Adult hypertrophic pyloric stenosis - Clinicals, Diagnosis, and Management

Upper GI

Clinicals - History

Fact Explanation
An adult patient, commonly a male. Adult type pyloric stenosis can differ from pediatric component from very subtle ways. Even though there is not a prominent male predominance as in pediatric component of it, adult pyloric stenosis has been found to have a male to female ratio of 3:1. An adult patient, commonly a male.
Adult type pyloric stenosis can differ from pediatric component from very subtle ways. Even though there is not a prominent male predominance as in pediatric component of it, adult pyloric stenosis has been found to have a male to female ratio of 3:1.
Vomiting Vomiting of pyloric stenosis is copious, projectile, nonbilious, contains undigested food, and usually follows soon after eating. In adult kind, vomiting has an insidious onset of a few months and it progresses into the characteristic type slowly. Vomiting is unrelated to the type of food. Hematemesis and malena are not to be seen in vomitus unless complicated with gastritis or peptic ulceration. Diarrhea and fever are not commonly associated. Vomiting
Vomiting of pyloric stenosis is copious, projectile, nonbilious, contains undigested food, and usually follows soon after eating. In adult kind, vomiting has an insidious onset of a few months and it progresses into the characteristic type slowly. Vomiting is unrelated to the type of food. Hematemesis and malena are not to be seen in vomitus unless complicated with gastritis or peptic ulceration. Diarrhea and fever are not commonly associated.
Feeling of fullness in the upper abdomen The patients commonly complain of a feeling of fullness in the epigastrium due to the blockage. Eating aggravates the discomfort. Feeling of fullness in the upper abdomen
The patients commonly complain of a feeling of fullness in the epigastrium due to the blockage. Eating aggravates the discomfort.
Weight loss There can be a significant weight loss due to copious vomiting and poor feeding. Weight loss
There can be a significant weight loss due to copious vomiting and poor feeding.
Burning epigastric pain and with cramps In some instances, adult pyloric stenosis is associated with peptic ulcers and gastritis. Burning epigastric pain and with cramps
In some instances, adult pyloric stenosis is associated with peptic ulcers and gastritis.
Several times treated as dyspepsia By the time they present with full blown obstruction, they might have had several times of hospital admissions and misdiagnosed as dyspepsia and treated for it, with no clinical improvement. Several times treated as dyspepsia
By the time they present with full blown obstruction, they might have had several times of hospital admissions and misdiagnosed as dyspepsia and treated for it, with no clinical improvement.
Other underlying causes for pyloric stenosis Adult pyloric stenosis can be secondary to another illness, such as Crohn's disease, peptic ulcer disease, hernia, chronic gastritis associated with Helicobacter pylori, or even a malignant growth. Prostaglandin is also known to cause foveolar hyperplasia and secondary pyloric obstruction. Other underlying causes for pyloric stenosis
Adult pyloric stenosis can be secondary to another illness, such as Crohn's disease, peptic ulcer disease, hernia, chronic gastritis associated with Helicobacter pylori, or even a malignant growth. Prostaglandin is also known to cause foveolar hyperplasia and secondary pyloric obstruction.

Clinicals - Examination

Fact Explanation
Tenderness in the upper abdomen Some patients report a tenderness in the epigastrium and right hypochondrium. This could be due to obstruction or peptic ulcers. Tenderness in the upper abdomen
Some patients report a tenderness in the epigastrium and right hypochondrium. This could be due to obstruction or peptic ulcers.
Features of dehydration. i.e. dry mucus membranes, reduced sweating. Due to copious amount of vomiting. Features of dehydration.
i.e. dry mucus membranes, reduced sweating. Due to copious amount of vomiting.
Evident weight loss Due to feeding intolerance and dehydration. Evident weight loss
Due to feeding intolerance and dehydration.

