Immediate Emergency Department Diagnosis of Pyloric Stenosis with Point-of-care Ultrasound

Gastric Outlet Obstruction (GOO) is a clinical syndrome characterized by postprandial vomiting, epigastric pain, and abdominal distension due to mechanical or motility disorders. The suspicion will mainly rely on abdominal radiological imaging (computed tomography, barium studies) that might not be widely available or even be contraindicated. We report a 65-year-old male who developed progressive epigastralgia, anorexia, and vomiting. Physical examination revealed mild abdominal distension and epigastric tenderness on deep palpation. With the presumptive diagnosis of gastric outlet obstruction, an abdominal point-of-care ultrasound (POCUS) was performed and showed impaired gastric emptying and a “target sign.” A gastroscopic exploration confirmed inflammatory pyloric stenosis due to coexisting antral and duodenal ulcers. POCUS could play an essential role in the easy ultrasonographic diagnosis of gastroparesis, helping to differentiate from other causes of obstruction and even raise suspicion in the diagnosis of pyloric stenosis as a consequence of a GGO. POCUS may serve as a first-line imaging test that can raise suspicion of this difficult to diagnose and probably underreported disease.

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“…POCUS can help getting to a bedside diagnosis and thus, to an earlier treatment[ 8 ] as well as monitor the resolution of obstruction.…”

Section: Discussionmentioning

confidence: 99%

Point-of-care ultrasound diagnosis of gastric outlet obstruction syndrome

Tung‐Chen¹,

Gutirrez-Rojas²,

Hernndez-Montero³

et al. 2023

J Med Ultrasound

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“…La asociación de la EHP con otras enfermedades hace que la evolución de los pacientes sea más compleja pues, en ocasiones, estas malformaciones o condiciones médicas impiden y retardan el tratamiento de la estenosis congénita hipertrófica del píloro y ensombrece el pronóstico de esta enfermedad. (5,6)…”

Section: Epidemiologíaunclassified

“…La madre refiere que el bebé presenta vómitos postprandiales abundantes y explosivos, de color blancos sin bilis, lo cual dificulta la alimentación, nutrición y crecimiento adecuado del paciente. (6) El lactante con un cuadro de estenosis congénita hipertrófica del píloro se encuentra ávido por los alimentos; en ocasiones se muestra irritable; también, puede presentar signos clínicos evidentes de deshidratación como pliegue cutáneo, sequedad de piel y mucosas, llanto sin lágrimas, disminución de la diuresis y decaimiento marcado, todo esto como consecuencia de la pérdida de líquido y electrólitos por los vómitos. (7) Por otro lado, cuando el cuadro progresa y no aparece un cuadro agudo de deshidratación, se puede constatar que el paciente presenta constipación por insuficiente ingesta de leche, color amarillo de piel y mucosas (íctero) y escasa o nula ganancia de peso, incluso desnutrición marcada.…”

Section: Diagnósticounclassified

Estenosis hipertrófica congénita del píloro

Ortiz Mora,

Torres Baux,

Escudero Requena

et al. 2023

Afecciones Clínico-Quirúrgicas Frecuentes en La Infancia

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La estenosis congénita hipertrófica del píloro (EHP) es una afección frecuente en la etapa neonatal y de lactancia. Predomina en primogénitos del sexo masculino y, a pesar de los avances en el campo de la cirugía pediátrica y la neonatología, tanto en la investigación como en la práctica médica, la causa no está bien definida aún. Esta enfermedad se caracteriza por el estrechamiento del canal pilórico debido a la hipertrofia muscular del píloro que obstaculiza el vaciamiento gástrico. Las manifestaciones clínicas están dadas por vómitos en proyectil sin bilis, poco aumento de peso o desnutrición, avidez por los alimentos y, en los casos severos, deshidratación y alteraciones ácido-básicas. El manejo de esta condición debe ser oportuno para evitar las complicaciones y lograr el crecimiento y desarrollo normal del niño. Existe

