AIIMS RAIPUR

SUBJECT : MEDICAL SURGICAL NURSING

TOPIC : PYLORIC STENOSIS
SUBMITTED TO, SUBMITTED BY,

Mr. P D DEEPAK GEETHIKA SATHEESH

NURSING TUTOR ROLL NO: 2020-439
COLLEGE OF NURSING BSc(H) NURSING 2ND YEAR
AIIMS RAIPUR COLLEGE OF NURSING
AIIMS RAIPUR
 GENERAL OBJECTIVE

At the end of the session , group will be able to explain the topic
pyloric stenosis
 SPECIFIC OBJECTIVES

At the end of the session the group will be able to:

❑ Introduce the topic pyloric stenosis

❑ Explain the epidemiology of pyloric stenosis
❑ Postulate the causes of the disease
❑ List out the risk factors
❑ Understand the pathophysiology of the disease
❑ Explain the clinical manifestations of the disease
❑ Point out the nursing diagnoses related to the disease
❑ Explain the managements of pyloric stenosis
❑ postulate the preventive measures of the disease
❑ Conclude the topic
 INTRODUCTION

Pyloric stenosis is a problem that affects infants and

cause forceful vomiting that can lead to dehydration. It
is the second most common problem requiring surgery
in newborns. This problem occurs due to the narrowing
of the pylorus. This narrowing prevents food from
emptying out of the stomach.
 DEFENITION
Pyloric stenosis, also known as infantile hypertrophic pyloric
stenosis (IHPS), is an uncommon condition in infants
between birth and 6 months of age, characterized by
abnormal thickening of the pylorus muscles in the stomach
leading to gastric outlet obstruction
ADULT IDIOPATHIC HYPERTROPHIC PYLORIC STENOSIS

Adult Idiopathic hypertrophic pyloric stenosis (AIHPS) is a rare but

well-defined entity in adults with only 200-300 cases reported so far in
the literature.

It can be occur in an adult who is having a recurrent history of

peptic ulcer & hypertrophic changes in mucosa of stomach.

It is underreported due to a difficulty in diagnosis. The most common

symptoms of AIHPS are postprandial nausea, vomiting, early satiety,
and epigastric pain.
 EPIDEMIOLOGY

➢ The incidence of pyloric stenosis is 2 to 5 in 1000 live births per year.

➢ It is more common in males;
➢ there is a male to female ratio of 4 to 1.
➢ There is a familial link, but the hereditary pattern is polygenic
➢More common in first born child
➢ Pyloric stenosis is more common in the white population. It is less
commonly seen in Indian, Asian, and Black populations.
➢ The incidence is 2.4 per 1000 in whites, 1.8 in Hispanics, 0.7 in blacks,
and 0.6 in Asians.
 ETIOLOGY

The exact etiology of infantile hypertrophic pyloric stenosis is unknown.

Some studies have shown that,

➢ young infants treated with macrolide antibiotics
➢ Postnatal exposure to erythromycin
➢ Preterm birth
➢ if the mother was a heavy smoker during pregnancy
 RISK FACTORS

Caesarean Being first

section born

Congenital 1 Maternal
malformations smoking
during
pregnancy
Small weight or
gestational age Preterm
delivery
 RISK FACTORS cont.…

Race Early
antibiotic
Male sex use
2
Nitric oxide Bottle
synthesis feeding
deficiency
 PATHOPHYSIOLOGY
❑ Due to any etiological factors

❑ A diffuse hypertrophy and hyperplasia of smooth muscles of pyloric sphincter

❑ Narrowing of pylorus with partial and then complete obstruction

❑ Stomach contents cannot flow easily through constricted pylorus

❑ In an attempt to push the food forward, vigorous peristalsis occurs

❑ Persistent vomiting (projectile vomiting) and dilated stomach musculature

❑ Infant develops dehydration and hypochloremic alkalosis

 CLINICAL MANIFESTATIONS

➢ Vomiting after feeding. The baby may vomit

forcefully, ejecting breast milk or formula up to
several feet away that is projectile vomiting,
this is the classical symptom of pyloric stenosis.
Vomiting might be mild at first and gradually
become more severe as the pylorus opening
narrows. The vomit may sometimes contain
blood.
• Stomach contractions. wavelike contractions
(peristalsis) that ripple across the baby's upper
abdomen soon after feeding but before vomiting.
This is caused by stomach muscles trying to force
food through the narrowed pylorus.

• Dehydration. baby might cry without tears or

become lethargic.

Presence of pyloric mass. Some times an olive shaped

pyloric mass can be palpated above the umbilicus.
• Changes in bowel movements. Since pyloric stenosis
prevents food from reaching the intestines, babies with this
condition might be constipated.

• Weight problems. Pyloric stenosis can cause weight loss.

