Pediatrics Surgery I: Presenter: Osoro Yvonne Kwamboka Facilitator: DR Wairimu Ndegwa

Pediatrics surgery I
Presenter: Osoro Yvonne Kwamboka

Facilitator: Dr Wairimu Ndegwa
Infantile hypertrophic pyloric stenosis (IHPS)
Etiology
• The etiology is unclear.
• Genetic predisposition in conjunction with
environmental factors is thought to play a role
Epidemiology
• Incidence is 1:300 infants
• Male to female ratio is 4:1
Pathophysiology
• Pyloric stenosis is characterized by hypertrophy of
the pyloric musculature, leading to mechanical
obstruction of the gastric outlet in the affected
infant.
• Protracted vomiting leads to dehydration and loss of
Cl⁻ and H⁺
• This leads to loss of Na⁺ in the kidneys to preserve H⁺
• Aldosterone is then secreted leading to renal
reabsorption of Na⁺ and loss of K⁺
Clinical presentation
• Typically presents in the first 2-12 weeks of life
• Non-bilious vomiting that becomes increasingly
projectile over time
• The infant is hungry after vomiting and eager to feed
leading to a cycle of feeding and vomiting
Physical Examination
• Baby may appear well or underweight in severe
cases
• Signs of dehydration
• Visible peristalsis passing from the left to right across
the upper abdomen
• A palpable “olive” mass in the right upper quadrant-
hypertrophied pylorus
Investigations
• Serum electrolytes – have hypochloremic, hypokalemic
metabolic alkalosis
• Renal function tests – dehydration
• Ultrasonography – thickened pylorus muscle and narrowed
pyloric canal. Pyloric muscle thickness >4mm and a pyloric
channel length>16mm
• Upper GI series – (in cases where there is still doubt) will
show a narrowed pyloric channel
UGI contrast showing pyloric stenosis.
Management
• Correction of electrolyte imbalance and fluid
depletion
• Fluids: 0.45% saline in 5% dextrose with 2-4mEq/kg
added once there is adequate urine output
(>1ml/kg/hr)
• NPO
• NGT decompression
• Urinary catheterization
Definitive treatment
Surgery- Ramstedt’s pylorotomy either laparoscopically

or via laparotomy
• The pylorus is identified,
• An incision is made through the serosa and
• The circular muscle is split down to the mucosa
• Upward bulging of the submucosa indicates relief of
obstruction
• Oral feeding can be started 4-6 hours post-op
Operative view of pyloric mass.
Spreading of the divided pyloric muscle.
Myotomy with mucosal bulge.

Complications
• Bleeding
• Mucosal perforation
• Wound infection and dehiscence
• Persistent vomiting – gastric atony, inadequate
myotomy, gastroesophageal reflux
Prognosis – good with surgery

Malrotation and midgut volvulus
• Malrotation is a spectrum of anatomic
abnormalities of incomplete rotation and
fixation of the intestinal tract during fetal
development.
Embryology
• During the 6th week – midgut herniation into the
umbilical cord
• Lengthening of the midgut
• 6th-10th week – midgut undergoes a 270ᴼ
counterclockwise rotation around the superior
mesenteric artery
• 10th - 12th week – return of the midgut into the
abdominal cavity
• At the end of rotation, there is a broad base of small
bowel mesentery that stabilizes its position
• Malrotation results in a narrow base for the
small bowel mesentery predisposing it to
midgut volvulus
• Intestinal obstruction and bowel infarction can
result from volvulus
Clinical presentation
• Can occur at any age but is most often seen in the
first few weeks of life
• Bilious vomiting
• Hematochezia – as the bowel strangulates
• Malnutrition
• Hemodynamic instability - shock
Physical examination
• Abdominal signs are minimal in the early stages
• Late stages : -abdominal distention and tenderness

-signs of shock
-peritonitis due to ischemia
Investigations
• Abdominal x ray - may show “double bubble” sign
due duodenal obstruction 2ᵒ to volvulus
• Upper GI series- duodenum may show cock screw
appearance
- complete duodenal obstruction
-small bowel loops completely in the right side of
the abdomen (non rotation)
Management
Initial management
 Correction of fluid and electrolyte imbalance
 NGT decompression
 Urinary catheterization
 Keep NPO
Definitive treatment
Surgery:
• Untwist the volvulus
• Widen the base of the small bowel mesentery (Ladd’s
procedure)
• Appendectomy
• The bowel is returned with the cecum in the left lower
quadrant
• If there is widespread ischemia, limited bowel resection is
done with a second-look exploration 48 to 72 hours later to
confirm viability of the remaining bowel.
Severe small bowel ischemia due to volvulus.
Complications
• Bleeding
• Wound infection and dehiscence
• Postoperative ileus
• Stricture formation
• Short bowel syndrome
Prognosis and outcome
• With prompt diagnosis and surgery prognosis is good
• Factors associated with increased mortality:
-Younger age <30 days
-Bowel necrosis
-Other clinical abnormalities
References
Bailey and Love’s Short Practice of Surgery, 26th Edition, Chapter
8, Principles of Pediatric surgery
Schwartz’s Principles of Surgery 9th Edition, Chapter 39, Pediatric
Surgery
Paediatric Surgery: A Comprehensive Text for Africa, Volume II,
Chapter 59, Infantile Hypertrophic Pyloric Stenosis. Chapter
65, Intestinal Malrotation and Midgut Volvulus
THANK YOU

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Pediatrics surgery I

Presenter: Osoro Yvonne Kwamboka

Surgery- Ramstedt’s pylorotomy either laparoscopically

Myotomy with mucosal bulge.

Prognosis – good with surgery

• Late stages : -abdominal distention and tenderness

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