eMedicine Specialties > Emergency Medicine > Pediatric

Pediatrics, Pyloric Stenosis: Treatment & Medication

Author: Jagvir Singh, MD, Director, Division of Pediatric Emergency Medicine, Lutheran General Hospital of Park Ridge
Coauthor(s): Dara A Kass, MD, Clinical Assistant Instructor, Department of Emergency Medicine, State University of New York Downstate Medical Center, Kings County Hospital; Richard Sinert, DO, Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center
Contributor Information and Disclosures

Updated: Jan 22, 2008

Treatment

Prehospital Care

  • As with all pediatric resuscitations, prehospital care should be consistent with pediatric advanced life support (PALS) recommendations for infants who are dehydrated or in shock.
  • Immediate treatment requires correction of fluid loss, electrolytes, and acid-base imbalance. Once intravenous access is obtained, the dehydrated infant should receive an initial bolus (20 mL/kg) of crystalloid fluid. The infant should remain nothing by mouth (NPO).

Emergency Department Care

  • Infantile hypertrophic pyloric stenosis (IHPS) is a medical emergency.
  • Immediate treatment requires correction of fluid loss, electrolytes, and acid-base imbalance. Once intravenous access is obtained, an initial fluid bolus (20 mL/kg) of crystalloids should be infused immediately if the infant is dehydrated.
  • More than 60% of infants present to the ED with normal electrolyte values or are not in clinical shock. These infants should receive 1.5-2 times maintenance intravenous fluid: 5% dextrose in 0.25% or 0.33% sodium chloride with 2-4 mEq KCl per 100 mL replacement. The infant's fluid status should be continuously reassessed with special attention to acid-base status and urine output.
  • The definitive treatment for IHPS is corrective surgery.
  • The Ramstedt pyloromyotomy is the procedure of choice, during which underlying antro-pyloric mass is split leaving the mucosal layer intact.
    • Traditionally, the pyloromyotomy was performed through a right upper quadrant transverse incision. Recent studies have compared the operative time, cost, and hospital stay associated with the traditional incision, a circumbilical incision (believed to have improved cosmesis), and a laparoscopic procedure. The laparoscopic pyloromyotomy has been found to be safe and effective, with shorter operative times and hospital stay.
    • A study from the United Kingdom observed less time to full feedings, less analgesia, less emesis, and faster discharge in the laparoscopic group compared with the traditional approach.2
    • A study from France showed that laparoscopic pyloromyotomy does not decrease the incidence of postoperative vomiting and may lead to a risk of inadequate pyloromyotomy.3
    • Pyloromyotomy performed in specialized centers in pediatric surgery and a general surgery teaching hospital had similar complication rates in a study from the Netherlands.4
    • Recently, various surgical approaches, such as the supraumbilical skin-fold incision and umbilical incision, have been used with easy access, and these approaches have better cosmetic results. Also, a study from Montreal showed superior cosmesis with the supraumbilical (SU) approach than with the right upper quadrant (RUQ) approach.5
  • Nonsurgical treatment for IHPS with atropine sulfate, both intravenous and oral, has shown encouraging results. In one study, infants were given 21 days of atropine via nasogastric tube and regression of pyloric hypertrophy was monitored sonographically. One patient needed intravenous atropine, as nasogastric tube feedings were not tolerated for the first 2 days, but the patient did well subsequently. In this study, all 12 patients were successfully treated nonsurgically without complication.
  • Surgical correction is considered the standard of care for all patients with IHPS; therefore, medical management should be reserved for patients who are poor surgical candidates or whose parents are opposed to surgery.

Consultations

A surgeon comfortable with neonatal care should be consulted as soon as the diagnosis of IHPS is entertained.

Medication

Surgical correction is considered the standard of care for IHPS. Limited data exist for nonsurgical treatment (see Treatment).

More on Pediatrics, Pyloric Stenosis

Overview: Pediatrics, Pyloric Stenosis
Differential Diagnoses & Workup: Pediatrics, Pyloric Stenosis
Treatment & Medication: Pediatrics, Pyloric Stenosis
Follow-up: Pediatrics, Pyloric Stenosis
References
[ CLOSE WINDOW ]

References

  1. Rogers IM. The true cause of pyloric stenosis is hyperacidity. Acta Paediatr. Feb 2006;95(2):132-6. [Medline].

  2. Aldridge RD, MacKinlay GA, Aldridge RB. Choice of incision: the experience and evolution of surgical management of infantile hypertrophic pyloric stenosis. J Laparoendosc Adv Surg Tech A. Feb 2007;17(1):131-6. [Medline].

  3. Leclair MD, Plattner V, Mirallie E, Lejus C, Nguyen JM, Podevin G. Laparoscopic pyloromyotomy for hypertrophic pyloric stenosis: a prospective, randomized controlled trial. J Pediatr Surg. Apr 2007;42(4):692-8. [Medline].

  4. van den Ende ED, Allema JH, Hazebroek FW, Breslau PJ. Can pyloromyotomy for infantile hypertrophic pyloric stenosis be performed in any hospital? Results from two teaching hospitals. Eur J Pediatr. Jun 2007;166(6):553-7. [Medline].

  5. Taqi E, Boutros J, Emil S, Dubé S, Puligandla P, Flageole H. Evaluation of surgical approaches to pyloromyotomy: a single-center experience. J Pediatr Surg. May 2007;42(5):865-8. [Medline].

