National Board of Examination - Journal of Medical Sciences, Volume 2, Issue 6

National Board of Examination - Journal of Medical Sciences

Volume 2, Issue 6, Pages 1–4, June 2024
DOI 10.61770/NBEJMS.2024.v02.i06.007

CASE REPORT

Isolated pylorospasm in an infant: A diagnostic and therapeutic conundrum

Dhruv Mahajan,1,* Shubhi Gupta2 and Hari Krishna3

1
Assistant Professor, Department of Paediatric Surgery, Geetanjali Medical College, and Hospital,
Udaipur
2
Assistant Professor, Department of Obstetrics and Gynaecology, Geetanjali Medical College, and
Hospital, Udaipur
3
Assistant Professor, Department of Paediatric Surgery, Government Medical College, Goa

Accepted: 13-April-2024

Abstract
Persistent vomiting in a small infant can be due to delayed gastric emptying which is a
significant cause of distress and morbidity. After ruling out common medical causes, evaluation
for a surgical cause such as pyloric stenosis is imperative. The diagnosis of pylorospasm is
often missed between the medical and surgical realms. We describe a six-week-old infant with
persistent nonbilious vomiting who was referred with a suspicion of pyloric stenosis. However,
on evaluation clinical findings and imaging were not suggestive of pyloric stenosis. A diagnosis
of pylorospasm was made and the patient was managed with anticholinergics without any
surgery. The patient had an unremarkable recovery. The diagnosis of pylorospasm needs to be
kept in mind in an infant with persistent nonbilious vomiting. It responds satisfactorily with
pharmacotherapy and avoids the need for surgery.

Keywords: Pylorospasm, pyloric stenosis, anticholinergic, infant, nonbilious vomiting

*Corresponding author: Dhruv Mahajan

Email: [email protected]

1
National Board of Examination - Journal of Medical Sciences, Volume 2, Issue 6

Abbreviations presented with a history of multiple

GERD: Gastroesophageal reflux disease episodes of nonbilious projectile vomiting
IHPS: Infantile hypertrophic pyloric for five days. There was no previous
stenosis comorbidity. The child was born via normal
PS: Pylorospasm vaginal delivery at full term with
UGI: Upper gastrointestinal appropriate for age weight and had been
breastfeeding normally until five days prior.
Introduction At examination, the patient was well
Repeated episodes of nonbilious preserved with a weight of 3.6 kilograms
vomiting in infants are a common cause of with depressed fontanelle and delayed
discomfort for the child and parents. capillary refill time. There was no history of
Significant vomiting and intolerance of fever, loose stools, inconsolable crying, or
feeds leading to dehydration need careful any other localizing signs. On abdominal
examination and evaluation. Common examination, there was no abdominal
causes in infants aged 2-8 weeks include distension, tenderness, or guarding. No
infantile hypertrophic pyloric stenosis mass or olive was palpable. There was
(IHPS) and gastroesophageal reflux disease metabolic acidosis (pH 7.2) in blood gas
(GERD). Pylorospasm (PS) is often with normal serum electrolytes. Complete
considered as a differential but without any blood counts were normal with a total
set diagnostic or management criteria. In leucocyte count of 10,000/uL. Serum C-
the absence of any specific symptom, sign, Reactive Protein was 2mg/L and serum
or investigation, it is more of a diagnosis by Procalcitonin was 0.05ng/ml. Along with
exclusion [1]. In the recent literature, there initial resuscitation with intravenous fluids,
have seldom been any reports of this entity. ultrasonography was ordered. There were
Pyloric narrowing leading to no signs of hypertrophic pyloric stenosis on
gastroparesis causes a functional ultrasonography with a normal pyloric
obstruction at the pylorus imitating IHPS canal wall thickness, length, and diameter
and possibly GERD [2]. Clinical (Figure 1). However, a distended stomach
examination and imaging can reliably was found. A contrast study revealed
diagnose IHPS. However, no such narrowing and stasis at the pylorus with a
clinching signs are available for PS. Hence, distended stomach, which subsequently had
a high index of suspicion is necessary to a small delayed clearance with a significant
avoid any unnecessary surgery or persistent hold-up of contrast in the stomach (Figure
symptoms, as possible PS cases can be 2). There was no GERD or malrotation
managed medically successfully. Here, we observed in the contrast study. Nasogastric
describe a six-week-old infant with decompression via nasogastric tube was
vomiting managed as PS and discuss the done and the child was kept nil per oral. The
available literature on the same topic. nasogastric tube was removed after three
days, and small-volume trophic feeds were
Case report initiated with anti-GER measures. There
A six-week-old first-born male was recurrent projectile vomiting and on
infant born to a thirty-year-old female repeat ultrasound, there was no IHPS.

