Case Report Hps Dian

7/26/2019 Case Report Hps Dian

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CASE REPORT

Hypertrophic Pyloric Stenosis and

Severe Marasmic Type Malnourishment in a Month-Old Boy

ITRO!"CTIO

Hypertrophic pyloric stenosis (HPS), also known as infantile hypertrophic

pyloric stenosis (IHPS), is the most common cause of infant gastrointestinal

obstruction that requiring surgery in the first months of life.

1,

It is characteri!e" by a

marke" hypertrophy of the pylorus muscle, which lea"s to a blockage of the gastric

outlet an" pro#okes increasingly se#ere episo"es of pro$ectile #omiting.,% &he

inci"ence of IHPS is appro'imately two to fi#e per 1, births per year in most white

populations, although it #aries with the geographic area an" the time perio" being

re#iewe". Pyloric stenosis appears to be more common in infants of caucasian

"escent an" is less common in In"ia an" among black an" sian populations, with a

frequency that is one*thir" to one*fifth that in the white population. +,,-&here is male*

to*female ratio of +1, with reporte" ratios ranging from ,1 to ,1.1,+,

Hypertrophic pyloric stenosis ten"s to run in families, howe#er, the e'act pattern of

inheritance is unclear. &he inci"ence rate is 1 in 1+ if the father is affecte", the rate is

e#en higher if the mother is affecte".1/irst*born chil"ren ha#e been note" to be more

likely affecte", an" a familial link is seen with a greater than fi#efol" increase in the

risk in first*"egree relati#es.,-

Infants classically present at to - weeks ol" with gra"ually progressi#e

#omiting that becomes pro$ectile an" remains nonbilious. Infants remain #igorous

with a ra#enous appetite. &hey rapi"ly finish an entire fee"ing, only to regurgitate the

entire #olume in a pro$ectile fashion. In the later stages of the "isease, chil"ren may

e'hibit #isible wa#es of ab"ominal peristalsis in response to intense contractions

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against an obstruction. 0hil"ren in the later stages of "isease may e'hibit marasmus

(protein*calorie malnutrition) as a result of impaire" nutrient absorption.1,+,-

lthough its etiology remains unknown, our un"erstan"ing of the clinical

manifestation an" treatment of HPS has un"ergone a remarkable e#olution. In

patients in whom clinical e'amination is unsuccessful, mo"ern imaging techniques

are highly accurate in facilitating the "iagnosis.+&he "iagnosis of HPS is ascertaine"

after obtaining an appropriate history an" by the palpation of a pyloric calle" oli#e

sign2. &he "iagnosis may be establishe" by ultrasonography (3S4) of the pylorus.

0hil"ren may ha#e a palpable pylorus, commonly referre" to as an oli#e in the right

epigastrium, on ab"ominal e'amination. Placement of a nasogastric tube an"

emptying the stomach or placement of the infant in the prone position often facilitates

palpation.1,5,6

7ost chil"ren probably are best manage" with hospital a"mission for

rehy"ration, correction of electrolyte abnormalities an" also for management of the

marasmus. Hypertrophic pyloric stenosis can be "iagnose" or e'clu"e" by using

3S4. &hus, infants presenting with nonbilious #omiting shoul" be "irecte" to un"ergo

3S4 if HPS is a consi"eration. Hypertrophic pyloric stenosis may be confirme" by

ultrasonography or upper gastrointestinal series. 3ltrasonography is the "iagnostic

mo"ality of choice because it is simple, rea"ily a#ailable, an" without serious

complications such as aspiration. 8ith both mo"alities, reporte" accuracy is greater

than 9:. 3ltrasonography e'amination re#eals a thickene" pylorus, which is

"iagnostic. characteristic string sign,2 reflecting passage of contrast material

through the narrowe" pyloric sphincter, can be seen in the upper gastrointestinal

tract. In a"#ance" stages with complete obstruction at the pylorus, plain films may

re#eal an enlarge" bo"y of the stomach an" pylorus. 1,+,-,5 If the patient has HPS, the

appropriate surgical referral is ma"e rapi"ly an" accurately. If the sonogram

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"elineates a normal pylorus, a search for other causes, may allow i"entification of

preampullary "uo"enal stenosis or hiatal hernia. 3pper gastrointestinal (34I)

e'amination may be performe" if further e#aluation for these con"itions is

warrante".1,+,5

Surgical correction of pyloric stenosis is not an emergency, an" therefore the

electrolyte "isturbances can an" shoul" be meticulously correcte" before operation.

