eMedicine Specialties > Pediatrics: General Medicine > Gastroenterology

Pyloric Stenosis, Hypertrophic: Differential Diagnoses & Workup

Author: Hisham Nazer, MB, BCh, FRCP, DCh, DTM&H, Professor of Pediatrics, Consultant in Pediatric Gastroenterology, Hepatology and Clinical Nutrition, Bushnaq Medical Centre, University of Jordan
Coauthor(s): Dena Nazer, MD, Fellow, Child Protection Center, Children's Hospital of Michigan; Daniel A Beals, MD, Attending Staff, Cornerstone Pediatric Surgery
Contributor Information and Disclosures

Updated: Oct 31, 2008

Differential Diagnoses

Adrenal Insufficiency
Gastroenteritis
Alkalosis, Metabolic
Gastroesophageal Reflux
Bowel Obstruction in the Newborn
Intestinal Malrotation
Duodenal Atresia
Sandifer Syndrome
Failure to Thrive

Other Problems to Be Considered

Adrenal crisis
Cow's milk protein allergy
Eosinophilic gastroenteritis
Gastric outlet obstruction
Inborn errors of metabolism
Pyloric antral web

Workup

Laboratory Studies

  • Serum electrolytes: Document adequacy of fluid resuscitation and correction of electrolyte imbalances before surgical repair of hypertrophic pyloric stenosis (HPS). See Medical Care. Infants with severe vomiting can develop profound hypochloremia and hypokalemia. The classic biochemical abnormality in hypertrophic pyloric stenosis is hypochloremic, hypokalemic metabolic alkalosis.

Imaging Studies

  • Ultrasonography has become the criterion standard imaging technique for diagnosing hypertrophic pyloric stenosis. It is reliable, highly sensitive, highly specific, and easily performed. An experienced ultrasonographer increases the test's predictive value. Necessary measurements include pyloric muscle thickness and pyloric channel length. Muscle wall thickness 3 mm or greater and pyloric channel length 14 mm or greater are considered abnormal in infants younger than 30 days.
  • Barium upper GI (UGI) study is an effective means of diagnosing HPS when ultrasonography is not diagnostic. It should demonstrate an elongated pylorus with antral indentation from the hypertrophied muscle. The UGI may demonstrate the "double track" sign when thin tracks of barium are compressed between thickened pyloric mucosa or the "shoulder" sign when barium collects in the dilated prepyloric antrum. After UGI barium study, irrigating and removing any residual barium from the stomach is advisable to avoid aspiration.
  • Although UGI endoscopy would demonstrate pyloric obstruction, physicians would find it difficult to differentiate accurately between hypertrophic pyloric stenosis and pylorospasm. Endoscopy is reserved for patients with atypical clinical signs when ultrasonography and UGI studies are nondiagnostic. Endoscopic dilatation has rarely been used as a method of treatment. This treatment is not standard for hypertrophic pyloric stenosis; endoscopy should be used rarely, if ever.

More on Pyloric Stenosis, Hypertrophic

Overview: Pyloric Stenosis, Hypertrophic
Differential Diagnoses & Workup: Pyloric Stenosis, Hypertrophic
Treatment & Medication: Pyloric Stenosis, Hypertrophic
Follow-up: Pyloric Stenosis, Hypertrophic
References
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References

  1. Elinoff JM, Liu D, Guandalini S, Waggoner DJ. Familial pyloric stenosis associated with developmental delays. J Pediatr Gastroenterol Nutr. Jul 2005;41(1):129-32. [Medline].

  2. Kawahara H, Takama Y, Yoshida H, et al. Medical treatment of infantile hypertrophic pyloric stenosis: should we always slice the "olive"?. J Pediatr Surg. Dec 2005;40(12):1848-51. [Medline].

  3. Alain JL, Grousseau D, Terrier G. Extramucosal pyloromyotomy by laparoscopy. Surg Endosc. 1991;5(4):174-5. [Medline].

  4. Georgeson KE, Corbin TJ, Griffen JW, Breaux CW Jr. An analysis of feeding regimens after pyloromyotomy for hypertrophic pyloric stenosis. J Pediatr Surg. Nov 1993;28(11):1478-80. [Medline].

  5. Allan C. Determinants of good outcome in pyloric stenosis. J Paediatr Child Health. Mar 2006;42(3):86-8. [Medline].

  6. Aspelund G, Langer JC. Current management of hypertrophic pyloric stenosis. Semin Pediatr Surg. Feb 2007;16(1):27-33. [Medline].

  7. Dahshan A, Donovan KG, Halabi IM, et al. Helicobacter pylori and infantile hypertrophic pyloric stenosis: is there a possible relationship?. J Pediatr Gastroenterol Nutr. Mar 2006;42(3):262-4. [Medline].

