Pyloric stenosis - Revision history

Chris.Rishel at 17:32, 2 September 2022

2022-09-02T17:32:34Z

← Older revision		Revision as of 10:32, 2 September 2022
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	== Signs and symptoms<!-- Describe the signs and symptoms of this comorbidity. --> ==		== Signs and symptoms<!-- Describe the signs and symptoms of this comorbidity. --> ==

	* Progressively worsening vomiting in the first weeks to 6 months of life		* Progressively worsening vomiting in the first weeks to 3 months of life
	* Dehydration		* Dehydration
	* Poor feeding and weight loss		* Poor feeding and weight loss
			*Palpable "olive-like" mass in right upper quadrant of abdomen<ref>{{Cite journal\|last=Macdessi\|first=J.\|last2=Oates\|first2=R. K.\|date=1993-02-27\|title=Clinical diagnosis of pyloric stenosis: a declining art\|url=https://pubmed.ncbi.nlm.nih.gov/8461768/\|journal=BMJ (Clinical research ed.)\|volume=306\|issue=6877\|pages=553–555\|doi=10.1136/bmj.306.6877.553\|issn=0959-8138\|pmc=1677170\|pmid=8461768}}</ref>

	== Diagnosis<!-- Describe how this comorbidity is diagnosed. --> ==		== Diagnosis<!-- Describe how this comorbidity is diagnosed. --> ==

Chris.Rishel: Added specific preoperative electrolyte thresholds

2022-09-02T16:51:05Z

Added specific preoperative electrolyte thresholds

← Older revision		Revision as of 09:51, 2 September 2022
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	* Delay surgery for fluid resuscitation and electrolyte correction		* Delay surgery for fluid resuscitation and electrolyte correction
	** Procedure is urgent but not emergent		** Procedure is urgent but not emergent
			*Recommended preoperative thresholds include:<ref>{{Cite journal\|last=van den Bunder\|first=Fenne A. I. M.\|last2=Hall\|first2=Nigel J.\|last3=van Heurn\|first3=L. W. Ernest\|last4=Derikx\|first4=Joep P. M.\|date=2020\|title=A Delphi Analysis to Reach Consensus on Preoperative Care in Infants with Hypertrophic Pyloric Stenosis\|url=https://pubmed.ncbi.nlm.nih.gov/31958865/\|journal=European Journal of Pediatric Surgery: Official Journal of Austrian Association of Pediatric Surgery ... [et Al] = Zeitschrift Fur Kinderchirurgie\|volume=30\|issue=6\|pages=497–504\|doi=10.1055/s-0039-3401987\|issn=1439-359X\|pmid=31958865}}</ref>
			** pH ≤7.45 (base excess ≤3.5)
			** Bicarbonate <26 mmol/L
			** Sodium ≥132 mmol/L
			** Potassium ≥3.5 mmol/L
			** Chloride ≥100 mmol/L
			** Glucose ≥4.0 mmol/L (72 mg/dL)

	=== Intraoperative management<!-- Describe how this comorbidity may influence intraoperative management. --> ===		=== Intraoperative management<!-- Describe how this comorbidity may influence intraoperative management. --> ===

Chris.Rishel at 16:47, 2 September 2022

2022-09-02T16:47:04Z

← Older revision		Revision as of 09:47, 2 September 2022
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	** Respiratory compensation with hypoventilation and increased arterial pCO<sub>2</sub>		** Respiratory compensation with hypoventilation and increased arterial pCO<sub>2</sub>
	* Secondary hyperaldosteronism from decreased blood volume		* Secondary hyperaldosteronism from decreased blood volume
	** Hypernatremia
	**Hypokalemia		**Hypokalemia
			**± Hypernatremia
	*Hypochloremia		*Hypochloremia

Chris.Rishel at 16:39, 2 September 2022

2022-09-02T16:39:52Z

← Older revision		Revision as of 09:39, 2 September 2022
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	Gastric outlet obstruction due to hypertrophy of the pylorus impairs emptying of gastric contents into the duodenum. Thus, stomach contents can only exit via vomiting. This leads to a number of physiologic derangements, including:		Gastric outlet obstruction due to hypertrophy of the pylorus impairs emptying of gastric contents into the duodenum. Thus, stomach contents can only exit via vomiting. This leads to a number of physiologic derangements, including:

	* Hypochloremia
	* Metabolic alkalosis		* Metabolic alkalosis
	** Respiratory compensation with hypoventilation and increased arterial pCO<sub>2</sub>		** Respiratory compensation with hypoventilation and increased arterial pCO<sub>2</sub>
	* Secondary hyperaldosteronism ~~due to~~ decreased blood volume		* Secondary hyperaldosteronism from decreased blood volume
	** Hypernatremia~~, hypokalemia~~		** Hypernatremia
			**Hypokalemia
			*Hypochloremia

