging studies. After intravenous administration of atropine, projectile vomiting resolved and weight increased without complications. On imaging studies, barium introduced into the stomach by tube rapidly entered the duodenum after atropine administration. Ultrasonography initially showed no reductions in hypertrophic muscle in the pyloric region, but gradual reductions were identified in subsequent months.

Conservative treatment of infantile hypertrophic pyloric stenosis with intravenous atropine sulfate does not replace pyloromyotomy

Pyloromyotomy as described by Weber and Ramstedt has been the standard therapy for infantile hypertrophic pyloric stenosis since the 1960's and conservative therapy has been abandoned. The objective of this study was to test the effectiveness of systemic atropine applied intravenously for 7 days as a conservative therapeutic strategy and as an alternative to primary operation. Forty-two consecutive term infants with infantile hypertrophic pyloric stenosis were enrolled in the study over a period of 5 years. After confirmation of the diagnosis they all received intravenous atropine at a dose of 0.04 mg/(kg day) and increased by 0.01 mg/(kg day) up to 0.12 mg/(kg day), given as 6-8 single doses per/day. Nine pairs of parents requested that their child should be operated before completing the 7 days of medical therapy. Surgery was necessary in 8 of the remaining 33 infants (24,.2%) who did not improve after 7 days of conservative treatment. Successful treatment with i.v. atropine sulfate was achieved only in 25/33 term infants at an average maximal dose of 0.11 mg/(kg day), without any major side effects. Intravenous atropine sulfate has been considered as a potential alternative therapeutic strategy in the treatment of infantile hypertrophic pyloric stenosis. Clinical improvement however was often not seen before the 6th or 7th day of intravenous treatment. A success rate for the conservative approach of only 75% at day 7 in our study does not favour atropine therapy, in view of success rates above 95% with surgical repair.

Medical treatment of infantile hypertrophic pyloric stenosis: should we always slice the "olive"?

BACKGROUND/PURPOSE

Laparoscopic pyloromyotomy has recently gained wide acceptance as the optimum treatment of infantile hypertrophic pyloric stenosis (IHPS). However, medical treatment may be superior to laparoscopic surgery in invasiveness. The efficacy of our regimen of intravenous atropine therapy for IHPS was assessed in comparison with surgical treatment.

METHODS

Medical treatment was initially chosen for 52 (61%) of 85 infants with IHPS at our institute between 1996 and 2004. Atropine was given intravenously at 0.01 mg/kg 6 times a day before feeding. When vomiting ceased and the infants were able to ingest 150 mL/kg per day of formula after stepwise increases in the feeding volume, they were given 0.02 mg/kg atropine 6 times a day orally, and the dose was decreased stepwise.

RESULTS

Of the 52 patients, 45 (87%) ceased projectile vomiting with treatment using intravenous (median, 7 days) and subsequent oral (median, 44 days) atropine administration. The median hospital stay was 13 days (6-36), and no significant complications were encountered during atropine therapy. The remaining 7 patients required surgery. Of 40 who underwent surgery, 4 had wound infections and 1 with hemophilia had postoperative hemorrhagic shock. The patients who underwent successful atropine therapy had body weights comparable with those who underwent surgery at the age of 1 year.

CONCLUSIONS

The high success rate of intravenous atropine therapy for IHPS suggests that this therapy is an effective alternative to pyloromyotomy if the length of the hospital stay and the necessity of continuing oral atropine medication are accepted.

Sténose hypertrophique du pylore : comparaison entre deux protocoles de réalimentation postopératoire : « progressif » et « ad libitum »

A recent alternative feeding regimen at the progressive feeding (PF) after a pyloromyotomy for hypertrophic pyloric stenosis (HPS) is the so-called ad libitum feeding (AL). The aim of this study was to determine if this new feeding regimen has modified the follow-up of postoperative course in HPS.

POPULATION AND METHODS

From January 1998 to December 2003, 97 consecutive neonates have been operated on for HPS in our hospital. This retrospective study was based on the comparison between two groups of patients with different postoperative feeding regimens: group one of 30 neonates with PF regimen and group two of 60 neonates with AL regimen. Seven remaining neonates had had a mucosal perforation and were not included in this comparative study but in a separate group (MP). The clinical, ultrasonographic, operative and postoperative data were compared.

RESULTS

There was no difference between the PF and AL groups for sex ratio M/F=4/1, preoperative weight loss ratio, ultrasonographic data and intra-operative difficulties rate. A small difference was found - which was not significative - between the PF and the AL groups for median age at diagnosis (44,6 v 36,7 days, respectively). A statistically significative difference between the PF and the AL groups was observed for time to establish feeding (69 vs 35.6 hours, respectively) (P<0,001), postoperative stay (4.16 vs 2.98 days, respectively) (P<0,001) and total hospital charges. We didn't found any difference in the incidence and severity of postoperative emesis whether slow (PF) or rapid (AL) feeding regimens were used. Furthermore, intra-operative mucosal tear didn't influence postoperative course and the duration of hospital stay.

CONCLUSION

We recommend AL regimen for routine feeding in simple cases after pyloromyotomy for HPS. It has a positive impact on length of hospital stay, and decreases hospital charges. Most neonates with MP can be managed with a rapid feeding regimen.

Single-nucleotide promoter polymorphism alters transcription of neuronal nitric oxide synthase exon 1c in infantile hypertrophic pyloric stenosis

Infantile hypertrophic pyloric stenosis (IHPS), characterized by enlarged pyloric musculature and gastric-outlet obstruction, is associated with altered expression of neuronal nitric oxide synthase (nNOS). Here we have studied molecular mechanisms by which nNOS gene expression is altered in pyloric tissues of 16 infants with IHPS and 9 controls. A significant decreased expression of total nNOS mRNA was found by quantitative RT-PCR in IHPS after normalization against GAPDH, which predominantly affected exon 1c with a reduction of 88% compared with controls (P < 0.001). After normalization against the neuronal-specific gene PGP9.5, expression of exon 1c was still decreased (P < 0.001), whereas expression of exon 1f was increased significantly (P = 0.001), indicating a compensatory up-regulation of this nNOS mRNA variant. DNA samples of 16 IHPS patients and 81 controls were analyzed for nNOS exon 1c promoter mutations and single-nucleotide polymorphism (SNP). Sequencing of the 5'-flanking region of exon 1c revealed mutations in 3 of 16 IHPS tissues, whereas 81 controls showed the wild-type sequence exclusively. Carriers of the A allele of a previously uncharacterized nNOS exon 1c promoter SNP (-84G --> A) had increased risk for development of IHPS (odds ratio, 8.0; 95% confidence interval, 2.5-25.6). Reporter gene assays revealed an unchanged promoter activity for mutations but a approximately 30% decrease for the -84A SNP (P < 0.001). In summary, our findings indicate that genetic alterations in the nNOS exon 1c regulatory region influence expression of the nNOS gene and may contribute to the pathogenesis of IHPS.