WISEMD Pediatric Pyloric Stenosis

Question 1

Is bilious emesis considered a surgical emergency in infants until proven otherwise? Why?

Answer 1

1) Yes

2) Bilious emesis suggests the possibility of midgut volvulus, which is fatal is not operated on immediately

Question 2

What are causes of non-bilious emesis in infants?

Answer 2

1) GERD
2) Milk allergy
3) Formula intolerance
4) Pyloric stenosis
5) Malrotation

Question 3

What are causes of bilious emesis in infants?

Answer 3

1) Atresia
2) Enterocolitis
3) Incarcerated hernia
4) Malrotation
5) Volvulus

Question 4

What is the age of presentation of pyloric stenosis?

Answer 4

2 weeks - 2 months

Question 5

What is the gender, race, and child order number most related to pyloric stenosis?

Answer 5

Male, caucasian, first-child

Question 6

How should one characterize the emesis that arises from pyloric stenosis?

Answer 6

Increasingly frequent and forceful emesis

Question 7

What are signs of dehydration in an infant with pyloric stenosis that one can obtain from a history?

Answer 7

1) Decreased frequency of wet diapers

2) Lethargy

Question 8

What are signs of dehydration in an infant with pyloric stenosis that one can obtain from a physical exam?

Answer 8

1) Sunken fontanelles
2) Dry mucous membranes
3) Decreased capillary refill
4) Tachycardia

Question 9

What is the PPV of a palpable mass in the abdomen for pyloric stenosis?

Answer 9

99% PPV, but it can be difficult to palpate

Question 10

What is the progression of electrolyte disturbance in pyloric stenosis and in continued emetic patients?

Answer 10

1) Emesis causes chloride, potassium, and volume loss
2) Hypovolemia and metabolic alkalosis
3) Kidneys retain sodium to correct hypovolemia
4) Excretion of hydrogen in Na-H exchange transport
5) Exacerbation of metabolic alkalosis (paradoxic aciduria)

Question 11

What is the gold standard technique for diagnosing pyloric stenosis?

Answer 11

Ultrasound

Question 12

Even if you have confirmed the diagnosis of pyloric stenosis, if there is any sign of volvulus or malrotation of the midgut what study should be done to rule out the additional diagnosis?

Answer 12

Upper GI-series

Question 13

What are the two steps in treatment of the patient with pyloric stenosis?

Answer 13

1) Resuscitation by administering IV fluids

2) Pylorotomy

Question 14

What post-op complications in the treatment of pyloric stenosis would require immediate reoperation?

Answer 14

1) Incomplete myotomy

2) Perforation of the mucosa