Cases Of Hypertrophic Pyloric Stenosis Research Articles

The impact of high-frequency transducers on the sonographic measurements of the pyloric muscle thickness in infants.

Ultrasound is the modality of choice for the diagnosis of hypertrophic pyloric stenosis (HPS). The evolution of high-frequency transducers in ultrasound has led to inconsistent ways of measuring the pylorus. To standardize the measurements and evaluate the appearance of the normal and hypertrophied pylorus with high-frequency transducers. We retrospectively analyzed abdominal ultrasounds of infants with suspected HPS from January 2019-December 2020. We classified the layers of the pylorus while assessing the stratified appearance. Two pediatric radiologists measured the muscle thickness of the pylorus independently by two methods for interrater agreement. Measurement (a) includes the muscularis propria and muscularis mucosa. Measurement (b) includes only the muscularis propria. We also evaluated the echogenicity of the muscularis propria. The interrater agreement, mean, range of the muscle thickness, and the diagnostic accuracy of the two sets of measurements were calculated. We included 300 infants (114F:186M), 59 with HPS and 241 normal cases. There was a strong agreement between the readers assessed in the first 100 cases, and ICC was 0.99 (95% CI, 0.98-0.99). Measurement (a), median thickness is 2.4mm in normal cases and 4.8mm in HPS. Measurement (b), median thickness is 1.4mm in normal cases and 4.0mm in HPS. Measurement (a) has an accuracy of 89.7% (95% CI, 85.7-92.8%) with 98.3% sensitivity and 87.6% specificity. Measurement (b) has an accuracy of 98.0% (95% CI, 95.7-99.3%) with 89.8% sensitivity and 100.0% specificity. The pylorus stratification is preserved in all normal cases and 31/59 (52.5%) cases of HPS. There was complete/partial loss of stratification in 28/59 (47.5%) cases of HPS. In all HPS cases, the muscularis propria was echogenic. Measuring the muscularis propria solely has a better diagnostic accuracy, decreasing the overlap of negative and positive cases. The loss of pyloric wall stratification and echogenic muscularis propria is only seen in HPS.

Artificial Intelligence in Medicine: A Comparative Study of ChatGPT and Google Bard in Clinical Diagnostics

Introduction The introduction of Artificial Intelligence (AI) tools like ChatGPT and Google Bard promises transformative advances in clinical diagnostics. The aim of this study is to examine the ability of these two AI tools to diagnose various medical scenarios. Methods Experts from varied medical domains curated 20 case scenarios, each paired with its ideal diagnostic answer. Both AI systems, ChatGPT (updated in September 2021) and Google Bard (updated in January 2023), were tasked with diagnosing these cases. Their outcomes were recorded and subsequently assessed by human medical professionals. Results In the diagnostic evaluations, ChatGPT achieved an accuracy of 90%, correctly diagnosing 18 out of 20 cases, while Google Bard displayed an 80% accuracy rate, correctly answering 16 questions. Notably, both AIs faltered in specific complex scenarios. For instance, both systems misdiagnosed a labor situation, and while ChatGPT incorrectly identified a case of hypertrophic pyloric stenosis, Google Bard suggested a less suitable diagnostic procedure (pelvic ultrasound) for a 56-year-old patient. Conclusion This study showcases the promising capabilities of ChatGPT and Google Bard in the realm of clinical diagnostics, with both AI tools achieving commendable accuracy rates.

Hypertrophic Pyloric Stenosis: 10 Years' Experience with Standard Open and Laparoscopic Approach.

PurposeHypertrophic pyloric stenosis (HPS) is the most common cause of gastric obstruction in newborns. Extra-mucosal pyloromyotomy can be performed through a small laparotomy or laparoscopy. The aim of this study was to compare the two surgical techniques. We also analyzed the incidence of HPS in infants in the last 10 years in relation to the demographic trend of our province.MethodsWe analyzed all the cases of HPS treated at our Unit between January 2010 and December 2019. The data were obtained from operating systems. Data about the demographic trends, in particular, the number of births and the population residing in the province of Verona from 2010 to 2019, were also retrieved.ResultsDuring the study period, 60 patients were treated for HPS and met the inclusion criteria. Of these, 56 males and 4 females with an average age of 38±14 days at surgery were included. No differences were found in terms of the duration of surgery, post-operative complications, duration of hospitalization, and weight at the time of surgery. The only statistically significant data was the chlorine level in cases with and without post-operative vomiting (97±3.5 vs. 102±3.3 mmol/L, p<0.05). There was a lower incidence of HPS from 2014 to 2019; however, there was no significant evidence regarding the correlation between this and the reduced birth rate recorded in the province of Verona during the same period.ConclusionAlthough laparoscopic pyloromyotomy is a highly complex procedure, it is a feasible alternative to the classic open technique.