	== Signs and symptoms<!-- Describe the signs and symptoms of this comorbidity. --> ==		== Signs and symptoms<!-- Describe the signs and symptoms of this comorbidity. --> ==

Chris.Rishel at 16:36, 2 September 2022

2022-09-02T16:36:03Z

← Older revision		Revision as of 09:36, 2 September 2022
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	* Hypochloremia		* Hypochloremia
	* Metabolic alkalosis		* Metabolic alkalosis
	** ~~Compensatory~~ hypoventilation/increased arterial ~~pCO2~~		** Respiratory compensation with hypoventilation and increased arterial pCO<sub>2</sub>
	* Secondary hyperaldosteronism due to decreased blood volume		* Secondary hyperaldosteronism due to decreased blood volume
	** Hypernatremia, hypokalemia		** Hypernatremia, hypokalemia

Chris.Rishel at 15:11, 2 September 2022

2022-09-02T15:11:30Z

← Older revision		Revision as of 08:11, 2 September 2022
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	\| other_names = Infantile hypertrophic pyloric stenosis, IPHS		\| other_names = Infantile hypertrophic pyloric stenosis, IPHS
	\| anesthetic_relevance = Critical		\| anesthetic_relevance = Critical
	\| anesthetic_management = ~~Empty~~ stomach ~~contents~~		\| anesthetic_management = *Delay surgery to correct electrolyte abnormalities and hypovolemia
	Modified RSI ~~induction~~		*Decompress stomach prior to induction
			*Modified RSI
	\| specialty = Pediatric surgery		\| specialty = Pediatric surgery
	\| signs_symptoms = Projectile vomiting		\| signs_symptoms = Projectile vomiting

Chris.Rishel: Created page with "{{Infobox comorbidity | other_names = Infantile hypertrophic pyloric stenosis, IPHS | anesthetic_relevance = Critical | anesthetic_management = Empty stomach contents Modified RSI induction | specialty = Pediatric surgery | signs_symptoms = Projectile vomiting | diagnosis = Ultrasound | treatment = Fluid resuscitation Correction of electrolytes Surgery | image = | caption = }} '''Pyloric stenosis''' (also called '''infantile hypertrophic pyloric stenosis''', '''IHPS''..."

2022-09-02T15:05:36Z

Created page with "{{Infobox comorbidity | other_names = Infantile hypertrophic pyloric stenosis, IPHS | anesthetic_relevance = Critical | anesthetic_management = Empty stomach contents Modified RSI induction | specialty = Pediatric surgery | signs_symptoms = Projectile vomiting | diagnosis = Ultrasound | treatment = Fluid resuscitation Correction of electrolytes Surgery | image = | caption = }} '''Pyloric stenosis''' (also called '''infantile hypertrophic pyloric stenosis''', '''IHPS''..."

New page

{{Infobox comorbidity
| other_names = Infantile hypertrophic pyloric stenosis, IPHS
| anesthetic_relevance = Critical
| anesthetic_management = Empty stomach contents
Modified RSI induction
| specialty = Pediatric surgery
| signs_symptoms = Projectile vomiting
| diagnosis = Ultrasound
| treatment = Fluid resuscitation
Correction of electrolytes
Surgery
| image =
| caption =
}}

'''Pyloric stenosis''' (also called '''infantile hypertrophic pyloric stenosis''', '''IHPS''') is a disorder of early infancy caused by hypertrophy of the pylorus which leads to a narrowing of the opening from the stomach to the first part of the small intestine. This can cause an obstruction of the gastric outlet, leading to projectile vomiting without the presence of bile.

== Anesthetic implications ==

=== Preoperative optimization ===

* Delay surgery for fluid resuscitation and electrolyte correction
** Procedure is urgent but not emergent

