Video capsule endoscopy and CT enterography in diagnosing adult hypertrophic pyloric stenosis

Primary adult hypertrophic pyloric stenosis is a rare but important cause of gastric outlet obstruction that may be misdiagnosed as idiopathic gastroparesis.Clinically,patients present with early satiety,abdominal fullness,nausea,epigastric discomfort and eructation.Permanent gastric retention of a video capsule endoscope is diagnostic in differentiating between the two diseases,in the absence of an organic gastric outlet obstruction.This case presents the longest video capsule retention in the medical literature to date.It is also the first case report of adult hypertrophic pyloric stenosis diagnosed with video capsule endoscopy or a computed tomography scan.Finally,an unusual"plugging"of the gastric outlet with free floating capsule has an augmented effect on disease physiology and on patient’s symptoms.

Pathophysiology of Hypertrophic Pyloric Stenosis Revisited: The Use of Isotonic Fluid for Preoperative Infusion Therapy Is Supported

Background: The aim of this study was to elucidate the preoperative clinical and biochemical profile of infants with IHPS to optimize infusion therapy. Patients and Method: We retrospectively analyzed data from 56 infants who were operated for IHPS. Our study includes growth and laboratory data prior to the initiation of therapy. Results: Median duration of propulsive vomiting was 4 d;the median age was 37 d (18 - 108), and the median body weight was 3840 g (2760 -5900). Metabolic alkalosis (MAlk) with a pH of 7.45 ± 0.06 and an stHCO3- of 28.7 ± 4.5 mmol/l was found. In a subgroup of the infants, negative base excess (BE) was observed. The sodium concentration was normal or reduced (mean/median of 137 mmol/l). There was a strong negative correlation between stHCO3- and K+. The carbon dioxide partial pressure tended to increase (5.72 ± 0.84 kPa). Calculations of osmolality revealed a normal osmolarity. Hypoglycemia did not occur. The creatinine clearance according to the Schwartz formula remained at a normal level (85.3 ± 24.3 ml/min/1.73 m2). Discussion: The presented case series is characterized by a short duration of preoperative vomiting. MAlk can be classified as a chloride deficiency syndrome. It is accompanied by normo- or hyponatremic dehydration with normal osmolality. Partial respiratory compensation occurred. A normal creatinine clearance indicated good glomerular renal function. Conclusion: The presented study supports the use of an isotonic infusion fluid with a low glucose concentration for preoperative infusion therapy.

Double Incomplete Pyloromyotomy (A. Ezzat Technique): A New Technique for Infantile Hypertrophic Pyloric Stenosis: Preliminary Study

Background-Purpose: The study aimed to see the outcome of Double Incomplete Pyloromyotomy as new technique for surgical management of infantile hypertrophic pyloric stenosis (IHPS). Methods: This study was conducted in pediatric surgery unite, Zagazig University Hospital, Egypt. Fifteen patients were included in this study (11 male and 4 female) with IHPS from January 2012 to January 2013. Under general anesthesia, two longitudinal separated incisions at different planes as pyloromyotomy. Results: Postoperative vomiting and weight gain were recorded. Follow up period was 3 months. Vomiting improved within first 48 hours then stopped after that. Weight gain significantly increased after theoperation when compared preoperatively. Conclusion: Double Incomplete Pyloromyotomy is a new, safe and effective procedure for treatment of infantile hypertrophic pyloric stenosis.

Idiopathic non-hypertrophic pyloric stenosis in an infant successfully treated via endoscopic approach

Non-peptic, nonhypertrophic pyloric stenosis has rarely been reported in pediatric literature. Endoscopic pyloric balloon dilation has been shown to be a safe procedure in treating gastric outlet obstruction in older children and adults. Partial gastric outlet obstruction (GOO) was diagnosed in an infant by history and confirmed by anupper gastrointestinal series (UGI). Abdominal ultrasonography and computed tomography scan excluded idiopathic hypertrophic pyloric stenosis, abdominal tumors, gastrointestinal and hepato-biliary-pancreatic anomalies. Endoscopic findings showed a pinhole-sized pylorus and did not indicate peptic ulcer disease, Helicobacter pylori infection, antral web, or eviden-ce of allergic and inflammatory bowel diseases. Three sessions of a step-wise endoscopic pyloric balloon dilation were conducted under general anesthesia and a fluoroscopy at two week intervals using catheter balloons (Boston Scientific Microvasive?, MA, USA) of increasing diameters. Repeat UGI after the first session revealed normal gastrointestinal transit and no intestinalobstruction. The patient tolerated solid food without any gastrointestinal symptoms since the first session. The endoscope was able to be passed through the pylorus after the last session. Although the etiology of GOO in this infant is unclear (proposed mechanisms are herein discussed), endoscopic pyloric balloon dilation was a safe procedure for treating this young infant with non-peptic, non-hypertrophic pyloric stenosis and should be considered as an initial approach before pyloroplasty in such presentations.

