Which clinical finding would the nurse expect to identify in an infant with hypertrophic pyloric stenosis?
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Pyloric stenosis is a rare condition that makes the valve between a newborn's stomach and small intestine get thick and narrow. This makes it harder for food to go from the baby's stomach into the intestine. It affects about three out of every 1,000 babies born in the United States. Signs of pyloric stenosis usually show up when a baby is 3 to 5 weeks old. Babies who have it don't look sick, but they throw up a lot. Sometimes they projectile vomit -- this means it can go several feet into the air. It also might smell sour because it comes from your
baby's stomach, where it’s been mixed with stomach acid. In time, your baby might vomit more and more
often. Some babies with this condition can't keep any food down. It doesn't affect babies’ appetites, though -- they’re often hungry again soon after they throw up. Other symptoms include: Call your pediatrician if your baby has symptoms like these -- pyloric stenosis needs to be treated right away. The pylorus is a valve that sits between the stomach and small intestine. It stays closed to hold food in the stomach, then it opens to let food move into the intestine, where it’s digested. In babies with pyloric stenosis, the pylorus gets thicker, and food moves into the small intestine more slowly.
When food can't get from the stomach into the intestine, the baby throws it back up. Doctors don't know exactly why the pylorus gets bigger, but it might be partly caused by changes in a gene. It's often passed down through families. If one or both parents have pyloric stenosis, their baby has up to a 20% greater chance of getting it. Other things that can make a baby more likely to have it include: Your pediatrician will ask questions about your baby's symptoms. Tell the doctor how often they throw up and what the vomit looks like. The doctor will also check your child's weight and growth. Then they’ll feel your baby's belly for any lumps: An enlarged pylorus feels like an olive. Your baby’s doctor may want to get a closer look with one of
these: Your baby also might need blood tests to check levels of things like sodium and potassium. If your baby throws up often, they can lose too much of these important minerals. Your baby will first get fluids and nutrients through an IV to treat dehydration -- they’ll drip in through a needle that goes directly
into a vein. Then surgery (called pyloromyotomy) will be done to open up the blockage. Your baby will get medicine to make them sleep, so the surgery won’t hurt. The surgeon cuts open the thickened pylorus muscle to create a wider passage for food to travel into the intestine. Sometimes, this can be done with tiny instruments through very small cuts in the baby's belly. This is called laparoscopy. The surgery takes between 15 minutes and an hour. Your baby
should be able to go home a day or two later. Babies usually go back to eating normally right away, but some may vomit for a few days afterward. Pyloric stenosis is a thickening or swelling of the pylorus — the muscle between the stomach and the intestines — that causes severe and forceful vomiting in the first few months of life. It is also called infantile hypertrophic pyloric stenosis. The enlargement of the pylorus causes a narrowing (stenosis) of the opening from the stomach to the intestines, which blocks stomach contents from moving into the intestine. Pyloric stenosis usually affects babies between 2 and 8 weeks of age, but can occur anytime from birth to 6 months. It is one of the most common problems requiring surgery in newborns. It affects 2-3 infants out of 1,000. Babies with pyloric stenosis usually have progressively worsening vomiting during their first weeks or months of life. The vomiting is often described as non bilious and projectile vomiting, because it is more forceful than the usual spit ups commonly seen at this age. The severe vomiting can result in dehydration, which may cause your baby to sleep excessively, to cry without tears, or have fewer wet or dirty diapers during a 24-hour period. Some infants experience poor feeding and weight loss, but others demonstrate normal weight gain. Constant hunger, belching, and colic are other possible signs of pyloric stenosis because your baby is not able to eat properly. Dehydration and electrolyte imbalance are common problems and can prolong a hospital stay. Diagnosing pyloric stenosis is made after taking a careful medical and family history and performing a physical examination. Radiographic studies are often recommended as well. On exam, palpation of the abdomen may reveal a mass in the upper central region of the abdomen. This mass, which consists of the enlarged pylorus, is referred to as the “olive,” and is sometimes evident after your infant is given formula to drink. Feeling the mass by palpation is a diagnostic skill requiring much patience and experience. There are often palpable (or even visible) peristaltic waves due to the stomach trying to force its contents past the narrowed pyloric outlet. In addition to a complete history and physical exam, certain diagnostic procedures are used to confirm the diagnosis of pyloric stenosis:
