Changing patterns of diagnosis and treatment of infantile hypertrophic pyloric stenosis: A clinical audit of 303 patients

doi:10.1016/S0022-3468(96)90032-9

Journal of Pediatric Surgery

Volume 31, Issue 12, December 1996, Pages 1611-1615

https://doi.org/10.1016/S0022-3468(96)90032-9 Get rights and content

Abstract

This review of 303 patients with infantile hypertrophic pyloric stenosis (IHPS) concentrates on the influence of clinical audit on diagnosis, complications, and factors contributing to hospital stay. Although the audit has enabled improvement in care by pediatric surgeons, there has been less change in areas controlled by other specialities. During a 12-year period, the number of patients diagnosed solely by clinical examination decreased from 74% to 28%, and the use of diagnostic tests increased (ultrasonography from 16% to 65% and barium meal from 12% to 28%). This trend continued throughout the series despite a review after 8.5 years, which recommended fewer tests. Although there may be some benefit from earlier confirmation of IHPS (the percentage of patients with a serum chloride value of less than 85 mmol/L decreased from 26% to 15%), the need for diagnostic tests could be reduced by expectant management. Better improvement occurred with surgical complications; the incidence of mucosal perforation decreased from 7 of 151 (4.6%) in the first 6 years to 0 of 152 in the last 6 years, and wound dehiscence was reduced from 3 to 0. The wound infection rate decreased from 9% to 4%, but had fluctuations. The average length of stay was reduced from 3.7 to 3.2 days. Further reductions in hospital stay will depend on earlier operation for patients with normal electrolyte values at the time of admission (61%) and a preparedness to confidently discharge patients even if there is vomiting. From the data available, early operation on the day of admission and discharge the next day would be a reasonable strategy for the majority of patients whose admission electrolyte values are normal. Complications such as mucosal perforation and wound dehiscence should be rare. This is not to suggest that IHPS is a condition of minor consequence; the surgeon must be skilled and care meticulous. If electrolytes are disturbed at the time of operation or if unrecognized mucosal perforation occurs, what should be an uneventful illness can result in disaster.

References (14)

KE Georgeson et al.
An analysis of feeding regimens after pyloromyotomy for hypertrophic pyloric stenosis
J Pediatr Surg
(1993)
DA Wattchow et al.
Abnormalities of peptide-containing nerve fibers in infantile hypertrophic pyloric stenosis
Gastroenterology
(1987)
CO Carter et al.
Inheritance of congenital pyloric stenosis
J Med Genet
(1969)
T McKeown et al.
The familial incidence of congenital pyloric stenosis
Ann Eugen Comb
(1951)
OS Nielsen
Familial disposition to congenital pyloric stenosis
Acta Paediatr
(1954)
CW Breaux et al.
Changing patterns in the diagnosis of hypertrophic pyloric stenosis
Pediatrics
(1988)
AL Zhang et al.
Infantile hypertrophic pyloric stenosis: A clinical review from a general hospital
J Paediatr Child Health
(1993)

There are more references available in the full text version of this article.

Cited by (37)