Two Cases of Hypertrophic Pyloric Stenosis in Patients Presenting With Prenatal Polyhydramnios

Two Cases of Hypertrophic Pyloric Stenosis in Patients Presenting With Prenatal Polyhydramnios

Not Cancer … but Pyloric Stenosis in a 69-year-old?

Idiopathic hypertrophic pyloric stenosis (IHPS) is most commonly reported in infants with rates ranging from 0.25% to 0.8% of all live births. Adult IHPS is rare and only 200 cases have been reported in the literature. We present a patient in her late-sixties with cachexia and severe malnutrition with a gastric mass visualized on CT that initially was concerning for malignancy and was subsequently diagnosed with IHPS. A 69-year-old woman, with limited healthcare exposure, was admitted to the hospital with weight loss, anorexia, fatigue, severe malnutrition (BMI 13.7), severe anemia, elevated inflammatory markers (CRP >200, ESR 76), and hypotension leading to a traumatic fall. She was an active smoker with a 51 pack-year history and consumed 2 alcoholic drinks daily. She denied history of acid reflux and had no known history of H. pylori. Rheumatologic workup was negative. Given lack of medical history and severe cachexia, CT chest and abdomen were obtained as there was concern for malignancy. A right ovarian cyst and cystic lesion in the head of pancreas was initially reported and were subsequently determined to be benign. Due to her continued inability to tolerate oral intake, EGD was performed which revealed gastric stenosis with pinhole opening at the pylorus and no visible ulcerations. Biopsy revealed reactive gastropathy and foveolar hyperplasia without inflammation. Review of CT did show evidence of hypertrophy around the pyloric sphincter. She was endoscopically dilated and was able to advance her diet with careful monitoring for refeeding syndrome. At her three-month follow-up visit, she was tolerating general diet, was slowly gaining weight, and her anemia had resolved. This case demonstrates an uncommon case of adult-onset IHPS causing severe malnutrition and cachexia. Most cases of hypertrophic pyloric stenosis are diagnosed in early infanthood. Initial management often includes nasogastric tube placement to remove gastric contents. Gastrectomy, pyloromyotomy, and pyloroplasty have been recommended for surgical management with laparoscopic pyloroplasty as the preferred intervention due to its favorable safety profile. Dilation is another acceptable treatment option; however has a high recurrence rate of stenosis.Figure: Computed tomography, coronal view of pyloric stenosis in a 69-year-old female.

First Report of A Unique Presentation of Hypertrophic Pyloric Stenosis Following Type I Esophageal Atresia; A Case Report

Combination of congenital esophageal atresia and subsequent hypertrophic pyloric stenosis is a rare condition which occurs in early infancy. The underlying etiology and pathophysiology of this association still remains unclear. In this paper we report a unique case of hypertrophic pyloric stenosis, for the first time, which occurred in an infant who underwent surgery for type I esophageal atresia. Therefore, we intend to highlight the role of poor nutrition intake in the incidence of this condition.

肥厚性幽門狭窄症 351 例の検討 : 第 28 回九州小児外科研究会アンケート調査報告

肥厚性幽門狭窄症 351 例の検討 : 第 28 回九州小児外科研究会アンケート調査報告

Hypertrophic pyloric stenosis in the Maritimes: examining the waves of change over time.

Changing patterns of referral and management of pediatric surgical conditions, including hypertrophic pyloric stenosis (HPS), have recently been described and often relate to comfort with early nonoperative management, anesthesia and corrective surgery. Travelling distance required for treatment at pediatric centres can also be burdensome for families. We assessed referral patterns for HPS in the maritime provinces of Canada over 10 years to quantify the burden on families travelling for surgical care. We reviewed the charts of all patients with HPS in the Maritimes. Length of hospital stay (LOS) and complication rates were analyzed in regards to resuscitation and management at a pediatric centre and/or peripheral centres. We used postal codes for each patient to track distance travelled for management. We assessed 751 cases of HPS. During the study period (Jan. 1, 2001-Dec. 31, 2010), referral to pediatric centres increased from 49% to 71%. Postoperative complications were 2.5-fold higher in peripheral centres. Infants referred to pediatric centres were 78% less likely to have an LOS longer than 3 days. Laparoscopic pyloromyotomy, which was performed only in pediatric centres, was associated with a shorter postoperative LOS. Our study supports the current literature demonstrating improved outcomes, shorter overall LOS and decreased risk of complications when infants with HPS are treated in pediatric centres. This should be considered when planning access to pediatric surgical resources.