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“…Під час визначення товщини пілоричного м'яза слід пам'ятати, що тангенціальне положення датчика та скорочення м'яза можуть зумовити псевдостовщення. Окрім того, вимірювання має включати лише товщину гіпоехогенного м'язового шару, який є зовнішнім, і не включати гіперехогенного пілоричного каналу, на чому наголошують й інші дослідники [5,9].…”

Section: результати дослідження та їх обговоренняunclassified

“…За даними літератури, при ГПС товщина пілоричного м'яза коливалася в межах 3-5 мм [9,22], а за результатами нашого дослідження, -6,4±0,3 мм (межі коливань -3-10 мм), (рис. 3) і не корелювала При пілороспазмі, який клінічно може симулювати ГПС, товщина пілоричного м'яза становила 3,02±0,1 мм, що достовірно менше порівняно в немовлят із ГПС (t-критерій Стьюдента -1,983; р=0,0000), що підтверджують й інші дослідники [10,15].…”

Section: результати дослідження та їх обговоренняunclassified

Ultrasonography in diagnostic of hypertrophic pyloric stenosis in children: advantages and pitfalls

Borova-Halay¹,

Malovanyy²,

Pereyaslov³

et al. 2022

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Hypertrophic pyloric stenosis (HPS) in newborns is the one of the most frequent causes of vomiting that required surgery. During long period of time, X-ray was the main method for the confirming diagnosis of HPS, however after first reports about possibilities of ultrasonography (US), this method was widely applied in clinical practice. Purpose - to summarize own experience of US applying for the diagnostic of HPS; determining advantages and disadvantages of this method of examination. Materials and methods. This study based on the US results of 93 patients with HPS and 27 children with pylorospasm that were observed and treated in Lviv regional children’s clinical hospital for 2009-2020 years. By US measured the thickness of pyloric muscle, length, front-posterior (transverse) size, and diameter of orifice of pyloric canal. Results of the study were evaluated by the statistical program StatPlus: mac, AnalystSoft Inc. (version v8). Results. The thickness of pyloric muscle and pyloric canal length are the major criteria of confirming/excluding HPS diagnosis. By the measurement of pyloric muscle thickness, it is necessary to remember that tangential position of transducer and muscles’ contraction can cause pseudo-thickening. According to the results of the study, the thickness of pyloric muscle in case of HPS was 6.4±0.3 mm (a range - 3-10 mm) and was no correlation nor with duration of illness (p=0.364) nor with age of child (p=0.534). In pylorospasm, which clinically can simulate HPS, the thickness of the pyloric muscle was 3.02±0.1 mm, what is significantly less compared to infants with HPS (Student’s t-test - 1.983; p=0.0000). Pyloric canal length in case of HPS was 22.9±0.6 mm (a range - 16-32 mm), what also was significantly differed than in case of pylorospasm - 15.8±0.5 mm (Student’s t-test - 1.998; p=0.0000). This was only indicator that clear correlated with child’s age (p=0.004) and duration of illness (p=0.006). Diameter of pyloric canal orifice and front-posterior size differed from indices in children with pylorospasm also. According to the results of ROC analysis, the best markers for the confirming diagnosis of HPS was thickness of pyloric muscle, its length, and front-posterior size, while the diameter of pyloric canal orifice shows the moderate prognostic significance. Conclusions. Ultrasonographic examination makes it possible to establish the diagnosis of HPS in newborns with a high degree of reliability. A doctor, who performs US in a child with suspected pylorostenosis, should be guided by the size of the unchanged pyloric canal and in case of its hypertrophy remember the «pitfalls» in the examination and know the ways to overcome them. The research was carried out in accordance with the principles of the Helsinki Declaration. The study protocol was approved by the Local Ethics Committee of all participating institutions. The informed consent of the patient was obtained for conducting the studies. No conflict of interests was declared by the authors.

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Immediate Emergency Department Diagnosis of Pyloric Stenosis with Point-of-care Ultrasound

Cited by 6 publications

References 4 publications

Point-of-care ultrasound diagnosis of gastric outlet obstruction syndrome

Point-of-care ultrasound diagnosis of gastric outlet obstruction syndrome

Estenosis hipertrófica congénita del píloro

Ultrasonography in diagnostic of hypertrophic pyloric stenosis in children: advantages and pitfalls

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