Hypertrophic Pyloric Stenosis: Early Diagnosis and Effective Treatment.

Hypertrophic Pyloric Stenosis: Early Diagnosis, Effective Treatment, and Lifesaving Care! 

Hypertrophic pyloric stenosis (HPS) is the most common acquired gastrointestinal disorder in infants. It occurs due to the hypertrophy of circular muscle fibers in the pylorus, leading to partial or complete obstruction between the stomach and duodenum. This condition causes feeding difficulties, projectile vomiting, and dehydration in infants.1

Clinical Presentation:

The classical presentation of hypertrophic pyloric stenosis (HPS) includes non-bilious vomiting that gradually increases in frequency and severity, often becoming projectile. The condition is 4–6 times more common in boys than girls. Vomiting typically starts after 3 weeks of age, but 20% of cases present at birth, with some diagnosed as late as 5 months².

Common symptoms include constipation, dehydration, malnutrition, and metabolic alkalosis due to persistent vomiting. Due to strong gastric contractions, visible peristaltic waves moving from the left hypochondrium to the umbilicus may be observed after feeding. A firm, olive-shaped mass in the mid-epigastrium is palpable in 75–80% of infants, especially post-feeding3.

Evaluation of pyloric stenosis:

Abdominal ultrasound is the gold standard for diagnosing hypertrophic pyloric stenosis (HPS), showing a pyloric muscle thickness >4 mm and a pyloric length >16 mm. Ultrasound has a 100% sensitivity and nearly 90% specificity in detecting HPS⁴.

In cases of diagnostic uncertainty, an upper gastrointestinal (GI) barium study may reveal a characteristic elongated pyloric channel. Alternatively, an upper GI endoscopy may be performed for further evaluation.

Differential Diagnosis:

If no palpable pyloric mass is detected and ultrasound is normal, consider other conditions such as:

• Gastroesophageal reflux disease (GERD)

• Cow’s milk protein allergy

• Antral or pyloric web¹

Management of pyloric stenosis:

The initial management of hypertrophic pyloric stenosis (HPS) focuses on rapid correction of dehydration and electrolyte imbalances. Intravenous (IV) fluids are administered to restore normal electrolyte levels, especially hypokalemia and hypochloremic alkalosis.

The definitive treatment is surgical, with pyloromyotomy (Ramstedt’s operation) being the procedure of choice³. This minimally invasive surgery involves incising the hypertrophied pyloric muscle, allowing normal gastric emptying.

References of pyloric stenosis:

1. Ghai OP. Essential Paediatrics. 10th ed. New Delhi: CBS Publishers; 2022.

2. Hockenberry MJ, Wilson D. Wong’s Essentials of Pediatric Nursing. 11th ed. St. Louis: Elsevier; 2021.

3. Kliegman RM, St. Geme JW, Blum NJ, Shah SS, Tasker RC, Wilson KM. Nelson Textbook of Pediatrics. 21st ed. Philadelphia: Elsevier; 2020.

4. Hernanz-Schulman M. Pyloric stenosis: Role of imaging. Pediatr Radiol. 2009;39(Suppl 3):S134-9.

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MCQs session:

1. Which infant is at the highest risk for developing hypertrophic pyloric stenosis (HPS)?

A. A 2-week-old girl with trisomy 21
B. A 4-week-old boy with a family history of HPS
C. A 6-month-old girl who is formula-fed
D. A newborn male with meconium ileus

✅ Correct Answer: B
Rationale: HPS is more common in male infants and has a strong genetic predisposition. It typically presents between 3-6 weeks of age.

2. The classic symptom of hypertrophic pyloric stenosis is:

A. Bilious vomiting
B. Projectile, non bilious vomiting
C. Vomiting with blood
D. Diarrhea with mucus

✅ Correct Answer: B
Rationale: HPS causes gastric outlet obstruction, leading to the projectile, non bilious vomiting due to the hypertrophied pylorus.

3. A nurse assessing an infant with pyloric stenosis is most likely to find:

A. Absent bowel sounds
B. A sausage-shaped mass in the left lower quadrant
C. A firm, olive-shaped mass in the mid-epigastrium
D. A distended abdomen with hepatosplenomegaly

✅ Correct Answer: C
Rationale: The hypertrophied pylorus is felt as a firm, olive-shaped mass in the right upper quadrant or mid epigastrium, especially after feeding.

4. What acid-base imbalance is expected in an infant with hypertrophic pyloric stenosis?

A. Metabolic acidosis
B. Respiratory acidosis
C. Metabolic alkalosis
D. Respiratory alkalosis

✅ Correct Answer: C
Rationale: Persistent vomiting leads to loss of hydrogen and chloride ions, causing hyperchloremic metabolic alkalosis.