Infants un"ergoing pyloromyotomy are assume" to ha#e a full stomach an" the

anaesthesiologist shoul" keep this in min". ;oth the anaesthesiologist an" surgeon

shoul" be #igilant "uring the operation to pre#ent aspiration of gastric $uice.,6

&he purpose of this report is to present a rare case of hypertrophic pyloric

stenosis an" se#ere marasmic type malnourishment in a month*ol" boy.

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CASE REPORT

gu"i 8aluyo

Hospital 8lingi because of #omiting. &he parents reporte" that #omiting ha"

starte" since a week before a"mission, non*bilious, non*pro$ectile an" non*

bloo"y, frequency ? 6*1 times@"ay, it happene" ? *1 minutes e#erytime he

finishe" nursing or bottle fee"ing, the amount is ?1*% ml each time an"

sometimes #omiting the entire #olume of his feee", contains milk. fter #omiting

the infant remains hungry an" still eager to fee". Pre#iously patient only ha"

breast fee"ing since he was born, but his mother ga#e him formula milk since ten

"ays before a"mission because he still looke" thirtsy after ha#ing breast

fee"ing. &he breast fee"ing frequency was e#ery one to two hours with the

length of breast fee"ing was 1*% minutes e#ery nursing an" there was no

"ifficulty fee"ing. &he mother ga#e e'tra formula milk about % times "aily with

amount of % ml e#ery bottle. &here is no history of fe#er, upper respiratory

infection (3AI) symptoms, "iarrhea, sei!ure, $aun"ice, hea" in$ury an" no sign of

"ehy"ration. &here is also no history of lump in the ab"omen before starting ha"

#omiting. He is less acti#e than normal. He is making fewer wet "iapers an" less

stool than usual.

Patient e'perience" weight loss since he ha" #omiting. He was born with

birth weight of - grams an" has weight gain of 9 grams when he was

three weeks in age. He loss his weight of + grams at the time when he was

a"mitte" in 8lingi hospital, an" when in the Saiful anwar hospital his bo"y weight

was grams.

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Patient ha" brought to pe"iatrician before by the parents when he ha"

#omiting for three "ays, but the pe"iatrician sai" there is no big problem an" that

was only or"inary #omiting that happene" to mostly baby, then the "octor ga#e

me"ication. ;ecause there is no impro#ement after taking me"ication from the

pe"iatrician for two "ays then the parent took him to another pe"iatrician. &he

secon" pe"iatrician referre" him to >gu"i 8aluyo 8lingi Hospital "ue to

suspecte" of HirschprungBs "isease. &he patient referre" to Saiful nwar Hospital

for further e'amination an" management.

Pasien was the first chil" an" "uring pregnancy there was no history of

blee"ing, #aginal "ischarge, fe#er, "iabetes mellitus, or hypertension of the

mother. She ne#er smoking an" also there is no history of taking "rugs or herbal

me"icine "uring pregnancy. She was routinely ha#ing ante natal care in mi"wife

e#ery month an" ha" 3S4 once in the obstetrician at the 5 months gestational

age. He was "eli#ere" spontaneously at*term by a mi"wife in nnisa Hospital

;litar, crie" spontaneously, weighe" - grams, no history of cyanosis,

respiratory "istress an" $aun"ice. &he amniotic flui" was greenish, then he was

hospitali!e" for "ays an" gi#en antibiotic.

&he mother was % years ol" house wife an" high school gra"uate". His

father was % years ol", high school gra"uate" an" work as employees in an

wel"ing in"ustrial. &here is no history of family with the same complain before.

Patient alrea"y ha" hepatitis ; immuni!ation.

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/igure 1. &he patientBs picture

&he physical e'amination foun" him alert, his weight grams (-,-:

of increament bo"y weight), bo"y length cms, hea" circumference %- cms (*1

stan"ar" "e#iation to mean) an" his weight for length was less than *% stan"ar"

"e#iation (SC).

His a'ilary temperature was %-.6D0, pulse rate 1+ beats per minute

strong an" regular, respiratory rate +- times per minute an" E saturation 99: .

His eyes were not yellowish an" the skin turgor in the forehea" was normal. &he

chest e'amination foun" symmetrical mo#ement, normal with clear breathing

soun"s an" no retractions. Heart auscultation re#eals a regular rhythm an" no

murmur. His ab"omen is slightly "isten"e" with acti#e bowel soun"s. >o

hepatosplenomegaly is note". He looks #ery thin with ol" man face an" baggy

pants. He has no inguinal hernias. 4enitalia are normal. ='tremities are normal.

