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IHPS- Infantile Hypertrophic Pyloric Stenosis- How To DIAGNOSE & TREAT/ Pediatric Surgery

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Infantile Hypertrophic Pyloric Stenosis- An Overview

  1. Infantile Hypertrophic Pyloric Stenosis (IHPS) An Overview

  2. 2. Dr.B.SELVARAJ,MS;MCh;FICS; Neonatal & Pediatric Surgeon Associate Professor Melaka Manipal Medical College Melaka- 75150 Malaysia

  3. OBJECTIVES •To discuss the etiology, clinical features, and pathophysiology of IHPS •To discuss workup to clinch the correct diagnosis •To discuss the various treatment options •To make you confident in managing an infant with IHPS

  4. PLAN • Etiology • Pathophysiology • History & Physical • Differential Diagnosis • Workup • Preop preparation • Management • Complications

  5. History • 1646-Sabricus Hildanus-1st described • 1888-Hirschsprung-Pathology • 1908-Fredet-Longitudinal incision closed transversely • 1912- Ramstedt- omitted transverse closure • 1986- Tan&Bianchi- Periumbilical incision • 1992- Lap Pyloromyotomy

  6. Etiology • Hypertrophy of muscles surrounding pyloric channel • Idiopathic • Various Hypothesis: Milk curd theory& theory of Aganglionosis • Male: Female 4:1 • Female parent with the disorder four times more chances of having affected offspring • Increased incidence within families

  7. Pathology • Hypertrophied muscles • Gastric outlet obstruction • Nonbilious projectile vomiting • Gastric fluid loss • Hypochloremic Hypokalemic Alkalosis • Paradoxical Aciduria

  8. History&Physical • Cyclical Nonbilious projectile vomiting at 2wks to 2 months of age • Usually first-born male child • Failure to thrive • Loss of weight & Dehydration • Visible Gastric PeristalsisVGP • Olive tumor • Occasional jaundice

  9. History Physical • Nonbilious projectile vomiting at 3 to 6 weeks of age • Usually first born male child • Failure to thrive • Loss of weight Dehydration • Visible Gastric PeristalsisVGP Olive tumor – Occasional jaundice

  10. IHPS- Paradoxical Aciduria

  11. Differential Diagnosis • GE Reflux • Faulty feeding techniques • Indirect marker of illness like UTI, ICP, and Congenital adrenal hyperplasia • Pyloric Atresia • Pyloric Membrane Neonatal only • Antral Atresia • Antral Membrane

  12. Workup • AXR- Erect: Dilated Stomach • Barium meal series: String sign and Railroad track sign • USG Abdomen: Dilated and elongated pyloric channel muscles • Serum electrolytes • Arterial blood gas analysis

  13. Plain AXR Barium Meal

  14. USG Abdomen

  15. USG Diagnostic criteria IHPS • Pyloric channel length1.5 to 2 cms (Normal 1.2cms) • Pyloric channel diameter1.3 to 1.5cms (Normal 1 cms) • Circular muscle thickness 4 to 5 mms (Normal 2mms)

  16. Preop Preparation • NPO • NGT Decompression and gastric lavage • Correction of dehydration and alkalosis with D5W with 1/2 normal saline • Serum bicarbonate should be 28 meq/ ltr and Serum chloride should be 100 meq/ltr before taking up the child for surgery

  17. Management • Fredet- Ramstedt’s Pyloromyotomy conventional open procedure • Laparoscopic Pyloromyotomy • PostopProgressive increase in feeding from 8 hrs onwards • D/C IVF if child tolerates 60ml Q3H

  18. Fredet- Ramstedt’s Pyloromyotomy

  19. Fredet- Ramstedt’s Pyloromyotomy

  20. Laparoscopic Pyloromyotomy

  21. Laparoscopic Pyloromyotomy

  22. Complications • Unrecognised Duodenal perforation • Occasional intraabdominal bleeding • Postop persistent vomiting: If 1Wk Redo Surgery Torgerson’s muscle incision • Wound infection/ Wound dehiscence

  23. Infantile Hypertrophic Pyloric Etiology Tt Complications • Fredet-Ramstedt’s Pyloromyotomy • Unrecognised perforation with peritonitis • Occasional bleeding • Persistent vomiting • Wound infection and dehiscence P Preop prep IHPS Imaging • Hypertrophied muscle • G O Obstruction • Non-bilious vomiting • Gastric fluid loss • Hypochloremic alkalosis • Paradoxical aciduria • Idiopathic • Milk curd Theory • Familial Pathology H P • AXR- dilated stomach • Ba Meal- String sign • USG Abd- dilated elongated pyloric muscles • 1st born male child • Cyclical non-bilious projectile vomiting • Dehydration loss of weight • Olive tumor • NPO • NGT aspiration gastric lavage • Correction of dehydration Electrolytes imbalance M Stenosis

  24. Mindmaps in Surgery




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