Infantile Hypertrophic

Pyloric Stenosis
Dr Feeroz Alam Khan
Pediatric Surgeon
 Introduction
• Not a congenital abnormality
• Most common cause of gastric outlet
obstruction in infants
• Prevalence: 1.5 to 4 per 1000 live births
• More common in boys
2:1 to 5:1
• First-born infant
 Etiology
• Idiopathic
• Genetic and Environmental factors
Method of feeding
Seasonal variability
Erythromycin exposure
Transpyloric feeding of premature infants
• Family history: more common in Caucasian
infants
 Anatomy
Gross appearance:
Enlarged, pale muscle
mass
2 to 2.5 cm in length
1 to 1.5 cm in diameter
Histology:
Marked hypertrophy &
hyperplasia of circular
muscle
 Pathophysiology
Hypertrophied muscles
Gastric outlet obstruction
Non-bilious projectile
vomiting
Gastric fluid loss
Hypochloremic
hypokalemic alkalosis
Paradoxical aciduria
 Clinical Features
• Onset of nonbilious vomiting at 2 to 8 weeks
of age
• Peak occurrence at 3 to 5 weeks
• Projectile emesis
• Brownish or coffee ground appearance
• Remains hungry after emesis
• Not ill-appearing or febrile
• Severe dehydration leads to lethargy
 Differential Diagnosis
Causes of nonbilious vomiting

Medical causes Surgical causes

• Over feeding • Antral webs
• Gastroenteritis • Pyloric atresia
• Increased • Duplication cyst of
intracranial pressure the antropyloric
• Metabolic disorders region
• Ectopic pancreatic
tissue within the
pyloric muscle
 Diagnosis
• Nonbilious projectile vomiting
• Visible peristalsis
 Diagnosis
• Palpation of an enlarged ‘Olive’
Plain Radiograph
 Ultrasonography
A positive US study
Pyloric muscle thickness: 4 mm or more
Pyloric muscle length: 16 mm or more
Pyloric diameter: 14 mm or more
Ultrasonography
Surgery
Surgery
 Complication during Surgery
Perforation: entrance into the lumen
Rare
Sub mucosa should be approximated with fine
interrupted suture
A portion of omentum placed over the site
Rotate the pylorus 180 ͦ
Perform a myotomy on the posterior wall
 Complication
• Vomiting
Gastro esophageal reflux
Discoordination of gastric peristalsis
Gastric atony
• Incomplete myotomy
• Unsuspected perforation

Persistent & frequent vomiting beyond 1

week: Reexploration