Pediatrics, Pyloric Stenosis Treatment & Management

  • Author: Jagvir Singh, MD; Chief Editor: Richard G Bachur, MD   more...
 
Updated: Jun 22, 2010
 

Prehospital Care

  • As with all pediatric resuscitations, prehospital care in patients with pyloric stenosis 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).
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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 infantile hypertrophic pyloric stenosis 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.[6]
    • 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.[7]
    • Pyloromyotomy performed in specialized centers in pediatric surgery and a general surgery teaching hospital had similar complication rates in a study from the Netherlands.[8]
    • 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.[9]
  • Nonsurgical treatment for infantile hypertrophic pyloric stenosis 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 infantile hypertrophic pyloric stenosis; therefore, medical management should be reserved for patients who are poor surgical candidates or whose parents are opposed to surgery.
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Consultations

  • A surgeon comfortable with neonatal care should be consulted as soon as the diagnosis of infantile hypertrophic pyloric stenosis is entertained.
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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 H Sinert, DO  Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center

Richard H Sinert, DO is a member of the following medical societies: American College of Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Garry Wilkes, MBBS, FACEM  Director of Emergency Medicine, Bunbury Hospital, Western Australia; Medical Consultant, St John Ambulance, WA Ambulance Service; Adjunct Associate Professor, Edith Cowan University; Clinical Associate Professor, Rural Clinical School, University of Western Australia

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Pharmacy Editor, eMedicine

Disclosure: Nothing to disclose.

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.

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  Associate 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.

References

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Lateral view from an upper GI study demonstrates the double-track sign.
 
 
 
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