International Journal of Contemporary Pediatrics

Kumar A et al. Int J Contemp Pediatr. 2016 May;3(2):473-476

http://www.ijpediatrics.com pISSN 2349-3283 | eISSN 2349-3291

DOI: http://dx.doi.org/10.18203/2349-3291.ijcp20160698
Research Article

Study of clinical, biochemical evaluation and outcome

in hypertrophic pyloric stenosis
Anil Kumar, Umesh K. Gupta, Prashant Gupta, Somendra Pal Singh*, Mohit Gupta,
Praveen Singh, Manas Prakash

Department of Surgery, UP RIMS & R, Saifai, Etawah, UP, India

Received: 28 February 2016

Accepted: 03 March 2016

*Correspondence:
Dr. Somendra Pal Singh,
E-mail: [email protected]

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Gastric outlet obstruction (GOO) in infancy and childhood may result from congenital causes, antral
diaphragm, pyloric atresia, heterotrophic pancreas, and infantile hypertrophic pyloric stenosis (IHPS), or acquired
causes (peptic ulcer, caustic ingestion, tumour, chronic granulomatous disease and Eosinophilic gastroenteritis).
Infantile hypertrophic pyloric stenosis (IHPS) is among the most common surgical disorders in infancy and presents
in approximately 3:1000 live births in the United States. In India it is estimated to be 1 in 3,500 live births
The objective of the study was to analyse the age and sex of presentation, try to compare preoperative and
postoperative biochemical alteration and find out how to reduce the incidence of complications of infantile
hypertrophic pyloric stenosis (IHPS).
Methods: Children attending at surgery OPD or emergency UP RIMS & R for no bilious vomiting during 15 March
2015 to 15 February 2016 less than 1 Year of age of both sex.
Results: we found that IHPS was more common among first born male child in more commonly in Hindus and most
common time of presentation is first 8 weeks dyselectronemia was a common feature.
Conclusions: Infantile hypertrophic pyloric stenosis (IHPS) which is caused by thickened antropyloric muscle is a
disease which causes gastric outlet obstruction. It is the most common surgical condition in infants within two month
of postnatal life. This disease is presented with projectile non-bilious vomiting which may be blood tinged if it is
prolonged without correction may cause hypochloremic hypokalemic alkalosis and death in more than 50% of the
affected patients.

Keywords: Infantile hypertrophic pyloric stenosis, Non bilious vomiting, Dyselectronemia

INTRODUCTION the most common surgical disorders in infancy and

presents in approximately 3:1000 live births in the United
Gastric outlet obstruction (GOO) in infancy and States. In India it is estimated to be 1 in 3,500 live births.7
childhood may result from congenital causes, antral There is a 4:1 male dominance, and white infants are
diaphragm, pyloric atresia, heterotrophic pancreas, and more commonly affected. In literature IHPS is also
infantile hypertrophic pyloric stenosis (IHPS), or reported in approximately 200 adult person.8-10 Birth
acquired causes (peptic ulcer, caustic ingestion, tumour, order seems to play a role, because first born male child
chronic granulomatous disease and eosinophilic are more likely to be affected by the disorder than their
gastroenteritis).1-5 When IHPS is excluded, the other siblings. The precise cause of the pyloric circular muscle
causes of GOO in children are rare and the incidence of hypertrophy remains poorly understood. Numbers of
the other causes was only 1 in 100,000 live births.1,6 theories for IHPS are present but none can explain fully
Infantile hypertrophic pyloric stenosis (IHPS) is among the pathogenesis of infantile hypertrophic pyloric

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 Kumar A et al. Int J Contemp Pediatr. 2016 May;3(2):473-476

