Pyloric stenosis: symptoms, diagnosis and treatment of pathology in newborns. Pyloric stenosis in children, methods of diagnosis and treatment Inflammatory and tumor processes of neighboring organs
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This is one of the most common causes of partial high obstruction in children in the first weeks and months of life. Thickening of the pylorus during pyloric stenosis was first noted by M. Hirschprung in 1887. It is regarded as a defect in the innervation of the pyloric sphincter. At first, a deficiency of innervation causes a spastic state of the sphincter, and then, under its influence, degeneration of the smooth muscle fibers of the pylorus occurs. Smooth muscle fibers are large, with a large core.
In some cases, atypia of the pyloric mucosa is detected - dystopia and the formation of multiple cystic cavities in the thickness of the muscle layer. The nerve nodes of the muscle layer are surrounded by fibrous tissue, the nerve cells are wrinkled, the glial elements are hyperplastic, and the bundles of nerve fibers in the serosa are deformed. In recent years, the genetic nature of this developmental defect has been proven. The relative risk of pyloric stenosis among relatives is quite high, and is higher in the sons of patients, which indicates a partial dependence of the inheritance of the defect on gender.
The pylorus thickens, lengthens, becomes dense and glassy, and its lumen sharply narrows. Clinical manifestations become most noticeable by the beginning of the third week of the child’s life and progress. The most striking clinical manifestation of pyloric stenosis is the characteristic “fountain” vomiting. It is observed 1 - 1.5 hours after feeding. Its contents are curdled milk without any admixture of bile with a sour odor and an acidic reaction. The amount of vomit exceeds the amount of food eaten before, as it remains in the stomach from previous feedings. In some cases, streaks of blood can be seen in the vomit. Sometimes quite severe stomach bleeding occurs.
Constipation appears, urination becomes less frequent. Prolonged persistent vomiting leads to exhaustion. The child's face has sunken eyes, the skin becomes flabby and dry due to constant dehydration. A characteristic sign of pyloric stenosis is increased gastric peristalsis, visible through a thinned abdominal wall in the form of an hourglass: two rounded protrusions with a bridge in the center appear in the epigastric region, gradually smoothing out and disappearing. Peristalsis is better detected after feeding. It can be provoked by lightly stroking the epigastrium with your fingers. Laboratory data indicate blood thickening (decreased blood volume, increased hemoglobin, hematocrit), hypochloremia, hypokalemia, metabolic alkalosis.
At x-ray examination pay attention to an increase in the size of the stomach, the presence of a high level of fluid on an empty stomach, and reduced gas filling of the intestinal loops. X-ray contrast examination is performed in a vertical position 30-40 minutes after giving a contrast agent (5% aqueous suspension of barium in breast milk in the volume of a single feeding). Segmenting peristalsis of the stomach and the absence of primary evacuation into the duodenum are visible. An X-ray in the lateral projection reveals a narrowed pyloric canal, a “beak” symptom. All radiographs should be taken with the child in an upright position. Typically, no further testing is required.
Recently, for the diagnosis of pyloric stenosis, fibroesophagogastroscopy. In this case, the expanded folded antrum of the stomach is visible, the lumen of the pyloric canal is sharply narrowed to the size of a pinhead, and does not open when inflated with air (unlike pyloric spasm). In addition, fiberoscopy makes it possible to examine the esophagus and determine the severity of reflux esophagitis, which often accompanies pyloric stenosis. It is also possible ultrasound diagnostics pyloric stenosis. An experienced ultrasound operator not only detects the presence of a hypertraffic pylorus, but can measure its length and width, the length of the pyloric canal, the thickness of the muscle layer and mucous membrane. The advantage of the method is its non-invasiveness and lack of radiation exposure.
Treatment
The radical method of treating pyloric stenosis is surgery. Since 1912, extramucosal pyloromyotomy according to Frede-Ramstedt has been generally accepted. The intervention is preceded by preoperative preparation aimed at correcting hypovolemia, alkalosis, and hypokalemia. During the operation, the anatomical obstacle is removed and the pyloric patency is restored. 3-6 hours after the operation, the child begins to drink a 5% glucose solution, then 5-10 ml of milk after 2 hours.