Traditional X-rays of the abdomen are not useful in diagnosing pyloric stenosis, except when needed to rule out other potential problems. The first step in treating pyloric stenosis is to stabilize your baby by correcting the dehydration and electrolyte imbalance, which can have a serious impact on developing babies. Your child will receive an intravenous (IV) line to replace the fluids and salts she's lost through vomiting. This can usually be accomplished in about 24-48 hours. Blood tests will monitor how she's doing. Once the blood tests come back normal, your baby's surgery — called a pyloromyotomy — will be scheduled. Surgery is necessary to treat pyloric stenosis. Your baby will not be able to breast or bottle feed until the surgery has been performed to correct the pyloric stenosis. Many children are fussy in this pre-surgery time because they cannot eat, but it is extremely important to minimize the chances that they vomit. As a result, children with pyloric stenosis will remain on IV fluids to keep them hydrated before surgery. Pyloric stenosis surgerySurgery to correct pyloric stenosis is called a pyloromyotomy. In this procedure, surgeons divide the muscle of the pylorus to open up the gastric outlet. At The Children’s Hospital of Philadelphia, the pyloromyotomy is done laparoscopically through small incisions and with tiny scopes. By doing laparoscopic surgery, we can minimize scarring, decrease potential infections and improve recovery time for children. Your baby will receive general anesthesia to put her to sleep during the procedure. Once she's asleep, the surgeon will make small laparoscopic incisions in the belly. The surgeon cuts the muscle layer, then puts a numbing medicine into the area and closes the incision. These stitches will be under the skin and won't need to be removed. After your baby wakes up, she'll go to the recovery room for several hours, then to her own hospital room. Here's what to expect:
Your baby will be discharged one or two days after surgery if she doesn't have a fever, is eating and not vomiting, and her incision isn't red or draining. If your child is still having problems with frequent spitting up after surgery, she may be diagnosed with gastroesophageal reflux (GER). You should follow up with your primary care physician to be evaluated for gastroesophageal reflux. Be sure to call your child's doctor (at Children's Hospital, you should call 215-590-2730) if:
Pyloric stenosis is unlikely to reoccur. Babies who have undergone surgery for pyloric stenosis should have no long-term effects from it. What clinical signs are found in an infant with pyloric stenosis?Signs include:. Vomiting after feeding. The baby may vomit forcefully, ejecting breast milk or formula up to several feet away (projectile vomiting). ... . Persistent hunger. Babies who have pyloric stenosis often want to eat soon after vomiting.. Stomach contractions. ... . Dehydration. ... . Changes in bowel movements. ... . Weight problems.. Which assessment finding would the nurse expect in an infant diagnosed with pyloric stenosis?Classically, the infant with pyloric stenosis has nonbilious vomiting or regurgitation, which may become projectile (in as many as 70% of cases), after which the infant is still hungry. Jaundice. The infant may develop jaundice, which is corrected upon correction of the disease. Dehydration and malnutrition.
What is the clinical significance of hypertrophic pyloric stenosis?Hypertrophic pyloric stenosis (HPS) causes a functional gastric outlet obstruction as a result of hypertrophy and hyperplasia of the muscular layers of the pylorus. In infants, hypertrophic pyloric stenosis is the most common cause of gastric outlet obstruction and the most common surgical cause of vomiting.
What is hypertrophic pyloric stenosis in infants?Infantile hypertrophic pyloric stenosis (IHPS) is a disorder of young infants caused by hypertrophy of the pylorus, which can progress to near-complete obstruction of the gastric outlet, leading to forceful vomiting.
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