Pyloric Stenosis
With Dr. Bhargava Muliudi · StayCurrentMD
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Pyloric stenosis is hypertrophy and hyperplasia of the inner circular layer with associated mucosal hypertrophy
Pyloric stenosis leads to gastric outlet obstruction in infants between 2 to 10 weeks of age
Pyloric stenosis is more common in males
There is increased risk for first born infants with a positive family history
Patients with pyloric stenosis typically present with non-bilious vomiting, usually seen between 2 to 10 weeks of life
Infants with pyloric stenosis are otherwise well appearing and hungry after vomiting
Emesis in pyloric stenosis will progress until it is projectile
Hyperbilirubinemia can occur in up to 14% of patients with pyloric stenosis due to downregulation of hepatic enzymes associated with starvation
Bilious emesis should always be worked up to rule out intestinal malrotation with midgut volvulus
Ultrasound is the gold standard for diagnosing pyloric stenosis
Pyloric stenosis is diagnosed on ultrasound when pyloric muscle is 3 millimeters thick and 14 millimeters long or greater
The classic electrolyte abnormality in pyloric stenosis is hypochloremic, hypokalemic, metabolic alkalosis
Prolonged gastric outlet obstruction leads to persistent vomiting and loss of hydrochloric acid, which leads to hypochloremia and loss of protons leading to metabolic alkalosis
The kidneys compensate for dehydration by increasing the activity of the sodium potassium pump to retain fluid, leading to urinary excretion of potassium to preserve sodium and water
In later stages of pyloric stenosis, excretion of protons leads to paradoxical aciduria, which further worsens metabolic alkalosis
In the US, pyloromyotomy is the standard of care for pyloric stenosis
In some countries, atropine is used as a non-surgical option for pyloric stenosis, with a success rate of about 60 to 90%
Cincinnati Children's follows a resuscitation protocol published by the Children's Mercy Group in Kansas City for pyloric stenosis
If chloride is less than 85, give 3 boluses separated by an hour and then recheck labs
If chloride is between 85 and 97, give two boluses
If chloride is greater than 97, give 1 bolus
If bicarbonate is greater than 40, give 3 boluses
If bicarbonate is greater than or equal to 33, give 2 boluses
Prior to going to the operating room, serum chloride must be corrected to greater than 100 and bicarbonate to less than 30
The proximal edge of the pylorus can be easily identified as the antrum transitions to a thick pylorus
The distal extent of the pyloromyotomy is generally to the crossing vein of Mayo or the white line, which marks the pyloroduodenal junction
After the pyloromyotomy is completed, the submucosa should bulge into the myotomy site
After adequate pyloromyotomy, each side of the pylorus should move independently
Complications from pyloromyotomy include incomplete myotomy, mucosal perforation, aspiration, wound infection, and incisional hernias
There is a slight increased risk of incomplete myotomy and perforation with a laparoscopic approach, but the overall low incidence of complications decreases the clinical significance of the differences between the two approaches
For mucosal perforation during pyloromyotomy, you can close the mucosa using a low profile needle and suture like Vicryl on a TF needle, or perform a full thickness repair and redo a myotomy about 180 degrees from the first one, usually on the posterior wall
Most infants can be fed immediately after pyloromyotomy
Evidence supports ad-lib feeds after pyloromyotomy; once the infant is alert and awake, these infants achieve full feeds sooner with no increase in readmission rates
Small episodes of emesis after pyloromyotomy are almost to be expected as the stomach recovers from days to weeks of progressive dilation
Odds of emesis is slightly higher in early and ad-lib feedings compared to gradual or delayed feedings, but the length of stay for ad-lib feedings is much shorter