PYLORIC STENOSIS

Question 1

Approach to the Cricially Ill Pyloric Stenosis

Answer 1

Normal Saline 20 ml / kg

Avoid Lactated Ringers

Maintenance Fluid D5 0.45% NS

4 cc/kg/hr for 1st 10 kg
2 cc/kg/hr for 10-20 kg
1 cc/kg/hr for every kg > 20 kg

KCl @ 0.5 mEq/kg/hr IV

Serum potassium <3mEq/L give total of 1 mEq/kg (up to adult dose)
Serum potassium 3-3.5 mEq/L give 0.2 mEq/kg and recheck

Obtain i-STAT labs, including glucose.

Analgesia:
morphine 0.05-0.1 mg/kg IV
OR
fentanyl 1 μg/kg IV

Ondansetron:
2 mg < 15 kg
4 mg > 15 kg
8 mg > 30 kg

Urgent Ultrasound

Surgical Consultation

Question 2

Pathophys / Key Concepts

Answer 2

Idiopathic hypertrophy of the pyloric muscle -> gastric outlet obstruction

Typical presentation 2 - 6 weeks (as late as 20 wks)

Males 4:1

1/250 births

Question 3

History and Physical

Answer 3

2-6 wks age

Classically Male, First born

Progressive projectile NON-BILIOUS vomiting following feeds

Continued interest in feeds

Generally well appearing with no abdominal pain

May have olive-sized mass in epigastrum

Assess Dehydration

Question 4

Investigations

Answer 4

CBC
Lytes: hypochloremic metabolic alkalosis + hypokalemia
Creatinine

Ultrasound: Near 100% sensitivity. Muscle wall thickness (>3 mm), channel length (>12-15 mm), observed dynamic funciton of the pylorus

Upper GI contrast study if Ultrasound not available

Question 5

Management

Answer 5

Fluid ressussitation and correct metabolic as above

Surgical Consult

not a true surgical emergency

Question 6

Disposition

Answer 6

Typically Admitted to surgical service with pediatric consultation to co-manage metabolic abnormalities