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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 15  |  Issue : 3  |  Page : 471-473

Infantile hypertrophic pyloric stenosis: Transabdominal ultrasonography diagnosis


Department of Radio Diagnosis, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University) ,Wardha, Maharashtra, India

Date of Submission04-Sep-2020
Date of Decision20-Sep-2020
Date of Acceptance25-Sep-2020
Date of Web Publication1-Feb-2021

Correspondence Address:
Dr. Suresh Phatak
Department of Radio.Diagnosis, Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha - 442 001, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_132_19

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  Abstract 


Infantile hypertrophic pyloric stenosis is an important cause of vomiting in the first 6 weeks of life in a neonate. The condition is life-threatening if left untreated because vomiting can lead to dehydration and electrolyte imbalance. Transabdominal sonography is highly accurate in its diagnosis. We present the case of a 2-month-old male infant presented with a complaint of vomiting for 1 month which was milky (nonbilious) and used to occur after feeding. Classical sonographic findings are discussed.

Keywords: Neonatal vomiting, pyloric stenosis, sonography


How to cite this article:
Jain S, Phatak S, Shah A, Gupta A. Infantile hypertrophic pyloric stenosis: Transabdominal ultrasonography diagnosis. J Datta Meghe Inst Med Sci Univ 2020;15:471-3

How to cite this URL:
Jain S, Phatak S, Shah A, Gupta A. Infantile hypertrophic pyloric stenosis: Transabdominal ultrasonography diagnosis. J Datta Meghe Inst Med Sci Univ [serial online] 2020 [cited 2021 Mar 4];15:471-3. Available from: http://www.journaldmims.com/text.asp?2020/15/3/471/308542




  Introduction Top


Infantile hypertrophic pyloric stenosis (IHPS) is a disorder of infancy characterized by hyperplasia of smooth muscle fibers of the pylorus, i.e. the lower portion of the stomach leading to narrowing of the pyloric canal causing gastric outlet obstruction and thus preventing food from moving from the stomach to the intestine.[1] It is seen in 2–5/1000 Caucasian newborns per year. Among the total incidences in Caucasians, Asians and Asians constitute 20%–30% of it. Male-to-female ratio is 4:1, and it ranges from 2.5 to 5.5:1.[2] The condition is life-threatening if left untreated since the delay in diagnosis can lead to continuous vomiting, dehydration, electrolyte imbalance, and death. Therefore, prompt and accurate diagnosis is mandatory for the early surgery which is curative in almost 100% cases.[3]


  Case Report Top


A 2-month-old male infant weighing 2.26 kg came with a complaint of vomiting for 1 month. In the 1st month, there was no history of vomiting following feeding. He was born at 36.3 weeks of gestational age through a normal vaginal delivery with no neonatal intensive care unit stay. In the 2nd month of life, he started having multiple episodes of vomiting which was milky (nonbilious) and used to occur after feeding. On per abdominal examination, a mass was felt on palpation in the left upper quadrant of the epigastric region, which was olive shaped, and it used to become prominent after each feed and moved while feeding. On transabdominal sonography, there was evidence of a large amount of residue seen in the overly distended stomach, [Figure 1] elongated pyloric canal with length of 24 mm, [Figure 2] and thickened muscle wall of 6 mm [Figure 3] suggestive of the hypertrophic pylorus. In the transverse direction, the hypertrophied pylorus appeared as a round hypoechoic solid mass with a central area of increased echogenicity, known as the “doughnut” or “target” sign [Figure 4].
Figure 1: Over distended stomach with residual food within

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Figure 2: Longitudinal scan showing markedly thickened, hypoechoic gastric antral muscle and elongated pyloric canal which is nearly 24 mm in length

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Figure 3: Longitudinal scan showing thickness of the pylorus muscle (6 mm)

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Figure 4: Transverse scan showing typical hypoechoic “doughnut” or “target sign” appearance, central echogenic mucosa with fluid-filled crevices

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The patient was operated for pyloromyotomy, and hypertrophic pyloric stenosis was confirmed at surgery. The patient showed improvement in his condition after the pyloromyotomy surgery.


  Discussion Top


IHPS is one of the most common surgical causes of vomiting in infancy. Hypertrophic pyloric stenosis occurs due to the hypertrophy and thickening of the circular and longitudinal muscle of the pylorus which reduces the lumen of the pyloric channel and also elongates it. The narrowed pyloric lumen causes failure of peristaltic waves to pass through the pyloric canal, resulting in gastric outlet obstruction, gastric distention, and possibly retrograde peristalsis.[4] IHPS has shown to be associated with several congenital malformations, including trisomy 18, long-arm deletion of chromosome 21, Turner's syndrome, Smith–Lemli–Opitz syndrome, and Cornelia de Lange syndrome. It is also known to be associated with esophageal atresia, fetal ketonuria, maternal myasthenia gravis, congenital rubella, and thalidomide embryopathy.[5] The cause of IHPS is still subject to speculation, but possible causes that have been proposed include (1) prolonged spasm associated with gastric irritation and subsequent hypertrophy of the muscle (2) abnormal innervation of the pylorus with associated dysmotility, and (3) hypergastrinemia with associated increased acid content in the stomach and gastric irritation.[6]

Typically, an infant with IHPS will have a period of normal feeding for the first 2–3 weeks of life, followed by the onset of nonbilious vomiting soon after feeding, a palpable epigastric mass (which is the thickened pylorus), and dehydration (hypochloremic metabolic alkalosis due to loss of acid in the vomitus).

