The Roentgen Diagnosis of Hypertrophic Pyloric Stenosis in Infants

Abstract

Hypertrophic pyloric stenosis in infants is a fairly common disease, the recognition of which is usually quite reliable and simple by means of the history and clinical signs. The first symptom of the disease, usually noticed about two to three weeks after birth, is vomiting which soon becomes projectile and is most noticeable immediately after meals. Gastric peristalsis can be seen in the greater number of cases and the hypertrophied muscle is palpable in many instances. Rapid inanition and extreme emaciation take place in many infants and, along with these, severe constipation. Male infants are predominantly affected, the ratio between male and female being 4:1. Pathologically a tumor is found in the prepyloric region, as hard as cartilage and usually 2 to 3 cm. long and 1 to 1.5 cm. thick. It corresponds to the prepyloric portion of the stomach directly adjoining the pylorus. Its borders are sharply defined. Microscopically it is described as hypertrophy of the muscularis mucosae with some hypertrophy of the connective tissue and some engorgement of the vessels. The etiology is undetermined. Some investigators believe that the hypertrophy is secondary to a spasm; others maintain that it is primary. There is at times a familial tendency to the disease. Other conditions may simulate pyloric stenosis, especially the gastric symptoms of a spastic infant, but also obstructions lower in the intestinal tract and at times even diseases of other organs which produce vomiting of extended duration. The only truly reliable diagnostic sign for the clinician is the palpation of the prepyloric tumor. This is possible in a large percentage of cases. The figure varies as given in the literature: Rinvik, 72 per cent; Seeger, “usually palpable … with care”; Tallermann, 94 per cent; Brown, 50 per cent, with 10 per cent questionable; Donovan, 100 per cent; Parmelee, “usually; now and then not possible.” At the Milwaukee Children's Hospital and the Milwaukee Hospital the pediatricians and surgeons are divided in their opinions about reliable palpation of the tumor; some believe it possible to feel the tumor in most cases while others think it is palpable in less than 50 per cent. It has been noted that on some occasions when a tumor was believed to have been felt it was not found at operation. One may say that the clinical diagnosis is usually reliable, but that in a certain percentage of cases—not too small—the clinical picture may lead to a wrong diagnosis. The roentgen diagnosis of pyloric stenosis has been used to supplement the clinical diagnosis. The first report on x-ray examination for this disease was made by Kerley and LeWald in 1923. Only the emptying rate of the stomach was considered, and the method did not become widely used. The first description of a direct demonstration of the narrowed prepyloric canal was given by Meuwissen and Sloof (1932).