stenosis, which implies that the cause may be Patient evaluation

multifactorial. Patients often present with a marked bio-
chemical electrolyte abnormalities requiring correction All patients with provisional diagnosis of IHPS admitted
prior to surgery to prevent anaesthetic complications e.g. in our institute in the above mentioned period for,
apneas due to compensatory carbon dioxide retention.11-14
 Clinically and systematically examined for
In IHPS hypertrophy of circular smooth muscle lead to presence of signs of dehydration or electrolyte
partial luminal outflow obstruction. This partial imbalance.
obstruction causes vomiting of feeds and gastric content  Investigations like USG, serum electrolytes
leads to dehydration, electrolyte imbalance and in late parameter, urinary pH by strip/litmus paper and
cases failure to thrive. IHPS Patients typically present symptomatology.
with hypochloremic metabolic alkalosis. Although the
serum potassium level may be normal or low, often there Parameters studied
is total-body potassium depletion. The observed
metabolic alkalosis is a result of two related but a) Mean age of the patient at the time of operation
independent processes: loss of acid and retention of b) Sex incidence of the IHPS
bicarbonate. c) Religion wise incidence of patient and
preponderance if any (Hindu /Muslim).
Initially, vomiting of gastric contents results in excessive d) Preoperative and postoperative blood
loss of hydrogen chloride which leads to a metabolic biochemical and urinary pH alteration.
alkalosis. Under normal circumstances, carbonic acid in e) Postoperative complication: wound dehiscence
the villi of the stomach dissociates into hydrogen and with bowel evisceration; wound gaping, sepsis,
bicarbonate. The hydrogen ions cross the luminal death.
membrane of the enterocyte and enter the stomach, from f) Hospital stay
where they are transported to the duodenum. The entry of
acid into the duodenum stimulates the secretion of an RESULTS
equal amount of pancreatic bicarbonate. This normal
stimulus is absent in pyloric stenosis because of the We studied 25 cases of IHPS relevance history, examined
mechanical obstruction: the diminished secretion of and investigated for sign and symptoms, admitted in the
pancreatic bicarbonate into the GI tract contributes department during the above mentioned period.
further to the metabolic alkalosis created by stomach acid
lost through vomiting. We selected 25 of IHPS patient prospectively which have
complete data regarding history, examination, operated in
Aims and objectives the department and full follow up with time.

In this study we are going to analyse the age and sex of In our study,
presentation, try to compare preoperative and
postoperative biochemical alteration and find out how to  We found that 25 cases of IHPS admitted in our
reduce the incidence of complications of infantile department 84% (21) of patients were males and
hypertrophic pyloric stenosis (IHPS). 16% (4) of patients were females.
 In these 25 patients Hindu patients were 64%
 Age and sex of presentation (16) and Muslim patients were 36% (9).
 Analysis of pre-operative clinical features  Among Hindu patient male were 81.25% (13)
 Pre-operative observations of serum electrolytes and female were 18.75% (3), in Muslim patient
(Na+, K+ ,Cl- , HCo3- ) and urine PH male were 77.77% (7) and female were 22.22%
 Postoperative observations are: (3).
 IHPS children less than four week are 28% (7) in
 Hospital stay which all were male and among these Hindu was
 Serum electrolytes (Na+, K, Cl-, HCo3-) and 16% (4) and Muslim was 12% (3).
urine pH  IHPS Children between four to eight week were
 Incidence of wound infection 48 % (12), among these 24 % (6) of Hindu male,
 Any other complications within 3 months 4% (1) of Hindu female, 20 % (5) of Muslim
male and 0% (0) Muslim female.
METHODS  IHPS children’s more than eight week 24% (6),
in which Muslim were 16% (4) (4 male and 0
Children attending at surgery OPD or emergency UP female) and Hindu were 12% (2) (2 male and 0
RIMS & R for nonbilious vomiting during 15 March female).
2015 to 15 February 2016 less than 1 year of age of both  72% (18) infant are first birth order, 20% (5) are
sex. second birth order, 4% (1) are third birth order
and 4% (1) of infant are fifth birth order.

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 Kumar A et al. Int J Contemp Pediatr. 2016 May;3(2):473-476

 Patient’s mother had no significant antenatal patient varies from 4:1 and Mitchell LE et al found in
complications neither any more was say there study male female ratio 2:1 to 5:1 in IHPS patient.
significant family history.
 All IHPS infant presented with clinical feature of Birth order in IHPS patients of our study 72% of Patients
non-bilious vomiting in our hospital. Children’s are first birth order similar to Mac Mahon study in the
with non-bilious vomiting 24 patient have Mac Mahon study they found that the prevalence of IHPS
history of Projectile vomiting and 1 baby non decline with increasing birth order and highest prevalence
projectile regurgitation like history was present. among first-born infants.24
 Dehydration was present in 52% (13) of
children’s; no sign of dehydration was present in Visible peristalsis present in 60% which is higher than
48% (12) of patient. Taylor ND et al in there study they seen 25% visible
 Visible peristalsis present in 60% (15) patient peristalsis in IHPS patient.25
but no visible peristalsis seen in 40% (10)
patient. Electrolytes abnormalities found in 64 % which was low
 Patient’s electrolytes 64% (16) of patient had from David J. Wilkinson, et al study.26 David J.
dyselectronemia and 36% (9) of baby have no Wilkinson et al in there study observe 69.53%
dyselectromea found. Urinary pH abnormality in electrolytes abnormalities.
pre-operative or post operatively was not found
in any patient. Ultra sonography was diagnostic in all IHPS suspected
 Ultra sonography was diagnostic in all suspected cases similar to Iqbal CW et al study.27 Iqbal CW et al in
cases. there study they found that overall, US had 100%
 Patient has no electrolytes abnormalities first sensitivity and specificity for PS. Thickness of 3 mm or
post-operative follow up cases. higher was 100% sensitive and 99% specific, and pyloric
 Most of patients were discharge on 2nd post of length of 15 mm or higher was 100% sensitive and 97%
day. specific.

