Structural Defects: Pyloric Stenosis (Nursing)

00:01 Hi, I'm Dr. Jackie Calhoun and today we're going to talk about Pyloric stenosis.

00:07 This is everything we're going to cover in this lecture.

00:09 So we'll talk about the definition, the epidemiology or who gets this, the causes, the signs and symptoms, which are also the cues, the diagnosis and the treatment of this disorder.

00:22 Let's start with the definition.

00:25 So in order to do that, we need to review our anatomy.

00:27 Let's remember that the stomach is in the left upper quadrant of the abdomen.

00:32 And the esophagus connects the mouth to the stomach.

00:36 And this is where, when someone eats, the food starts in the mouth goes down the esophagus, and then enters the stomach.

00:43 And then the pylorus is at the exit of the stomach before the small intestine.

00:48 before the small intestine.

00:50 And you can see here that first part of the small intestine, it's called the duodenum.

00:53 And in pyloric stenosis, this muscle, the pylorus is thickened.

01:00 And it actually can get so thick that it causes an obstruction where the food can't exit the stomach into the small intestine.

01:08 And then that food obstructs and backs up and causes vomiting.

01:14 Who gets pyloric stenosis? This condition, it only happens in babies.

01:19 And it happens in every 2 to 3 out of every 1000 infants.

01:25 That number or either 0.2 to 0.3%, it might not sound like a lot, but that's actually pretty common for pediatric conditions.

01:34 It happens in male babies five times more in than in females.

01:38 And then it happens more often in firstborn males than it does in other males.

01:43 So what causes pyloric stenosis? We know that this develops in infants who are less than three months old.

01:50 But what we don't know is the exact cause.

01:53 It seems like genetics might be at play here because siblings who have other siblings with pyloric stenosis because siblings who have other siblings with pyloric stenosis are at an increased risk to develop it themselves.

02:04 Things that we think might also contribute are maternal smoking.

02:08 So if the mother smokes while she's pregnant with the baby, if that baby receives certain antibiotics during the first few weeks of their life, or maybe there might be an association between or maybe there might be an association between bottle feeding and an increased risk, but none of these are for sure.

02:25 What are the signs and symptoms of pyloric stenosis? And we want to remember that signs and symptoms are also cues.

02:32 The first cue is that, we want to remember that these patients are between three and six weeks old at the time of their diagnosis.

02:40 They always will have non-bilious projectile vomiting soon after eating and this is a huge cue.

02:48 It's a huge sign and symptom.

02:49 When you see or hear of a patient having non-bilious projectile vomiting, you should be concerned for pyloric stenosis.

02:57 And we want to remember that bilious, it comes from the word bile, and we know that bile is green.

03:04 So if it's non-bilious, this is not green projectile vomiting, It's often just going to look like what they ate.

03:10 So it's going to look like milky or like formula.

03:15 When these babies aren't eating and vomiting, they actually look really good.

03:20 They look healthy, they look not sick.

03:22 They look healthy, they look not sick.

03:23 They have normal mental status, the rest of their physical exam looks great.

03:27 And this is in comparison to a baby with gastroenteritis, Who looks sick, and who's throwing up maybe more often than just after eating.

03:37 And then the baby was pyloric stenosis, if they get their symptoms progressed, they often develop dehydration, and this is because they're eating but they're not actually digesting that formulas but they're not actually digesting that formulas so not really taking anything because they're throwing it up right away.

03:52 But their bodies are still making urine, they're still making stool.

03:56 And so they're putting out a lot more liquid than they're taking in and they can be dehydrated.

04:02 They may have gastric peristaltic waves, which is a way of just saying you can actually see their intestines moving as you look at their abdomen because their bodies want that food so badly but they just can't get it past the pylorus but they're trying to digest whatever they can.

04:19 And lastly, and this is the other big cue besides that non-bilious projectile vomiting, there might be a 2 to 3 centimeter olive-shaped mass that can be felt just to the right of the epigastrium.

