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    Infantile Hypertrophic Pyloric Stenosis (IHPS) : Incidence

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    Raed Alhnaity
    Infantile hypertrophic pyloric stenosis (IHPS) is a condition where the pylorus becomes thickened, causing projectile vomiting in infants. It typically presents between 2-5 weeks of age and is more common in males. Risk factors include family history and bottle feeding. Ultrasound shows thickening of the pylorus. Treatment is pyloromyotomy surgery to cut the thickened muscle. The surgery provides relief of symptoms but some vomiting may persist initially as the stomach recovers.

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    Infantile Hypertrophic Pyloric Stenosis (IHPS) : Incidence

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    Raed Alhnaity
    188 views9 pages
    Infantile hypertrophic pyloric stenosis (IHPS) is a condition where the pylorus becomes thickened, causing projectile vomiting in infants. It typically presents between 2-5 weeks of age and is more common in males. Risk factors include family history and bottle feeding. Ultrasound shows thickening of the pylorus. Treatment is pyloromyotomy surgery to cut the thickened muscle. The surgery provides relief of symptoms but some vomiting may persist initially as the stomach recovers.

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    Infantile hypertrophic pyloric stenosis (IHPS) is a condition where the pylorus becomes thickened, causing projectile vomiting in infants. It typically presents between 2-5 weeks of age and is more common in males. Risk factors include family history and bottle feeding. Ultrasound shows thickening of the pylorus. Treatment is pyloromyotomy surgery to cut the thickened muscle. The surgery provides relief of symptoms but some vomiting may persist initially as the stomach recovers.

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    © All Rights Reserved
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    Download as pdf or txt
    188 views9 pages

    Infantile Hypertrophic Pyloric Stenosis (IHPS) : Incidence

    Uploaded by

    Raed Alhnaity
    Infantile hypertrophic pyloric stenosis (IHPS) is a condition where the pylorus becomes thickened, causing projectile vomiting in infants. It typically presents between 2-5 weeks of age and is more common in males. Risk factors include family history and bottle feeding. Ultrasound shows thickening of the pylorus. Treatment is pyloromyotomy surgery to cut the thickened muscle. The surgery provides relief of symptoms but some vomiting may persist initially as the stomach recovers.

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    INFANTILE HYPERTROPHIC PYLORIC STENOSIS

    (IHPS)

     Previously called Congenital Hypertrophic Pyloric Stenosis (CHPS)

    But changed as the baby is born completely normal (usually full-

    term) not congenitally abnormal

     Isolated congenital anomaly

    Incidence:

    1- 2 - 3.5 / 1000 live born infants

    2- Males: Females ratio 4:1 up to 6:1

    3- 30 - 40% of the affected babies are usually the first-born

    child
    4- It affects pre-mature infants slightly higher than the full-

    term neonates

    Etiological Factors:

    1- Family history:

     high in certain families.

     20% of boys and 10% of girls born to a mother who had an

    operation for IHPS will suffer from the condition.

    2- Smoking mothers will have 1.5 double the incidence to have an

    infant with IHPS

    3- Certain antibiotics (the macrolides group ex: Erythromycin and

    Azithromycin) used by the mother during last weeks (8th or 9th

    month) of pregnancy or given to the neonate during the first 2

    weeks of life

    4- Bottle feeding increases the risk of developing IHPS by 4 folds

    regardless the formula used.

    5- Genetic predisposition and Environmental factors

    6- Hypergastrinemia and hyperacidity but with a little evidence of

    connection

    7- An autonomic nervous system imbalance and humoral factors may

    cause hypertrophy of the pyloric circular muscle fibers


    C/P:

    Symptoms and signs:

     Timing: Usually starts between the end of the 2nd and 5th

    week. Rarely after the 12th post-natal week (if after 12th week

    look for other causes of vomiting)

     Vomiting (4Ps): Progressive, Persistent, Projectile and Non-bilious

    (as it’s before the bile duct insertion)

    o Progression:

    At the end of the 2nd week (day 10 or 11 usually) the

    vomiting is a couple of minutes after the meal 

    immediately after the feeding  in the middle of the

    feeding
     Characters of the vomiting?

