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Pyloric Stenosis [keywords]
- PTU-049 How Rewarding Is Gastroscopy In Diagnosis Of Cancer In Isolated Iron Deficiency Anaemia? [Journal Article]
- Gut 2014 Jun.:A59-60.
The ultimate goal of the UK Cancer plan is to 'offer patients a maximum one month wait from an urgent referral for suspected cancer to the beginning of treatment'. The North London Cancer Network has devised and implemented a suspected cancer referral form for Primary Care Practitioners for patients to be seen within two weeks of referral to secondary care. One group referred on the suspected upper GI cancer referral form is patients unexplained iron deficiency anaemia (IDA) without other symptoms. Whilst IDA is a recognised finding in upper GI cancer we hypothesise that it is a rare presentation of upper GI cancer in the absence of other symptoms.The aim of this study is to assess the presenting symptoms in patients diagnosed with upper GI cancer when endoscopy is performed for anaemia as the primary indication. A single centre, retrospective analysis of all patients undergoing endoscopy for IDA from August 2008 for 5 years at a District General Hospital in North London was performed. Data was collected using electronic patient records and unisoft endoscopy database. Those diagnosed with upper GI cancer were scrutinised for presence of symptoms in addition to anaemia at presentation.Over the study period, 1529 patients were gastroscoped for IDA, and 1228 colonoscopied for IDA. 20 upper GI cancers (16 stomach, 4 oesophageal) were detected during the study. No patients with upper GI cancer had IDA alone with addition symptoms including weight loss (9 patients), malaena (3), dysphagia (3), abdominal pain (2), anorexia (2), abnormal CT scan (2), altered bowel habit (2). Other benign diagnosis at gastroscopy in anaemic patients included: Barrett's oesophagus (52), oesophagitis (159), oesophageal varices (11), gastric erosions (27), gastritis (438), pyloric stenosis (2), angiodysplasia (20), duodenal ulcer (35), duodenitis (139). In the group colonoscopied for anaemia findings included: Normal in 550, 66 had colorectal cancer, polyps in 173, angiodysplasia in 33, and IBD in 16.From this study we conclude that upper GI cancer is diagnosed on gastroscopy in only 1.3% of patients presenting with IDA. When Upper GI cancer is diagnosis in IDA it is always associated with an additional symptom such as weight loss, anorexia, dysphagia, malaena or an abnormal CT scan. Patients should not be referred with IDA on a suspected upper GI cancer referral form unless accompanied by additional alarm features. If a patient has isolated IDA and cancer is suspected a diagnostic colonoscopy is more rewarding than a gastroscopy and it is more appropriate to refer these patients to the colorectal cancer pathway. If similar findings are replicated than National guidelines should be informed and altered accordingly.None Declared.
- Laparoscopic distal gastrectomy for pyloric stenosis caused by heterotopic glands in a young female: report of a case. [JOURNAL ARTICLE]
- Surg Today 2014 Jul 2.
A 17-year-old female was referred to our hospital with worsening dietary intake and abdominal bloating. She had epigastric fullness, but no abdominal pain. Gastrointestinal endoscopy revealed food residue and pyloric stenosis. A contrast-enhanced radiograph also showed pyloric stenosis, and gastrografin was not passed well through her pylorus. Computed tomography revealed similar findings. The biopsy results indicated hyperplasia of the gastric glands. The patient was diagnosed with a benign lesion, and underwent endoscopic balloon dilation several times. However, her stenosis worsened and we decided to perform surgery. In consideration of the cosmetic outcome, we performed laparoscopic distal gastrectomy. The postoperative course was good, and the patient was discharged on postoperative day 10. The final diagnosis was pyloric stenosis caused by heterotopic glands. No malignant lesions were found. Since gastric stenosis caused by heterotopic glands has not been reported previously, we consider this to be a very rare case.
- Population-based study to determine mortality in spina bifida: New York State congenital malformations registry, 1983 to 2006. [JOURNAL ARTICLE]
- Birth Defects Res A Clin Mol Teratol 2014 Jun 27.