Persistent hunger. Babies who have pyloric stenosis often

want to eat soon after vomiting.
 DIAGNOSTIC PROCEDURES

In addition to complete medical history and physical

examination, diagnostic procedures for pyloric stenosis may
include,

Blood test: ABG- these tests evaluate dehydration and

mineral imbalance.

Abdominal X-Ray: A test that uses invisible electro magnetic

energy beams to produce images of internal organs, bones
and internal tissue onto the film.
Abdominal ultra sound: A diagnostic imaging technique
that use high frequency sound waves and a computer to
create images of blood vessels, tissues and organs.

Barium swallow/ Upper GI series: A diagnostic test that

examines the organs of the upper part of the digestive
system; The esophagus , stomach and the duodenum (
first section of small intestine ). A fluid called barium ( A
metallic , chemical, chalky liquid used to coat the inside
of the organs so that they will show up on an X-Ray ) is
swallowed. X-Rays are then taken to evaluate the
digestive system.
Some times an olive shaped pyloric mass can be palpated
above the umbilicus

Some times we can see superficially visible peristaltic waves

during observation of abdomen.
 NURSING DIAGNOSES

➢ Fluid volume deficit related to frequent vomiting as evidenced by

dry skin and mucous membrane.

➢ Imbalanced nutrition less than body requirement related to

vomiting as evidenced by weight loss

➢ Risk for impaired skin integrity related to surgery and nutritional

deficit
➢ Constipation related to limited fluid intake as evidenced by
verbalization of parents

➢ Risk for infection related to surgery

➢ Compromised family coping related to seriousness of

illness and impending surgery

➢ Deficient knowledge related to surgical management as

evidenced by anxiety of parents
 NURSING INTERVENTIONS

Fluid volume deficit related

to frequent vomiting as
evidenced by dry skin and
mucous membrane

Imbalanced nutrition less

than body requirement
related to vomiting as
evidenced by weight loss
 Risk for impaired skin
integrity related to surgery
and nutritional deficit

Constipation related to
limited fluid intake as
evidenced by verbalization of
parents
Risk for infection related to
surgery

Compromised family coping

related to seriousness of
illness and impending
surgery.
 MANAGEMENT
MEDICAL MANAGEMENT

# Rehydration and correction of electrolyte imbalances.

- If no or mild signs of dehydration are evident, 5% dextrose with 0.25% NaCl

and 2 meq KCl per 100 mL is given.

- If moderate or severe, recommend higher IVF NaCl concentrations.

- Bicarbonate levels should be corrected and monitored, given the impact on

potential hypoventilation.

- NG tube should be considered.

# Intravenous and oral Atropine

- It has a success rate of 85-89% compared to nearly 100% for

pyloromyotomy, however it requires prolonged hospitalization,
skilled nursing and careful follow up during treatment.
 SURGICAL MANAGEMENT

Open Pyloromyotomy

In this surgery the surgeon makes an

incision in the wall of the pylorus. The
lining of the pylorus bulges through the
incision, opening a channel from the
stomach to the small intestine.
 Laparoscopic Pyloromyotomy

surgeon slits the tense muscle and

with a laparoscopic spreader, the muscle is
separated sufficiently to relieve the
obstruction.

Laparoscopic pyloromyotomy is
much more usual and safer process.
A: Typical B: Two examples of open pyloromyotomy
postoperative scar appearance. The photograph on the left
appearance 1 year was taken 2 weeks after surgery. The
after laparoscopic photograph on the right is another patient 6
pyloromyotomy. months after surgery
.
 NURSING MANAGEMENT

PREOPERATIVE NURSING CARE

➢Observe and record vital signs of the infant.

➢Note and record the amount and characteristics of the vomitus

and the stool.

➢Stop oral feeding and administer intravenous fluids as prescribed.

➢If oral feeds are allowed (in case of partial obstruction), then give
small frequent feeds
➢Weigh the infant daily, in order to determine the degree of
dehydration.

➢Maintain strict intake – output chart

➢Provide warmth to the infant and protect from infections

➢Make sure fluid and electrolyte losses are corrected, 24-48

hours before surgery.
 POSTOPERATIVE NURSING CARE

➢ Observe for signs of complications

❖ The nurse must observe the incision for signs of infection and
inflammation.

❖ Check for any drainage from the incision site

❖ Keep the incision site clean and dry

❖ Use aseptic techniques while dressing

❖ Observe for indications of shock such as rapid weak pulse, pallor,
cold skin and restlessness

❖ Monitor abdominal girth to detect abdominal distension(caused

by air that the infant has swallowed or by infection of the
peritoneum)

❖ Do not give tub bath to the infant until the incision site heals.
 ➢ Management of pain

❖ To minimize post operative pain, administer acetaminophen as

prescribed

❖ Provide a calm quite and restful environment to the infant.