0olor, perfusion, an" capillary refill are goo". >eurologic e'amination is normal.

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/igure . &he patientBs growth chart

Initial laboratory fin"ings at the time of presentation at Saiful nwar

Hospital are shown in table 1.

&able 1. Initial laboratory tests results (%*%*1)

Hemoglobin 1+.+ gms@"l 0AP .- mg@"F

Feukocytes 1-.9@mm% PP& 11.% secon"s&hrombocytes +++,@mm% P&& %9.6 secon"s

Hematocrits %9 : lbumin +.-- gms@"lCifferential count

=osinofil@;asofil@

>eutrophil@Fymfosit

@7onosit

.-@.+@+5.9@[email protected] So"ium@Potasi

um@0hlori"el@

0alsium@

Phosfor

1-@%.+6@[email protected]@+.%

S4E&@S4P& +-@1+ m3@"l

plain ab"ominal G*ray on 7ay +th1 showe" the "ilatation of gaster.

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/igure %. 0hest G*ray an" plain ab"ominal G*ray , 7ay % th1

;ase" on the anamnesis, clinical signs an" ra"iological fin"ings, the initial

"iagnosis was #omiting "ue to "iffrential "iagnosis with hypertrophy pyloric

stenosis (HPS), gastro esophagal reflu' "isease (4=AC), pylorospasm, pyloric

atresia, an" se#ere marasmic type malnourishment. n ab"ominal 3S4 was

planne" to confirm the "iagnosis. Initial treatment of the patient was o'igenation,

flui" an" nutritional support, antibiotics, an" micronutrient. &hose are nasal

canule o'igen liters per minutes if clinicaly there were "yspneau "ue to

"isplacement by enlarge" stomach, semifowler position %, intra#enous flui"

"rip Ce'trose 1, ,16 >a0l ,9: % ml@"ay, lipi" : ml (, gms@kg bo"y

weight@"ay), aminosteril infant -: 6- ml (1, gms@kg bo"y weight@"ay), ampicillin

%'5mg (1mg@kg bo"y weight@"ay), #itamin 1' I3, #itamin = 1' I3,

#itamin 1'1mg, #itamin 0 1'mg, #itamin ; comple' 1' 1@+ tablet, !inc

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1'1mg, folic aci" 1'1mg an" breast fee"ing - ml gi#en intermitten.Patient also

consulte" to surgery "epartement. &he conclusion from surgery "epartment was

high le#el bowel obstruction "ue to suspecte" hypertrophic pyloric stenosis an"

planne" to ha#e ab"ominal 3S4.

&he b"ominal 3S4 on 7ay th1, foun" thickening of the walls of

the pylorus with the thickness of ?.- cms along the ?1.-9 cms, with the patient

postion tilte" to the right, there were still a little liqui" that passes through the

pylorus. &he conclusion of ab"ominal 3S4 was hypertrophic pyloric stenosis.

/rom surgery "epartement patient planne" to ha#e pylorotomy.

/igure +. b"ominal 3S4, 7ay th1

En June %r"1 the surgery "epartment performe" pyloromyotomy to

patient. Eperation report showe" there were thickeness of pylorus along ?1.-

cms an" thickeness of serous muscularis length ?.- cms.

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!ISC"SSIO

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Hypertrophic pyloric stenosis is the most common cause of infantile

gastrointestinal obstruction beyon" the first month of life. &he first clinical "escription

of HPS was by /abricious Hil"anus in 1-5, but Haral" HirschsprungBs seminal

article in 1666 le" to our mo"ern un"erstan"ing of the con"ition.lthough HPS is the

most common surgical con"ition pro"ucing emesis in infancy,its etiology is unknown.

8hether the con"ition is congenital or acquire" is "ebate".- Infants classically

present at to - weeks ol" with gra"ually progressi#e emesis that becomes

pro$ectile an" remains nonbilious. In general, #omiting in IHPS is pro$ectile, but in

these patients was not foun". Aesearch by San"ra et al foun" only 69: of infants

with HPS showe" manifestation pro$ectile #omiting.1

Infants remain #igorous with a ra#enous appetite.1,Infants classically present

at to - weeks ol" with gra"ually progressi#e #omiting that becomes pro$ectile an"

remains nonbilious.&he cause of pyloric stenosis is unknown. 4enetic, familial,

gen"er, an" ethnic origin can influence the inci"ence rates of HPS.6,11,1 &here is

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e#i"ence both for an" against an increase" inci"ence in the first*born chil", an" there

is familial clustering of HPS, but not in a 7en"elian pattern.,-&here is male*to*

female ratio of +1, with reporte" ratios ranging from ,1 to ,1.1,+,

;ottle*fee"ing has been suggeste" to increase the risk of HPS. Aesearch by

rogh et al an" 7c.teer et al showe" that bottle*fe" infants e'perience" a +.-*fol"

higher risk of pyloric stenosis (PS) compare" with infants who were not bottle*fe".

