SUCCESSFUL MANAGEMENT OF ADULT HYPERTROPHIC PYLORIC STENOSIS

Abstract

Whereas congenital hypertrophic pyloric stenosis (HPS) is a common condition, adult HPS is much rarer and its etiology remains unclear. The radiological features of this condition are inconsistent, and diagnoses have generally been made surgically. Treatment is largely surgical as well, with mixed results. A case is presented in which HPS in an adult is diagnosed with endoscopic ultrasound (EUS) and successfully treated with submucosal botulinum toxin (Botox) injections into the pylorus. History: RD, a 23-year-old male without any significant past medical or surgical history, presented with a long history of epigastric fullness and early satiety. Twice a year he experienced a “butterfly-like” sensation in his upper abdomen followed an hour later by up to 24 hours of severe projectile vomiting. He denied a history of gastric ulcers or other abnormalities. At upper endoscopy, there was no evidence of gastric or duodenal ulcer disease. The pylorus appeared narrowed and there was slight resistance to scope passage through the channel. A gastric emptying study confirmed significantly prolonged gastric emptying for solids, with half of the gastric contents (T1/2) clearing in 226 minutes (upper limit of normal 90 minutes). Subsequent EUS showed expansion of the 4th gastric layer of the pylorus (muscular layer), consistent with pyloric hypertrophy. Forty units of Botox were injected into the pylorus in each of 5 quadrants (200 units total). A repeat gastric emptying study performed two months later revealed normal gastric emptying (T1/2 = 64 minutes). Conclusion: This case presents novel approaches to both diagnosis and treatment of adult HPS. We suggest that EUS may provide a highly effective approach toward diagnosing this rare yet potentially debilitating condition. Botox has been used successfully in the treatment of achalasia and anal fissures, and isolated reports describe its use in treating postoperative pyloric spasm, idiopathic gastroparesis and diabetic gastroparesis. However, its successful use in HPS has not been described. We propose that EUS and Botox injection may provide a successful nonsurgical approach toward managing this condition.