Pyloric Stenosis

 Not present at birth.

 Associated with eosinophilic gastroenteritis, Apert syndrome, Zellweger
syndrome, trisomy 18, Smith-Lemli-Opitz syndrome, Cornelia de Lange
syndrome.
 Use of erythromycin with higher risk if given within first 2 weeks of life.
 Female infants of mothers treated with macrolide antibiotics during pregnancy
and breastfeeding.
 Abnormal muscle innervation, elevated serum levels of prostaglandins, infant
hypergastrinemia.
 Symptoms
o Non-bilious vomiting – initial symptom.
 Progressive, occurring immediately after feeding.
 Emesis might follow each feeding or intermittent.
 Usually stars after 3 weeks of age. (1 week – 5 months).
o Hyperbilirubinemia – unconjugated more than conjugated.
 Diagnosis
o Palpating the pyloric mass.
 Mass is firm, movable, about 2 cm in length, olive shaped, hard,
best palpated from left side and located above and right of
umbilicus in mid epigastrium beneath liver’s edge.
 Best palpated after vomiting.
o Presence of gastric peristaltic wave after eating.
o Ultrasound – confirms.
 DDX
o Gastroesophageal reflux with or without hiatal hernia. Differentiated by
radiology.
o Adrenal insufficiency from adrenogenital syndrome. Rule out: absence of
metabolic acidosis and elevated serum potassium and urinary sodium.
 o Inborn errors of metabolism – includes emesis with alkalosis or acidosis
and lethargy, coma, seizures.
o Vomiting + diarrhea = gastroenteritis but some may have in pyloric
stenosis.
 Treatment
o Preoperative:
 Correcting fluid, acid-base, electrolyte losses.
 Correction of alkalosis to prevent postoperative apnea associated
with anesthesia. Most infants need 24 hours.
o Surgery: pyloromyotomy
 Ramstedt procedure done through short transverse skin incision.
 Underlying pyloric mass cut and incision closed.
o Postoperative:
 Vomiting – half the infants.
 Initiate feeding within 12-24 hrs after surgery.
 Maintenance feeding 36-48 hours after.
 Atropine IV 0.01 mg/kg 6x/day 5 min before feeding.
o Monitor HR by ECG.
 Oral feeding started at 10 mL formula 6x/day.
 Gradual increase until patient can tolerate 150 mL/kg/day
unless vomiting occurs more than twice a day.
 Once patient can eat 150 mL/kg/day without vomiting, give
atropine 0.02 mg/kg orally 6x/day before feeding.
 Persistent vomiting = incomplete pyloromyotomy, gastritis,
gastroesophageal reflux disease, some other obstruction.
 Do endoscopic balloon dilation for incomplete
pyloromyotomy.
o Conservative management with nasoduodenal feedings who are not
good for surgery.
o Oral and intravenous atropine sulfate (pyloric muscle relaxant).
Pyloric Atresia
 Symptoms
o Nonbilious vomiting
o Feeding difficulties
o Abdominal distension during first day of life.
o Gastric aspirate at birth is large (> 20 mL) – remove to prevent aspiration.
o Rupture of stomach may occur as early as first 12 hours of life.
 Polyhydramnios + low birth weight.
 Diagnosis
o Finding of large, dilated stomach on abdominal plain radiograph or in utero
ultrasonography.
o UGI contrast
 Avoid aspiration
o Older children (endoscopy)
 Treatment
o All gastric outlet obstruction in neonates start with correction of
dehydration and hypochloremic alkalosis.
o Persistent vomiting relieved with nasogastric decompression.
o Surgical or endoscopic repair only when patient stable.
Intestinal atresia, stenosis, malrotation
 Obstruction may be partial or complete and simple or strangulating.
 Intrinsic causes
o Inherent abnormalities of intestinal innervation
o Mucus production
o Tubular anatomy (most common and manifest as obliteration or narrowing
of intestinal lumen)
 Extrinsic
o Compression of bowel by vessels, organs, cysts
o Abnormalities in intestinal rotation during fetal development.
 Symptoms
o Bowel distension – accumulation of food, gas, intestinal secretions
proximal to point of obstruction.
o Absorption of intestinal decreased, secretion of fluid and electrolytes
increased – hypokalemia
o Less blood flow – lack of mucosal integrity – bacterial proliferation
(coliforms, anaerobes). Bacteria can travel – endotoxemia, bacteremia,
sepsis.
o High intestine obstruction:
 Large volume, frequent, bilious emesis with little/no abdominal
distension.
 Intermittent pain relieved by vomiting.
o Distal bowel small obstruction
 Moderate or marked abdominal distension with emesis that is
progressively feculent.
 o Both have obstipation.
 Diagnosis
o History, PE, radiology.
o Polyhydramnios – high intestinal obstruction.
o Radiology – contrast studies or CT because neonate colonic haustra not
fully developed.
 Treatment
o Initial for children and infants – fluid resuscitation and stabilization.
o Nasogastric decompression – for pain and vomiting.
o Broad spectrum antibiotics for ill looking neonates
o No improvement in 12-24 hours, operation.

Duodenal obstruction
 Symptoms