pyloric

• HYPERTROPHIC PYLORIC STENOSIS (HPS)

  • Constriction of the pyloric sphincter with obstruction of the gastric outlet

  • Circumferential muscle of pyloric sphincter thickened → elongation & narrowing of pyloric channel

  • Outlet obstruction, compensatory dilation, hypertrophy, hyperperistalsis of stomach

  • 1 st few weeks of life

  • Projectile vomiting, DHN, metabolic alkalosis, failure to thrive

  • Etiology: unknown

  • Genetic predisposition

  • Siblings / offspring of the affected person – First born children, males – Full term, less frequent in African-American & Asian infants
• PATHOPHYSIOLOGY pyloric

  • Circular muscle of pylorus thickens due to hypertrophy and hyperplasia → severe narrowing of pyloric canal → partial obstruction lumen

  • Edema and inflammation → decrease size opening → complete obstruction

  • Hypertrophied pylorus – Olive shaped mass in the upper abdomen
• DIAGNOSTIC EVALUATION pyloric

  – Olive like mass easily palpated when stomach is empty, infant quiet, relaxed abdominal muscles

  – Vomiting 30-60 minutes after feeding, projectile

  – Emesis – stale milk, non-bilous

  – UTZ – elongated sausage shaped mass with elongated pyloric channel

  – Upper GI radiography

  – Decrease in Na & K

  – Hemoconcentration

  – Decrease in Cl levels, increase in pH and HCO3

  – metabolic alkalosis

  – Increase in BUN
• CLINICAL MANIFESTATIONS pyloric

  – Projectile vomiting – Infant hungry, avid nurser, eager, accepts a 2nd feeding after vomiting

  – Evidence of pain and discomfort

  – Weight loss

  – Signs DHN

  – Distended upper abdomen

  – Olive shaped tumor in right of epigastrum

  – Visible peristaltic waves that move from L-R across epigastrum
• THERAPEUTIC MANAGEMENT pyrloic

  • Pyloromyotomy (Fredet-Ramstedt procedure)

  • Feedings: 4-6 hours post op

  • Small frequent feedings of glucose H2O or electrolyte solutions

  • 24 hours post op – start formula in stepwise increments

  • Discharged on 2nd – 3 rd post op day

  • Laparoscopy – another procedure – Shorter surgical time, more rapid post op feeding, quicker discharge

  • Prognosis: most infants recover completely

  • Post op complications: persistent pyloric obstruction, wound, dehiscence, GER
• NURSING CONSIDERATIONS pylo

  • Considered in very young infants who – Appears alert but fails to gain weight – (+) history vomiting after meals

  • Observe for eating behaviours and evidence of other characteristic clinical manifestations
• Pre Operative Care pylori

  • Restore hydration and electrolyte balance – NPO; IVF with glucose and electrolyte replacement based on serum elect – Strict I&O, urine specific gravity det. – Vomiting and characteristics of stool – Vital signs: indicate F & E imbalance – Check for metabolic alkalosis – Skin and mucous membranes, weigh OD

  • Stomach decompression& gastric lavage – Ensure that tube is patent and functioning properly – Position flat or head slightly elevated – Those who receive IVF and/or have NGT for continuous drainage – check if needle or tube is dislodged

  • General hygiene care
• Post Operative Care pylo

  • (+) post op vomiting

  • IVF until infant can tolerate oral feedings

  • Observe physical signs, I & O

  • Observe for pain - analgesis

  • Feedings – soon after surgery

  • Clear liquids – milk

  • Head elevated