Formula-feeding and hypertrophic pyloric stenosis: is there an association? A case–control study

BackgroundThe etiology of infantile hypertrophic pyloric stenosis (HPS) is not fully understood. The objective of this study was to determine whether formula-feeding is associated with increased incidence. MethodsThis case–control study included HPS cases and controls admitted between 1992 and 2012. Demographic data including feeding method were collected from patient charts and analyzed. ResultsWe identified 882 HPS cases and 955 controls. The highest incidence of HPS presentation was in summer (P=0.0028). Infants with HPS were more likely to have been exclusively formula-fed, have a family history of HPS, and be male compared to infants in the control group (P<0.001); they were also more likely to live in rural areas, although not significantly so. After adjusting for family history, sex, place of residence, and season of presentation, exclusively formula-fed infants were 1.36 times more likely to develop HPS compared with exclusively breastfed infants (RR 1.36, 95% CI 1.18–1.57, P<0.005). ConclusionsFormula-feeding is associated with significantly increased risk of HPS. Further investigation may help to determine the components of formula that simulate hypertrophy of the pylorus muscle, or the components of breast milk that are protective, as well as other influencing factors.Level of evidence: 3b.

Early presenting hypertrophic pyloric stenosis with transient antroduodenal dysmotility in a preterm neonate: A case report

Abstract Hypertrophic pyloric stenosis (HPS) is one of the most common gastrointestinal disorders that require surgical intervention in early infancy. Clinical presentation, diagnosis, and treatment have been well established in typical cases. We herein describe an unusual case of early presenting HPS with transient postoperative feeding intolerance after complete myotomy in a preterm newborn. An ex-31-week preterm newborn (birth weight, 1760 g) with persistent feeding intolerance since the first feeding was referred for surgery on the 7th day of life. Abdominal ultrasonography (USG) revealed an elongated pyloric channel (11 mm) with thickened pyloric muscle (2.1 mm). Laparotomy was performed and confirmed suspected HPS. Pylomyotomy was successful, but feeding intolerance persisted until postoperative day 12. USG on postoperative day 12 noted antroduodenal dysmotility, and transpyloric tube feeding was started. Full feeds were reached 8 days after tube feeding, which was then converted to full oral feeding. HPS should be considered in patients who show feeding intolerance shortly after birth. USG criteria for HPS in preterm infants has not yet been established. Transient antroduodenal dysmotility could be a reason for persistent feeding intolerance after complete myotomy in preterm infants, and transpyloric tube feeding could be a treatment in such cases.

Hypertrophic Pyloric Stenosis Following Repair of Esophageal Atresia and Tracheo-Esophageal Fistula

Two cases of hypertrophic pyloric stenosis (HPS) developed after a few weeks of repair of an esophageal atresia and tracheo-esophageal fistula (EA&amp;TEF). Both cases were dealt successfully with laparoscopic pyloromyotomy.

Hypertrophic pyloric stenosis: Early presentation with hyperbilirubinemia

Hypertrophic Pyloric Stenosis commonly presents with non-bilious progressive vomiting usually after a feed. The vomiting usually starts after third week with a range of symptoms onset from first week to fifth month of life. Less commonly it is associated with hyperbilirubinemia (unconjugated &gt; conjugated) which subsides after surgical correction. We report a case of Hypertrophic Pyloric Stenosis who presented early in fifth day of life with repeated vomiting after each feed and unconjugated hyperbilirubinemia. Ultrasonography revealed Hypertrophic Pyloric Stenosis without any evidence of other cause of jaundice. Patient was treated conservatively, prepared for surgery, surgical correction done with Ramstedt’s Pyloromyotomy following that vomiting and jaundice both subsided. Early presentation of HPS may suggest congenital etiology and association of unconjugated hyperbilirubinemia should alert clinician for future Gilbert Syndrome.

