Ultrasonographic Evaluation in Early Diagnosis of Infantile Hypertrophic Pyloric Stenosis

Background: Infantile hypertrophic pyloric stenosis (IHPS) is a common cause of gastric outlet obstruction in infants. This study was conducted to identify the accuracy of ultrasonography in the diagnosis of infantile Hypertrophic pyloric Stenosis. Methods: This cross-sectional descriptive. Study was conducted in Department of radiology and imaging, institute of child and mother health during two year period from 16th September 2016 to 16th September 2018. Fifty patients <8 weeks of age who presented with complaints of non-bilious vomiting were included in the study. Abdominal ultrasound was performed in all the cases. On ultrasonography pyloric canal length, diameter and pyloric muscle wall thickness was measured. Open surgery was performed as per indications and after informed consent. The pre-operative findings were compared with ultrasongraphic findings. Study variable were male to female ratio, percentage of cases in which pyloric mass was palpable. We also compare the duration of onset of symptoms with pyloric canal length, diameter and muscle thickness. Results: In this study, out of 50 patients, 46 (92%) were male and 4 (8%) were females. Gastric peristalsis was visible in 100% patients and mass was palpable in 14 (28%) patients. Pyloric canal length was more than standard in 98% cases; canal diameter was more than the standard in 87% cases and pyloric muscle thickness in 60% of cases. Ultrasonographic findings remained 98% accurate in this study. Conclusion: Ultrasonography is an investigation of choice for early diagnosis of IHPS before significant fluid and electrolyte imbalance occur. It is cost effective, harmless, freely available and easier to perform. J Dhaka Medical College, Vol. 28, No.2, October, 2019, Page 208-211

Sonography and Test-Feeding in the Diagnosis of Infantile Hypertrophic Pyloric Stenosis

Objective: To determine the use of sonography and test-feeding in the diagnosis of infantile hypertrophic pyloric stenosis (IHPS). Methodology: A total of 79 infants from 2 weeks up to 12 weeks presenting with clinical signs (projectile vomiting) of IHPS were included in the study while sent to sonography. The study duration was February 2014 to December 2019. Results: The mean age of patients was 5.18 ± 2.69 weeks ranging from 1 to 12 weeks. Male gender was predominant with 62 (78.5%) cases. Of the total 79 cases, 36 (54.6%) were suggested as positive cases of IHPS and 43 (54.4%) were as normal with sonography. Most of the cases of IHPS (23; 29.1%) were observed in firstborn babies. Mean pyloric length in normal and IHPS was 12.69 ± 0.87 and 20.78 ± 2.28 mm, respectively, and mean pyloric muscle thickness in the normal and IHPS was 2.24 ± 0.36 and 5.27 ± 0.82 mm, respectively, while mean pyloric diameter in normal and IHPS was 12.69 ±0.87 and 15.01± 2.52 mm, respectively. Conclusion: The reliability of sonographic findings was better than test-feeding in the diagnosis of IHPS. Male infants, in this cohort, were five times more susceptible to develop IHPS, compared with females.

Idiopathic Hypertrophic Pyloric Stenosis

Idiopathic hypertrophic pyloric stenosis (IHPS) is a common cause of nonbilious, projectile vomiting in the infant. Progressive hypertrophy of the pyloric muscle leads to an obstruction of the gastric outlet. The condition is easily corrected with a pyloromyotomy. Mortality is <0.5% in most specialty centers when hydration and normal electrolyte status is restored prior to surgery, appropriate precautions are taken preoperatively, and the patient is carefully monitored for known postoperative complications. This chapter discusses the related epidemiology and etiology; clinical presentation; use of imaging studies; preoperative preparation; and anesthetic, surgical, nonsurgical, and postoperative management of these patients. Topics covered include metabolic alkalosis, electrolyte abnormality, dehydration, pulmonary aspiration, and pyloromyotomy.

In vivoEffects of Temperature on the Heart and Pyloric Rhythms in the Crab,Cancer borealis

Summary StatementTemperature elevation increases the frequency of the heart and pyloric rhythms of the crab,Cancer borealis, but the heart rhythm has a higher critical temperature than the pyloric rhythm.AbstractThe heart and pyloric rhythms of crustaceans have been studied separately and extensively over many years. Local and hormonal neuromodulation and sensory inputs onto these central pattern generating circuits play a significant role in the animals’ responses to perturbations, but are usually lost or removed duringin vitrostudies. To examine simultaneously thein vivomotor output of the heart and pyloric rhythms, we used photoplethysmography (PPG). In the population measured (n = 49), the heart rhythm frequencies ranged from 0.3–2.3 Hz. The pyloric rhythms varied from 0.2–1.6 Hz. During multiple hour-long recordings, many animals held at control temperature showed strong inhibitory bouts in which the heart decreased in frequency or become quiescent and the pyloric rhythm also decreased in frequency. Many animals show significant coherence in frequency between the rhythms at the frequency of the heart rhythm. We measured the simultaneous responses of the rhythms to temperature ramps by heating or cooling the saline bath while recording both the heart and pyloric muscle movements. Q10s, critical temperatures (temperatures at which function is compromised), and changes in frequency were calculated for each of the rhythms tested. The heart rhythm was more robust to high temperature than the pyloric rhythm.

