In this lecture, we’re going to discuss
structural gastro and intestinal
diseases in children.
Specifically, ones involving
the enteric system.
Let’s start with congenital
hypertrophic pyloric stenosis.
So here’s a case for you.
A baby who’s a male who is four weeks
old and is born to a P1G1 mother.
In other words, it’s her first
pregnancy and first child,
presents to the emergency
department with new onset
vomiting after feeding.
Physical exam reveals a firm,
olive-shaped abdominal mass.
So new onset projectile nonbilious
vomiting after feeding,
firm, olive-shaped abdominal
mass in a first time mother.
This is a classic case of pyloric stenosis.
So pyloric stenosis is a
hypertrophy of the pylorus muscle,
resulting in a gastric
This happens typically in about one to
three out of every thousand live births.
As a pediatrician, we see
this fairly frequently.
Risk factors include being a first born
male, which is fully one-third cases,
having a family history
of pyloric stenosis,
but also macrolide antibiotic use
in the first two weeks of life
increases the risk
of pyloric stenosis.
So it has both genetic and
none of which are
Typically, these patients
will present with nonbilious
because the constriction is before
the outlet of the gallbladder.
It’s projectile because the stomach
contents are under quite a bit of pressure
and will literally fly out
of the child’s mouth,
and it’s usually postprandial.
They eat and then they
And usually, they’re hungry
again after they vomit.
You may palpate an olive-like
mass in the right upper quadrant.
That is a very high-yield
But the fact that that’s a high-yield
test question is a little bit absurd
because in reality, we almost never
actually feel the olive-like mass.
I felt it myself once in
patient with a ventral hernia,
but other than that, I’ve
never appreciated the mass.
Nonetheless, it’s common
on test questions.
What you might see in a patient if you were
to offer that child formula or Pedialyte,
as their child is trying to eat, is you
might appreciate peristaltic waves
proceeding through the stomach as
that child is trying to digest the food.
Children will get dehydrated quickly
because they’re really not capable
of keeping anything down.
And they may have worsened jaundice
simply because of inability to pass
stool because of a lack of food.
On this slide, you can see a very severe
case, on the very right side of the slide.
Here, you can see the palpable mass in
this child’s abdomen and distended belly.
This child has been having
pyloric stenosis for a long time
and this is really
One thing that’s key that you’ll notice
that is unique to pyloric stenosis
is you will see a hypochloremic
These children will have a low chloride
because they have been vomiting up their
hydrochloric acid that the stomach makes.
And that’s also why
They will also have a
So if you suspect pyloric stenosis,
the test of choice is the ultrasound.
It’s a simple expedient test
where the probe is placed just
over the outlet of the stomach
and a thickened pylorus is measured.
If we have a patient with pyloric stenosis,
the first step is to stabilize the child.
So certainly if a child is having
alkalosis, we want to correct that.
Usually simple hydration is sufficient.
Then, the patient in the United States
is typically taken for a pyloromyotomy.
This is a very quick and relatively
simple and safe procedure
where surgeons make a longitudinal
incision through the pylorus
to the outer layer
of the submucosa.
They don’t cut directly through
the full wall of the mucosa,
simply through the muscular
layer on the outside of it.
That loosens things up and
allows the food to pass through.
They can do this laparoscopically.
And after the procedure,
they then will proceed to reinitiate
feeding, generally 12 or 24 hours later
and see how things go.
Usually, children eat just fine
afterwards and have a great outcome.
In some parts of the world,
instead of doing a pyloromyotomy,
they will simply advance a tube and
feed the child postpylorically.
This is somewhat controversial.
Most time in the US, the surgeons
prefer to do pyloromyotomy
because the child is not n.p.o.
for any period of time.
Remember, if a child’s made n.p.o., they
may have feeding difficulties later.
Additionally, in the hands
of experienced surgeons,
this is an extraordinarily