&he result a""s to the e#i"ence supporting the a"#antage of e'clusi#e breastfee"ing

in the first months after birth.

%,1+

&his is a case that occurre" in infants age" 1 month with onset at age

weeks, present with non bilious an" pro$ectile #omiting. In epi"emiology in

accor"ance with an a#erage age IHPS is *- weeks. Patient is male an" was the

first born chil" but there is no history of HPS in his parents. In these patients from

birth to age weeks "oes not in"icate an abnormality. He starte" ha#ing complain of

#omiting since weeks of age. &his complain note" by her mother since she ga#e

e'tra bottle fee"ing instea" of gi#ing breast fee"ing. ;ase" on the research about

bottle fee"ing is associate" with an increase" risk of HPS, this patient ha" only

breast fee"ing before he starting #omiting. &he mother starte" gi#ing bottle fee"ing

instea" of breast fee"ing because she felt that his baby still look thirsty after ha#ing

nurse" on her. &hat coul" happene" because she "i"inBt know how to gi#e correctly

breast fee"ing since this is the first chil".

Ene of "ifferential "iagnosis of this this patient is 4=AC as the #omiting of

this patient was not pro$ectile. &he results of ab"ominal plain G*ray shows there is

stomach wi"ene", meaning there is probablitiy of obstruction in the stomach.

&he "iagnosis of HPS is initially suggeste" by the typical clinical presentation.

Palpation of the har" muscle mass, or oli#e, is "iagnostic but is often challenging an"

time consuming. In e'perience" han"s an" with a"equate time an" preparation,

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ab"ominal palpation can be successful in 6:L1: of infants.+ 0hil"ren may ha#e

a palpable pylorus, commonly referre" to as an oli#e in the right epigastrium, on

ab"ominal e'amination. Placement of a nasogastric tube an" emptying the stomach

or placement of the infant in the prone position often facilitates palpation.1 If the

pylorus is palpate" by an e'perience" clinician, no further imaging is necessary.

4astric "istension or #isible gastric peristalsis, seen as a wa#e of contraction from

the left upper qua"rant to the epigastrum, may be seen in some cases. &he inability

of a clinician to palpate an oli#e "oes not rule out the "iagnosis of HPS.

,-,6

/rom the patientBs physical e'amination we "i"nBt fin" oli#e sign2, so that we

nee" further e'amination to make the correct "iagnosis. /luoroscopic upper

gastrointestinal contrast stu"y was first propose" in 1916, an" is performe" with the

chil" "rinking from a bottle.In patients with HPS, there is failure of rela'ation of the

prepyloric antrum an" the pyloric canal is outline" by a string of contrast material.

&he thickene" muscle causes an e'ternal impression on the gastric antrum, terme"

the shoul"er sign.2 /luoroscopy can be time consuming an" in#ol#es ra"iation.

Sensiti#ity as high as 9: is reporte" but "epen"s on e'perience an" skill of the

e'aminer.3ltrasonography is nonin#asi#e, can be performe" quickly an" there is no

ra"iation e'posure. ccuracy approaches 1: in e'perience" han"s, with 99.:

sensiti#ity an" 1: specificity.,-&his woul" normally confirm the presence of a

pyloric tumour2. &he characteristic appearance of pyloric stenosis on ultrasoun" is

that of a "oughnut2 or bullBs eye2 on cross section of the pyloric channel. &he

hypertrophie" pyloric canal may range from 1+ mm to more than mm in length

an" the muscle thickness is #ariable (from % to mm). Aeal time obser#ation of

failure of rela'ation of the pyloric canal is important. &hese limits may be lower in

infants younger than % "ays of age. n e'perience" sonographer will recogni!e

perio"s of rela'ation in infants with pylorospasm, commonly confuse" with pyloric

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stenosis at e'amination.,-,6 &he 3S4 e'amination of this patient we foun" that there

is thickening of the walls of the pylorus with the thickness of ?.- cms along the

?1.-9 cms. &his ab"ominal 3S4 result retaine" HPS.

