Postgrad Med J: first published as 10.1136/pgmj.26.291.24 on 1 January 1950. Downloaded from 24 CONGENITAL PYLORIC STENOSIS Together with Reports of Two Cases of, Duodenal and One Case of Jejunal Atresia By DAVID LEVI, M.S., F.R.C.S. The aetiology of congenital pyloric stenosis re- operated on three brothers successively in the mains unknown. The theory at present fashion- same family. able is that the development of the neuro-muscular plexus has been delayed and that the pyloric Pathology sphincter fails to relax and consequently hyper- The stomach shows a generalized hypertrophy trophies. The fact is that the whole musculature of the whole musculature reaching an extreme of the stomach is hypertrophic. This hyper- degree at the pylorus. The transition from the trophy is not present at birth, but appears with thickened muscle of the stomach to the thin considerable rapidity in patients presenting symp- duodenum is abrupt. The circular fibres of the toms. The following case history shows that the pyloric sphincter are most affected. hypertrophy is acquired rather than congenital:- Viewed from the duodenal side, the hyper- The author was asked to operate on a child trophic Sphincter has been likened to a small aged ten days, both of whose brothed had been cervix, but it does not project into the duodenum operated on by him for pyloric stenosis. The as the cervix projects into the vagina. The fold of mother and the maternity nurse were certain that duodenal mucosa at the junction of the duodenumby copyright. this child had the same trouble. No tumour was has been called the dangerous angle and may be found on examination or at operation and the injured at operation. stomach appeared to be perfectly normal. The With the persistent vomiting and failure of food abdomen was therefore closed without further to reach the small intestine, the blood chemistry procedure. Three weeks later the abdomen was is seriously altered. The blood urea rises, the re-opened on account of persistent symptoms and alkali reserve is increased, the urine is diminished on this occasion a well-formed tumour was present. in quantity and its chlorides diminished or absent. The muscle was therefore divided in the usual The alkalosis is caused by the persistent loss of acid manner and the child made a good recovery. radicles in the vomit, whilst the blood urea is http://pmj.bmj.com/ Babies suffering from pyloric stenosis are now raised by the combination of starvation and brought to hospital comparatively early in the vomiting. course of the disease. The starved infants of In a child which has died from the disease the former years are now rarely seen. We hope that stomach is hypertrophic, the hypertrophy ex- more children are breast-fed. The truth of the tending up to the oesophageal opening. It is most saying that ' breast milk never disagrees with a marked at the pylorus. The gastric mucosa shows baby' is generally recognized. The teaching that changes caused by the associated gastritis. There 'if a breast-fed baby vomits persistently, it may be ' coffee ground' content inside the organ. on September 25, 2021 by guest. Protected probably has pyloric stenosis-look for it' is The body generally shows signs of dehydration, bearing fruit. alkalosis and starvation. Apart from the effects of The disease occurs more frequently in males and these pathological and biochemical changes the usually manifests itself in infants between three body and organs are normal. and eight weeks old. It may commence earlier. One child in this series vomited from birth. If an Symptoms and Signs infant with pyloric stenosis reaches the age of The first symptom is vomiting. This is com- three months without operation, the condition is monly projectile and comes on after feeding. The said to undergo spontaneous resolution. This is vomit never contains bile. It persists and is not absolutely true as operation was necessary for associated with constipation and loss of weight. one child of five and a half months (Harris, C., In the later stages the vomit may contain blood 1938, Proc. Roy. Soc. Med., 31, 767). The babies coming fromthe inflamed gastric mucosa. If a new- are always hungry, alert children and the con- born child vomits and the vomit is bile-stained, dition may occur in several members of the same the child is not suffering from pyloric stenosis but family. As already indicated, the author has may be suffering from intestinal obstruction. The Postgrad Med J: first published as 10.1136/pgmj.26.291.24 on 1 January 1950. Downloaded from Yanuary I1950 LEVI: Congenital Pyloric Stenoiis 25 obstruction may be in the duodenum, as in persistently. It will become alkalosed, having