  6. Adibe OO, Nichol PF, Lim FY, Mattei P. Ad libitum feeds after laparoscopic pyloromyotomy: a retrospective comparison with a standardized feeding regimen in 227 infants. J Laparoendosc Adv Surg Tech A. Apr 2007;17(2):235-7. [Medline].

  7. Cohen HL, Blumer SL, Zucconi WB. The sonographic double-track sign: not pathognomonic for hypertrophic pyloric stenosis; can be seen in pylorospasm. J Ultrasound Med. May 2004;23(5):641-6. [Medline].

  8. Garcia VF, Randolph JG. Pyloric stenosis: diagnosis and management. Pediatr Rev. Apr 1990;11(10):292-6. [Medline].

  9. Godbole P, Sprigg A, Dickson JA. Ultrasound compared with clinical examination in infantile hypertrophic pyloric stenosis. Arch Dis Child. Oct 1996;75(4):335-7. [Medline].

  10. Hernanz-Schulman M. Infantile hypertrophic pyloric stenosis. Radiology. May 2003;227(2):319-31. [Medline].

  11. Hernanz-Schulman M, Sells LL, Ambrosino MM. Hypertrophic pyloric stenosis in the infant without a palpable olive: accuracy of sonographic diagnosis. Radiology. Dec 1994;193(3):771-6. [Medline].

  12. Huang YC, Su BH. Medical treatment with atropine sulfate for hypertrophic pyloric stenosis. Acta Paediatr Taiwan. May-Jun 2004;45(3):136-40. [Medline].

  13. Irish MS, Pearl RH, Caty MG, Glick PL. The approach to common abdominal diagnosis in infants and children. Pediatr Clin North Am. Aug 1998;45(4):729-72. [Medline].

  14. Kim SS, Lau ST, Lee SL. Pyloromyotomy: a comparison of laparoscopic, circumumbilical, and right upper quadrant operative techniques. J Am Coll Surg. Jul 2005;201(1):66-70. [Medline].

  15. Liacouras CA, Cook-Sather SD, Schreiner MS, Bellah RD. Endoscopic findings in hypertrophic pyloric stenosis: appearance in classic and evolving disease. Gastrointest Endosc. May 1997;45(5):371-4. [Medline].

  16. Nagita A, Yamaguchi J, Amemoto K, et al. Management and ultrasonographic appearance of infantile hypertrophic pyloric stenosis with intravenous atropine sulfate. J Pediatr Gastroenterol Nutr. Aug 1996;23(2):172-7. [Medline].

  17. Schechter R, Torfs CP, Bateson TF. The epidemiology of infantile hypertrophic pyloric stenosis. Paediatr Perinat Epidemiol. Oct 1997;11(4):407-27. [Medline].

  18. Sorensen HT, Skriver MV, Pedersen L. Risk of infantile hypertrophic pyloric stenosis after maternal postnatal use of macrolides. Scand J Infect Dis. 2003;35(2):104-6. [Medline].

  19. Spinelli C, Bertocchini A, Massimetti M. Muscle thickness in infants hypertrophic pyloric stenosis. Pediatr Med Chir. Mar-Apr 2003;25(2):148-50. [Medline].

  20. Sretenovic A, Smoljanic Z, Korac G. [Conservative treatment of hypertrophic pyloric stenosis in children]. Srp Arh Celok Lek. Oct 2004;132 Suppl 1:93-6. [Medline].

  21. Takahashi T. Pathophysiological significance of neuronal nitric oxide synthase in the gastrointestinal tract. J Gastroenterol. 2003;38(5):421-30. [Medline].

  22. van der Bilt JD, Kramer WL, van der Zee DC. Early feeding after laparoscopic pyloromyotomy: the pros and cons. Surg Endosc. May 2004;18(5):746-8. [Medline].

  23. Vasavada P. Ultrasound evaluation of acute abdominal emergencies in infants and children. Radiol Clin North Am. Mar 2004;42(2):445-56. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

pyloric stenosis in children, pyloric stenosis in infants, pyloric stenosis, intestinal obstruction in infancy, intestinal obstruction in infants, gastric outlet obstruction, infantile hypertrophic pyloric stenosis, IHPS

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Jagvir Singh, MD, Director, Division of Pediatric Emergency Medicine, Lutheran General Hospital of Park Ridge
Jagvir Singh, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Coauthor(s)

Dara A Kass, MD, Clinical Assistant Instructor, Department of Emergency Medicine, State University of New York Downstate Medical Center, Kings County Hospital
Dara A Kass, MD is a member of the following medical societies: American College of Emergency Physicians, Emergency Medicine Residents Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Richard Sinert, DO, Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center
Richard Sinert, DO is a member of the following medical societies: American College of Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Garry Wilkes, MBBS, FACEM, Director of Emergency Medicine, Bunbury Health Service, Western Australia Country Health Service; Adjunct Associate Professor, School of Exercise, Biomedical and Health Sciences, Faculty of Computing, Health and Science, Edith Cowan University; Medical Director, St John Ambulance Service
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

Grace M Young, MD, Associate Professor, Department of Pediatrics, University of Maryland Medical Center
Grace M Young, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Emergency Physicians
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Richard G Bachur, MD, Assistant Professor of Pediatrics, Harvard Medical School; Associate Chief and Fellowship Director, Attending Physician, Division of Emergency Medicine, Children's Hospital of Boston
Richard G Bachur, MD is a member of the following medical societies: American Academy of Pediatrics, Society for Academic Emergency Medicine, and Society for Pediatric Research
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.