Vomiting, Pyloric Mass, and Point-of-Care Ultrasound: Diagnostic Test Accuracy for Hypertrophic Pyloric Stenosis-A Meta-Analysis
2023, Journal of Emergency Medicine
Hypertrophic pyloric stenosis is a common cause of nonbilious vomiting in infants younger than 6 months. Its history, physical examination, and point-of-care ultrasound (POCUS) have not been compared for their diagnostic test accuracy.
The aim of this systematic review was to quantify and compare the diagnostic test accuracy of a history of vomiting, a pyloric mass on palpation, and POCUS.
We performed three searches of the literature from 1977 to March 2022. We evaluated bias using the QUADAS-2 (Quality Assessment Tool for Diagnostic Accuracy-2) tool. We performed a bivariate analysis.
From 5369 citations, we identified 14 studies meeting our inclusion criteria. We quantified three diagnostic elements: POCUS, a pyloric mass on palpation, and vomiting. We identified five studies that analyzed POCUS, which included 329 patients. POCUS had a sensitivity of 97.7% (95% confidence interval (CI) 93.1–99.3%) and a specificity of 94.1% (95% CI 88.7–97.1%) for detecting pyloric stenosis. We identified six studies that analyzed the presence of a pyloric mass, which included 628 patients. The palpation of a pyloric mass had a sensitivity of 73.5% (95% CI 62.6–82.1%) and a specificity of 97.5% (95% CI 93.8–99.0%). We identified four studies that analyzed vomiting, which included 355 patients. Vomiting had a sensitivity of 91.3% (95% CI 82.1–96.0) and a specificity of 60.8% (95% CI 8.5–96.3). Both POCUS and palpation of a pyloric mass had a high positive likelihood ratio (LR+: 17 and 33, respectively). The LR+ for vomiting was 5.0.
Both POCUS and palpable mass had high specificity and positive LR, whereas vomiting provided the lowest diagnostic test measures.
Pyloric stenosis - Postoperative care on a nonsurgical ward
2015, Journal of Surgical Research
Citation Excerpt :
Recently, the management of infants with hypertrophic pyloric stenosis (HPS) has been streamlined. The diagnosis is typically recognized earlier leading to less metabolic derangement on presentation, prompt operative intervention, fewer surgical complications, and shorter postoperative hospital length of stay (LOS) [1–4]. A shorter hospital LOS is also attributed to the development of standardized postoperative feeding regimens [5–9].
Recent progress has been made in the care of infants with hypertrophic pyloric stenosis (HPS), including earlier operative intervention and shorter hospital length of stay (LOS), which is attributable to expedited postoperative feeding protocols developed and implemented by surgeons. We hypothesized that patients with HPS admitted to a unit that is co-managed by nonsurgeon providers postoperatively have a longer LOS than those on the surgical ward.
We reviewed the medical records of infants who underwent pyloromyotomy for HPS at a single institution from April, 2009–July, 2013.
A total of 259 patients underwent pyloromyotomy (35 female; 13.5%), 205 (79%) were admitted to the surgical ward; 46 had a planned neonatal intensive care unit (NICU) admission (18%) and were co-managed with the neonatology team. Eight (3%) had an unplanned NICU admission and were excluded from the analysis. The groups did not differ in terms of sex, age, serum electrolytes at presentation, or time between surgeon evaluation and operative intervention. Surgical ward patients had longer preoperative symptom duration. Operative time was longer in the NICU patients. Comparing the two groups, there was no difference in postoperative apnea, hypoxic, or bradycardic episodes. NICU patients achieved ad libitum feeds later than floor patients (2.0 versus 1.4 d; P = 0001) and had a longer postoperative LOS (2.2 versus 1.6 d; P = 0.0012).
Patients with HPS admitted to the NICU postoperatively had a longer time to full feeds and hospital LOS. The reduction in LOS between hospital wards may be improved with implementation of a hospital-wide postoperative protocol for patients with HPS.
Factors contributing to prolonged hospitalization of patients with infantile hypertrophic pyloric stenosis
2011, Pediatrics and Neonatology
Citation Excerpt :
The diagnosis of IHPS is based on a history of projectile, nonbilious vomiting and palpation of a pyloric tumor in infants between 2 weeks and 5 weeks of age.1–4 In infants without dehydration or lost weight, pyloric swelling cannot be palpated easily.11 Van der Schouw et al15 reported that in IHPS without the palpable mass, sonography was not perfect in 57% of their group compared with 5.6% in our group.
To study the influence of clinical audit on diagnosis, complications, and factors contributing to hospitalization of patients with infantile hypertrophic pyloric stenosis.
Retrospective cohort study.
There were 214 patients from 1991 to 2004 from three medical centers in Kaohsiung. Data were analyzed with respect to diagnostic methods, complications, and factors requiring patient hospitalization.
The ratio of male to female was 4.8:1 (177 males and 37 females). The diagnoses before admission were as follows: 22% had milk intolerance and 14.5% had esophageal reflux. There was a significant increase in the use of sonogram diagnostic test (p = 0.005) and a decrease in the incidence of diagnosis by olive mass palpation but not by barium meal test. Surgery time of 48 hours after admission was significant with barium meal examination and related to longer hospital stay (p < 0.001). Weight gain less than 800 g before admission (n = 125) was related to longer hospital stay (p = 0.026).
