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Pediatric Hypertrophic Pyloric Stenosis Treatment & Management

  • Author: Hisham Nazer, MB, BCh, FRCP, , DTM&H; Chief Editor: Carmen Cuffari, MD  more...
 
Updated: Aug 14, 2015
 

Medical Care

See the list below:

  • 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 alkalosis. 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. 
    • 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.
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Surgical Care

Pyloromyotomy remains the standard of treatment, and outcome is excellent.[17] 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. While complication rates were similar between the 2 groups, significantly superior long-term cosmetic results were noted in the laparoscopic group.[18] A systematic review of 502 patients echoed these results, finding laparoscopic pyloromyotomy does not lead to significant postoperative complications compared to open pyloromyotomy.[19]
  • 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.
    • 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.
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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.

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Diet

Feedings are usually resumed 6-8 hours after operation.[20] In most instances, gradually increasing the volume and strength of feedings is recommended (see Surgical Care).

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Contributor Information and Disclosures
Author

Hisham Nazer, MB, BCh, FRCP, , DTM&H Professor of Pediatrics, Consultant in Pediatric Gastroenterology, Hepatology and Clinical Nutrition, University of Jordan Faculty of Medicine, Jordan

Hisham Nazer, MB, BCh, FRCP, , DTM&H is a member of the following medical societies: American Association for Physician Leadership, Royal College of Paediatrics and Child Health, Royal College of Surgeons in Ireland, Royal Society of Tropical Medicine and Hygiene, Royal College of Physicians and Surgeons of the United Kingdom

Disclosure: Nothing to disclose.

Coauthor(s)

Dena Nazer, MD, FAAP Assistant Professor of Pediatrics, Wayne State University School of Medicine; Chief, Child Protection Team, Children's Hospital of Michigan

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

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.

B UK Li, MD Professor of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Medical College of Wisconsin; Attending Gastroenterologist, Director, Cyclic Vomiting Program, Children’s Hospital of Wisconsin

B UK Li, MD is a member of the following medical societies: Alpha Omega Alpha, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Disclosure: Nothing to disclose.

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, Royal College of Physicians and Surgeons of Canada

Disclosure: Received honoraria from Prometheus Laboratories for speaking and teaching; Received honoraria from Abbott Nutritionals for speaking and teaching.

Additional Contributors

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

Jeffrey J Du Bois, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, California Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

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.

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