In the next day, the amount of milk is increased daily by 100 ml (10 ml per feeding). By the 6th day, the feeding volume is increased to 60 - 70 ml with an interval of 3 hours, after which the child is transferred to normal feeding. In the first days after surgery, the deficiency of fluid, electrolytes, protein and other ingredients is replenished through infusion therapy and auxiliary parenteral nutrition, as well as the administration of microenemas (5% glucose solution and Ringer-Locke solution in equal quantities of 30 ml, 4 times a day in warm form).
One of the complications of the operation may be injury to the mucous membrane of the duodenum. Damage is detected when the wall of the stomach is compressed and its contents move through the pylorus. When perforation occurs, air bubbles and sometimes intestinal contents appear in the lower corner of the wound. The discovered hole is sutured with one or two sutures in the transverse direction. Repeated pyloromyotomy is performed on the opposite side of the sphincter. The prognosis is favorable. Children require clinical observation for further treatment of malnutrition, anemia, and hypovitaminosis.
Bychkov V.A., Manzhos P.I., Bachu M. Rafik H., Gorodova A.V.
Pyloric stenosis is hypertrophy of the muscles of the pylorus of the stomach, manifested by a violation of its patency in the first 12-14 days of a child’s life. The following frequency of pyloric stenosis is published: 1.5 - 4 cases per 1000 newborns. Boys get sick 2-5 times more often than girls.
Causes of pyloric stenosis
The hereditary theory is confirmed by the high frequency of the disease in boys born from mothers with pyloric stenosis: from 5 to 20% of sons and 2-7% of daughters inherit this pathology.
Disruption of the innervation of the pyloric muscles consists of a decrease in the number of nerve cells in the circular muscles or degenerative changes in the nerve ganglia.
Increased concentration of gastrin and other gastrointestinal peptides, causing chronic pyloric spasm, leading to hypertrophy of the pylorus.
The lack of nitric oxide production in the muscular structures of the pylorus causes chronic pyloric spasm with the subsequent development of pyloric stenosis.
Pathological anatomy
Severe hypertrophy of the circular muscles of the pylorus, causing partial occlusion of its lumen.
Symptoms of pyloric stenosis
The main and constant symptom is “fountain” vomiting, which appears at 2-4 weeks of life. Vomit does not contain bile, and its amount exceeds the amount of milk drunk.
Retention of stool, some patients have dyspeptic “hungry” stools.
The number of times you urinate and the amount of urine produced decreases.
During an external examination of the abdomen, there is some swelling in the epigastric region, retraction in the lower sections and visible peristalsis of the stomach in the form of an “hourglass”, which is more clearly manifested in the lungs of the abdominal wall.
With light palpation of the abdomen, a thickened pyloric section of the stomach can be identified in the middle between the navel and the xiphoid process and slightly to the right.
Laboratory blood tests show an increase in hematocrit, a decrease in chlorides, potassium, and the manifestation of metabolic alkalosis.
Diagnosis of pyloric stenosis
X-ray examination begins with a plain radiograph of the abdominal cavity, which reveals the stomach distended with air and fluid. Gastric contrast shows a delay in evacuation of 5% barium from 3 to 24 hours.
Ultrasound examination has become the most common and informative diagnostic method. The diagnosis is based on the following data: the diameter of the pylorus is at least 14 mm, the thickness of its muscle layer is more than 4 mm and the length is 16 mm.
Fibrogastroscopy helps to identify narrowing of the lumen of the pyloric canal.
Treatment of pyloric stenosis
Preoperative preparation consists of rehydration with isotonic solutions of glucose and sodium chloride. Correction of water-electrolyte imbalances is carried out taking into account physiological needs and pathological losses with constant laboratory monitoring.
Conservative treatment of pyloric stenosis is possible by prescribing atropine sulfate at a dose of 0.06 mg/kg per day for 5-7 days in children with a high risk of anesthesiological and surgical treatment.
Surgical treatment of pyloric stenosis - extramucosal dissection of the muscular layer of the pylorus:
Traditional extramucosal pylorotomy according to Frede-Ramstedt can be performed through the following approaches: transverse, subcostal incision or right supraumbilical incision;
Laparoscopic pylorotomy meets modern requirements for minimally invasive
Pyloric stenosis is a disease of the outlet of the stomach - the pylorus, which consists in its narrowing and difficulty in the passage of food further along the digestive tract. This pathology can be congenital (occurs as a result of a developmental defect) or acquired (scar tissue deformation, burn or mechanical damage). Pyloric stenosis in newborns is diagnosed already in the first weeks of life, and male children are much more often affected. The disease is characterized by a severe course and, in the absence of timely assistance, can lead to death.
