What's going on
The pylorus is a muscular ring at the exit of the stomach, which allows food to pass into the duodenum in portions. With pyloric stenosis, its muscle layer gradually thickens, and the lumen narrows almost to complete closure. The stomach tries to push through the contents, its wall hypertrophies, which is why in a thin child after feeding, waves of peristalsis are sometimes visible in the upper abdomen. Since the obstruction is located above the confluence of the bile duct, vomit never contains bile - this is an important diagnostic sign. With vomiting, hydrochloric acid and potassium are lost, and a characteristic metabolic disorder develops.
- Thickening of the pylorus muscle and narrowing of the gastric outlet
- Symptoms develop at 3–6 weeks of life rather than at birth
- Vomiting without bile
- Visible gastric peristalsis after feeding
- Loss of chlorine, potassium and acid in vomit
- Boys are more likely to get sick, especially firstborns
Symptoms
Parents usually notice that regurgitation increases day by day and turns into vomit, which is thrown out in a stream over a distance. It occurs soon after feeding, the volume of vomit is large, sometimes exceeds the volume of what was eaten, because milk from the previous time remains in the stomach. At the same time, the baby greedily takes the breast again, because he remains hungry. The frequency of urination gradually decreases, stool becomes scanty, the skin loses elasticity, and lethargy appears. Weight stops growing and then drops below what it was at birth.
- Increasing fountain vomiting after feedings
- Vomit without bile, sometimes curdled
- Constant feeling of hunger in a child
- Lack of weight gain and weight loss
- Rare urination, scanty stool, constipation
- Dry skin and mucous membranes, retraction of the fontanel
- Anxiety followed by lethargy
What can be confused with
Regular regurgitation occurs in most babies, but it is small in volume, not a stream, and the baby gains weight normally. Gastroesophageal reflux causes regurgitation immediately after eating and in a lying position, but weight is usually not affected. An intestinal infection is accompanied by diarrhea and often fever. If there is bile in the vomit, this indicates an obstruction below the pylorus and requires urgent examination. Overfeeding and improper feeding technique also cause excessive regurgitation, so a doctor can help you figure it out.
- Physiological regurgitation - small volume, normal increase
- Gastroesophageal reflux - regurgitation without weight loss
- Intestinal infection - diarrhea and fever
- Obstruction below the pylorus - vomiting with bile
- Overfeeding and aerophagia due to improper feeding
- Adrenogenital syndrome - vomiting with loss of salt
Diagnostics
The main method is ultrasound, in which the doctor measures the thickness of the muscle layer and the length of the pylorus. It is safe, does not require radiation and allows for an accurate diagnosis. Additionally, the child’s condition is assessed: the level of electrolytes, primarily potassium and chlorine, as well as the acid-base state of the blood is determined, because a shift to the alkaline side is typical. These indicators are important not only for diagnosis, but also for preparation for surgery: it is impossible to operate on a child with severe metabolic disorders; they are first corrected.
- Ultrasound of the pylorus with muscle thickness measurement
- Examination by a pediatric surgeon and palpation of the abdomen
- Blood electrolytes: potassium, sodium, chlorine
- Acid-base status and blood gases
- General clinical blood test
- X-ray contrast examination in doubtful cases
Treatment and recovery
Pyloric stenosis can only be treated surgically; conservative methods and changing the mixture do not solve the problem. However, the operation is not performed urgently in the first hours: first, fluids are replaced intravenously and electrolytes are adjusted, usually within a day or two. Then a pyloromyotomy is performed - dissection of the thickened muscle without opening the lumen of the stomach. The intervention is short and is often performed laparoscopically. Feeding is resumed after a few hours, starting with small volumes. Minor regurgitation in the first days after surgery is common.
- Infusion preparation and correction of electrolytes
- Pyloromyotomy, including laparoscopic
- Early resumption of small feedings
- Monitoring weight gain after discharge
- Relapses are extremely rare
- The prognosis for the child’s development is favorable
