Morning ReportJuly 6, 2012
Good Morning!
Symptoms
Acute /subacute ChronicLocalized Diffuse
Single MultipleStatic Progressive
Constant IntermittentSingle Episode Recurrent
Abrupt GradualSevere MildPainful NonpainfulBilious Nonbilious
Sharp/Stabbing Dull/Vague
Problem Characteristics
Ill-appearing/Toxic
Well-appearing/Non-toxic
Localized problem
Systemic problem
Acquired Congenital
New problem Recurrence of old problem
Semantic Qualifiers
Illness Script
Predisposing Conditions Age, gender, preceding events
(trauma, viral illness, etc), medication use, past medical history (diagnoses, surgeries, etc)
Pathophysiological Insult What is physically happening in
the body, organisms involved, etc.
Clinical Manifestations Signs and symptoms Labs and imaging
Ultrasound
Predisposing Conditions
5:1 Male predominanceMore common is 1st born (30% of
cases)CaucasianTypically between the age of 2 weeks
– 6 weeksFamily clusteringErythromycin exposure in 1st 2 weeks
of life
Pathophysiology
True etiology unknownHypertrophy of the pyloric muscle that
leads to gastric outlet constrictionExposure to erythromycin (less so with
other macrolides) Increases risk 8-fold Erythromycin interacts with smooth muscle
motilin receptors This causes strong gastric and pyloric
contractions Subsequent hypertrophy of the pyloric muscle
Anatomy
Hypertrophy of the pylorus
Elongation and thickening
Progresses to near-complete obstruction
Clinical Manifestations*Vomiting
Non-bilious Forceful/projectile Progressive (increasing frequency)
Progression Ravenously hungry Dehydrated/weight loss Lethargic
FTTJaundicePalpable “olive” (up to 90%)Peristaltic wave after eatingElectrolyte abnormalities
ElectrolytesMetabolic alkalosis**
Decreased excretion into small intestine (increase in serum)
Decreased total body K+ leads to shift of K+ outside of cell in exchange for H+
Increased re-absorption by kidney for fluid retentions (due to dehydration)
Hypochloremia*Hypokalemia* (late finding)Correction of electrolytes before surgery…
Correct dehydration (often with NS bolus) If mild-moderate dehydration…
D5 ½ NS at correction rate, KCl once voids
Diagnosis**
Primarily a clinical diagnosis
Ultrasound Pyloric muscle thickness > 4mm Pyloric muscle length > 14mm 85-100% sensitivity and specificity
UGI 89%-100% sensitive/specific “string sign”, “double track”
UGI
Pyloromyotomy
Thanks!!
Noon Conference…Respiratory Failure by Costa