Wednesday, February 24, 2016

A 3 Month Old Infant With Recurrent Forceful Vomiting

This 3-month-old boy was brought to the pediatrician's office with the complaints of recurrent forceful vomiting of milk since last 2 months. On examination his weight was found to be 3.4 kg. His birth weight was told to be 3.5 kg. Infant was moderately dehydrated and looked anxious and hungry. Certain strange movements were noticed by parents in upper abdomen especially after feeds.

1. What is the most probable diagnosis?
2. Presence of which clinical sign almost confirms the diagnosis?
3. Suggest its salient radiological and USG features
4. What is the management for this condition?

Answers And Discussion:

1. What is the most probable diagnosis?

Answer: Congenital hypertrophic pyloric stenosis (CHPS).

This picture classically reveals visible gastric peristalsis that indicates gastric outlet obstruction. Furthermore, history of recurrent forceful vomitings of milk starting around 1 month in a male baby associated with visible gastric peristalsis, constipation, dehydration and weight loss are very much suggestive of upper gastrointestinal (GI) obstruction most probably congenital hypertrophic
pyloric stenosis (CHPS). Since the vomitings are non-bile stained so obstruction is most likely to be above the opening of bile duct in duodenum.
CHPS is more common in males and presents around 4-6 weeks of age usually with recurrent forceful vomiting of milk. Visible gastric peristalsis is classically seen in such infants. Recurrent vomiting also results in hypochloremic alkalosis, dehydration, weight loss and constipation. These
children may also present later with failure to thrive, weight loss and severe degrees of Protein Energy Malnutrition.

2. Presence of which clinical sign almost confirms the diagnosis?

Answer: A pyloric mass of the size of an olive is palpable at the junction of the costal margin and the lateral border of the right rectus muscle that can be palpated especially when the infant is feeding. If it can be palpated clinically, it is pathognomonic of Congenital Hypertrophic Pyloric Stenosis.

3. Suggest its salient radiological and USG features?

Answer:  Barium meal examination reveals a vigorously peristaltic stomach with delayed or no emptying. A fine elongated pyloric canal is seen as single and sometimes as a double line of barium. This sign is called “String sign”. Duodenal cap is found to be stretched as an umbrella over the hypertrophied pylorus. A diverticulum may also be associated with it.
Ultrasound examination is very much helpful in the diagnosis and it reveals vigorous peristalsis. It may also demonstrate returning of milk after hitting the pyloric region.
Pyloric canal length is increased more than 14 mm and the pyloric muscle mass width measures more than 4 mm. Increased width of pyloric muscle is visible as a target on ultrasound examination with an echo free space in the region of the muscle. It is therefore called “Target sign” (because of hypertrophied pylorus).

4. What is the management for this condition?

Answer: Its management consists of pyloromyotomy or Ramstedt’s operation. Good results are noticed after surgery with good recovery and excellent prognosis
Before taking the infant for surgery, it is advisable to correct the dehydration in the infant with IV 5% dextrose normal saline or 0.45% saline with 5% dextrose to which KCl has been added. Addition of KCl helps in correction of hypochloremic alkalosis. 2 mEq/kg of potassium is added. A maximum
of 10 mEq is added to 100 ml intravenous solution


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