Antral web associated with distal antral hypertrophy and prepyloric stenosis mimicking hypertropic pyloric stenosis

A 3-year-old boy presented with postprandial vomiting and epigastric pain for 3 wk. Barium meal study suggested hypertrophic pyloric stenosis. Ultrasound of the stomach after water loading revealed an echogenic antral web with an eccentric aperture and distal antral hypertrophy.Subsequent endoscopy confirmed the ultrasound findings.Web resection and antropyloroplasty resulted in excellent recovery. To our knowledge, the barium meal and ultrasound findings of an antral web-associated distal antral hypertrophy and prepyloric stenosis has not previously been described.

Pyloric Stenosis and Nonbilious Vomiting in Infants: Negative Base Excess and Hypercapnia—Two Opposing Points of One Scale a Comparative Case Series

Background: Blood pH and bicarbonate estimations are basal acid-base laboratory tests that are performed in infants with infantile hypertrophic pyloric stenosis (IHPS). This study aimed to define the clinical value of pCO2 and BE in infants suspected to have IHPS. Methods: We collected data from 80 “surgical” infants younger than 100 days with prolonged nonbilious vomiting who were suspected to have IHPS. In 65 infants, pyloric stenosis was confirmed, and 15 infants had nonsurgical conditions. Capillary blood was tested for standard acid-base parameters and lactate. The two groups were compared. Results: Eighty-eight percent of the IHPS infants had elevated standard bicarbonate levels (st bicarb) > 25 mmol/l, and 60% had BE > 3.5 mmol/l;12% of the infants showed hypercapnia (pCO2 ≥ 50 mmHg) associated with markedly increased standard bicarbonate and BE. Infants with nonsurgical vomiting were older at admission (p = 0.002), had a longer duration of vomiting (p < 0.001), were older (p = 0.002) and weighted more at admission (p = 0.004), had lower pCO2 (p = 0.021), lower st bicarb (p < 0.001) and lower BE (p = 0.001). In addition, nonsurgical infants showed a trend to anemia (p = 0.002). Conclusions: In infants with IHPS/nonbilious vomiting, acid-base analysis (ABA) is equivocal or inconclusive. These findings may be misleading and could result in a false clinical decision. Nonsurgical vomiting is associated with a lower degree of alkalosis, normocapnia to slight hypercapnia and a base deficit. However, even infants with IHPS may present with a negative BE. In infants with IHPS and severe alkalosis, hypercapnia carries a risk for respiratory depression. Monitoring the infant’s respiration allows for the early detection of respiratory deterioration.

Case Report: Four Siblings with Osteopetrosis and Pyloric Stenosis and Three Cousins with Osteopetrosis

Osteopetrosis incidence is less than 1:200,000 births in most populations. It’s more common in consanguineous people as it’s unusual for two members of the same family. The incidence of Hypertrophic pyloric stenosis is 1 in 300 - 900 newborns. Hypertrophic pyloric stenosis is due to hypertrophy of the smooth muscle of the pyloric sphincter. The classic age of occurrence is the first few months of life, and the classic presentation is non-bilious projectile vomiting after feeding. We report a rare association of osteopetrosis and pyloric stenosis in four siblings and osteopetrosis in three cousins. All four patients were operated on and followed by nephrology and metabolic departments for osteopetrosis and metabolic acidosis.

