Pediatric Hypertrophic Pyloric Stenosis Treatment & Management

  • Author: Hisham Nazer, MB, BCh, FRCP, DCh, DTM&H; Chief Editor: Carmen Cuffari, MD   more...
 
Updated: Feb 2, 2012
 

Medical Care

  • Surgical repair of hypertrophic pyloric stenosis (HPS) is fairly straightforward and without many complications, yet properly preparing the infant for this procedure is vitally important. Most infants with hypertrophic pyloric stenosis do not have complete gastric outlet obstruction and can tolerate their inherent gastric secretions.
  • Repeated episodes of vomiting following attempts to feed the infant cause progressive dehydration and loss of hydrogen chloride from the gastric juices. Preoperative management is directed at correcting the fluid deficiency and electrolyte imbalance.
    • Base fluid resuscitation on the infant's degree of dehydration. Most infants can have their fluid status corrected within 24 hours; however, severely dehydrated children sometimes require several days for correction.
    • If necessary, administer an initial fluid bolus of 10 mL/kg with lactated Ringer solution or 0.45 isotonic sodium chloride solution. Continue intravenous (IV) therapy at an initial rate of 1.25-2 times the normal maintenance rate until adequate fluid status is achieved.
    • Adequate amounts of both chloride and potassium are necessary to correct metabolic acidosis. Unless renal insufficiency is a concern, initially add 2-4 mEq of KCL per 100 mL of IV fluid. Adequate chloride for resuscitation can usually be provided by 5% dextrose in 0.4% sodium chloride solution. Avoid adding hypertonic chloride or ammonium chloride.
    • Urine output and serial electrolyte determinations are performed during resuscitation. Correction of serum chloride level to 90 mEq/L or greater is usually adequate to proceed with surgical intervention.
    • Before induction of anesthesia, aspirate the infant's stomach with a large-caliber suction tube to remove any residual gastric fluid or barium. Saline irrigation is occasionally necessary to remove a large quantity of barium.
Next

Surgical Care

Pyloromyotomy remains the standard of treatment, and outcome is excellent.[5] The best surgical outcome and lowest complications are more likely when the surgeon has specialist pediatric surgical training.

  • Ramstedt pyloromyotomy remains the standard procedure of choice for hypertrophic pyloric stenosis because it is easily performed and is associated with minimal complications. The usual approach is via a right upper quadrant transverse incision that splits the rectus muscle and fascia.
  • Some authorities report that laparoscopic pyloromyotomy has a significantly shorter recovery time compared with open pyloromyotomy but that open pyloromyotomy has higher efficacy and fewer complications. However, a small (N=98) 2011 prospective, randomized trial found no difference in operating time, length of stay, or difference in time to full feeds between open and laparoscopic pyloromyotomy. While complication rates were similar between the 2 groups, significantly superior long-term cosmetic results were noted in the laparoscopic group.[6]
  • Endoscopic pyloromyotomy is a simple procedure and can be performed as an outpatient procedure.
  • Recently, endoscopic balloon dilatation of hypertrophic pyloric stenosis after failed pyloromyotomy has been used with greater frequency.
  • Several other approaches have been described. A supraumbilical curvilinear approach has gained popularity with good cosmetic results.
  • Postoperative management
    • Continue IV maintenance fluid until the infant is able to tolerate enteral feedings. In most instances, feedings can begin within 8 hours following surgery. Graded feedings can usually be initiated every 3 hours, starting with Pedialyte and progressing to full-strength formula.
    • Although schedules that advance the volume of feeds more quickly or those that begin with ad lib feeds are associated with more frequent episodes of vomiting, they do not increase morbidity and actually may decrease the time to hospital discharge.
    • Addition of a histamine 2 (H2) receptor blocker sometimes can be beneficial.
    • Treat persistent vomiting expectantly because it usually resolves within 1-2 days.
    • Avoid the temptation to repeat ultrasonography or UGI barium study; these invariably demonstrate a deformed pylorus and results are difficult to interpret.
Previous
Next

Consultations

Early consultation with a surgeon familiar with neonatal care is warranted because treatment is essentially surgical. Early consults facilitate decisions for diagnostic studies, fluid resuscitation, and scheduling the operative procedure. This is especially important if the child requires transfer to another facility for surgical care. The American Pediatric Surgical Association offers guidelines for appropriate consultation and transfer of small infants. Good outcome has been shown to depend on the quality of preoperative correction of fluid and electrolyte abnormalities, availability of a pediatric anesthetist, and training level of the surgeon.