In the adult population, the pathology develops quite rarely and is a complication of pylorospasm or scarring of an extensive ulcer.
Reasons for the development of the disease
Pyloric stenosis in adults develops as a result of:
Congenital pyloric stenosis in children occurs for reasons of unknown etiology. Scientists have been trying for a long time to determine the factors contributing to the development of pathology, but have not yet come to a consensus. It has been established that the risk of developing the disease in children increases if the mother has problems with the functioning of the endocrine system, in the case of taking certain medications during gestation, as well as an unfavorable course of the disease (severe toxicosis, infectious and inflammatory processes, etc.). In the presence of such factors, part of the muscles or the entire pyloric section of the stomach is replaced by connective tissue, and the outlet becomes excessively narrowed.
Symptoms of pyloric stenosis
Pyloric stenosis in adults is quite severe and constantly progresses. The patient often suffers from nausea and heaviness in the stomach, which is caused by difficult passage of food through the pylorus. Often after eating food, patients complain of colic and bursting pain in the stomach. When eating solid food or in case of overeating, pain occurs, which brings instant relief. The patient is constantly tormented by belching.
Due to disruption of the digestive process, a sufficient amount of nutrients, vitamins and minerals does not enter the body, which acutely affects a person’s general well-being, causing weakness, drowsiness and irritability. As a result of frequent vomiting and poor absorption of elements, the patient quickly loses weight.
In medicine, there are three degrees of pyloric stenosis:
- Compensated. It is characterized by heaviness and a feeling of fullness in the stomach, as well as vomiting in case of malnutrition.
- Subcompensated. Stagnation of food forms in the stomach, and after a heavy meal, severe vomiting is observed.
- Uncompensated. Food practically does not penetrate the intestines, which provokes its rotting in the stomach, causing vomiting, severe pain and discomfort.
Pyloric stenosis in newborns manifests itself quite acutely. The first warning symptom is profuse vomiting. In this case, the amount of vomit is equal to the milk eaten, it lacks bile and has an unpleasant sour smell. As the disease progresses, the child shows signs of dehydration and exhaustion, and is often constipated or has no bowel movements at all.
Diagnosis of pyloric stenosis
To diagnose pyloric stenosis, an examination is required, during which he collects an anamnesis and performs palpation of the abdomen. To confirm the diagnosis in adults, X-ray examination with contrast is used. Fibrogastroscopy can also be used, which allows you to identify a narrowed section of the pylorus and assess the amount of scar or connective tissue.
Pyloric stenosis in a child can be identified by a visual examination (the abdomen is strongly sunken in the stomach area and resembles an hourglass in appearance) and an analysis of the symptoms described by the mother. Additionally, a general and biochemical blood test is performed, and a consultation with a surgeon is carried out. An ultrasound of the stomach, abdominal organs and an X-ray with contrast are also required.
Treatment of pyloric stenosis
Pyloric stenosis is treated surgically. The essence of the operation is plastic surgery of the pylorus, increasing the width of the passage to an anatomically correct size. 3 days before the operation, preparatory work is carried out - the patient is given a solution of electrolytes and glucose, which is necessary to eliminate dehydration. In the presence of ulcers, polyps or tumor neoplasms in adults, partial resection (excision) of the stomach is indicated.
After surgery, it is important to properly organize rehabilitation. The patient should be fed frequently, but in very small portions, gradually bringing it to physiologically normal sizes. In most cases, children recover fairly quickly. In adults, the recovery period and further condition depend on whether the causes of the pathology are eliminated.
This is a congenital narrowing (stenosis) of the pylorus (pylorus) of the stomach.
Acute forms of pyloric stenosis include a type of clinical manifestation of this malformation in which the symptoms of the disease begin suddenly and proceed violently.
Clinical picture
The time of onset of symptoms of the disease depends on the degree of narrowing of the pyloric canal and the compensatory capabilities of the body. The first signs of the disease appear between the ages of several days and 1 month.