DISCUSSION In our IHPS patients, total hospital stay was 3-6 day
similar to Behrouz Banieghbal study.28 Standard fluid
Gastric outlet obstruction (GOO) in infancy and protocol resulted in near-complete correction of alkalosis
childhood may result from congenital cause’s e.g -antral and hypochloremia within 12-48 h.
diaphragm, pyloric atresia, heterotrophic pancreas, and
infantile hypertrophic pyloric stenosis, supra ampullary CONCLUSION
duodenal obstruction or acquired causes e.g. (peptic
ulcer, caustic ingestion, tumour, chronic granulomatous Infantile hypertrophic pyloric stenosis (IHPS) which is
disease, and eosinophilic gastroenteritis.15-18 Among caused by thickened antropyloric muscle is a disease
them, IHPS is the most common cause. When IHPS is which causes gastric outlet obstruction. It is the most
excluded, however, the other causes of GOO in children common surgical condition in infants within two month
are relatively rarely encountered, and the incidence of the of postnatal life.
latter causes was only one in 100,000 live births.14,19
Debate still continues as to whether it is congenital or This disease is presented with projectile non-bilious
acquired.20 vomiting which may be blood tinged if it is prolonged
without correction may cause hypochloremic
Our study carried out in UP RIMS & R, Department of hypokalemic alkalosis and death in more than 50% of the
surgery from Jan 2015 to Dec 2015. We studied a total of affected patients. Characteristic history of projectile non-
25 cases of infantile hypertrophic pyloric stenosis that bilious vomiting, gastric visual peristalsis and Palpation
were fully examined and investigated for symptom and of an olive-like mass in the right upper quadrant (RUQ) is
signs. considered diagnostic. Sometimes clinical examination of
a crying infant is difficult, doubtful and time consuming
76% of patient below eight week which is similar to Puri so help of imaging findings increases yield of the
and Lakschmanadass study.21 In the study of Puri and diagnosis and definitively exclude other pathology of
Lakschmanadass they found in there study that IHPS is gastric outlet obstruction. The sensitivity and specificity
the most common condition requiring surgery in the first of US to diagnosis of IHPS is 89%-100% and an
few months of life, typically occurring between 3 and 6 accuracy approximately of 100%. In ultrasonography
weeks of age. muscle thickness >3 to 4 mm and a canal diameter >15-
16 mm is diagnostic. Patient should be corrected for
Our study revealed male to female ratio found 5.25:1 hypovolmia and serum biochemical abnormality prior to
which is more than Liao Z et al study but approximately operative procedure. Mini laparotomy or laparoscopic
same as Mitchell LE et al study.22,23 Liao Z, et al they surgery is option of current surgical treatment.
found in there study that male female ratio in IHPS laparoscopic surgery have good cosmetic result, less
postoperative pain, early return of bowel habit, early

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 Kumar A et al. Int J Contemp Pediatr. 2016 May;3(2):473-476

enteral feeding are few advantages over open or mini 15. Sharma KK, Agrawal P, Toshiniwal H. Acquired
laparotomy. Carefully evaluation and biochemical gastric outlet obstruction during infancy and
management prior to surgery reduces mortality childhood: A report of five unusual cases. J Pediatr
approximately 50% (untreated cases) to less than 1%. Surg. 1997;32:928-30.
16. Ciftci AO, Tanyel FC, Kotiloglu E. Gastric
Funding: No funding sources lymphoma causing gastric outlet obstruction. J
Conflict of interest: None declared Pediatr Surg. 1996;31:1424-6.
Ethical approval: The study was approved by the 17. Granot E, Matoth I, Korman SH. Functional
Institutional Ethics Committee gastrointestinal obstruction in a child with chronic
granulomatous disease. J Pediatr Gastroenterol Nutr.
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