Pyloric Stenosis

INTRODUCTION:

• Not congenital (symptoms are not present at birth)usually presents at 3 to 4 weeks of life
• More common in boys (4:1)
• Pylorus thickened, elongated and lumen narrowed due to hypertrophy of circular muscle
• Increased incidence in 0 and B groups
• Increased risk in Turner syndrome and Trisomy 18
• Erythromycin or azithromycin exposure, in the first 2 weeks of life – increased incidence

CLINICAL FEATURES:

• The classical presentation is non-bilious, projectile vomiting between 2 – 8 weeks of age
• Persistent vomiting & dehydration, malnutrition, hypokalemic, hypochloraemic alkalosis and paradoxical aciduria
• Visible gastric peristaltic waves moving from left to right across the upper abdomen
• In Congenital  hypertrophic  pyloric stenosis of infancy Baby is hungry soon after vomiting
• Abdominal lump,Constipation,Weight Loss is seen
• Palpation of the pyloric tumor (olive-shaped) in the epigastrium or right upper quadrant is pathognomic
• The classical electrolyte abnormality associated withpyloric stenosis is 
• Hypokalemic, 
• Hypochloremic metabolic alkalosis, presumably due to ongoing gastric acid loss from vomiting. 
• Paradoxical acidurea is sometimes noted (with progressive Hypokalemia and hypovolemia) because the kidney excretes protons in exchange of sodium in an attempt to conserve fluid

DIAGNOSIS:

• X-ray after barium meal shows string sign or double neck sign and shoulder sign & Single bubble appearance
• Diagnosis confirmed by USG>95% accuracy
• Persistent pyloric muscle thickness more than 3 to 4 mm
• Pyloric canal length more than 15 to 18 mm in the presence of functional gastric outlet obstruction
• Pyloric thickness (serosa to serosa) of 15 mm or greater
• Target sign on transverse images of the pylorus
• Failure of the channel to open during a minimum of 15 minutes of scanning
• Retrograde or hyperperistaltic contractions
• Antral nipple sign (prolapse of redundant mucosa into the antrum, which creates a pseudomass)
• Double-track sign(redundant mucosa in the narrowed lumen, which creates 2 mucosal outlines)

 TREATMENT:

• Fluid resuscitation and correction of electrolyte abnormalities and metabolic alkalosis is essential before surgery. 
• Surgery done is Fredet-Ranzstedt pyloromyotomy. (In it the pyloric mass is split without cutting the mucosa)Ramstedt’s operation (pyloromyotomy) is the treatment of choice. The hypertrophied circular muscle fibres are cut longitudinally