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Pediatric Surgery (Pg 68-81) - page 9 / 33

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Pyloric Stenosis:

Progressive hypertrophy of the musculature of the pylorus of infants, eventually leading to gastric outlet obstruction

Common disorder. 1:500 infants. M:F = 4:1.  Strong familial component.

Etiology unknown.  Hypotheses include:

1.) abnormal development of ganglion cells in the wall of the pylorus

2.) milk curds propelled against the pylorus submucosal edema blocks gastric outlet subsequent work hypertrophy of muscular pylorus.

Presentation: Symptoms begin b/t 2-8 wks with nonbillious vomiting after feeding.  Vomiting maybe projectile, and becomes progressively worse until food isn’t tolerated.  Infant remains hungry and sucks vigorously.  Stool frequency and urinary output is significantly decreased.

Exam:  Infant is irritable and dehydrated.  Peristaltic waves seen moving across abdomen.  Hallmark is palpable “olive”, a hard, round, movable mass in epigastrium.

Pyloric mass maybe more palpable following empting of stomach with NG tube.

When olive is identified, no imaging studies are necessary (i.e. palpable olive is pathognomonic for pyloric stenosis).

If no olive is found U/S is highly accurate in diagnosing P.S.  Length, diameter, and wall thickness all increased.  

Barium swallow can be utilized if U/S neg. and still have clinical suspicion.  It will show a narrowed, elongated pyloric channel.

Treatment:  

1.

Preoperative rehydration is essential.  Infants are likely to have hypochloremic hypokalemic metabolic alkalosis (d/t vomiting).

2.

Pyloromyotomy – operative longitudinal split of hypertrophic pyloric muscle that extends down to mucosa, but doesn’t enter it.

3.

Feeding initiated 6 to 12 hrs postop and gradually incrased.

Acute Abdomen:

Children present a challenge to physicians b/c of the following factors:

1.

Children tend to have a uniform reaction to infection.  Whether they have strep pharyngitis, pneumonia, appendicitis, etc. they often have fever, vomiting and a “stomachache”

2.

Surgical diseases in children are age dependent.  Relative risks vary greatly with age.

3.

Children have limited ability to express their symptoms.

4.

Children in pain are not cooperative; examination is difficult.

5.

Parental anxiety adds to the stress of the situation.

Appendicitis:

Most common condition requiring emergent surgery in childhood.  

Rare in infants, incidence increases thereafter and peaks in adolescents and young adults.

Caused by obstruction of the appendix base by fecalith or lymphoid hyperplasia.  

Mucosal secretions expand the appendix increased intraluminal pressure bacterial overgrowth impairment of perfusion perforation within 24-48 hrs

Delayed recognition more likely in children.  Those under 5 usually have perforation by the time of presentation.

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