;efore surgery we ha#e to keep the patientMs general con"ition to remain

stable. ;ecause the patient was also suffering from se#ere marasmic type

malnourishment which is one of the complications of HPS, then we "i" treatment of

malnutrition. 7alnutrition is a pathologic state of #arying se#erity with clinical features

cause" by "eficiency, e'cess, or imbalance of essential nutrients. &he cause may be

primary (in#ol#ing the quantity or quality of foo" consume") or secon"ary (in#ol#ing

alterations in nutrient requirements, utili!ation, or e'cretion). Historically, malnutrition

in chil"ren has been "efine" using the terms marasmus an" kwashiorkor. 7arasmus

"e#elops after se#ere "epri#ation of calories an" is characteri!e" by weight loss an"

wasting of fat an" muscle tissue. Fow weight*for*height an" a re"uce" height*for age

are commonly obser#e". In the chil" with kwashiorkor, protein "eficits outweigh

calorie "eficits. ="ema "ue to #isceral protein "epletion occurs along with muscle

wasting. lthough some "egree of growth failure may be present, weight*forheight

may not be notably low secon"ary to retention of flui" in the e'tra#ascular

compartment. Irritability, apathy, anore'ia, an" fatigue may be seen in both

marasmus an" kwashiorkor.1 &he "iagnosis of se#ere marasmic type

malnourishment from this patient base" on clinical fin"ing an" anthropometric

e#aluation. /rom the anthropometric we foun" that his weight for length was less

than *% SC with percentage of increament bo"y weight was 9,9:. /rom the physical

e'amination patient looks like ol" man face with #ery thin bo"y an" there was baggy

pants. 1-,15

In the stabilisation phase a cautious approach is require" because of the

chil"Bs fragile physiological state an" re"uce" homeostatic capacity. /ee"ing shoul"

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be starte" as soon as possible after a"mission an" shoul" be "esigne" to pro#i"e

$ust sufficient energy an" protein to maintain basic physiological processes. ;ase"

on 8HE the essential features of fee"ing in the stabilisation phase are15

N small, frequent fee"s of low osmolarity an" low lactose

N oral or nasogastric (>4) fee"s (ne#er parenteral preparations)

N 1 kcal@kgs@"ay

N 1*1. grams protein@kgs@"ay

N 1% ml@kgs@"ay of flui" (1 ml@kgs@"ay if the chil" has se#ere oe"ema)

N if the chil" is breastfe", encourage to continue breastfee"ing but gi#e the

prescribe" amounts of starter formula to make sure the chil"Bs nee"s are met.

&his patient ha" problem profuse #omiting "ue to HPS ma"e the enteral

nutrition will barely "ifficult to gi#e, so we ga#e parenteral nutrition (P>) for this

patient. &he time when P> shoul" be initiate" will "epen" both on in"i#i"ual

circumstances an" the age an" si!e of the infant or chil". In the small preterm infant

star#ation for $ust one "ay may be "etrimental an" where it is clear that enteral fee"s

will not be tolerate" soon P> must be institute" shortly after birth. Howe#er in ol"er

chil"ren an" in a"olescence longer perio"s of ina"equate nutrition up to about se#en

"ays may be tolerate", "epen"ing on age, nutritional status, an" the "isease, surgery

or me"ical inter#ention.16

0arbohy"rates are the main source of energy in nutrition an" usually pro#i"e

+L-: of the energy supply in western "iets. &he ma$ority of the carbohy"rate

"eri#e" from a normal "iet reaches the bo"yBs peripheral tissues as glucose. 4lucose

is utilise" by all cells an" ser#es as metabolic fuel for muscle, li#er, heart, ki"neys

an" gut an" as the obligate energy source for brain, renal me"ulla an" erythrocytes.