Single-site umbilical laparoscopic pyloromyotomy in neonates less than 21-day old

Single-site umbilical laparoscopic pyloromyotomy for hypertrophic pyloric stenosis in neonates <3-week old has rarely been reported in the literature. This article reports our initial experience with this procedure. Overall, 13 cases of hypertrophic pyloric stenosis occurred in neonates <3-week old from January 2010 to April 2013 in our hospital. All neonates were treated by a single-site laparoscopic procedure. A 5-mm trocar and endoscope were introduced through an incision in the center of the umbilicus, and two 3-mm working instruments were inserted directly into the abdomen via separate lateral fascial stab incisions in the umbilical fold, and a single-site umbilical laparoscopic pyloromyotomy was then performed. The procedure was performed in 13 infants (12 male) with mean age of 17.3 days. The average length of the operation was 26 min. The mean postoperative hospital stay was 4.5 days. All patients were discharged home on full feeds. Follow-up examinations were scheduled 2 to 6 weeks after discharge, and no postoperative complications were noted in any of the patients. These cases had shorter and thinner pylori than their older counterparts. However, the laparoscopic procedure was safe and feasible, with good postoperative results and excellent cosmesis. Surgeons should have a firm foundation of advanced minimal access surgical skills prior to attempting the procedure.

Evaluation of Hypertrophic Pyloric Stenosis by Pediatric Emergency Physician Sonography

The objective was to evaluate the accuracy of pediatric emergency physician (EP) sonography for infants with suspected hypertrophic pyloric stenosis (HPS). This was a prospective observational pilot study in an urban academic pediatric emergency department (PED). Patients were selected if the treating physician ordered an ultrasound (US) in the department of radiology for the evaluation of suspected HPS. Sixty-seven patients were enrolled from August 2009 through April 2012. When identifying the pylorus, pediatric EPs correctly identified all 10 positive cases, with a sensitivity of 100% (95% confidence interval [CI] = 62% to 100%) and specificity of 100% (95% CI = 92% to 100%). There was no statistical difference between the measurements obtained by pediatric EPs and radiology staff for pyloric muscle width or length (p = 0.5 and p = 0.79, respectively). Trained pediatric EPs can accurately assess the pylorus with US in the evaluation of HPS with good specificity.

Electrolyte Profile of Pediatric Patients With Hypertrophic Pyloric Stenosis

Recent investigations have demonstrated that the classic hypochloremic, hypokalemic, metabolic alkalosis of hypertrophic pyloric stenosis (HPS) is not a common finding.Some have suggested a trend over time, but none has investigated factors contributing to laboratory derangement, such as duration of vomiting or patient age at presentation. We sought to determine the proportion of patients with HPS with normal and abnormal laboratory findings as a function of year of presentation, duration of vomiting, and patient age. This is a retrospective chart review of 205 patients younger than 6 months with operative diagnosis of HPS at a tertiary, regional pediatric center from 2000 to 2009. We examined the acid-base status and electrolyte levels (serum bicarbonate [CO2], serum potassium [K], and serum chloride [Cl]) at the time of the index visit to determine the proportion of normal, high, and low values for each as a function of year of presentation, duration of vomiting, and patient age. The proportion of HPS cases with normal CO2 was 62%; low serum CO2, 20%; and high CO2, 18%. The proportion with normal serum K was 57%; low K, 8%; and high K, 35%. The proportion with normal Cl was 69%; low Cl, 25%; and high Cl, 6%. Logistic regression analysis demonstrated that the prevalence of metabolic alkalosis increased across the decade, whereas the prevalence of metabolic acidosis decreased and that advancing age was associated with the presence of alkalosis. We observed that normal laboratory values are the most common finding in HPS and that metabolic alkalosis was found more commonly in the latter part of the decade and in older infants.

Is hypertrophic pyloric stenosis a secondary disease?

Hypertrophic pyloric stenosis (HPS) is the most common gastrointestinal obstructive disease in infants which requires surgery. Typical presentation is at 4-6 weeks of life but can present very earlier or congenitally. Here we present 3 cases of HPS which presented in the first day of life with co-existing malrotation, annular pancreas, and duodenal atresia. The exact etiology of HPS is not fully understood, however, genetic and maternal factors, hormonal factors, abnormalities of various components of the pyloric muscle, growth factors, extracellular matrix elements, nerve and ganglion cells synapses, nerve supporting cells, neurotransmitters and interstitial cells, drugs, and feeding have been implicated. In the HPS concomitant with a distal obstruction, mean that these obstructions may role in pathogenesis of HPS or may exacerbate other factors to produce HPS in a very early age or congenitally. The purpose of this manuscript is to present three cases of HPS in the first day of life with other GI anomalies. We hypothesize that the etiology of some cases of HPS may be secondary to distal intestinal obstructions especially when it presents very early in life, or at least to concern a distal obstructions in this very early presentation.

