Which of the following symptoms would be apparent with a child who has been admitted with a possible pyloric stenosis?

Pyloric stenosis occurs when the passage between the stomach and small bowel (known as the “pylorus”) narrows. This is because the passage is made up of muscle which becomes thicker than normal, making the pylorus smaller and preventing the stomach from moving milk and food into the small intestine. It most often occurs in babies between two and six weeks of age. It’s not clearly known why pyloric stenosis develops but it is more common in boys than girls.

Signs and symptoms

• Vomiting after feeding. The vomiting becomes worse over a few days and can often be forceful and projectile.
• Baby often shows signs of hunger and wants to feed again after vomiting.
• Weight loss or poor weight gain.
• Possible decrease in the number of nappies with poo, as very little food is reaching the bowel.
• Dehydration can develop quickly as the vomiting worsens. The baby can become lethargic, less active and their “soft spot” (fontanelle) on the top of their head can become sunken. They can have fewer wet nappies and when they cry, may not be able to make any tears.

Dehydration in young babies is a very serious condition. If your baby has persistent vomiting, you should see your doctor immediately.

Diarrhoea is NOT usually a symptom of pyloric stenosis.

How is the pyloric stenosis diagnosed?

The doctor will take a full history from you about your baby’s feeding pattern and weight. Sometimes, during physical examination of your baby, the doctor can feel a small hard lump on the right side of your baby’s stomach. They may refer your baby for an ultrasound of the stomach area (this is similar to the ultrasound that you may have had during pregnancy). This will give the doctor some pictures of the thickened pyloric muscle.

Treatment

One of the complications of pyloric stenosis is vomiting and dehydration which can lead to changes in your baby’s blood salts (known as electrolytes). When your baby is admitted to hospital, they will have an intravenous drip (IV) inserted and have frequent blood tests (generally by pricking the heel) to make sure the electrolyte levels are stable. Your baby will also have fluid by the IV drip. At this stage, your baby won’t be allowed to have a breast feed or bottle in order to help control the vomiting. The IV fluid will be helping to rehydrate your baby. If your baby continues to vomit, the nurses may put a small tube (nasogastric tube) into their nose which then goes down to the stomach. The nurses can use this tube to remove any contents of the stomach by either drawing it out with a syringe (this is called aspirating) or by allowing it to drain itself into a small container (this is called free drainage).

Once your baby is rehydrated and the blood electrolytes are normal, an operation known as a “pyloromyotomy” will be performed under a general anaesthetic. There are no alternatives to surgery to fix pyloric stenosis. Both the surgeon and the anaesthetist will talk to you about the surgery and any risks or possible complications.

Once your baby has had surgery, they will return to the ward. The nurses will closely monitor your baby’s pain, wound and IV fluids. After six hours or so, your baby will start to feed with small amounts which will be increased slowly depending on how your baby tolerates it. Some babies continue to have small vomits after the operation but as the stomach heals, the vomiting should reduce and they should start feeding normally again. Once your baby is feeding well, you will be able to be discharged home, usually two to three days after the surgery.

Care at home

Your baby may still experience some pain from the surgery so ensure you have some pain relief available at home (such as liquid paracetomol). Dressing your baby in loose clothing may also help. The stitches used by the doctor during the surgery will dissolve so you won’t need to come back to have them removed. Your baby can have a shallow bath but try to keep the wound and dressing area dry for a few days after surgery to allow time for the wound to heal properly. Your surgeon will advise you as to whether or not you need to be seen at Queensland Children’s Hospital again or if you can see your family doctor (GP) for review after your baby has gone home.

You should call your family GP or 13 HEALTH if you have the following concerns

• Your baby is in a lot of pain and pain relief does not seem to help.
• Your baby is not feeding well and has signs of dehydration (dry nappies, lethargy, sunken soft spot).
• Your baby has a high temperature (37.50 C or higher) and paracetomol does not bring it down.
• The area around the operation site looks red or inflamed, is hot to touch or is oozing around the area.
• Your baby continues to vomit and bring up milk and is not gaining weight.

Contact us

Queensland Children’s Hospital 501 Stanley Street, South Brisbane

t: 07 3068 1111 (general enquiries)

In an emergency, always call 000.

If it’s not an emergency but you have any concerns, contact 13 Health (13 43 2584). Qualified staff will give you advice on who to talk to and how quickly you should do it. You can phone 24 hours a day, seven days a week.

Pyloric stenosis is a thickening or swelling of the pylorus — the muscle between the stomach and the intestines — that causes severe and forceful vomiting in the first few months of life. It is also called infantile hypertrophic pyloric stenosis.

The enlargement of the pylorus causes a narrowing (stenosis) of the opening from the stomach to the intestines, which blocks stomach contents from moving into the intestine.

Pyloric stenosis usually affects babies between 2 and 8 weeks of age, but can occur anytime from birth to 6 months. It is one of the most common problems requiring surgery in newborns. It affects 2-3 infants out of 1,000.