Gastrojejunostomy for pyloric stenosis after acute gastric dilatation due to overeating

A 34-year-old woman presented at our hospital withabdominal distention due to overeating.Acute gastric dilatation was diagnosed.The patient was hospitalized,and nasogastric decompression was initiated.On hospitalization day 3,she developed shock,and her respiratory state deteriorated,requiring intubation and mechanical ventilation.Nasogastric decompression contributed to the improvement in her clinical condition.She was discharged 3 mo after admission.During outpatient follow-up,her dietary intake decreased,and her body weight gradually decreased by 14 kg.An upper gastrointestinal series and endoscopy revealed pyloric stenosis; therefore,we performed gastrojejunostomy 18 mo after her initial admission.The patient was discharged from the hospital with no postoperative complications.Gastric necrosis and perforation due to overeating-induced gastric dilatation are life-threatening conditions.Surgical intervention may be required if delayed pyloric stenosis occurs after conservative treatment.We report a case of pyloric stenosis due to overeating-induced gastric dilatation treated by gastrojejunostomy 18 mo after the initial presentation.

Pyloric stenosis associated Crohn's disease responding to adalimumab therapy

Gastroduodenal Crohn’s disease (CD) is rare and the response to standard medical therapy is often poor. Anti-tumor necrosis factor therapy has revolutionised the treatment of CD. We present a patient with pyloric stenosis associated with CD which improved with Adalimumab therapy. We recommend considering antitumor necrosis factor therapy in symptomatic gastroduodenal CD.

New insights on the pathogenesis of pyloric stenosis of infancy. A review with emphasis on the hyperacidity theory

A review is presented on the theories concerning the cause of pyloric stenosis with emphasis on the primary position of inherited hyperacidity in pathogenesis. Existing theories are critically analysed and the hyperacidity theory is precisely defined in the light of recent physiological insights into the gastrointestinal hormone motilin. The progressive fixed fasting hypergastrinaemia within the first few weeks of life will, in the baby who inherits acid secretion at the top of the normal range, produce hyperacidity of sufficient severity to trigger the process of acid-induced work hypertrophy of the pylorus. The potential contribution of motilin is discussed. The baby who inherits a normal gastric acidity will not reach acid levels severe enough to trigger sphincter hypertrophy despite the early gastrin stimulus. The potential threat will cease when gastrin naturally declines with age and the pyloric canal becomes wider. Genetic factors clearly must also be involved and these are separately discussed.

Cytomegalovirus-associated gastric ulcer:A side effect of steroid injections for pyloric stenosis

The local injection of triamcinolone acetonide(TA) is effective in preventing pyloric stenosis and deformity following large endoscopic submucosal dissection(ESD).However,because of its long-acting nature,TA can induce long-term local immunosuppression and subsequent adverse events.We report a case of a cytomegalovirus(CMV) ulcer that formed only at the TA local injection site.A 68-year-old man underwent ESD to treat early gastric cancer that formed over the pylorus.The lesion extended to the duodenum,and an artificial ulcer covered more than two-thirds of the circumference of the pylorus.To prevent pyloric stenosis,TA was locally injected into the ulcer floor.On day 12,a deeper ulcer 10 mm in diameter was discovered in the center of the post-ESD ulcer.Biopsies revealed large cells with intranuclear inclusion bodies,which stained positive for the anti-CMV antibody.Local TA injections are useful,however,CMV ulcer might occur as adverse events.

Incidence and Concurrent Laparoscopic Repair of ypertrophic Pyloric Stenosis and Patent Processus Vaginalis

INTRODUCTIONAlthough laparoscopic herniorrhaphy is the most common procedure performed by pediatric surgeons at present, herniorrhaphy with an asymptomatic patent processus vaginalis （PPV） remains controversial. The incidence of contralateral PPV on laparoscopy in previous studies was reported as 20%-50%, but it is believed to approach 100% in premature infants. It has been reported that 4%-34% patients have the risk of developing subsequent metachronous contralateral hernia after a repair of an ipsilateral hernia.Iu If this is true, then the identification and closure of a PPV at the time of ipsilateral hernia repair will obviate the need for a second operation in thousands of children every year. With recent advances in minimally invasive surgery, transinguinal diagnostic laparoscopy has emerged as a safe and effective method for evaluating a pediatric patient with PPV. Meanwhile, the laparoscopy has been widely used to manage the infantile hypertrophic pyloric stenosis （IHPS）, due to equally high success rate, minimal complications, and a shorter hospital stay.