The diagnostic method was changed from olive mass palpation to sonogram. Weight gain less than 800 g before admission and surgery time of 48 hours after admission were related to longer hospital stay.
Idiopathic hypertrophic pyloric stenosis: Our experience
2006, Medical Journal Armed Forces India
Citation Excerpt :
The condition is more prevalent in the western world especially in infants of Caucasian descent and is less common amongst Asians [1]. The aetiology of pyloric stenosis remains unknown; however it is multifactorial with contributions from environmental and familial factors [3]. This paper presents our experience with a series of infants diagnosed to have IHPS.
A typical infant with idiopathic hypertrophic pyloric stenosis is described as a male child, first in the order of birth with a positive family history. However our experience suggests otherwise which is presented in this report. Methods : A retrospective analysis of medical records of 8 infants, who were diagnosed to be suffering from idiopathic hypertrophic pyloric stenosis and subjected to surgical treatment, was undertaken.
There were 5 (62.5%) males and 3 (37.5%) females. There was no family history and only one child (12.5%) was first born in the order of birth. One infant was preterm and one case (12.5%) had associated congenital anomaly (single kidney). Definitive diagnosis was established in 6 (75%) babies at admission whereas, other 2 cases (25%) required further evaluation. All the infants were in a state of moderate dehydration and in a varying state of hypochloremic alkalosis. The pH and serum chloride levels ranged from 7.52 to 7.67 and 86-94 mmol/L respectively. All were subjected to traditional Ramstedt's pyloromyotomy after having undergone vigorous correction of fluids and electrolytes for 24-48 hours. Intraoperatively, there was one iatrogenic mucosal perforation, which was closed with an omental patch. Postoperative feeding was initiated 12 hrs after surgery in 6 (75%) babies.
Our series suggests a clinical profile of hypertrophic pyloric stenosis in our subset of patients which is different from what is described in literature.
Gastrointestinal surgery in the neonate
2006, Current Paediatrics
The surgical treatment of neonates has enjoyed rapid development during the last 50 years. Neonatal surgery has now become an independent branch of general surgery, which requires the expertise of dedicated paediatric surgeons. Much of the development of neonatal surgery is due to the close collaboration between paediatric surgeons, neonatologists, anaesthetists, pathologists, radiologists, biochemists, and nurses. There has been a steady improvement in the outcome of most neonatal diseases requiring surgery. For example at Great Ormond Street Hospital for Children, London, the mortality for the most common congenital intestinal obstructions has declined from 50% in the 1950s and 1960s to 25% in the 1960s and 1970s to a current mortality of less than 5%. The reasons for this improvement can be ascribed to a better understanding of the physiology of surgical neonates, to the advances in fluid management, nutrition, mechanical ventilation, and not least to refinements in surgical techniques. There is still considerable work to be done to improve the survival of neonates with severe conditions such as necrotizing enterocolitis (NEC). Surgery of the gastro-intestinal tract is required for congenital abnormalities and acquired lesions. In this article the authors focus on the most common congenital anomalies of the gastro-intestinal tract requiring surgery. In addition they discuss two acquired conditions requiring surgery in neonates: NEC and hypertrophic pyloric stenosis. It is beyond the scope of this article to discuss anomalies of the abdominal wall, gastro-oesophageal reflux, and anomalies of the pancreato-biliary system.
Hypertrophic pyloric stenosis
2005, EMC - Pediatrie
La sténose hypertrophique du pylore est une pathologie chirurgicale fréquente du nourrisson. Son étiologie n'a pas encore été élucidée, mais elle est probablement multifactorielle : génétique et environnementale. Son diagnostic est évoqué par la clinique, devant un tableau caractéristique de vomissements de lait caillé. La confirmation du diagnostic fait appel à l'échographie. Si le traitement chirurgical est bien codifié, il ne sera réalisé qu'après une correction des troubles hydroélectrolytiques lorsqu'ils existent. La guérison sans séquelle fonctionnelle est la règle.
Hypertrophic pyloric stenosis is a frequently encountered disease in neonates. Its aetiology remains unknown, but is probably multifactorial: genetic and environmental. Diagnosis is usually based on clinical presentation, with typical (non-bilious) vomiting. Confirmation of the diagnosis relies on ultrasonography. Surgical treatment takes place after correcting the fluid deficiency and electrolyte imbalance. Recovery without sequelae is usual.

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Changing patterns of diagnosis and treatment of infantile hypertrophic pyloric stenosis: A clinical audit of 303 patients

Abstract

J Pediatr Surg

Gastroenterology

Inheritance of congenital pyloric stenosis

J Med Genet

The familial incidence of congenital pyloric stenosis

Ann Eugen Comb

Familial disposition to congenital pyloric stenosis

Acta Paediatr

Changing patterns in the diagnosis of hypertrophic pyloric stenosis

Pediatrics

Infantile hypertrophic pyloric stenosis: A clinical review from a general hospital

J Paediatr Child Health