2
National Board of Examination - Journal of Medical Sciences, Volume 2, Issue 6

Figure 1. Ultrasound depicting normal pyloric parameters: normal wall thickness, normal
diameter, and canal length, not suggestive of pyloric stenosis. Passage of gastric contents and
opening of the pylorus were observed while monitoring via ultrasound over a span of 10
minutes.

Figure 2. Upper gastrointestinal contrast study showing (A) a distended stomach with (B)
hold up of contrast at the pylorus. However, a slow distal contrast run-off is observed after 40
minutes (C).

3
National Board of Examination - Journal of Medical Sciences, Volume 2, Issue 6

Isolated anti-GER measures were for two days and then small-volume feeds
unable to alleviate the symptoms. All the (expressed breast milk) were started
history, investigations, and treatments were initially at the rate of 5ml every 3 hourly.
reviewed and a suspicion of pylorospasm as The feeds were gradually increased and
the cause was considered. breastfeeding was started on the third day
Gastroesophageal reflux was ruled out after initiating medication. By the morning
based on history and even then anti-reflux of the fifth day, the baby was accepting
measures were started after admission. breastfeeding ad-lib. The child tolerated
However, there was no response. feeds without any vomiting. The child was
Gastroenteritis and Drug-induced discharged on the fifth day and the dose was
gastroparesis were ruled out based on decreased to 0.2mg once daily. Repeat
feeding history. The baby was fed only ultrasonography after two weeks, showed
breastfed and no top feed was given. normal pyloric wall thickness, length, and
Hygiene-related issues were ruled out after diameter. Following this, 0.2mg alternate
evaluating the mother’s feeding habits. The day was given for one week and then the
stool microscopy and culture were also medication was stopped completely. The
negative. There was mild dehydration, child had no recurrence of symptoms and is
which was corrected on admission. thriving well at follow-up performed at six
However, the symptoms persisted even months of age with adequate weight gain.
then. Sepsis was ruled out clinically and
laboratory tests as CRP and PCT were Discussion
negative. Intestinal obstruction and An infant with repeated episodes of
malrotation of the gut were ruled out on persistent nonbilious vomiting requires
plain abdominal radiographs and urgent attention. Since smaller infants have
ultrasonograms, respectively. There were poor reserves and are prone to dehydration
no signs, symptoms, or any other indication leading to electrolyte disturbances, this can
suggestive of a raised intracranial pressure. be deadly. With the advent and wide-scale
Since the symptoms were acceptance of ultrasonography, the
intractable and persistent even on diagnosis of hypertrophic pyloric stenosis
conservative management and reflux as a cause is readily picked up and treated.
measures. The parents were duly explained However, in the absence of sonographic
about the differential diagnosis of findings, the remaining cases are attributed
pylorospasm. The parents were also to either GERD or anecdotal. PS is an
explained that hyoscine is not the uncommonly described entity in patients
traditional management and has been rarely with similar symptoms. The patients with
used in children, so the side effect profile is PS are unlikely to improve with therapy
not well known in children. The patient was directed at GERD and may worsen if not
kept in the PICU for 48 hours after starting treated promptly.
the medication, without any cost to the However, the exact etiology or
patient. incidence of PS in infants is unknown. One
Given the suspicion of PS, the child case reported pylorospasm in a neonate due
was started on antispasmodic therapy in the to an underlying subhepatic abscess due to
form of hyoscine butylbromide at 0.2 mg staphylococcus aureus [3]. PS is a
twice daily. The patient was kept nil per oral commonly suspected, seldom found, and