04:30 that can be felt just to the right of the epigastrium.

04:32 So, the epigastrum is kind of in the middle and it would be right here.

04:36 And it would feel like a little hard mass, olive or oval shaped mass in their abdomen.

04:44 So now we know about our cues, but how do we actually diagnose Pyloric stenosis? An abdominal ultrasound is the most definitive way or the way that we almost always diagnose pyloric stenosis.

04:58 It's nice because it doesn't have radiation, and it can show you what you need to see.

05:03 If a patient does have pyloric stenosis, it would look elongated and thickened like it does on the picture on this slide.

05:11 If however, for some reason, we weren't able to see that pylorus very well in the abdominal ultrasound, the patient might need to have an upper gastrointestinal series, the patient might need to have an upper gastrointestinal series, or upper GI series, which is where the babies drink a special formula.

05:26 And as they're drinking, they use X-rays to follow that formula from their mouth and down their esophagus and into their stomach and in a normal baby through their stomach.

05:36 But in a baby that has pyloric stenosis, you would see that formula stop at the end of the stomach because of that hypertrophied pylorus.

05:45 Now, how do we treat pyloric stenosis? It's important to note before any of the treatment that we don't know how to prevent this.

05:53 It's just something that happens. And so we don't know what causes it.

05:56 So it's hard to prevent it.

05:57 But once a baby does have it, the first thing that we do is initially treat them with rehydration and correction of any electrolytes, because of all the vomiting they've been having.

06:08 This rehydration is done with IV fluids because these patients if they ate, they're gonna throw up, and we know that.

06:18 Then the next part of the treatment is surgery.

06:21 So all these patients have a surgical correction to fix that pylorus.

06:26 It's a quick operation, and the babies can start eating soon after the procedure is over.

06:32 The surgery is called a laparotomy and it involves a few small incisions through which the surgeons put scopes, and they make an incision then along the length of the pylorus.

06:45 And then they open it up and make it wider and they suture it back together.

06:51 And the baby is left with a normal pylorus and a small incision in the upper part of their abdomen once the surgery is done.

06:59 So now that we went through all that, let's put it all together in the clinical judgment model.

07:04 We're going to look at layers two and three.

07:05 And we're going to recognize the cues are those signs and symptoms.

07:09 And the ones that we really want to remember are the non-bilious projectile vomiting, so forceful, straight out of the mouth, formula looking vomiting soon after eating.

07:20 And then that discreet 2 to 3 centimeter olive-shaped or oval shaped mass that you can feel in the middle part of their upper abdomen.

07:30 We want to remember that these babies look pretty healthy, when they're not eating and when they're not throwing up.

07:36 Unlike a baby that has a gastroenteritis.

07:40 It's possible that these babies if their symptoms lasts long enough that they'll develop those signs of dehydration because they're just not getting anything in and they're putting things out with the vomiting and they're putting things out with the vomiting and the stooling and the urine.

07:53 And then lastly, you may see those gastric peristaltic waves because of that increased intestinal activity.

07:58 Let's analyze all those cues and signs and symptoms.

08:02 So we want to just remember again, that the most important things are the non-bilious projectile vomiting, and that discrete olive-shaped mass, and then looking for signs and symptoms of this condition on their physical exam.

08:16 We diagnose this condition with abdominal ultrasound.

08:21 And if that's not conclusive, we need more evidence, And if that's not conclusive, we need more evidence, then they may have an upper GI series as well.

08:28 Let's develop our action plan. And there's two parts to this.

08:32 The first part is initial treatment with IV rehydration and correcting any electrolyte abnormalities.

08:38 And then the second is always surgical intervention And then the second is always surgical intervention to fix that hypertrophied pylorus.

08:45 So thank you for watching this video.

08:47 I hope you learned about something about pyloric stenosis today, and we'll see you next time.