=== Intraoperative management ===

* Decompress stomach via OG or NG prior to induction<ref>{{Cite journal|last=Cook-Sather|first=S. D.|last2=Liacouras|first2=C. A.|last3=Previte|first3=J. P.|last4=Markakis|first4=D. A.|last5=Schreiner|first5=M. S.|date=1997|title=Gastric fluid measurement by blind aspiration in paediatric patients: a gastroscopic evaluation|url=https://pubmed.ncbi.nlm.nih.gov/9043730/|journal=Canadian Journal of Anaesthesia = Journal Canadien D'anesthesie|volume=44|issue=2|pages=168–172|doi=10.1007/BF03013006|issn=0832-610X|pmid=9043730}}</ref>
** Supine, left lateral decubitus, and right lateral decubitus positions
* Modified RSI IV induction<ref>{{Cite journal|last=Park|first=Raymond S.|last2=Rattana-Arpa|first2=Sirirat|last3=Peyton|first3=James M.|last4=Huang|first4=Jia|last5=Kordun|first5=Anna|last6=Cravero|first6=Joseph P.|last7=Zurakowski|first7=David|last8=Kovatsis|first8=Pete G.|date=2021-02-01|title=Risk of Hypoxemia by Induction Technique Among Infants and Neonates Undergoing Pyloromyotomy|url=https://pubmed.ncbi.nlm.nih.gov/31361669/|journal=Anesthesia and Analgesia|volume=132|issue=2|pages=367–373|doi=10.1213/ANE.0000000000004344|issn=1526-7598|pmid=31361669}}</ref>
** No increased risk of aspiration compared to traditional RSI
** Traditional RSI leads to more hypoxia
* Extubate awake

=== Postoperative management ===

* Feeding can resume within hours after surgery<ref>{{Cite journal|last=Gibbs|first=M. K.|last2=Van Herrden|first2=J. A.|last3=Lynn|first3=H. B.|date=1975|title=Congenital hypertrophic pyloric stenosis. Surgical experience|url=https://pubmed.ncbi.nlm.nih.gov/1127996/|journal=Mayo Clinic Proceedings|volume=50|issue=6|pages=312–316|issn=0025-6196|pmid=1127996}}</ref>
** Modest regurgitation is not uncommon and should not delay feeding

== Related surgical procedures ==

* [[Pyloromyotomy]]

== Pathophysiology ==
Gastric outlet obstruction due to hypertrophy of the pylorus impairs emptying of gastric contents into the duodenum. Thus, stomach contents can only exit via vomiting. This leads to a number of physiologic derangements, including:

* Hypochloremia
* Metabolic alkalosis
** Compensatory hypoventilation/increased arterial pCO2
* Secondary hyperaldosteronism due to decreased blood volume
** Hypernatremia, hypokalemia

== Signs and symptoms ==

* Progressively worsening vomiting in the first weeks to 6 months of life
* Dehydration
* Poor feeding and weight loss

== Diagnosis ==

* Ultrasound

== Treatment ==

=== Medication ===

* IV fluid resuscitation
* Correction of electrolytes
* [[Atropine]] can be used as an alternative to surgical correction with an 85-89% success rate<ref>{{Cite journal|last=Aspelund|first=Gudrun|last2=Langer|first2=Jacob C.|date=2007|title=Current management of hypertrophic pyloric stenosis|url=https://pubmed.ncbi.nlm.nih.gov/17210480|journal=Seminars in Pediatric Surgery|volume=16|issue=1|pages=27–33|doi=10.1053/j.sempedsurg.2006.10.004|issn=1055-8586|pmid=17210480}}</ref>

=== Surgery ===
A [[pyloromyotomy]] is the definitive treatment for pyloric stenosis. The procedure is most commonly performed laparoscopically, but can be performed open via a small incision. Incomplete correction requiring repeat surgery is rare.

=== Prognosis ===
Once corrected, pyloric stenosis generally has no long-term side effects or impact on the child's future health.

== Epidemiology ==

* Male > female<ref>{{Cite journal|last=Naffaa|first=Lena|last2=Barakat|first2=Andrew|last3=Baassiri|first3=Amro|last4=Atweh|first4=Lamya Ann|date=2019|title=Imaging Acute Non-Traumatic Abdominal Pathologies in Pediatric Patients: A Pictorial Review|url=https://pubmed.ncbi.nlm.nih.gov/31558965|journal=Journal of Radiology Case Reports|volume=13|issue=7|pages=29–43|doi=10.3941/jrcr.v13i7.3443|issn=1943-0922|pmc=6738493|pmid=31558965}}</ref>
** Firstborn males 4x likely
* Caucasian > Hispanic > Black ≈ Asian
* Exposure to erythromycin<ref>{{Cite journal|last=Maheshwai|first=Nitin|date=2007|title=Are young infants treated with erythromycin at risk for developing hypertrophic pyloric stenosis?|url=https://pubmed.ncbi.nlm.nih.gov/17337692|journal=Archives of Disease in Childhood|volume=92|issue=3|pages=271–273|doi=10.1136/adc.2006.110007|issn=1468-2044|pmc=2083424|pmid=17337692}}</ref>

== References ==
<references />
[[Category:Comorbidities]]