Preoperative Management of Pyloric Stenosis

Guideline · Nov 2018 · 1 min read

In brief

Educational content on optimizing preoperative fluid and electrolyte management in infants with hypertrophic pyloric stenosis. Based on evidence-based protocols for correcting metabolic alkalosis and dehydration prior to pyloromyotomy to minimize surgical complications.

Pyloric stenosis presents with progressive non-bilious emesis and hypochloremic, hypokalemic metabolic alkalosis.
Resuscitate with D5 ½ NS at 1.5x maintenance plus KCl; delay surgery until HCO3<30, Cl>100, and K normalized.
Post-pyloromyotomy: start ad lib feeds at 2 hours; discharge after 3 consecutive feeds tolerated despite occasional emesis.
Ad lib feeding post-op yields equivalent or shorter hospital stays compared to protocolized advancement.
Ultrasound diagnosis requires pyloric muscle width >3mm and length >14mm.

Written by the GCMD Library team from the guideline.

Diagnosis and Initial Assessment

Pyloric stenosis presents with progressive non-bilious emesis and palpable epigastric olive on exam. Diagnosis is confirmed by ultrasound showing muscle width >3mm and length >14mm, with labs typically revealing hypochloremic, hypokalemic metabolic alkalosis.

Preoperative Management and Resuscitation

Admit to surgery service and initiate fluid resuscitation with NS bolus if clinically dehydrated, followed by maintenance IV fluids at 1.5x rate using D5 ½ NS. Add 10 mEq KCl once urine output is established, with surgery delayed until metabolic derangements correct (HCO3<30, Cl>100, K normal).

Postoperative Feeding Protocol

Keep patient NPO for 2 hours post-pyloromyotomy, then initiate ad lib home feeds (breast milk or formula). Continue ad lib feeding even with 2-3 episodes of emesis; discharge when patient tolerates 3 consecutive feeds without vomiting.

Management of Postoperative Emesis

If persistent emesis occurs, make patient NPO for 2 hours then restart feeds. Ad lib feeding is associated with equivalent or shorter hospital stays compared to protocolized feeding, though patients may experience more emesis episodes.

Statements in this guideline

Hypertrophic pyloric stenosis presents with progressive non-bilious emesis and palpation of an olive in the epigastrium.
Established
Laboratory findings in pyloric stenosis include hypochloremic, hypokalemic metabolic alkalosis.
Established
Ultrasound diagnosis of pyloric stenosis requires muscle width greater than 3 mm and length greater than 14 mm.
Established
Patients with pyloric stenosis should be admitted to Surgery.
RecommendationPlan
If clinically dehydrated, bolus normal saline according to the resuscitation schematic.
RecommendationPlan
Maintenance intravenous fluids should be given at 1.5 times maintenance with D5 half normal saline.
RecommendationPlan
Add 10 mEq potassium chloride to intravenous fluids once urine output is established.
RecommendationPlan
Proceed to the operating room when bicarbonate is less than 30, chloride is greater than 100, and potassium is normal.
RecommendationPlan
Administer Ancef on call to the operating room.
RecommendationPlan
Keep the patient NPO for 2 hours after pyloromyotomy.
RecommendationPost-Op from Pyloromyotomy
Initiate home feeds (breast milk or formula) ad lib after the 2-hour NPO period.
RecommendationPost-Op from Pyloromyotomy
Discharge the patient when they tolerate 3 consecutive feeds without emesis.
RecommendationPost-Op from Pyloromyotomy
Continue ad lib feeds even if the patient has 2 to 3 episodes of emesis.
RecommendationPost-Op from Pyloromyotomy
If persistent emesis occurs, make the patient NPO for 2 hours and then restart feeds.
RecommendationPost-Op from Pyloromyotomy
Ad lib feeding is associated with equivalent or shorter hospital stay compared to protocolized feeding.
ResearchPost-Op from Pyloromyotomy
Patients on ad lib feeds may have more emesis than those on protocolized feeds.
ResearchPost-Op from Pyloromyotomy

Full text

History and physical exam consistent with pyloric stenosis•Progressive non-bilious emesis•Palpation of olive in epigastrium Labs: Hypochloremic, hypokalemic metabolic alkalosis Ultrasound: Muscle width > 3 mm, length >14 mm Plan: •Admit to Surgery•If clinically dehydrated, bolus NS (see adjacent schematic) •MIVF at 1.5 x maintenance with D5 ½ NS •Add 10 meqKClonce UOP established To OR when HCO3<30, Cl>100, and K normal (Ancef on call) Suggested Resuscitation: Source: Dalton BGA, et al. Optimizing fluid resuscitation in hypertrophic pyloric stenosis. J PediatrSurg2016;51(8):1279-1282. Updated 1/2019 v1.0

Post-Op from Pyloromyotomy NPO x 2 hours Initiate home feeds (breast milk or formula) ad lib** Discharge when tolerates 3 consecutive feeds without emesis Continue ad lib even if patient has 2-3 episodes of emesis If persistent emesis, can make patient NPO x 2 hours and then re-start feeds Updated 1/2019 v1.0Sources:•Markel TA, et al. A randomized trial to assess advancement of enteral feeds following surgery for hypertrophic pyloric stenosis.J PediatrSurg2017;52(4):534-539. •AdibeOO, et al. Protocol versus ad libitum feeds after laparoscopic pyloromyotomy: A prospective randomized trial. J PediatrSurg2014;49(1):129-132. •Graham KA, et al. A review of postoperative feeding regimens in infantile hypertrophic pyloric stenosis. J PediatrSurg2013;48:2175-2179. **Note: Ad lib feeding is associated with equivalent or shorter hospital stay (compared to protocolized feeding), although patients on ad lib feeds may have more emesis.

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