Background: The lifetime risk of death among individuals with spina bifida is 10-times higher compared with the general population. A population-based analysis on cause-specific mortality among individuals spina bifida is lacking. Methods: Using statewide, population-based New York Congenital Malformations Registry, we examined all births between years 1983 and 2006, and identified 1988 births with spina bifida and 10,951 births with congenital hypertrophic pyloric stenosis (CHPS). We linked registry records to birth and death files from vital records, and determined age- and cause-specific mortality for isolated and multiple spina bifida, and compared the findings with the less fatal CHPS. Results: Mortality in spina bifida is significantly high compared with CHPS (16.9% vs. 0.96%, respectively). The probability of survival in spina bifida was lower compared with CHPS. A majority of the deaths in spina bifida occurred in infants within the first year of birth; however, an increased risk of death persisted in young adulthood for both isolated and multiple cases of spina bifida. The common causes of death in children with spina bifida were hydrocephalus, infections, cardiac anomalies, pneumonia, and pulmonary embolism; while infections, heart or kidney failure, injuries and neoplasms contributed to deaths in adults. Conclusion: We conclude that mortality in spina bifida is a large concern, and individuals living with the defect require improved clinical care for lethal medical complications. Primary prevention of spina bifida through mandatory folic acid fortification remains as the best strategy to reduce both disability and mortality associated with this defect across the world. Birth Defects Research (Part A), 2014. © 2014 Wiley Periodicals, Inc.
- Roles for Nkx2-5 and Gata3 in the ontogeny of the murine smooth muscle gastric ligaments. [JOURNAL ARTICLE]
- Am J Physiol Gastrointest Liver Physiol 2014 Jun 26.
The gastric ligaments are superficial cord-like structures, located on the lesser curvature of the stomach, that extend from the pylorus to the esophagus. These ligaments have been documented in a wide variety of mammalian species, including humans, but their composition and ontogeny is unexplored. Here, we demonstrate that during ontogeny, the gastric ligaments are first visible as extensions from a C-shaped domain of Gata3-expressing cells that surround the future pylorus; this domain will later give rise to the pyloric outer longitudinal muscle (OLM). The open ends of the C are located ventrally and beginning at E13.5, the ligaments grow anteriorly from these points. While most other ligaments of the stomach are neurovascular in nature, the gastric ligaments are composed of smooth muscle cells that mature between embryonic days 14.5 and 16.5. The gastric ligaments co-express the transcription factors Gata3, Nkx2-5, and Sox9 and germline loss of Gata3 or conditional deletion of Nkx2-5 abrogates Sox9 expression and impairs gastric ligament smooth muscle development; similar phenotypes were previously seen in the OLM. In accord with this molecular contiguity between the OLM and gastric ligaments, three-dimensional image reconstruction highlights physical contiguity between these smooth muscle structures, suggesting that they may work together as a unit to control flexure of the pyloric region - a function similar to the ligament of Treitz at the duodenojejunal junction. These findings may have implications for our understanding of normal pyloric sphincter function, as well as the common human congenital pathology idiopathic hypertrophic pyloric stenosis.
- Risk of incomplete pyloromyotomy and mucosal perforation in open and laparoscopic pyloromyotomy. [Journal Article]
- J Pediatr Surg 2014 Jul; 49(7):1083-6.
Despite randomized controlled trials and meta-analyses, it remains unclear whether laparoscopic pyloromyotomy (LP) carries a higher risk of incomplete pyloromyotomy and mucosal perforation compared with open pyloromyotomy (OP).Multicenter study of all pyloromyotomies (May 2007-December 2010) at nine high-volume institutions. The effect of laparoscopy on the procedure-related complications of incomplete pyloromyotomy and mucosal perforation was determined using binomial logistic regression adjusting for differences among centers.Data relating to 2830 pyloromyotomies (1802 [64%] LP) were analyzed. There were 24 cases of incomplete pyloromyotomy; 3 in the open group (0.29%) and 21 in the laparoscopic group (1.16%). There were 18 cases of mucosal perforation; 3 in the open group (0.29%) and 15 in the laparoscopic group (0.83%). The regression model demonstrated that LP was a marginally significant predictor of incomplete pyloromyotomy (adjusted difference 0.87% [95% CI 0.006-4.083]; P=0.046) but not of mucosal perforation (adjusted difference 0.56% [95% CI -0.096 to 3.365]; P=0.153). Trainees performed a similar proportion of each procedure (laparoscopic 82.6% vs. open 80.3%; P=0.2) and grade of primary operator did not affect the rate of either complication.This is one of the largest series of pyloromyotomy ever reported. Although laparoscopy is associated with a statistically significant increase in the risk of incomplete pyloromyotomy, the effect size is small and of questionable clinical relevance. Both OP and LP are associated with low rates of mucosal perforation and incomplete pyloromyotomy in specialist centers, whether trainee or consultant surgeons perform the procedure.