Previous
Next

Diet

Feedings are usually resumed 6-8 hours after operation.[7] In most instances, gradually increasing the volume and strength of feedings is recommended (see Surgical Care).

Previous
Proceed to Medication
 
 
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 Faculty of Medicine, 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  Medical Director, Child Protection Center, Children's Hospital of Michigan; Assistant Professor, Wayne State University

Dena Nazer, MD is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, American Professional Society on the Abuse of Children, and Helfer Society

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.

Specialty Editor Board

Jeffrey J DuBois, MD  Chief of Children's Surgical Services, Division of Pediatric Surgery, Kaiser Permanente, Women and Children's Center, Roseville 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, and California Medical Association

Disclosure: Nothing to disclose.

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.

B UK 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 UK 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.

Steven M Schwarz, MD, FAAP, FACN, AGAF  Professor of Pediatrics, Children's Hospital at Downstate, State University of New York Downstate Medical Center

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: Curemark, LLC Consulting fee Board membership; Centocor, Inc. Grant/research funds Independent contractor; Johnson & Johnson, Inc. Grant/research funds Independent contractor

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.

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. Chung E. Infantile hypertrophic pyloric stenosis: genes and environment. Arch Dis Child. Dec 2008;93(12):1003-4. [Medline].

  3. 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].

  4. Panteli C. New insights into the pathogenesis of infantile pyloric stenosis. Pediatr Surg Int. Dec 2009;25(12):1043-52. [Medline].

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

  6. Siddiqui S, Heidel RE, Angel CA, Kennedy AP Jr. Pyloromyotomy: randomized control trial of laparoscopic vs open technique. J Pediatr Surg. Jan 2012;47(1):93-8. [Medline].

  7. 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].

  8. Alalayet YF, Miserez M, Mansoor K, Khan AM. Double-Y pyloromyotomy: a new technique for the surgical management of infantile hypertrophic pyloric stenosis. Eur J Pediatr Surg. Feb 2009;19(1):17-20. [Medline].

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

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

  11. Boneti C, McVay MR, Kokoska ER, Jackson RJ, Smith SD. Ultrasound as a diagnostic tool used by surgeons in pyloric stenosis. J Pediatr Surg. Jan 2008;43(1):87-91; discussion 91. [Medline].

  12. Copeland DR, Cosper GH, McMahon LE, Boneti C, Little DC, Dassinger MS. Return of the surgeon in the diagnosis of pyloric stenosis. J Pediatr Surg. Jun 2009;44(6):1189-92; discussion 1192. [Medline].

  13. 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].

  14. Emil S. Pyloromyotomy through an infra-umbilical incision: open technique and superb cosmesis. Eur J Pediatr Surg. Apr 2009;19(2):72-5. [Medline].

  15. Finkelstein JB, Stamell EF, Zilbert NR, Ginsburg HB, Nadler EP. Management and outcomes for children with pyloric stenosis stratified by hospital type. J Surg Res. Jan 2010;158(1):6-9. [Medline].

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

  17. Hall NJ, Eaton S, Pierro A. The evidence base for neonatal surgery. Early Hum Dev. Nov 2009;85(11):713-8. [Medline].

  18. Hall NJ, Pacilli M, Eaton S, Reblock K, Gaines BA, Pastor A. Recovery after open versus laparoscopic pyloromyotomy for pyloric stenosis: a double-blind multicentre randomised controlled trial. Lancet. Jan 31 2009;373(9661):390-8. [Medline].

  19. 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].

  20. Hernanz-Schulman M. Pyloric stenosis: role of imaging. Pediatr Radiol. Apr 2009;39 Suppl 2:S134-9. [Medline].

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

  22. 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].

  23. 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].

  24. 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].

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

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

Previous
Next
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
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.