Applications of gastric peroral endoscopic myotomy in the treatment of upper gastrointestinal tract disease

Gastric peroral endoscopic myotomy(G-POME)is an emerging minimally invasive endoscopic technique involving the establishment of a submucosal tun-nel around the pyloric sphincter.In 2013,Khashab et al used G-POME for the first time in the treatment of gastroparesis with enhanced therapeutic efficacy,prov-iding a new direction for the treatment of gastroparesis.With the recent and rapid development of G-POME therapy technology,progress has been made in the treatment of gastroparesis and other upper digestive tract diseases,such as congenital hypertrophic pyloric stenosis and gastric sleeve stricture,with G-POME.This article reviews the research progress and future prospects of G-POME for the treatment of upper digestive tract gastrointestinal diseases.

The Murmur of Dynamic Subortic Stenosis Recognition Through A Novel Graphic Display

Background: Dynamic subaortic stenosis occurs in differing situations, commonly with hypertrophic cardiomyopathy. Regardless of the underlying cause, the resulting murmurs usually possess a characteristic sound spectral pattern, manifesting a sharp and high frequency peak occurring late in systole, often bearing a striking resemblance to the subaortic Doppler flow pattern. Methods: Murmurs found in thirty one subjects with dynamic subaortic stenosis were analyzed after having been recorded with a novel portable device capable of spectral and waveform sound displays. Results: All subjects manifested characteristic frequency patterns, consisting of high and sharp peaks occurring in late systole. With significant subaortic stenosis (resting subaortic flow velocity > 2 m/sec) this pattern was evident at rest. In the presence of little or no resting subaortic obstruction (< 2 m/sec) this pattern was produced regularly by the Valsalva maneuver. Conclusions: Dynamic subaortic stenosis produces a specific sound spectral pattern that may provide a basis for clinical evaluation, especially in early detection of this disorder and in screening situations.

腹腔镜下幽门环肌切开术与经脐上小切口幽门环肌切开术治疗小儿先天性肥厚性幽门狭窄的效果比较

目的分析腹腔镜下幽门环肌切开术与经脐上小切口幽门环肌切开术治疗小儿先天性肥厚性幽门狭窄(CHPS)的效果。方法82例CHPS患儿根据治疗方法的不同分为两组,参照组接受经脐上小切口幽门环肌切开术治疗,研究组接受腹腔镜下幽门环肌切开术治疗,比较两组的围术期指标、疼痛程度、并发症。结果研究组的术中出血量少于参照组,术后恢复喂养时间及住院时间均短于参照组,术后48 h的CRIES评分低于参照组(P<0.05)。两组的手术时间、术后并发症总发生率比较,差异无统计学意义(P>0.05)。结论与经脐上小切口幽门环肌切开术相比,腹腔镜下幽门环肌切开术治疗小儿CHPS的创伤较小,可明显减轻患儿的术后疼痛程度,加快患儿术后恢复,且未明显增加术后并发症发生风险。

阿托品治疗肥厚性幽门狭窄的研究进展

肥厚性幽门狭窄(hypertrophic pyloric stenosis,HPS)是由于幽门肌增生肥厚引起的胃出口梗阻性疾病,其发病机制尚未完全清楚,可能继发于幽门肌的持续性痉挛或失弛缓。阿托品作为M胆碱能受体阻断剂,能解除幽门肌痉挛,被用于HPS的保守治疗。阿托品治疗HPS,最早采用口服给药,近年来又采用静脉注射给药。阿托品静脉注射治疗HPS,采取序贯用药的方式疗效较好,是HPS保守治疗的新方法。本文就阿托品治疗HPS的新进展进行综述。

