Created February 2023 Tag year Year 4 Tag Specialty Paediatric surgery Tag diagnosis Pyloric stenosis Learning aim To develop a greater understanding of the presentation and management of vomiting in the first few weeks of life ID: 1040331
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1. A vomiting babyAnum Salam, Gillian WinterCreated: February 2023Tag year: Year 4Tag Specialty: Paediatric surgeryTag diagnosis: Pyloric stenosis
2. Learning aimTo develop a greater understanding of the presentation and management of vomiting in the first few weeks of life.
3. PresentationA 3 week old boy presents to the paediatric assessment unit 'not looking quite right'This is the mums first child and she is worried as her baby has started to vomit a lot and she is unsure if this is normal.
4. List 8 differentials
5. What do you want to know about the vomiting?Non biliousProjectile After every feedQuite a large volumeThis Photo by Unknown author is licensed under CC BY-SA-NC.1234
6. Narrow down to 5 differentials
7. Mum says..."the baby has been very irritable and doesn’t seem to be gaining weight the way I expected, he is also always hungry right after he vomits. But on the bright side I haven't had to change his nappies as much anymore."This Photo by Unknown author is licensed under CC BY-SA-NC.
8. History continued...PMH - No concerns during the pregnancy , was very well up until 1 week ago when the vomiting started. FH- Dad required surgery as a baby for vomiting but is unsure whySH - Baby lives at home with mum and dad
9. Narrow down to 3 differentials
10. What would you expect to find for each differential? Pyloric stenosis( 1,2,3,4,5,6)Gastro oesophageal reflux (4,5,7,8)Over feeding (5,7,8)Olive shaped mass on examinationPeristaltic waveForceful/projectile vomitingFailure to thriveDoesn't vomit after every feed Baby continues to feed hungrilySmall volumeEffortless vomiting
11. Meanwhile let's watch the babyPyloric Stenosis of 4 week old baby - YouTube What did you see?
12. These are your positive examination findingsFirm and mobile olive shaped mass in the pyloric region Gastric peristalsisDepressed fontanelles, dry mucous membranes, poor skin turgor, lethargy Can you explain why each of these findings occur
13. Video showing peristaltic feed Peristaltic Waves in Pyloric Stenosis | NEJM - YouTube
14. What can you do next by the bedside?This Photo by Unknown author is licensed under CC BY-ND.
15. You also decide to take a blood gasWhat does it show?
16. What is your top differential?A condition where hypertrophy of the pyloric sphincter causes narrowing of the pyloric canal causing progressive gastric outlet obstruction.
17. Further investigationsUltrasound is required to confirm the diagnosis (false) More information: Ultrasound can be used if there is diagnostic uncertainty, but this is not requiredUltrasound is diagnostic for pyloric stenosis if muscle thickness >4mm and muscle length >14mm in term baby, (true) This Photo by Unknown author is licensed under CC BY-SA-NC.
18. Management What is your next step ?Immediate surgical management (although surgery is the definitive treatment and will be required, it is important to stabilise the child first)Reassure and discharge (this condition requires surgical intervention)Keep feeding the child to strengthen the pylorus muscle until the baby can keep milk down (this would not work)Stabilise the child and correct the electrolyte abnormality (Yes! In order to stabilise the child you should 1) Make the patient NBM, 2) insert an NG tube on free drainage 3) Give replacement, maintenance fluids and electrolytesThis Photo by Unknown author is licensed under CC BY.12
19. Surgical management Which procedure is indicated? 1)Ladd's procedure2)Kasai procedure3) Duodeno-duodenostomy4) Ramstedt's pyloromyotomy (Pyloromyotomy involves splitting of the pyloric muscle)This Photo by Unknown author is licensed under CC BY-ND.
20. RecoveryThe child can go home ifthere is no vomiting post-operativelythey can tolerate small amounts of feed without vomitingthere are no beds in the hospital they can tolerate their weight dependent feeding goal without vomitingThis Photo by Unknown author is licensed under CC BY-ND.
21. Identify 4 risk factors for pyloric stenosis in the history of our child?Jack is a 3 week old baby boy. He was born at full term but was delivered via C-section due to failure of progression of labour. He has been exclusively breastfed since birth. He is the first born in his family, his father had pyloric stenosis too.
22. Summary: Pyloric stenosis Pyloric stenosis is a paediatric surgical condition caused by the thickening of the pyloric sphincter which causes progressive gastric outlet obstructionIt is characterised by recurrent episodes of non-bilious vomiting after feedsIt can be diagnosed clinically by examination however ultrasound can also be used It is treated by initially stabilising the child with fluid and electrolyte replacement Definitive surgical management is a Ramstedt's pyloromyotomy
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