4lucose is the main carbohy"rate utilise" "uring foetal lifeK about 5 gms@kgs per "ay

(appro'imately mgs@kgs per minute) of glucose crosses the placenta in the last

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trimester of pregnancy. &he ma$or source of non*protein calories in P> is C*4lucose

("e'trose), which is pro#i"e" in the monohy"rate form for intra#enous use. Ce'trose

usually contributes most of the osmolality of the P> solution. Proteins are the ma$or

structural an" functional components of all cells in the bo"y. &hey consist of chains of

amino aci" subun, its $oine" together by pepti"e bon"s. &he chain length ranges from

two amino aci"s to thousan"s, with molecular weights subsequently ranging from

hun"re"s to hun"re"s of thousan"s of Caltons. /rom a nutritional perspecti#e, an

important aspect of a protein is its amino aci" composition. 8HE recommen"e"

gi#ing lipi" emulsions are use" in pae"iatric P> as a non*carbohy"rate source of

energy in a low #olume an" with low osmolarity. Fipi" intake shoul" usually pro#i"e

L+: of non*protein calories in fully parenterally fe" patients.16

;ase" on 8HE recomme"ation we ga#e parenteral nutrition with "e'trosa

1,: ,16 >a0l .9: combine" with lipi" : an" aminosteril infant -:. 8e still

ga#e breest fee"ing as enteral nutrition gi#en by intermitten fee"ing. &he enteral

nutrition gi#en as the patient complient. n" for the se#ere malnutrition we also ga#e

antibiotic an" micronutrient.

&his patient ha#e ha" operation using metho"e of pyloromyotomy by /re"et*

Aamste"t. Curing operation the surgeon foun" pylorus muscle thickening o#er - mm

an" a length of more than 1- mm pylorus. &he surgeon "i" incision e'stramukosal of

serous towar"s mucous without in$uring the mucosa. Surgery remains an option with

a success rate of almost 1:. &herapy with this operation has a mortality rate of

less than .:, morbi"ity between 1*:, an" 1*%: recurrence rate.19,

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/igure Ciagnostic lgorithm for Hypertrophic Pyloric Stenosis6

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S"MMAR#

gu"i 8aluyo 8lingi

Hospital because of #omiting since a week before a"mission, non bilious an" non

pro$ectile, frequency ? 6*1 times@"ay. Pre#iously patient only ha" breast fee"ing

since he was born, then his mother ga#e him formula milk since ten "ays before

a"mission. &here is no history of fe#er, upper respiratory infection (3AI) symptoms,

"iarrhea, sei!ure, $aun"ice, hea" in$ury an" no sign of "ehy"ration. &here is also no

history of lump in the ab"omen before starting ha" #omiting. He is less acti#e than

normal. He is making fewer wet "iapers an" less stool than usual.

Physical e'amination foun" him alert, looks #ery tiny with ol" man face an"

baggy pants. /rom the anthropometric we foun" that his weight for length was less

than *% SC with percentage of increament bo"y weight was 9,9:. His temperature

was %-.6 D0, pulse rate 1+ beats per minute strong an" regular, respiratory rate +-

times per minute. &here was no li#er an" spleen enlargement. Plain ab"ominal G*ray

showe" the "ilatation of gaster. /rom physical e'amination there were no oli#e sign2,

so that we perform 3S4 to make the correct "iagnosis as 3S4 is nonin#asi#e, can

be performe" quickly an" there is no ra"iation e'posure. &he 3S4 e'amination of

this patient we foun" that there is thickening of the walls of the pylorus with the

thickness of ?.- cms along the ?1.-9 cms. &his ab"ominal 3S4 result retaine"

HPS.

&his patient ha#e ha" surgery using metho"e of pyloromyotomy by

/re"et*Aamste"t. Curing operation the surgeon foun" pylorus muscle thickening

o#er - mm an" a length of pylorus more than 1- mm. &he "iagnosis was

hypertrophic pyloric stenosis (HPS) an" se#ere marasmic type malnourishment.

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RE$ERECES

1. 7ark . Hostetler. AosenMs =mergency 7e"icine * 0oncepts an" 0linical

Practice in 4astrointestinal Cisor"ers n"e". 0hapter 15. 1+1-6*165.

. rogh et al. Pre* an" Perinatal Aisk /actors for Pyloric Stenosis an" &heir

Influence on the 7ale Pre"ominance. merican Journal of

=pi"emiology.11*6.

%. rogh et al. ;ottle*fee"ing an" the Aisk of Pyloric Stenosis. Journal of &he

merican ca"emy of Pe"iatrics. 1K1+1*5.

+. Hernan!*Schulman. Infantile Hypertrophic Pyloric Stenosis.

Aa"iology.%K5%19*%%1.

. 0hir"an,Fohfa et al. Infantile Hypertrophic Pyloric Stenosis. 0hapter 9.

6%-6*%51.

-. 4u"run spelun", 0urrent 7anagement of Hypertrophic Pyloric Stenosis.

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Case Report Hps Dian

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