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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 14  |  Issue : 4  |  Page : 207-208

Infantile hypertrophic pyloric stenosis and bilious vomiting: An unusual presentation


1 Department of Surgery, Paediatric Surgery Unit, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria
2 Department of Surgery, Paediatric Surgery Unit, College of Medicine, Lagos University Teaching Hospital, University of Lagos, Idi-Araba, Lagos, Nigeria

Date of Web Publication8-Nov-2017

Correspondence Address:
Justina O Seyi-Olajide
P. O. Box 74480, Victoria Island, Lagos
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcls.jcls_39_17

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  Abstract 


Infantile hypertrophic pyloric stenosis (IHPS) is a common cause of gastric outlet obstruction in infants, presenting with nonbilious projectile vomiting. The authors report a rare case of bilious vomiting in a neonate with intraoperatively diagnosed IHPS and no other gastrointestinal anomalies.

Keywords: Bilious vomiting, gastric outlet obstruction, infantile hypertrophic pyloric stenosis


How to cite this article:
Seyi-Olajide JO, Ladipo-Ajayi OA, Ademuyiwa AO, Elebute OA, Alakaloko FM, Bode CO. Infantile hypertrophic pyloric stenosis and bilious vomiting: An unusual presentation. J Clin Sci 2017;14:207-8

How to cite this URL:
Seyi-Olajide JO, Ladipo-Ajayi OA, Ademuyiwa AO, Elebute OA, Alakaloko FM, Bode CO. Infantile hypertrophic pyloric stenosis and bilious vomiting: An unusual presentation. J Clin Sci [serial online] 2017 [cited 2020 Apr 7];14:207-8. Available from: http://www.jcsjournal.org/text.asp?2017/14/4/207/217816




  Introduction Top


Infantile hypertrophic pyloric stenosis (IHPS) is a common cause of gastric outlet obstruction in infants.[1] The cardinal features of IHPS are nonbilious projectile vomiting and visible peristalsis in the left upper abdominal quadrant. Bilious vomiting in this condition is rarely reported and may create confusions in diagnosis.[2] This is a report of an 11-day-old infant with IHPS presenting with bilious vomiting and is intended to raise awareness and enhance index of suspicion.


  Case Report Top


An 11-day-old female neonate presented with several repeated episodes of nonprojectile bilious vomiting from the 7th day of life. Vomiting was postprandial after every feed and bilious. No test feeding was done at presentation. There was no abdominal distension, constipation, or fever. She passed meconium on the first day of life. There was no history of macrolide or any other drugs use by the mother or baby who was being exclusively breastfed. She is the third child of parents with no similar history in any of the siblings.

Examination revealed a neonate who was dehydrated, afebrile, and not pale with a flat abdomen and clean normal umbilicus. There was visible patternless peristalsis in the left upper and left lower abdominal quadrants, and no palpable mass. Umbilicus was normal. There were no groin swellings and rectal examination revealed normal findings. Her external genitalia was normal. A clinical diagnosis of partial neonatal intestinal obstruction secondary to intestinal malrotation or duodenal stenosis was made. Nasogastric tube inserted drained minimal bilious fluid initially but later stopped draining. This was thought to be as a result of untwisting of a volvulus. Plain abdominal radiographs [Figure 1], showed a large gastric air bubble with moderate air lucencies within the intestine. Electrolytes showed mild hypokalemia (3.3 mmol/l), mild hyponatremia (133 mmol/l), and alkalosis (HCO328 mmol/l). An upper gastrointestinal contrast series was not ordered so as not to delay intervention while waiting to do the contrast study. The patient had an emergency laparotomy on the 2nd day of presentation. Surgery was done through a right upper quadrant transverse incision. Intraoperatively, there was no evidence of malrotation or bowel stenosis; however, the stomach was mildly dilated, and a pyloric mass was found. A Ramstedt's pyloromyotomy was done. The intraoperative finding of IHPS prompted a review of an ultrasound scan result from a private facility which had suggested IHPS. Ultrasonography results from private facilities are usually not relied upon in the management of our patients. The patient had an uneventful postoperative period, feeding was commenced after 24 h and she was discharged home on the third postoperative day. She was well at 3 months of follow-up.
Figure 1: Plain abdominal radiographs showing large gastric bubble

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  Discussion Top


IHPS is a common cause of nonbilious vomiting in infancy with a reported incidence of 1–4 per 1000 live births. Male to female ratio is 4:1 with reported ratios ranging from 2.5:1 to 5.5:1.[1] The commonly described classic presentation of IHPS is that of nonbilious projectile vomiting at 2–8 weeks of age with a peak at 3–5 weeks. The occurrence of nonbilious vomiting is not unexpected as this is a preampullary obstruction. The presence of bilious vomiting however is very rare. Eyal et al.[3] reported a case of IHPS with bilious vomiting and suggested that this form of presentation may be due to earlier diagnosis. This is however not validated. A retrospective review of 354 patients treated for IHPS revealed that 1.4% (5) of them had bilious vomiting.[2] The median pyloric thickness measurement on ultrasound scan in the review was 3.6 mm which was significantly smaller than median thickness of 4.3 in those without bilious vomiting. The authors speculated that bilious vomiting is possible through a thickened but not fully obstructed pyloric channel. Pyloric thickness in the index patient was however 4.1 mm. In a Tanzanian study involving 102 patients, all of them had nonbilious vomiting.[4]

The electrolyte picture was in keeping with derangements expected in IHPS. The changes were however mild in this patient due to early presentation and diagnosis.


  Conclusion Top


The presence of bilious vomiting does not necessarily exclude the diagnosis of IHPS, especially in this patient with a large gastric shadow on plain radiograph. The pylorus should be examined intraoperatively during surgery for neonates with bilious vomiting if no other intestinal anomaly is detected. Investigations with rare, unexpected findings from private facilities will be thoroughly reviewed and repeated when necessary.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Chirdan LB, Ameh EA, Hughes-Thomas A. Infantile hypertrophic pyloric stenosis. In: Ameh EA, Bickler SW, Lakhoo K, Nwomeh BC, Poenaru D, editors. Paediatric Surgery: A Comprehensive Text for Africa. Seattle, WA: Global HELP Organization; 2011. p. 368-71.  Back to cited text no. 1
    
2.
Piroutek MJ, Brown L, Thorp AW. Bilious vomiting does not rule out infantile hypertrophic pyloric stenosis. Clin Pediatr 2012;51:214-8.  Back to cited text no. 2
    
3.
Eyal O, Asia A, Yorgenson U, Nagar H, Schpirer Z. Atypical infantile hypertrophic pyloric stenosis. Harefuah 1999;136:113-4, 175.  Back to cited text no. 3
    
4.
Chalya PL, Manyama L, Kayange NM, Mabula JB, Massenga A. Infantile hypertrophic pyloric stenosis at a tertiary care hospital in Tanzania: A surgical experience with 102 patients over a 5-year period. BMC Res Notes 2015;8:690.  Back to cited text no. 4
    


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