Investigations - Diagnosis

Fact Explanation
Barium studies or Fluoroscopy The first line in investigation of choice in suspected gastric outlet obstruction. The Barium meal and follow through will show the site of obstruction, number of sites affected, and details of the luminal surface of the obstructed site. The usual method is to observe whether the Barium meal passes through the pylorus to the small intestine within 3-6 hours of ingestion, and if it delays that that, it is considered to be obstructed. The expected findings are dilated stomach, narrow antral lumen (string sign) which is duplicated due to puckering of the mucosa (double-track sign), pylorus indenting to the contrast-filled antrum (shoulder sign), base of the duodenal bulb (mushroom sign) and entrance to the pylorus being beak-shaped (beak sign). Barium studies or Fluoroscopy
The first line in investigation of choice in suspected gastric outlet obstruction. The Barium meal and follow through will show the site of obstruction, number of sites affected, and details of the luminal surface of the obstructed site. The usual method is to observe whether the Barium meal passes through the pylorus to the small intestine within 3-6 hours of ingestion, and if it delays that that, it is considered to be obstructed. The expected findings are dilated stomach, narrow antral lumen (string sign) which is duplicated due to puckering of the mucosa (double-track sign), pylorus indenting to the contrast-filled antrum (shoulder sign), base of the duodenal bulb (mushroom sign) and entrance to the pylorus being beak-shaped (beak sign).
Ultrasound scan of abdomen It is a non-invasive method of visualizing the pyloric muscle. The radiologists have criteria to diagnose depending on the thickness of the muscle layer. i.e. 3mm cut off value. Ultrasound scan of abdomen
It is a non-invasive method of visualizing the pyloric muscle. The radiologists have criteria to diagnose depending on the thickness of the muscle layer. i.e. 3mm cut off value.
Endoscopy of upper gastrointestinal tract It allows better visualization of the pyloric muscle. It also allows the surgeon to take biopsies of hypertrophies areas. Endoscopy of upper gastrointestinal tract
It allows better visualization of the pyloric muscle. It also allows the surgeon to take biopsies of hypertrophies areas.
Histopathological examination Gross hypertrophy of the muscle layer is expected. Importance is it excludes the malignancies and inflammatory lesions. Histopathological examination
Gross hypertrophy of the muscle layer is expected. Importance is it excludes the malignancies and inflammatory lesions.

Investigations - Management

Fact Explanation
Complete blood count To exclude presence of an infection or anemia prior to surgery. Complete blood count
To exclude presence of an infection or anemia prior to surgery.
Liver function tests i.e. Serum transaminases, bilirubin, gamma-GT, albumin and total protein. To exclude liver disease prior to surgery. Liver function tests
i.e. Serum transaminases, bilirubin, gamma-GT, albumin and total protein. To exclude liver disease prior to surgery.
Renal function tests i.e. serum electrolytes, urine full report, serum creatinine. To exclude renal disorders prior to surgery. Renal function tests
i.e. serum electrolytes, urine full report, serum creatinine. To exclude renal disorders prior to surgery.
Chest X-ray To exclude respiratory illness prior to surgery. Chest X-ray
To exclude respiratory illness prior to surgery.
Fasting blood sugar To look for diabetes as a risk factor for embolism and to exclude it prior to surgery. Fasting blood sugar
To look for diabetes as a risk factor for embolism and to exclude it prior to surgery.
Lipid profile To look for dyslipidemia as a risk factor for embolism and to exclude lipid disorder prior to surgery. Lipid profile
To look for dyslipidemia as a risk factor for embolism and to exclude lipid disorder prior to surgery.
12 lead electrocardiogram To exclude presence of atrial fibrillations a causative factor for embolism. 12 lead electrocardiogram
To exclude presence of atrial fibrillations a causative factor for embolism.
Echocardiogram To exclude the presence of luminal thrombus. Echocardiogram
To exclude the presence of luminal thrombus.

Management - Supportive

Fact Explanation
Re-hydration and correction of electrolytes The water balance and electrolytes should be restored to normal levels immediately because the patients usually present with copious vomiting for a considerable time. Alkalosis is life threatening and should be paid immediate attention to. Re-hydration and correction of electrolytes
The water balance and electrolytes should be restored to normal levels immediately because the patients usually present with copious vomiting for a considerable time. Alkalosis is life threatening and should be paid immediate attention to.

Management - Specific

Fact Explanation
Pylorotomy The definitive treatment mode is surgical pyloromyotomy,where the pyloric muscle is divided down to the submucosa. This can be performed both open and laparoscopically. The operation is curative and has very low morbidity. Pylorotomy
The definitive treatment mode is surgical pyloromyotomy,where the pyloric muscle is divided down to the submucosa. This can be performed both open and laparoscopically. The operation is curative and has very low morbidity.
Pyloroplasty Can be performed in the absence of ulceration. Endoscopic pyloroplasty is also available for minimal invasive technique. Pyloroplasty
Can be performed in the absence of ulceration. Endoscopic pyloroplasty is also available for minimal invasive technique.
Partial gastrectomy When a clear margin is not to be found, or in circumferential thickenings. Partial gastrectomy
When a clear margin is not to be found, or in circumferential thickenings.

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