The Progressive Development of Pyloric Stenosis: A Role for Repeat Ultrasound

Abstract

Introduction: Patients presenting in the first 3 months of life with nonbilious emesis are commonly studied by ultrasound. A negative study effectively rules out pyloric stenosis. However, the development of pyloric stenosis is a progressive and dynamic process. The rate of hypertrophy to the point of meeting diagnostic criteria is unknown and there is no data published in the literature regarding the role of repeat ultrasound in patients with persistent symptoms. During a prospective, randomized trial we identified 3 patients with negative ultrasounds who subsequently were diagnosed and treated for pyloric stenosis. We present this series as an illuminating depiction of the development of muscle hypertrophy in patients with pyloric stenosis. Methods: Patients with pyloric stenosis and repeat ultrasound were identified from our prospective, randomized trial. All patients had sonographic pyloric measurements obtained at our institution. Data included patient age upon presentation, ultrasound-defined pyloric parameters, operation, and outcome. Results: Three patients were identified with a negative ultrasound with a pyloric thickness ranging from 0.8 mm to 2.5 mm. Subsequent thickness on repeat ultrasound ranged from 3.5 to 6.2 mm. The rate of hypertrophy ranged from 0.17 mm/day to 0.5 mm/day. Conclusions: A negative pyloric sonogram may be due to the fact that the patient is in the very initial stages of development of pyloric stenosis. Caregivers should counsel parents to return if symptoms persist and there should be a low threshold for repeat ultrasound in these patients.

Key words

pyloric stenosis - diagnosis - ultrasound

References

• 1 Asai M, Katsube Y, Takita Y, Okada T, Hajikano M, Fujimatsu M, Kamisago M, Nishizawa Y, Fujita T. Intravenous atropine treatment in hypertrophic pyloric stenosis: evaluation by clinical course and imaging.  J Nippon Med Sch. 2007;  74 50-54
• 2 Blumer S L, Zucconi W B, Cohen H L, Scriven R J, Lee T K. The vomiting neonate: a review of the ACR appropriateness criteria and ultrasound's role in the workup of such patients.  Ultrasound Q. 2004;  20 79-89
• 3 Blumhagen J D, Maclin L, Krauter D, Rosenbaum D M, Weinberger E. Sonographic diagnosis of hypertrophic pyloric stenosis.  Am J Roentgenol. 1988;  150 1367-1370
• 4 Hernanz-Schulman M, Sells L L, Ambrosino M M, Heller R M, Stein S M, Neblett 3rd W W. Hypertrophic pyloric stenosis in the infant without a palpable olive: accuracy of sonographic diagnosis.  Radiology. 1994;  193 771-776
• 5 Huang Y C, Su B H. Medical treatment with atropine sulfate for hypertrophic pyloric stenosis.  Acta Paediatr Taiwan. 2004;  45 136-140
• 6 Kawahara H, Takama Y, Yoshida H, Nakai H, Okuyama H, Kubota A, Yoshimura N, Ida S, Okada A. Medical treatment of infantile hypertrophic pyloric stenosis: should we always slice the “olive”?.  J Pediatr Surg. 2005;  40 1848-1851
• 7 Mandell G A, Finkelstein M S. The role of ultrasonography in the diagnosis of pyloric stenosis: a decision analysis.  J Pediatr Surg. 1999;  34 376
• 8 Mandell G A, Wolfson P J, Adkins E S, Caro P A, Cassell I, Finkelstein M S, Grissom L E, Gross G W, Harcke H T, Katz A L, Murphy S G, Noseworthy J, Schwartz M Z. Cost-effective imaging approach to the nonbilious vomiting infant.  Pediatrics. 1999;  103 1198-1202
• 9 Ng W T, Lee S Y. Hypertrophic pyloric stenosis, congenital or not congenital: a critical overview.  Pediatr Surg Int. 2002;  18 563-564
• 10 Rohrschneider W K, Mittnacht H, Darge K, Troger J. Pyloric muscle in asymptomatic infants: sonographic evaluation and discrimination from idiopathic hypertrophic pyloric stenosis.  Pediatr Radiol. 1998;  28 429-434
• 11 Rollins M D, Shields M D, Quinn R JM, Wooldridge M AW. Pyloric stenosis: congenital or acquired?.  Arch Dis Child. 1989;  64 138-139
• 12 Spinelli C, Bertocchini A, Massimetti M, Ughi C. Muscle thickness in infants hypertrophic pyloric stenosis.  Pediatr Med Chir. 2003;  25 148-150
• 13 Peter St SD, Holcomb I IIGW, Calkins C M, Murphy J P, Andrews W S, Sharp R J, Snyder C L, Ostlie D J. Open versus laparoscopic pyloromyotomy for pyloric stenosis. A prospective, randomized trial.  Ann Surg. 2006;  244 363-370
• 14 Wallgren A. Preclinical stage of infantile hypertrophic pyloric stenosis.  Am J Dis Child. 1946;  72 371-376
• 15 Wesley J R, DiPietro M A, Coran A G. Pyloric stenosis: evolution from pylorospasm?.  Pediatr Surg Int. 1990;  5 425-428
• 16 Yamataka A, Tsukada K, Yokoyama-Laws Y, Murata M, Lane G J, Osawa M, Fujimoto T, Miyano T. Pyloromyotomy versus atropine sulfate for infantile hypertrophic pyloric stenosis.  J Pediatr Surg. 2000;  35 338-342