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Gastric Outlet Obstruction in an infantSophia L Fu, MD
Richmond University Medical CenterStaten Island, NY
SUNY Downstate Medical Center, Brooklyn, NY
January 20, 2010
downstatesurgery.org
History 14 mo male with intermittent nonbilious, nonprojectile,
nonbloody vomiting, ~30min-2hrs s/p feeding, 3 lb wt loss
in 2 mo, no ↓ appetite, ↓ stool & wet diapers
PMH: BW 6lbs 7oz, NICU stay x2mo 2º withdrawal Sx;
4day stay for RSV @6mo
FHx: maternal drug addiction
SocHx: FT, NSVD, older sister, immunizations
Gastric Outlet Obstructiondownstatesurgery.org
Physical Examination VS 98º 125/83 149 24
Wt 20.2lbs (3-10%) Ht 27.5in (<3%)
Gen: irritable, non-consolable, eager to eat/drink
HEENT: NCAT, MM dry
Cv: nl S1 S2, RRR, no m/r/g
Chest: CTAB/L
Abd: soft, NT, ND, no mass, +BS
Skin: warm, dry, good turgor, good cap refill
Gastric Outlet Obstructiondownstatesurgery.org
Laboratory work-upGastric Outlet Obstruction
134
2.1
80.3
38.9
13
0.213020.7
14.3
40.7583
10.7
UA – neg7.3
5.1
49
19
213
1.1
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Abdominal X-rayPyloro-antral Web downstatesurgery.org
UltrasoundGastric Outlet Obstruction
Impression – Highly Suspicious for Pyloric Stenosis
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Initial Management & Endoscopy
Resuscitation
D5 ¼ NS +20mEq KCl @80
NGT placement
GI Consult
Peds Surgery Consult
Gastric Outlet Obstructiondownstatesurgery.org
Upper GI SeriesGastric Outlet Obstructiondownstatesurgery.org
Surgical ExplorationGastric Outlet Obstructiondownstatesurgery.org
PathologyGastric Outlet Obstruction
Antral Web
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Operative Management/ Recovery Transverse upper abdominal incision
Gastrotomy – web resection
14Fr Bougie fit
Total OR time: 2:10
EBL minimal
D5 1/3NS180mL
Parathyroid Adenoma
POST-OP recovery
Await BM
Advance diet
D/C Home POD#4
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Pyloro-antral Web
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Etiology Maternal intrauterine vascular
accidents
Ischemic necrosis
Subsequent bowel atresia
Failure of recanalization
Redundancy and slipping of
epithelial lining
Genetics
Pyloroduodenal obstruction
Pyloro-antral Web downstatesurgery.org
Clinical Presentation Maternal Hx of polyhydramnios
Nonbilious vomiting
Gastric outlet obstruction
Respiratory Sx
Dyspnea
Tachypnea
Cyanosis
Excessive salivation
Epigastric fullness
Perforation
Pyloro-antral Web downstatesurgery.org
Abdominal RadiographyPyloro-antral Web downstatesurgery.org
Upper GI SeriesPyloro-antral Web downstatesurgery.org
PathologyPyloro-antral Web downstatesurgery.org
Surgery
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Treatment of Pyloric Atresia Gastrotomy
Distal passage of a catheter
Detect membranous obstructions
Excision of complete or partial diaphragm
Heineke-Mikulicz or Finney Pyloroplasty
Gastroduodenostomy
Alternative procedures using endoscopy
Balloon dilatation
Laser web excision
Laser radial incisions of membrane
Pyloro-antral Web downstatesurgery.org
References• Balaji NS, Peters JH: Minimally invasive surgery for esophageal motility disorders. Surg Clin North Am 82:763–
82, 2002.• Brace M, Taylor SM, Trites JR, Bethune D, Attia E, Hart RD. Endoscopic stapling versus external
transcervical approach for the treatment of Zenker diverticulum. J Otolaryngol Head Neck Surg. 2010 Feb 1;39(1):102-6.
• Bremner CG, DeMeester TR: Endoscopic treatment of Zenker's diverticulum. Gastrointest Endosc49:126–8, 1999.
• Sen P, Bhattacharyya AK: Endoscopic stapling of pharyngeal pouch. J Laryngol Otol 118:601–6, 2004.• Sohn H. J, DeMeester S. R, "Chapter 25. Resection of Esophageal Diverticula" (Chapter). Sugarbaker DJ, Bueno
R, Krasna MJ, Mentzer SJ, Zellos L: Adult Chest Surgery: http://www.accesssurgery.com/content.aspx?aID=5287346.
• Souba W, Fink M( \Jurkovich G, \Kaiser L, Pearce W, Pemberton J, Soper N. ACS Surgery: Principles and Practice 2010.
• Zollinger RM Jr, Zollinger RM Sr, "Zenker's Diverticulectomy" (Chapter). Zollinger RM Jr, Zollinger RM Sr: Zollinger's Atlas of Surgical Operations, 8th Edition: http://www.accesssurgery.com/content.aspx?aID=61515.
Zenker’s Diverticulumdownstatesurgery.org
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