Laparoscopic Pyloromyotomy: A Modified Simple Technique

Background: A modified laparoscopic pyloromyotomy (LP) technique may provide an alternative to treating infantile hypertrophic pyloric stenosis (IHPS) by improving operative timing with reduction of postoperative complication rates, compared with a three-port trocar system.Methods: Thirty-three infants were treated with IHPS at a single-centre between January 2002 and December 2011. The local surgical incision to the pylorus was performed according to Ramstedt’s pyloromyotomy; but with a two-port trocar system (umbilical and right lower abdominal crease ports), following a controlled stab wound into the epigastric region and a 3mm incision to allow introduction of ophthalmic knife. With the aid of atraumatic forceps and camera guidance, the ophthalmic knife was used to carefully incise the seromuscular layer, which allows improved manual tactile sensation compared to ergonomic laparoscopic spreaders. A Benson pyloric spreader was then used to further separate the pyloric muscle layer to complete the procedure.Results: In all 33 infants treated, LP was safely performed with no evidence of duodenal or mucosal perforation with complete pyloromyotomy achieved in each case. The postoperative course was rather uneventful apart from an umbilical wound infection.Conclusion: This modified approach is simple, safe and allows improved operative timing, whilst increasing surgeon’s confidence by tactile sensation.

The use of ultrasonography in infantile hypertrophic pyloric stenosis: do the patient’s age and weight affect pyloric size and pyloric ratio?

Aims: We aimed to obtain pyloric measurements of our patients with infantile hypertrophic pyloric stenosis (IHPS) using ultrasonography (US) and to evaluate the correlations between age, weight and pyloric size, pyloric ratio (PR). Material and methods: We designed a retrospective study including 20 term infants with surgically proven IHPS and studied the ultrasono- graphically obtained pyloric muscle thickness (PMT), pyloric diameter (width) (PD), pyloric length (PL) and PR (PMT/PD) to determine if there were statistically significant associations between patient age/weight and pyloric measurements. Results: The mean age of the infants was 38.7±17.3 days (range, 9–76 days) and their mean weight was 3688.5±772.7 g (range, 2810– 6000 g), at referral. Mean PMT was 4.98±1.04 mm (range, 3.5–6.8 mm). Mean PD was 14.04±2.39 mm (range, 10–18 mm). Mean PL was 22.16±4.02 mm (range, 16–31.5 mm) and mean PR was 0.35±0.04 (range, 0.29–0.42). The correlation between age and PMT (r=0.654, p0.05). Conclusions: The PMT and PD are age dependent parameters. The PR is age and weight independent and therefore, when combined with PMT, PD and PL, it can be useful in the diagnosis of IHPS in infants with early onset disease and/or in those with a lower weight.

Substance P is essential for maintaining gut muscle contractility: a novel role for coneurotransmission revealed by botulinum toxin

Substance P (SP) is commonly coexpressed with ACh in enteric motor neurons, and, according to the classical paradigm, both these neurotransmitters excite smooth muscle via parallel pathways. We hypothesized that, in addition, SP was responsible for maintaining the muscular responsiveness to ACh. We tested this hypothesis by using botulinum toxin (BoNT/A), a known blocker of vesicular release of neurotransmitters including ACh and neuropeptides. BoNT/A was injected into rat pyloric sphincter in different doses; as control we used boiled BoNT/A. At the desired time point, pylorus was dissected out and pyloric contractility was measured ex vivo in an organ bath and by measuring phosphorylation of myosin light chain 20 (MLC20). BoNT/A (10 IU) significantly reduced the response of pyloric muscle to exogenous ACh, an effect that was accompanied by reduced MLC20 phosphorylation in the muscle. Both effects were reversed by exogenous SP. CP-96345, a NK1 receptor antagonist, blocked the ability of exogenous SP to reverse the cholinergic hyporesponsiveness as well as the reduction in MLC20 phosphorylation induced by BoNT/A. In conclusion, we have identified a novel role for SP as a coneurotransmitter that appears to be important for the maintenance of muscular responsiveness to the principal excitatory neurotransmitter, ACh. These results also provide new insight into the effects of botulinum toxin on the enteric nervous system and gastrointestinal smooth muscle.