Re: Spot Diagnosis - Pediatrics neck and body seen in the hyperextansion position. could be opisthotonus symmetric masses seen in the upper abdomen .this may be neoplastic masses or hypertrophic muscle or hernia
Re: Spot Diagnosis - Pediatrics Don't know much about this condition (don't do paediatics), but looks like scaphoid abdomen - physical manifestation of a diaphragmatic hernia
Answer Xtra Edge Infantile hypertrophic pyloric stenosis (IHPS) is the most common condition requiring surgeryin the first few months of life. IHPS occurs secondary to hypertrophy and hyperplasia of themuscular layers of the pylorus, causing a functional gastric outlet obstruction. CAUSE The cause of IHPS is unclear. Proposed theories include, among others, abnormal circularmuscle innervation, immature ganglion cells, decreased nitric-oxide stimulation of muscle fibers,and abnormal levels of gastrin. PATHOPHYSIOLOGY Due to protracted loss of hydrogen and sodium ion due to the vomiting, there ensues ahyponatremic, hypokalemic, hypochloremic, metabolic alkalosis. It is imperative to correctthese metabolic problems before operating the baby. Hence, IHPS, despite being an obstruction,is a medical emergency. DIAGNOSIS IHPS most commonly is seen in infants aged 3-6 weeks. Premature infants tend to present at 3-6 weeks from birth and not at 3 to 6 weeks from the due date. IHPS is rarely seen in childrenolder than 6 months. Male-to-female ratio is 4 to 6:1. IHPS accounts for 30 percent of patientspresenting with non-bilious vomiting of curdled milk that may be projectile. On examination, the baby is dehydrated. There usually is seen a gastric peristalsis, whichmay be a normal finding in a thin baby. The most important and diagnostic feature is thepalpation of the olive shaped pyloric mass in the right upper quadrant at the lateral edge of the rectus abdominis muscle. This is best palpated after the infant has vomited and when calm,or when the gastric contents have been removed via nasogastric tube. Once this is felt, noimaging is required and one may proceed to surgery when appropriate. But with the reducing skill and patience to examine, more and more surgeons are shifting to ultrasonographic examination for diagnosis. With a 5 or 7.5 MHz transducer and in reliable hands, USG has a sensitivity and specificity of 100%. Sonographic signs of IHPS are: ”¢ Muscle thickness (serosa to mucosa) greater than 3 mm ”¢ Pyloric channel length greater than 17 mm ”¢ Pyloric thickness (serosa to serosa) of 15 mm or greater Barium meal and other imaging modalities have very little to contribute. At the time of inserting intravenous line, samples should be drawn for serum electrolytes,complete blood count and serum BUN. DIFFERENTIAL DIAGNOSIS Includes Gastro-esophageal reflux,adrenal hyperplasia, duodenal stenosis,achalasia cardia, pyloric antral web and gastroenteritis. MANAGEMENT The initial management aims to correct the dehydration and the fluid and electrolyte imbalance. The initial fluid should be dextrose 5% with normal saline (DNS) or dextrose + 0.45% saline (equal volume of NS and 10% dextrose). Once a urine output is established, KCl is added at 3meq/kg/day. The electrolytes are repeated periodically. Once the electrolytes normalize, the baby is taken for Ramstedt’s pyloromyotomy. Post-operatively the baby is started on glucosefeeds after 3-4 hours and later changed to milk. The baby can be discharged 48-72 hours afterthe surgery.