Babies with pyloric stenosis usually have progressively worsening vomiting during their first weeks or months of life. The vomiting is often described as non bilious and projectile vomiting, because it is more forceful than the usual spit ups commonly seen at this age.

The severe vomiting can result in dehydration, which may cause your baby to sleep excessively, to cry without tears, or have fewer wet or dirty diapers during a 24-hour period. Some infants experience poor feeding and weight loss, but others demonstrate normal weight gain.

Constant hunger, belching, and colic are other possible signs of pyloric stenosis because your baby is not able to eat properly. Dehydration and electrolyte imbalance are common problems and can prolong a hospital stay.

Diagnosing pyloric stenosis is made after taking a careful medical and family history and performing a physical examination. Radiographic studies are often recommended as well.

On exam, palpation of the abdomen may reveal a mass in the upper central region of the abdomen. This mass, which consists of the enlarged pylorus, is referred to as the “olive,” and is sometimes evident after your infant is given formula to drink.

Feeling the mass by palpation is a diagnostic skill requiring much patience and experience. There are often palpable (or even visible) peristaltic waves due to the stomach trying to force its contents past the narrowed pyloric outlet.

In addition to a complete history and physical exam, certain diagnostic procedures are used to confirm the diagnosis of pyloric stenosis:

• Ultrasound: the most common imaging test used to see the thickened pylorus.
• Upper GI series: a series of X-rays taken after your baby drinks a special contrast agent. The contrast agent illuminates the narrowed pyloric outlet and shows how the stomach empties.

Traditional X-rays of the abdomen are not useful in diagnosing pyloric stenosis, except when needed to rule out other potential problems.

The first step in treating pyloric stenosis is to stabilize your baby by correcting the dehydration and electrolyte imbalance, which can have a serious impact on developing babies. Your child will receive an intravenous (IV) line to replace the fluids and salts she's lost through vomiting. This can usually be accomplished in about 24-48 hours. Blood tests will monitor how she's doing.

Once the blood tests come back normal, your baby's surgery — called a pyloromyotomy — will be scheduled. Surgery is necessary to treat pyloric stenosis.

Your baby will not be able to breast or bottle feed until the surgery has been performed to correct the pyloric stenosis. Many children are fussy in this pre-surgery time because they cannot eat, but it is extremely important to minimize the chances that they vomit. As a result, children with pyloric stenosis will remain on IV fluids to keep them hydrated before surgery.

Pyloric stenosis surgery

Surgery to correct pyloric stenosis is called a pyloromyotomy. In this procedure, surgeons divide the muscle of the pylorus to open up the gastric outlet.

At The Children’s Hospital of Philadelphia, the pyloromyotomy is done laparoscopically through small incisions and with tiny scopes. By doing laparoscopic surgery, we can minimize scarring, decrease potential infections and improve recovery time for children.

Your baby will receive general anesthesia to put her to sleep during the procedure. Once she's asleep, the surgeon will make small laparoscopic incisions in the belly. The surgeon cuts the muscle layer, then puts a numbing medicine into the area and closes the incision. These stitches will be under the skin and won't need to be removed.

After your baby wakes up, she'll go to the recovery room for several hours, then to her own hospital room. Here's what to expect:

• Her incision will be covered with small strips of tape called Steri-strips®, or temporary glue called Dermabond®. The steri-strips will fall off on their own.
• The IV will stay in place until your baby is discharged; however, IV fluids will be stopped once your child is tolerating formula or breast milk.
• A few hours after the surgery, your child will be able to start feeding again. She may start off with Pedialyte® or go right to formula or breast milk. Either case will start with a small amount and increase slowly.
• Some vomiting may be expected during the first days after surgery as the gastrointestinal tract settles.
• If vomiting continues we may prescribe an antacid. The stomach lining can become inflamed with the persistent vomiting. The antacid will help to protect the stomach and can be discontinued at the post-operative visit.
• Your child's doctor or nurse will give her acetaminophen (Tylenol®, Tempra®, Panadol®) for pain.

Your baby will be discharged one or two days after surgery if she doesn't have a fever, is eating and not vomiting, and her incision isn't red or draining.

If your child is still having problems with frequent spitting up after surgery, she may be diagnosed with gastroesophageal reflux (GER). You should follow up with your primary care physician to be evaluated for gastroesophageal reflux.

Be sure to call your child's doctor (at Children's Hospital, you should call 215-590-2730) if:

• You see any signs of infection at the incision site such as redness, swelling, discharge or bleeding
• Your baby's pain gets worse, and acetaminophen doesn't help
• Your baby develops a fever greater than 101 degrees F
• Your baby forcefully vomits large amounts, or her vomit is green

Pyloric stenosis is unlikely to reoccur. Babies who have undergone surgery for pyloric stenosis should have no long-term effects from it.