➢ Provision of adequate fluid and nutrition.

❖ Intravenous fluids are administered until adequate amount of

oral feed can be taken and retained.

❖ Assess for return of bowel sounds, after which oral feeding

may be started
❖ Oral feeding are started with glucose water or electrolyte
solution, 4-6 hours after surgery.

❖ Gastric motility is delayed for up to 24 hours following

anaesthesia, so feeding should begin slowly and advance
cautiously.

❖ As the baby starts tolerating oral glucose water, breast

feeding can be started with frequent burping between feeds.
 ➢ Parental education and follow-up after surgery

❖ The infants are usually discharged on the 4th or 5th post

operative day. Prior to discharge the parents are taught how to
position the infant after feeding, frequent burping, keeping the
incision site clean and dry, and to observe for signs that should
be reported such as redness or any discharge from the incision,
persistent vomiting etc.

❖ The time and place of follow-up should be informed to the

parents.
 POST-OPERATIVE & REHABILITATIVE CARE

The only care is a continuation of intravenous fluids until they

tolerate feeding. Feeding can begin 4-6 hours after recovery from
anesthesia.
Up to 80% of patients continue to have some mild form of vomiting
after surgery. If vomiting persist 5 days post operatively, they would
indicate further radiologic studies such as an upper GI series. Post-
operatively infants should be observed in the hospital for surgical
complications such as incomplete pyloromyotomy, mucosal
perforation and bleeding.
The infants may be discharged when they are rehydrated and start to
tolerate feeding well.
 HEALTH EDUCATION
The infants are usually discharged on fourth or fifth post-operative
day. Prior to discharge the parents are taught:-

o How to position the infant after surgery

o Care of the incision:-
wash hands before touching or cleaning the incision area. The
incision from the operation will be covered by a dressing called steri-
strips . A small amount of blood on the strip is common. If the blood
seems fresh (bright red) or the amount of blood increases, press on the
area with a clean ,dry wash cloth for 5-6 minutes.
The steri -strip will fall off on their own. If they have not fallen off
already, take off the strips 7-10 days after surgery.
o Activities :-
Allow babies to do all the normal activities once they return home.
o Food and drink:-
During the first hours of surgery, infant may still vomit & it’s common.
The vomiting is usually due to the side effects of pyloric stenosis. It will
slowly get better. Baby should be able to eat the breast milk or formula
they normally eat after the surgery.
o Pain medicine:-
Baby can have pain medicine as needed after the first 24 hours. This
type of surgery is not usually painful, so baby only need plain
acetaminophen by mouth.
o Bathing:-
Can give baby a bath after 48 hours of surgery.
PREVENTION
 PREVENTION

There's no way to prevent pyloric stenosis.

Since it has a familial link, If you know pyloric stenosis runs in any
family, encourage them to report it to their healthcare provider. The
provider can be on the lookout for any signs or symptoms of the
condition. Provide the knowledge about the signs and symptoms of
pyloric stenosis so that they can get help as soon as possible.
A
N
Y D UBTS
 RECAPITULATION

I. What is pyloric stenosis?

II. What is the non surgical method of treating pyloric
stenosis?
III. postulate any two pre and post operative nursing
managements.
IV. list out some points that we can say to parents while health
education.
 CONCLUSION

Infants diagnosed with pyloric stenosis have an excellent

prognosis. Nursing care focuses on the management of fluid and
electrolytes and on education and support to the parents.
Although some non bilious vomiting does occur post-operatively,
most infants achieve normal feeding pattern and good weight
gain by their first post-operative visit. Parents can then focus on
the normal growth and development of their infant.
 BIBLIOGRAPHY
▪ Nursing care of the paediatric surgical patient, Nancy Tkacz Brown, lauras M Flanigan, 3rd
edition , page no: 375-380
▪ Nursing the surgical patient, Rosemary Pudner, Elsevier publications, 3rd edition, page no:
311
▪ Paediatric nursing care plans, assuma beevi, Elsevier publications, page number :170
▪ Textbook of paediatric nursing, assuma beevi, Elsevier publications , page no: 237
▪ Essentials of paediatric nursing , rimple sharma, Jaypee publications, 3rd edition , page no:
200-201

* Canadian journal of anaesthesia, Bissonnette & sulliven, pyloric stenosis

https://www.researchgate.net/publication/263124791_Canadian_Journal_of_Anesthesia

* Open Versus Laparoscopic Pyloromyotomy for Pyloric Stenosis

Annals of Surgery: September 2006 - Volume 244 - Issue 3 - p 363-370
doi: 10.1097/01.sla.0000234647.03466.27
.
https://dx.doi.org/10.1097%2F01.sla.0000234647.03466.27
H NKYO