Morning ReportJuly 6, 2012

Good Morning!

Symptoms

Acute /subacute ChronicLocalized Diffuse

Single MultipleStatic Progressive

Constant IntermittentSingle Episode Recurrent

Abrupt GradualSevere MildPainful NonpainfulBilious Nonbilious

Sharp/Stabbing Dull/Vague

Problem Characteristics

Ill-appearing/Toxic

Well-appearing/Non-toxic

Localized problem

Systemic problem

Acquired Congenital

New problem Recurrence of old problem

Semantic Qualifiers

Illness Script

Predisposing Conditions Age, gender, preceding events

(trauma, viral illness, etc), medication use, past medical history (diagnoses, surgeries, etc)

Pathophysiological Insult What is physically happening in

the body, organisms involved, etc.

Clinical Manifestations Signs and symptoms Labs and imaging

Ultrasound

Predisposing Conditions

5:1 Male predominanceMore common is 1st born (30% of

cases)CaucasianTypically between the age of 2 weeks

– 6 weeksFamily clusteringErythromycin exposure in 1st 2 weeks

of life

Pathophysiology

True etiology unknownHypertrophy of the pyloric muscle that

leads to gastric outlet constrictionExposure to erythromycin (less so with

other macrolides) Increases risk 8-fold Erythromycin interacts with smooth muscle

motilin receptors This causes strong gastric and pyloric

contractions Subsequent hypertrophy of the pyloric muscle

Anatomy

Hypertrophy of the pylorus

Elongation and thickening

Progresses to near-complete obstruction

Clinical Manifestations*Vomiting

Non-bilious Forceful/projectile Progressive (increasing frequency)

Progression Ravenously hungry Dehydrated/weight loss Lethargic

FTTJaundicePalpable “olive” (up to 90%)Peristaltic wave after eatingElectrolyte abnormalities

ElectrolytesMetabolic alkalosis**

Decreased excretion into small intestine (increase in serum)

Decreased total body K+ leads to shift of K+ outside of cell in exchange for H+

Increased re-absorption by kidney for fluid retentions (due to dehydration)

Hypochloremia*Hypokalemia* (late finding)Correction of electrolytes before surgery…

Correct dehydration (often with NS bolus) If mild-moderate dehydration…

D5 ½ NS at correction rate, KCl once voids

Diagnosis**

Primarily a clinical diagnosis

Ultrasound Pyloric muscle thickness > 4mm Pyloric muscle length > 14mm 85-100% sensitivity and specificity

UGI 89%-100% sensitive/specific “string sign”, “double track”

UGI

Pyloromyotomy

Thanks!!

Noon Conference…Respiratory Failure by Costa