Gradually, the frequency of vomiting increases and sometimes becomes forceful known as “projectile.” Despite stomach distension, affected infants seem to have an insatiable appetite and may cry inconsolably. Depending upon the duration of symptoms, patients may suffer from significant weight loss, falling even below the birth weight. In severe cases, a scaphoid abdomen and protruding ribcage may be present.[5] The most helpful imaging study is ultrasonography.[7]

Increased pyloric muscle thickness and canal length; increased transverse diameter of the pylorus; thickened, redundant mucosa; estimation of the degree of gastric outlet obstruction; and calculation of pyloric muscle volume, all have been used to diagnose pyloric stenosis. However, of all the criteria, thickening of the pyloric muscle and elongation of the pyloric canal have been found to be the most useful. The muscle is considered hypertrophied when the thickness is 3 mm or greater when measuring the hypoechoic single muscle layer transversely. Pyloric canal length of 15 mm is considered diagnostic of pyloric stenosis when seen in conjunction with thickened pyloric muscle. In the classic case of hypertrophic pyloric stenosis, the thickened muscle mass is seen as a hypoechoic layer just superficial to the more echogenic mucosal layer of the pyloric canal. In the transverse section, this “olive,” on clinical palpation, resembles a sonolucent “doughnut” medial to the gallbladder and anterior to the right kidney. In the longitudinal section, sonography also allows the evaluation of functional alterations at the pylorus. Active gastric peristalsis that ends abruptly at the margin of the hypertrophied muscle, absence of a normal opening of the pylorus, and diminished passage of fluid from the stomach into the duodenum are useful adjunctive findings in pyloric stenosis.[8],[9],[10],[11],[12],[13],[14]


  Conclusion Top


Ultrasonography is highly accurate in the diagnosis of IHPS which is a noninvasive investigation helping in better patient management.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ndongo R, Tolefac PN, Tambo FF, Abanda MH, Ngowe MN, Fola O, et al. Infantile hypertrophic pyloric stenosis: A 4-year experience from two tertiary care centres in Cameroon. BMC Res Notes 2018;11:33.  Back to cited text no. 1
    
2.
Bajaji A. Supererogate, sophomore, stricture: Infantile pyloric stenosis. G J Dig Dis 2018;4:4.  Back to cited text no. 2
    
3.
Hussain M. Sonographic diagnosis of infantile hypertrophic pyloric stenosis-use of simultaneous grey-scale and colour Doppler examination. Int J Health Sci 2008;2:134, 134-40.  Back to cited text no. 3
    
4.
Srivastava PK. Congenital Hypertrophic Pyloric Stenosis. Sonoworld; 2019.  Back to cited text no. 4
    
5.
Humphries JA, Steele A. Diagnosing infantile hypertrophic pyloric stenosis. Clin Rev 2012;22:10-2.  Back to cited text no. 5
    
6.
Thai SQ, Rouse GA, DeLange M, Grube GL. Infantile hypertrophic pyloric stenosis: The role of sonography. J Diagn Med Sonography 1987;3:269-74.  Back to cited text no. 6
    
7.
Haider N, Spicer R, Grier D. Ultrasound diagnosis of infantile hypertrophic pyloric stenosis: Determinants of pyloric length and the effect of prematurity. Clin Radiol 2002;57:136-9.  Back to cited text no. 7
    
8.
John SD, Munden MM. The paediatric gastrointestinal tract. In: Rumack CM, Levine D, editors. Diagnostic Ultrasound. 5th ed. Philadelphia, PA: Elsevier; 2018. p. 1835-8.  Back to cited text no. 8
    
9.
Kirnake V, Arora A, Sharma P, Goyal M, Chawlani R, Toshniwal J, et al. Non-Invasive Aspartate Aminotransferase to Platelet Ratio Index Correlates Well with Invasive Hepatic Venous Pressure Gradient in Cirrhosis. Indian J Gastroenterol 2018;37:335-41. Available from: https://doi.org/10.1007/s12664-018-0879-0. [Last accessed on 2020 Apr 08].  Back to cited text no. 9
    
10.
Sahu P, Hiwale K, Vagha S, Gode CS. Study of Various Gastrointestinal Tract Lesions by Endoscopic Biopsies. Int J Pharm Compd Res 2019;11: 1459-64. Available from: https://doi.org/10.31838/ijpr/2019.11.03.162. [Last accessed on 2020 Apr 08].  Back to cited text no. 10
    
11.
Jindal R, Swarnkar M. Outcomes Are Local: A Cross Sectional Patient Specific Study of Risk Factors for Surgical Site Infections in Major Abdominal Surgeries. J Krishna Inst Med Sci Univ 2020;9:43-50.  Back to cited text no. 11
    
12.
Rashmi S, Jajoo SN, Belsare A. Assessment of Correlation between Clinical Examination and Investigations with Outcome in Cases of Abdominal Malignancy. Int J Pharm Res 2019;11:1465-8. Available from: https://doi.org/10.31838/ijpr/2019.11.03.163. [Last accessed on 2020 Apr 08].  Back to cited text no. 12
    
13.
Yeola ME, Gode D, Bora AK. Diagnostic Laparoscopy as an Effective Tool in Evaluation of Intra-Abdominal Malignancies. World J Laparosc Surg 2018;11:68-75. Available from: https://doi.org/10.5005/jp-journals-10033-1338. [Last accessed on 2020 Apr 08].  Back to cited text no. 13
    
14.
Yeola ME, Gode D, Bora AK. Evaluation of Abdominal Malignancies by Minimal Access Surgery: Our Experience in a Rural Setup in Central India. World J Laparosc Surg 2018;11:115-20. Available from: https://doi.org/10.5005/jp-journals-10033-1350. [Last accessed on 2020 Apr 08].  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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