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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.

    00:41 On physical examination, we oftentimes find an olive mass in the upper quadrant of the abdomen.

    00:47 Because babies have relatively thin abdominal walls, this is easier to appreciate.

    00:52 On the left side of the screen is a palpation of the abdomen, finding this olive mass.

    00:57 And on the right side of the screen is an ultrasound.

    01:00 We’ll get to that in a second.

    01:05 Aside from a baby who may have projectile vomiting, they also have sunken fontanelles.

    01:11 What does that mean? As you’ll remember, the skull has not completely fused in an infant.

    01:16 And one of the first signs of dehydration is sunken fontanelles.

    01:22 A lethargic baby.

    01:24 This, obviously, is not specific to hypertrophic pyloric stenosis.

    01:28 As you'll recall from many other pediatric modules, a lethargic baby or one that has failure to thrive is an ill baby.

    01:37 There are some important findings on chemistry with patients with non-bilious projectile vomiting, such as in hypertrophic pyloric stenosis.

    01:45 Low sodium, low chloride, and low bicarb.

    01:51 The CBC may actually be completely normal.

    01:54 Next, let's move to an ultrasound imaging.

    01:57 Ultrasound imaging is first-line therapy.

    02:00 Again, it doesn't introduce any radiation to the baby.

    02:03 An ultrasound is particularly useful for pyloric channel stenosis.

    02:08 Here in this image, you notice two white dots on the image.

    02:11 It’s actually measuring the thickness of the channel.

    02:15 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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