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Hypertrophic Pyloric Stenosis: Examination

by Kevin Pei, MD

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    00:01 How do babies present? Classically, they vomit postprandially.

    00:06 The emesis is usually non-bilious.

    00:09 And the emesis is described classically as projectile.

    00:14 This makes anatomic sense.

    00:16 As a pyloric channel becomes stenotic, gastric content has nowhere to go.

    00:21 It’s non-bilious because it does not have the opportunity to mix with bilious content in the duodenum.

    00:27 Projectile, because as a stomach gets more and more distended, it's got a closed channel by the pylorus.

    00:33 The only way the patient can drain gastric content is by forceful vomiting.

    00:40 One important thing to notice is how the child is always hungry after vomiting and wants to feed again, a sign called the hungry vomiter.

    00:49 On physical examination, we oftentimes find an olive mass in the upper quadrant of the abdomen.

    00:55 Because babies have relatively thin abdominal walls, this is easier to appreciate.

    01:00 On the left side of the screen is a palpation of the abdomen, finding this olive mass.

    01:06 And on the right side of the screen is an ultrasound.

    01:09 We’ll get to that in a second.

    01:11 Aside from a baby who may have projectile vomiting, they also have sunken fontanelles.

    01:20 What does that mean? As you’ll remember, the skull has not completely fused in an infant.

    01:25 And one of the first signs of dehydration is sunken fontanelles.

    01:29 A lethargic baby.

    01:33 This, obviously, is not specific to hypertrophic pyloric stenosis.

    01:37 As you'll recall from many other pediatric modules, a lethargic baby or one that has failure to thrive is an ill baby.

    01:45 There are some important findings on chemistry with patients with non-bilious projectile vomiting, such as in hypertrophic pyloric stenosis.

    01:54 Low sodium, low chloride, and low bicarb.

    01:59 The CBC may actually be completely normal.

    02:02 Next, let's move to an ultrasound imaging.

    02:06 Ultrasound imaging is first-line therapy.

    02:08 Again, it doesn't introduce any radiation to the baby.

    02:12 An ultrasound is particularly useful for pyloric channel stenosis.

    02:16 Here in this image, you notice two white dots on the image.

    02:20 It’s actually measuring the thickness of the channel.

    02:23 Not only is the thickness important, the length of the channel is also important.


    About the Lecture

    The lecture Hypertrophic Pyloric Stenosis: Examination by Kevin Pei, MD is from the course Special Surgery.


    Included Quiz Questions

    1. Non-bilious
    2. Silent reflux
    3. Bilious
    4. Pre-prandial
    5. Non-projectile
    1. Olive mass in upper abdomen.
    2. Irregular mass below the right rib cage.
    3. Spongy-feeling mass in one or both sides or toward the back (flank area).
    4. Sausage-shaped masses.
    5. Tender, irregularly shaped mass in the right-upper quadrant.

    Author of lecture Hypertrophic Pyloric Stenosis: Examination

     Kevin Pei, MD

    Kevin Pei, MD


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    A very good lecture , presented accurately
    By Dvsvb R. on 30. December 2018 for Hypertrophic Pyloric Stenosis: Examination

    Explained in a way to understand very well for all . Presentation is good