    1- Starts as week projectile vomiting  increase in the

    power (ejected for a longer distances)

    2- At first form the mouth  then both mouth and nose

    3- Starts intermittent  then become persistent (after

    every meal)

    4- Progressive (increase in power also frequency)

     At the end the infant becomes


    Reminder:
    dehydrated and then
     defecation in children is usually 6 times
    constipated with loss of weight /day

     At the end of the first year it will decline

    to 2-3 times/day
    Physical Examination:

    o If early: the baby is still in good condition

    o If Late: signs and symptoms of dehydration, loss of weight and

    malnutrition (face muscle are wasted, skin wrinkled, sunken eyes,

    depressed fontanels)

    1- Inspection:

     Dehydration signs

     Epigastric fullness (dilated stomach unless post vomiting)

     Peristaltic movement common from Lt to Rt (visible but not

    palpable) if seen during the examination take a step back as

    it precedes the vomiting!


    2- Palpation:

    Mass

     not easily palpable

     At the pylorus to the rt side of the epigastrium, below the

    edge of the Rt lobe of the liver

     Found immediately after vomiting

    Metabolic Derangement:

    1- when the baby vomits, he loses hydrochloric acid and sodium in

    the vomitus and becomes alkalotic and hyponatremic

    2- Kidney compensation:

    secretion of Hydrogen ions and Potassium ions in exchange for

    Sodium ions to correct the already present hyponatremia 

    paradoxical aciduria

    3- The end result will be:

     Hypochloremia

     Hypokalemia

     Alkalosis

    Investigation:

    1- Labs:
     CBC: check for Hb

     Electrolyte panel

     ABG

     Kidney function

     Prothrombin time and concentration

    2- Imaging:

     U/S shows:

     dimension of the pyloric tumor/mass causing the

    obstruction

     Length and width of the pyloric canal

     X-Ray:

    Thin barium meal and follow through:

     dilated stomach

     delayed gastric empty

     narrowed elongated pyloric canal

    Management:

    Preoperative preparation:

    1- Nasogastric tube or gastric lavage with normal saline or Ringer

    lactate to AVOID chemical or bacterial gastroenteritis


    2- Fluids replacement with glucose 5% or 10% according to the

    general condition to OVERCOME dehydration and hypoglycemia

    3- Na/K adjustment to reach normal levels

    4- 6 hrs Preoperative give Vit. K (konakion) and Ca to decrease the

    incidence of bleeding

    Operative management
    Question: WHAT about endoscopic dilatation?

    Ramstedt's operation Or Balloon dilatation trials have been done but

    Pyloromyotomy 1- You may need to repeat

    2- Over inflation may cause complication

    So, it’s not successful and not traditionally used

    1- Laparoscopically / open around the umbilicus or through right

    small transverse subcostal incision above the pyloric tumor

    2- The incision in the pyloric tumor is done in its antero-superior

    aspect (the least vascular area)

    3- Serosa and partial (very thin layer) thickness of the circular

    muscle fibers of the pyloric tumor are incised by scalpel 11

     Cutting is done:

     Perpendicular to muscle fibers

     For the whole pyloric tumor

     Starting from the prepyloric vein to the near the

    duodenum
    4- Muscle fibers are separated by an artery forceps till the pyloric

    mucosa plugs

    5- Avoid perforation the mucosa specially at the duodenal forensics.

    6- If bleeding  diathermy or cautery

    7- Do not close the incision

    8- Use tube or rubber drain

    9- No need for truncal vagotomy

    Keep in Mind:

     HOW to check for serosal perforation?

    1- By your finger: distal to the duodenum and try to squeeze the stomach with

    closing near to it

    2- Injection of saline or Air in the stomach using Ryle tube

     If perforated, HOW to deal with?

    1- Close the opening by vicryl 5-0 with inverting sutures

    2- Omental patch attached to the edges of the incision

    Postoperative management:

    1- In non-complicated cases,

     start oral feeding by glucose 5% small feeds for 24 hrs

     Breast feeding can be re-started 48 hours later.


    2- In cases of perforated mucosa, oral feeding is postponed for at

    least 48 hours post-operatively

    3- Inform the parents that the vomiting will decrease gradually as

    there might be gastric congestion and edema of the gastric wall

    or the pyloric canal

    4- Females don’t do well after the pyloromyotomy

     Vomiting continue for a while after the operation

     Duodenal ileus

    _____________________________________________________

    Best wishes,

    Rawan Sayed

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