  8. Gasseling J. Hypertrophic pyloric stenosis. Radiol Technol. Mar-Apr 2004;75(4):314-6. [Medline].

  9. Hall NJ, Van Der Zee J, Tan HL, Pierro A. Meta-analysis of laparoscopic versus open pyloromyotomy. Ann Surg. Nov 2004;240(5):774-8. [Medline]. [Full Text].

  10. Ibarguen-Secchia E. Endoscopic pyloromyotomy for congenital pyloric stenosis. Gastrointest Endosc. Apr 2005;61(4):598-600. [Medline].

  11. Leaphart CL, Borland K, Kane TD, Hackam DJ. Hypertrophic pyloric stenosis in newborns younger than 21 days: remodeling the path of surgical intervention. J Pediatr Surg. Jun 2008;43(6):998-1001. [Medline].

  12. Ly DP, Liao JG, Burd RS. Effect of surgeon and hospital characteristics on outcome after pyloromyotomy. Arch Surg. Dec 2005;140(12):1191-7. [Medline].

  13. Mullassery D, Perry D, Goyal A, Jesudason EC, Losty PD. Surgical practice for infantile hypertrophic pyloric stenosis in the United Kingdom and Ireland--a survey of members of the British Association of Paediatric Surgeons. J Pediatr Surg. Jun 2008;43(6):1227-9. [Medline].

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

  15. Schwartz MZ. Hypertrophic Pyloric Stenosis. Pediatr Surg. 1998;1111-8.

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Further Reading

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Keywords

hypertrophic pyloric stenosis, HPS, congenital hypertrophic pyloric stenosis, infantile hypertrophic pyloric stenosis, IHPS, gastric outlet obstruction, dehydration, outflow obstruction, hypochloremic alkalosis, malnutrition, hypochloremia, hypokalemia

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Contributor Information and Disclosures

Author

Hisham Nazer, MB, BCh, FRCP, DCh, DTM&H, Professor of Pediatrics, Consultant in Pediatric Gastroenterology, Hepatology and Clinical Nutrition, Bushnaq Medical Centre, University of Jordan
Hisham Nazer, MB, BCh, FRCP, DCh, DTM&H is a member of the following medical societies: Royal College of Paediatrics and Child Health, Royal College of Physicians, Royal College of Surgeons in Ireland, Royal College of Surgeons of Edinburgh, and Royal Society of Tropical Medicine and Hygiene
Disclosure: Nothing to disclose.

Coauthor(s)

Dena Nazer, MD, Fellow, Child Protection Center, Children's Hospital of Michigan
Dena Nazer, MD is a member of the following medical societies: Ambulatory Pediatric Association and American Academy of Pediatrics
Disclosure: Nothing to disclose.

Daniel A Beals, MD, Attending Staff, Cornerstone Pediatric Surgery
Daniel A Beals, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Physicians, American Pediatric Surgical Association, American Society for Bioethics and Humanities, Kentucky Medical Association, Society for Fetal Urology, Society of Critical Care Medicine, and Southeastern Surgical Congress
Disclosure: Nothing to disclose.

Medical Editor

Jeffrey J DuBois, MD, Consulting Staff, Division of Pediatric Surgery, Kaiser Permanente, North Sacramento Medical Center
Jeffrey J DuBois, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, Association for Academic Surgery, California Medical Association, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal and Endoscopic Surgeons, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

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

Managing Editor

B U K Li, MD, Professor of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Director, Pediatric Fellowships and Gastroenterology Fellowship, Medical Director, Functional Gastrointestinal Disorders and Cyclic Vomiting Program, Medical College of Wisconsin; Attending Gastroenterologist, Children's Hospital of Wisconsin
B U K Li, MD is a member of the following medical societies: Alpha Omega Alpha, American Gastroenterological Association, and North American Society for Pediatric Gastroenterology and Nutrition
Disclosure: Nothing to disclose.

CME Editor

Steven M Schwarz, MD, FAAP, FACN, AGAF, Professor of Pediatrics, State University of New York, Downstate Medical Center College of Medicine; Distinguished Lecturer, New York Medical College, School of Public Health
Steven M Schwarz, MD, FAAP, FACN, AGAF is a member of the following medical societies: American Academy of Pediatrics, American College of Nutrition, American College of Physician Executives, American Gastroenterological Association, American Pediatric Society, Gastroenterology Research Group, New York Academy of Medicine, North American Society for Pediatric Gastroenterology and Nutrition, and Society for Pediatric Research
Disclosure: TAP Pharmaceuticals Honoraria Speaking and teaching; Curemark, LLC Consulting fee Board membership

Chief Editor

Carmen Cuffari, MD, Associate Professor, Department of Pediatrics, Division of Gastroenterology/Nutrition, Johns Hopkins University School of Medicine
Carmen Cuffari, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

 
 
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