Treatment
Prehospital Care
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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.
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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
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Infantile hypertrophic pyloric stenosis (IHPS) may be described as a medical emergency or a medical urgency based on how early in the course the patient presents.
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If significant dehydration has occurred, immediate treatment requires correction of fluid loss, electrolytes, and acid-base imbalance, starting with an initial fluid bolus (20ml/kg) of isotonic crystalloid.
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More than 60% of infants present to the ED with normal electrolyte values and are not significantly dehydrated. These infants should receive 1.5-2 times maintenance intravenous fluid: 5% dextrose in 0.45% normal saline with 20mEq/l of potassium chloride replacement. The infant's fluid status should be continuously reassessed with special attention to acid-base status and urine output.
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A request for pyloric ultrasound should be made for definitive diagnosis of pyloric stenosis. This is not emergent and may be performed after the patient is stabilized and as an in-patient as well.
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The definitive treatment for infantile hypertrophic pyloric stenosis is corrective surgery, thus once the diagnosis has been confirmed, a pediatric surgeon should be consulted.
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Consultations
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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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Medical Care
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Nonsurgical treatment for infantile hypertrophic pyloric stenosis with atropine sulfate, either intravenous or oral, is an alternative in the rare case that general anesthesia or surgery is contraindicated. [25] In a systematic review that identified 10 studies, treatment with atropine had a lower success rate and longer duration of therapy compared to conventional pyloromyotomy. [16]
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A recent nationwide review of pyloric stenosis management with atropine in Japan echoed similar findings – they found that surgical intervention has a higher success rates, minimal complications and shorter duration of hospital stay compared to atropine therapy. [17]
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Surgical Care
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The definitive treatment for infantile hypertrophic pyloric stenosis is corrective surgery.
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The Ramstedt pyloromyotomy is the current procedure of choice, during which the underlying antro-pyloric mass is split leaving the mucosal layer intact.
- Traditionally, the pyloromyotomy was performed through a right upper quadrant transverse incision. New 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.
- Studies have shown laparoscopic pyloromyotomy to have fewer complications, reduced time to full feeds and hospital length of stay compared to open pyloromyotomy. [18, 19, 24] However, a meta-analysis of 4 randomized controlled trials comparing laparoscopic pyloromyotomy to open pyloromyotomy found no difference in complication rates, or hospital length of stay between the two groups. It did find a reduction in time to full feeds by 2 hours in the laparoscopic pyloromyotomy group. [20]
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Media Gallery
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Point-of-care ultrasound performed by a pediatric emergency physician accurately identifying the pyloric wall thickness and length that meets criteria for pyloric stenosis diagnosis.
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The ‘antral nipple sign’ demonstrated by the arrow, the ‘X’ indicates the ‘shoulder sign’
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The ‘donut’ sign demonstrated by the arrow.
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Lateral view from an upper GI study demonstrates the double-track sign.
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