The Changing Clinical Presentation of Hypertrophic Pyloric Stenosis: The Experience of a Large, Tertiary Care Pediatric Hospital

The authors reviewed the clinical and laboratory data from cases of hypertrophic pyloric stenosis (HPS) diagnosed at their institution from 2006 to 2008. They assessed and compared presentation of patients with HPS over time at their institution. A total of 118 patients were included in this study. An “olive” was palpated in only 13.6% of cases. This is in contrast to older studies, where more than 50% of the patients were reported to have a palpable “olive” depending on when the study was conducted. In patients from this institution, hypochloremia was present in 23% and alkalosis in 14.4%, which are less frequent than the incidence of these abnormalities in older studies. There was a change in the additional “classical” symptoms, represented by the lower percentage of infants in whom an “olive” was palpated and the lower numbers of patients with severe electrolyte imbalances. The reason for this change appears to be the frequent use of ultrasound.

The Changing Clinical Presentation of Hypertrophic Pyloric Stenosis: The Experience of a Large, Tertiary Care Pediatric Hospital

The authors reviewed the clinical and laboratory data from cases of hypertrophic pyloric stenosis (HPS) diagnosed at their institution from 2006 to 2008. They assessed and compared presentation of patients with HPS over time at their institution. A total of 118 patients were included in this study. An "olive" was palpated in only 13.6% of cases. This is in contrast to older studies, where more than 50% of the patients were reported to have a palpable "olive" depending on when the study was conducted. In patients from this institution, hypochloremia was present in 23% and alkalosis in 14.4%, which are less frequent than the incidence of these abnormalities in older studies. There was a change in the additional "classical" symptoms, represented by the lower percentage of infants in whom an "olive" was palpated and the lower numbers of patients with severe electrolyte imbalances. The reason for this change appears to be the frequent use of ultrasound.

Pyloric stenosis in an iniencephalic infant with a congenital intra-thoracic stomach

We report the first case of hypertrophic pyloric stenosis in an intrathoracic stomach in a neonate with congenital ultra-short oesophagus and iniencephaly clausus. Antenatal ultrasound detected right-sided thoracic cystic lesions and postnatal investigations revealed an intra-thoracic stomach and spleen with an ultra-short oesophagus and intact diaphragm. Subsequently, she developed pyloric stenosis. Such neonates require urgent referral to surgical centres for what is a challenging diagnosis and complicated management.

Rapid correction of metabolic alkalosis in hypertrophic pyloric stenosis with intravenous cimetidine: preliminary results

Pyloromyotomy has been the treatment of choice for hypertrophic pyloric stenosis (HPS) for the past century. In most HPS cases, there is mild metabolic alkalosis, which requires intravenous fluid resuscitation with 5% dextrose/normal saline for 1-2 days. However, in some cases, due to a delay in diagnosis, alkalosis becomes severe and a much longer resuscitation period (5-10 days) is required to normalize serum pH. Metabolic alkalosis of HPS results from excessive vomiting of hydrochloric acid; and therefore if its production is reduced, serum pH can be normalized faster. In this study, the use of intravenous cimetidine (CM) in a small number of infants with HPS is presented. Over a 28-month period, 32 HPS cases, including a sub-group of 17 infants (aged 7-9 weeks) with arterial pH >7.60, were admitted to a tertiary referral unit. Four infants in this sub-group were treated with standard resuscitation fluids for 4 days prior to intravenous CM, while 12 infants received CM immediately. Intravenous CM (10 mg/kg) was given at twice daily until arterial pH was less than 7.50. In one case, intravenous omeprazole at 0.1 mg/kg was given instead of CM. In all 17 cases, CM treatment or omeprazole therapy (for 12-48 h) reduced pH to less than 7.50, thus allowing for Ramstedt pyloromyotomy the same day. These patients were allowed oral feeding on the following day and were discharged at 1-3 post-operative days. No complications due to CM (or omperazole) treatment were observed. Intravenous CM administration can rapidly normalize severe metabolic alkalosis in HPS patients. As a result, pyloromyotomy can be performed sooner reducing both hospital stay and costs.