5. The best diagnostic test for hypertrophic pyloric stenosis is:

A. Abdominal X-ray
B. Barium swallow study
C. Ultrasound
D. CT scan

✅ Correct Answer: C
Rationale: Ultrasound is the gold standard for HPS diagnosis, showing pyloric muscle thickness >4 mm and length >16 mm.

6. Which electrolyte imbalance is most common in hypertrophic pyloric stenosis?

A. Hyperkalemia
B. Hypochloremia
C. Hypernatremia
D. Hypercalcemia

✅ Correct Answer: B
Rationale: Vomiting leads to chloride loss, resulting in hypochloremia, which contributes to metabolic alkalosis.

7. The definitive treatment for hypertrophic pyloric stenosis is:

A. Fluid resuscitation
B. NPO status with IV hydration
C. Pyloromyotomy
D. Proton pump inhibitors

✅ Correct Answer: C
Rationale: Ramstedt’s pyloromyotomy is the treatment of choice, where the hypertrophied muscle is surgically split to relieve the obstruction.

8. Before pyloromyotomy, which intervention is the priority?

A. Administer oral rehydration therapy
B. Begin nasogastric feeding
C. Correct fluid and electrolyte imbalances
D. Start enteral nutrition

✅ Correct Answer: C
Rationale: Dehydration and electrolyte imbalances must be corrected before surgery to prevent complications from metabolic alkalosis.

9. A hallmark clinical finding in hypertrophic pyloric stenosis is:

A. Visible peristaltic waves moving from right to left
B. Visible peristaltic waves moving from left to right
C. Absent bowel sounds
D. Diarrhea with mucus

✅ Correct Answer: B
Rationale: Strong peristaltic waves move from the left hypochondrium to the umbilicus, trying to push food past the narrowed pylorus.

10. Which infant is most likely to present with hypertrophic pyloric stenosis?

A. A 2-day-old infant with projectile vomiting
B. A 3-week-old infant with progressive, forceful vomiting
C. A 6-month-old infant with chronic diarrhea
D. A newborn with meconium ileus

✅ Correct Answer: B
Rationale: HPS typically presents between 3-6 weeks of age with progressive, projectile vomiting.

11. Which laboratory finding supports the diagnosis of hypertrophic pyloric stenosis?

A. Hyperchloremia
B. Hypokalemic metabolic alkalosis
C. Hyperkalemia with metabolic acidosis
D. Increased bicarbonate and respiratory alkalosis

✅ Correct Answer: B
Rationale: Vomiting causes loss of potassium and hydrogen ions, leading to hypokalemic metabolic alkalosis.

12. A baby with pyloric stenosis is at risk for which complication?

A. Bowel perforation
B. Hypoglycemia
C. Dehydration
D. Hyperkalemia

✅ Correct Answer: C
Rationale: Persistent vomiting leads to severe dehydration, requiring IV fluid replacement.

13. What feeding instructions should be given post-pyloromyotomy?

A. Resume normal feeds immediately
B. Start with small, frequent oral rehydration solution
C. Delay oral feeds for 48 hours
D. Use nasogastric tube feeds for a week

✅ Correct Answer: B
Rationale: Small, frequent oral feeds are initiated postoperatively to prevent gastric distension and vomiting.

14. Which assessment finding indicates successful pyloromyotomy?

A. Absent bowel sounds
B. Immediate resolution of vomiting
C. Gradual tolerance to feeds
D. Persistent peristaltic waves

✅ Correct Answer: C
Rationale: After surgery, vomiting may persist briefly but gradually resolves as feeding tolerance improves.

15. Why is an upper GI barium study not the first choice for diagnosis?

A. It is less accurate than ultrasound
B. It is invasive and requires sedation
C. It increases the risk of aspiration
D. It exposes the infant to radiation

✅ Correct Answer: A
Rationale: Ultrasound is the gold standard, as it is non-invasive, highly sensitive (100%), and specific (90%).

16. The priority nursing diagnosis for HPS is:

A. Risk for aspiration
B. Risk for infection
C. Fluid volume deficit
D. Altered tissue perfusion

✅ Correct Answer: C
Rationale: Dehydration from vomiting is the biggest concern, requiring IV fluid replacement before surgery.

17. Which symptom differentiates pyloric stenosis from gastroesophageal reflux?

A. Vomiting is nonbilious
B. Vomiting is projectile
C. The infant is irritable after feeding
D. The vomiting is occasional

✅ Correct Answer: B
Rationale: Projectile vomiting is the key feature of pyloric stenosis, unlike the regurgitation seen in reflux.

 18. When is pyloromyotomy contraindicated?

A. Severe dehydration
B. Mild metabolic alkalosis
C. Male gender
D. Age above 2 months

✅ Correct Answer: A
Rationale: Dehydration must be corrected before surgery to prevent perioperative complications.

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