Pyloric Stenosis: Pre and Postoperative Management

Guideline · Feb 2019 · 1 min read

In brief

Educational content covering perioperative management of hypertrophic pyloric stenosis, including evidence-based approaches to fluid resuscitation and postoperative feeding protocols. Reviews randomized trials comparing protocol-based versus ad libitum feeding strategies following pyloromyotomy.

Pyloric stenosis diagnosis: non-bilious emesis, palpable olive, hypochloremic hypokalemic metabolic alkalosis, US muscle >3mm width
Preoperative resuscitation goal: correct electrolytes to HCO3<30, Cl>100, K normal before surgery using D5 ½NS at 1.5x maintenance
Postoperative feeding: initiate ad lib home feeds 2 hours after pyloromyotomy; discharge after 3 consecutive feeds without emesis
Ad lib feeding post-pyloromyotomy reduces hospital stay compared to protocolized feeding despite slightly more emesis episodes
Persistent postoperative emesis management: NPO x2 hours then restart feeds; continue ad lib feeding even with 2-3 emesis episodes

Written by the GCMD Library team from the guideline.

Diagnosis of Pyloric Stenosis

Clinical presentation includes progressive non-bilious emesis with palpable epigastric olive on physical exam. Laboratory findings show hypochloremic, hypokalemic metabolic alkalosis. Ultrasound confirmation requires pyloric muscle width >3mm and length >14mm.

Preoperative Management and Resuscitation

Admit to surgery service and initiate fluid resuscitation with NS bolus if clinically dehydrated. Maintenance IV fluids at 1.5x rate using D5 ½ NS with 10 mEq KCl added once urine output established. Patient ready for OR when bicarbonate <30, chloride >100, and potassium normalized; give Ancef on call to OR.

Postoperative Feeding Protocol

Keep patient NPO for 2 hours post-pyloromyotomy, then initiate ad lib home feeds with breast milk or formula. Discharge when patient tolerates 3 consecutive feeds without emesis. Continue ad lib feeding even if 2-3 episodes of emesis occur; if persistent emesis, hold feeds for 2 hours then restart.

Evidence Base for Ad Lib Feeding

Ad lib feeding after pyloromyotomy is associated with equivalent or shorter hospital stay compared to protocolized feeding regimens. Patients on ad lib feeds may experience more emesis episodes but this approach is supported by randomized trials and systematic reviews.

Statements in this guideline

Pyloric stenosis presents with progressive non-bilious emesis and palpation of an olive in the epigastrium.
Established
Pyloric stenosis is associated with hypochloremic, hypokalemic metabolic alkalosis.
Established
Ultrasound diagnosis of pyloric stenosis requires muscle width greater than 3 mm and length greater than 14 mm.
Established
If clinically dehydrated, bolus normal saline.
RecommendationPlan
Maintenance intravenous fluids should be given at 1.5 times maintenance with D5 half normal saline.
RecommendationPlan
Add 10 mEq potassium chloride 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
Keep the patient NPO for 2 hours post-operatively from pyloromyotomy.
RecommendationPost-Op from Pyloromyotomy
Initiate home feeds (breast milk or formula) ad lib after the 2-hour NPO period.
RecommendationPost-Op from Pyloromyotomy
Continue ad lib feeding even if the patient has 2-3 episodes of emesis.
RecommendationPost-Op from Pyloromyotomy
If persistent emesis occurs, make the patient NPO for 2 hours and then re-start feeds.
RecommendationPost-Op from Pyloromyotomy
Discharge when the patient tolerates 3 consecutive feeds without emesis.
RecommendationPost-Op from Pyloromyotomy
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.
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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