4
National Board of Examination - Journal of Medical Sciences, Volume 2, Issue 6

rarely proven entity in infants. There is no was described initially, but at an age of 2-8
concrete literature available on the weeks, when these patients are most
incidence or correlation with pyloric present; it is not a suitable therapy,
stenosis. Repeated episodes of non-bilious especially for those on exclusive
vomiting in a 4–6-week-old infant could be breastfeeding. Decreasing the volume of
due to IHPS, GERD, PS, antral webs, individual feeds and increasing the number
duplication cyst, gastritis, gastroenteritis, of feeds has also been described to cause
raised intracranial pressure, or metabolic alleviation of PS [7]. A therapy of frequent
disorders among other causes. For an infant stomach wash along with an injection of
with typical examination findings of olive atropine before feeding with a mixture of
with corroborative evidence in albumin milk and the dextrin-maltose
ultrasonography and/or UGI contrast study, combination has been tried in earlier times.
the diagnosis of IHPS can be made Drugs such as banthine bromide, procaine
conclusively. However, in the absence of amide, and rociverine have also been used
findings of IHPS or reflux on imaging, the successfully [8]. Anticholinergic therapy in
diagnosis of PS could be considered. The the form of intravenous atropine has been
double-track sign seen in ultrasound can be documented to have a success rate in the
seen in both IHPS and PS and lacks management of PS [9]. Oral
specificity [1,4]. An ultrasonographic anticholinergics that function as
examination that suggests IHPS for a part antispasmodics along with watchful
of the study but changes during the study observation are therapeutic. A strict follow-
itself could be suggestive of PS [5]. In the up is essential along with repeat evaluation
future, investigations like antroduodenal if symptoms recur. Since it is a single case,
manometry or ENDOFLIP could help to so it is difficult to conclude that the
diagnose this entity. But at present, the lack resolution of symptoms with treatment has
of availability and expertise limits its use in a temporal resolution or is serendipitous.
general clinical practice. Further research is necessary for a similar
Another school of thought is that PS cohort of patients regarding diagnostic and
as such could be a precursor in the natural management guidelines.
history of IHPS. Sustained contraction of
the pylorus could lead to hypertrophy of the Conclusions
pyloric muscle leading to IHPS over time. PS should be suspected in a small
Wesley et al. followed up on ten patients infant with recurrent nonbilious vomiting
with PS and found that all ten patients not attributable to any other cause. Medical
developed IHPS requiring surgery after 2 to treatment should be started when in doubt,
46 days (mean 13 days) [6]. Considering for resolution of the distressing symptoms.
this, it is paramount to follow-up these It is a treatable cause of repeated vomiting
patients to screen for resolution of in an infant with a good outcome, so a high
symptoms. In case of persistence of index of suspicion should be maintained.
symptoms, repeat imaging to rule out IHPS
is warranted. Statements and Declarations
A plethora of therapies have been Ethics approval
described in the literature for the Ethical approval is not applicable.
management of PS. Thick cereal feeding

5
National Board of Examination - Journal of Medical Sciences, Volume 2, Issue 6

Consent for publication 4. Cohen HL, Blumer SL, Zucconi WB.

Written informed consent was The Sonographic Double-Track Sign:
obtained from the patient’s parents for the Not Pathognomonic for Hypertrophic
publication of this case report and Pyloric Stenosis; Can Be Seen in
accompanying images. Pylorospasm. J Ultrasound Med.
2004;23(5):641-646.
Availability of data and material doi:10.7863/jum.2004.23.5.641
Not applicable 5. Gilet AG, Dunkin J, Cohen HL.
Pylorospasm (Simulating
Competing interests Hypertrophic Pyloric Stenosis) With
The authors declare that they have Secondary Gastroesophageal Reflux.
no competing interests. Ultrasound Q. 2008;24(2):93-96.
doi:10.1097/RUQ.0b013e31817c611
Funding 3
Not applicable 6. Wesley JR, DiPietro MA, Coran AG.
Pyloric stenosis: evolution from
References pylorospasm? Pediatr Surg Int.
1. Haran PJ, Darling DB, Sciammas F. 1990;5(6):425-428.
The Value of the Double-Track Sign doi:10.1007/BF00174341
as a Differentiating Factor between 7. Brackett AS. The Alleviation of
Pylorospasm and Hypertrophic Pylorospasm and Colic in Infants by
Pyloric Stenosis in Infants. Reducing the Volume of the Food
Radiology. 1966;86(4):723-725. Intake per Feeding. Yale J Biol Med.
doi:10.1148/86.4.723 1946;19(2):155-169.
2. Swischuk LE, Hayden CK, Tyson 8. Sadove MS. Management With
KR. Short segment pyloric Procaine Amide (Pronestyl) Of
narrowing: Polorospasm or pyloric Pylorospasm In Infants. J Am Med
stenosis? Pediatr Radiol. Assoc. 1954;154(16):1328.
1981;10(4):201-205. doi:10.1001/jama.1954.0294050000
doi:10.1007/BF01001582 8003
3. Kalyanaraman M, Espiritu-Fuller M, 9. Kim HJ, Shin JE, Han JH, et al.
Raghava P, et al. Methicillin- Successful Treatment of Neonatal
Resistant Staphylococcus aureus Pylorospasm with Intravenous
Subhepatic Abscess Presenting as Atropine. Neonatal Med.
Pylorospasm in a Neonate: Pediatr 2019;26(1):67-71.
Emerg Care. 2016;32(2):93-94. doi:10.5385/nm.2019.26.1.67
doi:10.1097/PEC.000000000000070
6