高频超声检查在小儿先天性幽门肥厚狭窄中的诊断价值

目的:探讨高频超声检查在小儿先天性幽门肥厚狭窄(CHPS)诊断中的应用价值。方法:选取2021年1月—2023年12月广元市中心医院收治的疑似CHPS患儿40例作为研究对象,均接受高频超声检查,以手术病理结果作为“金标准”,评估高频超声诊断价值,比较高频超声检查与手术病理检查幽门情况。结果:手术病理检查结果显示,CHPS患儿(阳性)32例,非CHPS患儿(阴性)8例;高频超声检查检出阳性31例,阴性9例;高频超声检查的准确度为97.50%(39/40)、特异度为100.00%(8/8)、灵敏度为96.88%(31/32)。高频超声检查与手术病理检查幽门处固有肌层厚度、幽门管直径比较,差异无统计学意义(P>0.05);高频超声检查幽门管长度短于手术病理检查结果,差异有统计学意义(P<0.05)。结论:小儿CHPS诊断中应用高频超声检查可取得较好的诊断结果,其诊断准确度、特异度与灵敏度较高,能减少误诊或漏诊;在检查幽门处固有肌层厚度、幽门管直径方面与手术病理结果差异小,可为临床诊断提供参考依据。

彩色多普勒超声技术在诊断及评估先天性肥厚性幽门狭窄的新应用价值

目的:旨在通过运用彩色多普勒超声的血流显像技术(CDFI)及脉冲多普勒(PW)频谱分析技术观察先天性肥厚性幽门狭窄(CHPS)患儿的幽门管组织的血流分布、血流速度等情况,以探讨彩色多普勒超声在诊断CHPS并评估其肥厚程度的应用价值。方法:选取2006—2015年广州市第一人民医院新生儿科经超声检查及X线造影检查确诊的65例CHPS患儿,以50例各项生命体征均正常且无临床症状的婴儿作为对照组,对65例CHPS患儿及对照组婴幼儿进行超声检查,记录受检者的幽门形态结构并分别测量幽门肌层厚度、幽门管长径、直径和幽门管内径,通过CDFI检查观察肥厚幽门黏膜各层的彩色血流分布特点并对幽门肌层进行血流分级;通过PW技术进行血流速度测量和频谱分析;另外将CHPS组肌层按厚度分为3组,比较肌层厚度与上述参数间的关系。结果:肥厚的幽门管各层黏膜组织的血流具有分布特征;肌层血流分级为2.83±0.38;最大血流速度(Vmax)为(16.96±0.91)cm/s;阻力指数(RI)为0.68±0.33。65例CHPS患儿的肌层厚度与年龄、体质量、幽门管直径、Vmax、RI均呈正相关(r=0.63、0.48、0.68、0.48、0.42,P均<0.05),与幽门管长度无相关性(r=0.13,P>0.05)。以肌层厚度分为3组的病例中第1组与第2组的血流分级、Vmax及RI无显著差别,血流均较丰富,第3组的血流分级较低,且Vmax加快,RI增大。结论:通过彩色多普勒超声技术检查,可准确掌握幽门管的黏膜各层的血流分布情况和肌层血流分级,并通过测量Vmax及RI以估计幽门狭窄的轻重程度,为临床选择治疗方式乃至为手术治疗方案提供宝贵的客观资料,且简便易行,具有较大的临床应用价值。

先天性肥厚性幽门狭窄的X线诊断

目的总结分析婴幼儿先天性肥厚性幽门狭窄的X线特征.方法回顾分析2000年1月～2004年6月经手术、病理证实的50例先天性肥厚性幽门狭窄患儿的X线检查及其表现.结果胃扩张50例,胃排空延迟50例,'双轨征'23例.'线样征'50例,'鸟嘴征'36例,'肩样征'22例,'蕈伞征'42例,胃食管返流20例.结论钡餐造影是诊断先天性肥厚性幽门狭窄的可靠方法.

超声测量小儿肥厚性幽门狭窄的相关性研究

目的探讨肥厚性幽门狭窄(HPS)患儿幽门肌层厚度和幽门管长度与患儿年龄和体质量间的相关性。方法回顾性分析手术确诊的111例HPS患儿,超声测量幽门肌层厚度及幽门管长度资料及其与年龄和体质量间相关性。结果Pearson相关分析显示HPS患儿幽门肌层厚度与年龄和体质量有显著相关性(r=0.60、0.49,P<0.01),而幽门管长度与年龄和体质量间无相关性(r=0.13、0.02,P=0.177、0.868)。结论 HPS患儿的幽门肌层厚度与年龄和体质量直接相关,提示对于年龄较小和(或)体质量较轻的疑似HPS新生儿,其肌层厚度和幽门管长度未达HPS的超声诊断标准时,可进行随访复查。