mAetiology:




Immaturity of the ganglion cells at the pyloric sphincter ®Achalasia (Failure of relaxation) ® hypertrophy of the circular muscle layer to overcome the obstruction.
mPathology:
1) Proximal: Dilatation
2) Distal: Collapse.
3) At pyloric sphincter.
l Cut section: hypertrophy starts in the pyloric antrum and become maximum in the circular muscle layer of the pylorus.
l Longitudinal section: hypertrophied sphincter project into duodenum like Os in Vaginal-fornices.
mCl. Picture:
Usually the 1st baby. Male > Female . May give + ve family history.
Symptoms and signs:
1) Vomiting which is, Projectile, Bile-free, Start 2:3 weeks after birth.
2) Dehydration and constipation. His stool resembling that of a rabbit.
3) Visible peristalsis from Lt. to Rt. in the epigastruim evoked by feeding.
To detect peristalsis: The abdomen should be watched throught a feed, under good light, until vomiting occurs.
4) Olive tumour: (false tumor) firm, round mobile mass in the Rt. hypochondrium.
To detect olive tumour l Palpate under the liver with worm hand.
l Give a feed to the child.
l Palpate more than once.
mInvestigations:
1) Gastric aspiration: 4 hs after meal > 50% of meal = stenosis.
2) Thin barium emulsion or better gastrographin meal: ®cone shaped termination of the stomach.
3) Ultrasonography: Now, it is considered as the investigation of choice as it can, without difficulty, detect the classical features in the pyloric canal. Contrast radiology is not now necessary.
mDiff. diagnosis: Other causes of vomiting in neonates
1) Gastroenteritis ® Diarrhea, fever, bile stained vomiting.
2) Pylorospasm ® Transient, no mass, respond to medical treatment.
3) Duodenal atresia ® bile stained vomiting, dates since birth.
The atresia occurs in the 2nd part below the ampulla of Vater So all secretions cann't descend to intestine ® severe dehydration.
4) Volvulus neonatorum:
Vomiting 2-3 days after birth, bile stained, Lanugo hair present in meconium for d.d. from duodenal atresia.
5) Arrested rotation of the intestine ( band of Ladd ):
Coecum remains in the left side ( as the foetal position) and a band extends from it to the right side of the abdomen crossing second part of the duodenum, ( Ladd's band which prevent rotation of the intestine ). This band causes a picture of duodenal obstruction.
6) Atresia or stenosis of ileum or jejunum ® more distension and bilous vomiting.
7) Intracranial haemorrhage (trauma during birth): Vomiting is associated with other neurological manifestation.

mTreatment:
1) Medical treatment: Only for cases
a) complicated by infection till infection subsides.
b) Without mass (pylorospasm).
c) Subacute cases discovered after 2 months.
l Regulation of feeding.
l Antispasmodic: Eumydrine 1/1000 4cc before meal.
2) Surgical treatment:

Pyloromyotomy " Ramstedt's operation" longitudinal incision over the mass cutting the hyper-trophied muscle till the mucosa bulge.
The prepyloric veins of Mayo represent the distal limit of incision. Otherwise, you will injure the dueodenal fornix.
Give an account on Pyloric obstruction?
Causes:
1) Cicatricial fibrosis of duodenal ulcer. (The commonest cause)
2) Malignant infiltration.
3) Cong. hypertrophic pyloric stenosis.(In infants)
4) Postoperative adhesive obst.
5) Pressure from outside.
What are False Tumours?
Olive Tumour.
Sternomastoid T: Haematoma due to birth injury.
Pott's puffy T: Osteomyelitis of the scalp.
Cock's piculiar T: Ulcerating sebaceous cyst.
SOURCE: DR. AYMAN SALEM'S BOOK
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