Pyloric stenosis

Answer 1

Impression:
Given projectile vomits, and at age of presentation I am most concerned about pyloric stenosis in this patient. concerned about potential for hypochloraemic hypokalaemia metabolic alkalosis and severe dehydration. Otherwise, vomiting is a non-specific presentation which may represent a wide range of pathologies.

Other differentials to consider include;

• Infective: sepsis, meningitis, gastroenteritis
• GIT: obstruction (volv, malrotation, intussuseption, etc), GORD
• Raised ICP: intracranial mass, Non-accidental injury
• Food intolerances: CMPI/FPIEs
• Metabolic disease: DKA, hyperthyroidism

Goals
- rule out complications with initial A to E assessment, take thorough Hx/Ex/Ix to rule of DDx, arrange for definitive treatment with paeds gastro surgeon whilst managing supportively in the interim.

Question 2

Pyloric stenosis - History

Answer 2

History

- vomiting: projectile vs posit

Question 3

Pyloric stenosis - History

Answer 3

History

• Vomiting: projectile vs posit, frequency, when started, colour and consistency, timing in relation to feeding
• Feeding: volume, type, regularity, etc, always hungry?
• other sx: infective (floppy, irritable, rash), Diarrhoea, urine changes
• Risks: 1st child, family hx
• Paeds + O&G hx: growth, obstetric complications,

Question 4

Pyloric stenosis - Examination

Answer 4

Examination

• General appearance + vital signs
• abdominal examination; RUQ olive-shaped mass, visible peristalsis, abdo distension, tenderness/pain, absent/tinkling bowel sounds
• Hydration status assessment
• genitals: testicular torsion or hernia

Question 5

Pyloric stenosis - Investigations

Answer 5

Investigations
This is normally a clinical diagnosis without any definitive investigations required, however I would utilise an abdominal ultrasound looking for pyloric elongation and thickening if diagnostically uncertain

Other

• Bedside: VBG,
• Labs: UEC, LFT, CRP/ESR, cultures, lactate

Question 6

Pyloric stenosis - Management

Answer 6

Management
Supportive
- IV fluids - NS + 5% dextrose
- electrolyte derangement correction and metabolic alkalosis over 48hr period
- NBM/cease enteral feeds, NG tube for decompression if continued vomiting, NJ tube for feeds in interim period.
- TPN if malnourished

Definitive

• Paeds gen surg referral for pyloromyotomy
• this would likely require transfer via NETS to tertiary centre

Ongoing
- regular review and paeds F/U