Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Pediatric Pyloric Stenosis Treatment & Management

  • Author: Jagvir Singh, MD; Chief Editor: Kirsten A Bechtel, MD  more...
 
Updated: Jul 27, 2015
 

Prehospital Care

See the list below:

  • 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).
Next

Emergency Department Care

See the list below:

  • 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.[12]
    • 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.[13]
    • 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.[14]
    • Pyloromyotomy performed in specialized centers in pediatric surgery and a general surgery teaching hospital had similar complication rates in a study from the Netherlands.[15]
    • 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.[16]
  • 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.
Previous
Next

Consultations

See the list below:

  • A surgeon comfortable with neonatal care should be consulted as soon as the diagnosis of infantile hypertrophic pyloric stenosis is entertained.
Previous
 
 
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)

Richard H Sinert, DO Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Vice-Chair in Charge of Research, Department of Emergency Medicine, Kings County Hospital Center

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

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

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, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Chief Editor

Kirsten A Bechtel, MD Associate Professor of Pediatrics, Section of Pediatric Emergency Medicine, Yale University School of Medicine; Co-Director, Injury Free Coalition for Kids, Yale-New Haven Children's Hospital

Kirsten A Bechtel, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Additional Contributors

Garry Wilkes, MBBS, FACEM Director of Clinical Training (Simulation), Fiona Stanley Hospital; Clinical Associate Professor, University of Western Australia; Adjunct Associate Professor, Edith Cowan University, Western Australia

Disclosure: Nothing to disclose.

Acknowledgements

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.

References
  1. Pandya S, Heiss K. Pyloric stenosis in pediatric surgery: an evidence-based review. Surg Clin North Am. 2012 Jun. 92(3):527-39, vii-viii. [Medline].

  2. Panteli C. New insights into the pathogenesis of infantile pyloric stenosis. Pediatr Surg Int. 2009 Sep 16. [Medline].

  3. McAteer JP, Ledbetter DJ, Goldin AB. Role of bottle feeding in the etiology of hypertrophic pyloric stenosis. JAMA Pediatr. 2013 Dec. 167(12):1143-9. [Medline].

  4. Lund M, Pasternak B, Davidsen RB, Feenstra B, Krogh C, Diaz LJ, et al. Use of macrolides in mother and child and risk of infantile hypertrophic pyloric stenosis: nationwide cohort study. BMJ. 2014 Mar 11. 348:g1908. [Medline]. [Full Text].

  5. Eberly MD, Eide MB, Thompson JL, Nylund CM. Azithromycin in early infancy and pyloric stenosis. Pediatrics. 2015 Mar. 135 (3):483-8. [Medline].

  6. Barclay L. Azithromycin Linked to Pyloric Stenosis Risk in Young Infants. Medscape Medical News. Available at http://www.medscape.com/viewarticle/839845. February 16, 2015; Accessed: July 28, 2015.

  7. Feenstra B, Geller F, Carstensen L, Romitti PA, Körberg IB, Bedell B, et al. Plasma lipids, genetic variants near APOA1, and the risk of infantile hypertrophic pyloric stenosis. JAMA. 2013 Aug 21. 310(7):714-21. [Medline]. [Full Text].

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

  9. Krogh C, Fischer TK, Skotte L, Biggar RJ, Oyen N, Skytthe A. Familial aggregation and heritability of pyloric stenosis. JAMA. 2010 Jun 16. 303(23):2393-9. [Medline].

  10. [Guideline] Cincinnati Children's Hospital Medical Center. Evidence based clinical practice guideline for hypertrophic pyloric stenosis. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2007 Nov 14. [Full Text].

  11. Maheshwari P, Abograra A, Shamam O. Sonographic evaluation of gastrointestinal obstruction in infants: a pictorial essay. J Pediatr Surg. 2009 Oct. 44(10):2037-42. [Medline].

  12. Saha N, Saha DK, Rahman MA, Aziz MA, Islam MK. Laparoscopic versus Open Pyloromyotomy for Infantile Hypertropic Pyloric Stenosis: An Early Experience. Mymensingh Med J. 2012 Jul. 21(3):430-4. [Medline].

  13. 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. 2007 Feb. 17(1):131-6. [Medline].

  14. 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. 2007 Apr. 42(4):692-8. [Medline].

  15. 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. 2007 Jun. 166(6):553-7. [Medline].

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

  17. 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. 2007 Apr. 17(2):235-7. [Medline].

  18. Kelley-Quon LI, Tseng CH, Jen HC, Shew SB. Hospital type predicts surgical complications for infants with hypertrophic pyloric stenosis. Am Surg. 2012 Oct. 78(10):1079-82. [Medline].

  19. 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. 2004 May. 23(5):641-6. [Medline].

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

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

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

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

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

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

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

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

  28. 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. 1996 Aug. 23(2):172-7. [Medline].

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

  30. 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].

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

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

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

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

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

Previous
Next
 
Lateral view from an upper GI study demonstrates the double-track sign.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.