duodenal atresia, or anywhere down the intestinal lost many of its chloride radicles in the vomit. tract as far as the anus. New-born babies may Later the vomit may contain blood coming from vomit because of a tight anus, not necessarily a the inflamed gastric mucosa. The blood urea complete atresia; or there may be some other rises and one case under the author's care had a cause for the vomiting. blood urea of 98 mg. per ioo cc. of blood. It To examine such a child the physician should made a good recovery after operation and is now wear a mask to prevent cross-infection, arid should 14 years old. have warm hands. The child should be in a warm The advanced stages of the disease are now room and a sterile feed should be available as fortunately rarely seen. The picture is unmistak- well as a sterile finger stall. The abdomen is un- able. The infant is emaciated, bluish grey in covered and inspected. Often if the sterile finger colour, with bright eyes and loose skin which stall is put on the index finger of the right hand hangs in folds from the abdomen and thighs, and it and this is placed in the baby's mouth the firm is constipated to an extreme degree. pyloric tumour will be felt mid-way between the ensiform and the umbilicus, just to the right of Treatment the mid-line. Marked segmentation of the rectus The treatment of hypertrophic pyloric stenosis abdominis, the edge of the liver, or the right is surgical, provided that there is an efficient kidney may give misleading evidence. The act surgical team and correct nursing and hospital of sucking stimulates gastric peristalsis; the facilities. The place for medical treatment in pylorus will contract and become palpable. The pyloric stenosis is at the onset of symptoms when tumour becomes hard and soft. If a tumour is the diagnosis is still in doubt, or when efficient felt, the diagnosis is assured. If the finger stall surgery is not obtainable. Once the diagnosis is method is not successful a feed should be given. made, valuable time should not be wasted in Whilst the child is drinking, the abdomen is medical measures; the surgeon should be con- palpated and the tumour should become palpable. sulted at once. by copyright. As the stomach fills, peristalsis may be seen passing There are three components to the surgical from left to right; often the whole outline of the team. The special hospital, the nursing staff and stomach is visible. Gastric peristalsis may be the surgeon and house officers. For perfect visible in children who are not suffering from results the three must work together. The hospital pyloric stenosis and by itself is of no diagnostic should have separate rooms for nursing mothers value. Associated with a palpable tumour, how- and their babies. If the baby is bottle-fed the ever, it clinches the diagnosis of pyloric obstruc- child must have a room to itself. Everything that tion. Finally, the child may vomit in characteristic goes into the room must be sterile. All visitors, fashion at the end of the feed. Should there still attendants and maids must be free from colds and be doubt about the diagnosis, the stomach should their throats must be free from haemolytic http://pmj.bmj.com/ be aspirated before each feed. A persistent gastric streptococci. Children must not have soiled residue is suggestive of pyloric stenosis. napkins changed at feeding times. The nurse Help may also be obtained by an X-ray examina- changing the child must regard this operation in tion. Infants take a barium meal quite well; it the same way as she would regard i surgical can be given by spoon feeding or can be run into dressing. She must scrub up before and after- the stomach through a catheter. As barium is apt wards. The soiled napkins must be put into a to lodge and remain in the colon becoming hard covered sterilized receptacle and sent away. The on September 25, 2021 by guest. Protected and inspissated and even giving rise to obstructive soiled squares must not all be tipped into an open symptoms, however, it is seldom used in the in- dustbin kept under the kitchen sink as was the vestigation of such infants. A lipiodol meal is custom in a certain hospital 25 years ago. preferable. The only necessary pre-operative treatment is a A large stomach with gastric delay is the usual gastric lavage to empty the stomach of its retained finding, although occasionally an opaque meal will contents and air. It is not the author's routine pass the pylorus in these infants. Sometimes it practice to give pre-operative fluids by other is possible to demonstrate the long thin pyloric routes than the mouth. No absolutely dogmatic canal running through the sphincter.* The statement can be made.