The main symptom of acute pyloric stenosis is vomiting "fountain", starting suddenly in the midst of full health. Vomit does not contain bile; its amount exceeds the amount of milk sucked during the last feeding. Often, vomit has a stagnant, sour odor, which indicates retention of gastric contents. Prolonged debilitating vomiting leads to a deterioration in the child’s general condition and disruption of water-salt metabolism (hypochloremia, exicosis, and sometimes hypokalemia). The acute stage of the disease is characterized by the fact that the child develops complete obstruction of the gastric patency within a few days. Feeding becomes impossible; a few sips of milk cause vomiting. Children lose up to 0.4–0.5 kg of body weight in 1–2 days. The number of urinations decreases. There is stool retention or dyspeptic “hungry” stools appear.
An indicator of the serious condition of a child with pyloric stenosis is the daily loss of body weight in relation to birth weight (as a percentage). According to this classification, three forms of the disease are distinguished:
light (0–0.1%),
moderate (0.2–0.3%) and
severe (0.4% and above).
In children with acute pyloric stenosis, body weight loss reaches 6–8%.
Upon examination, the child reacts poorly to his surroundings, with a pained expression on his face. The skin is pale, the mucous membranes are bright and dry. The fontanel sinks. Attracts attention swelling of the epigastric region, decreasing or disappearing after vomiting. When stroking the abdominal wall or after several sips of food, you may notice waves of stomach peristalsis. Often the stomach takes on the shape hourglass. This symptom is a constant sign of congenital pyloric stenosis and is of great importance for establishing the diagnosis.
X-ray examination
First, a survey radiograph of the abdominal cavity is taken with the child in an upright position. This reveals a large gas bubble and a high level of fluid in the distended stomach. There is little or no gas in the intestinal loops. Then they begin the contrast study. In newborns in the first days of life, it is used as a contrast iodolipol(5 ml), observing its passage through the gastrointestinal tract. Lack of gastric emptying for more than 24 hours indicates an obstruction in the pyloric region.
Differential diagnosis and treatment of pyloric stenosis
Differential diagnosis of acute pyloric stenosis should be carried out with pylorospasm, gastric obstruction, congenital high intestinal obstruction, habitual vomiting.
The greatest importance in children in the first days of life is differentiation from pylorospasm due to the different tactics used in their treatment. It should be borne in mind that with spasm the disease begins gradually, with spitting up, which are unstable in nature, without having a significant impact on the general condition of the child and his body weight. In cases where X-ray examination is performed to differentiate these conditions, it should be taken into account that with pylorospasm, gastric emptying begins 10 minutes after taking a contrast agent and ends after 3–6 hours. Congenital gastric obstruction is clinically and radiologically extremely difficult to distinguish from the acute form of pyloric stenosis . Usually the final diagnosis is made during surgery. Congenital anomalies of the duodenum, in which the obstruction is located below the papilla of Vater, can usually be easily distinguished from pyloric stenosis by bile-stained vomit and a characteristic x-ray pattern. Palpation of a thickened pylorus and the identification of lengthening and narrowing of the pyloric canal during X-ray examination speak in favor of pyloric stenosis. Sometimes the contrast agent (with pyloric stenosis) remaining in the stomach may appear on the radiograph as two depots located on either side of the spine, which is similar to the X-ray picture with high intestinal obstruction. In these cases, lateral radiography helps diagnosis - the dilated duodenum is usually located posterior to the stomach. Habitual vomiting and regurgitation are quite common in children in the first months of life, but this dysfunction of the stomach usually does not change the general condition of the child and does not cause a drop in body weight.
Treatment
Preoperative preparation
Preparation for surgery along with examination does not exceed 24 hours and is aimed at reducing disturbances in water-salt metabolism, as well as treating aspiration pneumonia. Immediately before the operation, gastric contents are suctioned.
Postoperative treatment
3-4 hours after the operation, if there was no injury to the mucous membrane of the stomach or duodenum, the child is given 7-10 ml of a 5% glucose solution through the nipple, after 1 hour - 10 ml of expressed breast milk, and then (if there is no vomiting) prescribe 10 ml of milk every 2 hours. To prevent wound infection and complications, it is used (6–7 days). Vitamin therapy is prescribed. Sutures are removed on the 10-12th day after surgery.
Crib
Pathognomonic signs of the disease
- vomiting fountain
- stomach resembles an hourglass