- Gastric duplication cyst presenting as acquired pyloric stenosis. [Letter]
- Gastrointest Endosc 2014 Jul; 80(1):194-5.
- Herpes simplex gastritis causing pyloric stenosis. [JOURNAL ARTICLE]
- ANZ J Surg 2014 Jun 18.
- Clinical and etiological heterogeneity in patients with tracheo-esophageal malformations and associated anomalies. [JOURNAL ARTICLE]
- Eur J Med Genet 2014 Jun 12.
Esophageal Atresia (EA) is a severe developmental defect of the foregut that presents with or without a Tracheo-Esophageal Fistula (TEF). The prevalence of EA/TEF over time and around the world has been relatively stable. EA/TEF is manifested in a broad spectrum of anomalies: in some patients it manifests as an isolated atresia or fistula, but in over half it affects several organ systems. While the associated malformations are often those of the VACTERL spectrum (Vertebral, Anorectal, Cardiac, Tracheo-Esophageal, Renal and Limb), many patients are affected by other malformations, such as microcephaly, micrognathia, pyloric stenosis, duodenal atresia, a single umbilical artery, and anomalies of the genitourinary, respiratory and gastrointestinal systems. Though EA/TEF is a genetically heterogeneous condition, recurrent genes and loci are sometimes affected. Tracheo-Esophageal (TE) defects are in fact a variable feature in several known single gene disorders and in patients with specific recurrent Copy Number Variations and structural chromosomal aberrations. At present, a causal genetic aberration can be identified in 11-12% of patients. In most, EA/TEF is a sporadic finding; the familial recurrence rate is low (1%). As this suggests that epigenetic and environmental factors also contribute to the disease, non-syndromic EA/TEF is generally believed to be a multifactorial condition. Several population-based studies and case reports describe a wide range of associated risks, including age, diabetes, drug use, herbicides, smoking and fetal alcohol exposure. The phenotypical and genetic heterogeneity seen in EA/TEF patients indicates not one underlying cause, but several. Unraveling the complex multifactorial and heterogeneous etiology of EA/TEF and associated features will require large cohorts of patients. Combined statistical analysis of component findings, genome sequencing, and genome wide association studies will elucidate new causal genetic defects and predisposing loci in the etiology within specific sub-populations. Improved knowledge of environmental risk factors, genetic predisposition and causal genetic syndromes may improve prediction and parental counseling, and prevent co-morbidity.
- Surgeon as Educator: Bedside Ultrasound in Hypertrophic Pyloric Stenosis. [JOURNAL ARTICLE]
- J Surg Educ 2014 Jun 12.
Our institution has demonstrated the diagnostic accuracy of surgeon-performed ultrasound (US) in the diagnosis of hypertrophic pyloric stenosis (HPS). Moreover, we have also shown this modality to be accurate and reproducible through surgeon-to-surgeon instruction. The purpose of this study was to determine whether a surgical resident with experience in diagnosing HPS can teach pediatric emergency medicine (PEM) fellows, with little experience in sonography, to accurately measure the pyloric channel with bedside US.A surgical resident with experience in diagnosing HPS with US-proctored 4 emergency medicine fellows for 5 bedside US examinations each. A PEM fellow, who was blinded to the results from the radiology department US, then performed bedside US and measured the pyloric channel in patients presenting to the emergency department with HPS. Results between the radiology department and the fellows were compared using the Student t test.In total, 18 USs were performed on 17 patients. There were no false-negative or false-positive results. There was no statistical difference between the radiology department and fellow measurement when evaluating muscle width (p = 0.21, mean deviation = 0.2mm) or channel length (p = 0.47, mean deviation = 0.6mm).Bedside-performed US technique for measuring the pylorus length and width in patients with HPS is reproducible and accurate when taught to PEM providers. The learning curve for this technique is short.
- Age at presentation of common pediatric surgical conditions: Reexamining dogma. [Journal Article]
- J Pediatr Surg 2014 Jun; 49(6):995-9.
The commonly cited ages at presentation of many pediatric conditions have been based largely on single center or outdated epidemiologic evidence. Thus, we sought to examine the ages at presentation of common pediatric surgical conditions using cases from large national databases.A retrospective analysis was performed on Healthcare Cost and Utilization Project databases from 1988 to 2009. Pediatric discharges were selected using matched ICD9 diagnosis and procedure codes for malrotation, intussusception, hypertrophic pyloric stenosis (HPS), incarcerated inguinal hernia (IH), and Hirschsprung disease (HD). Descriptive statistics were computed.A total of 63,750 discharges were identified, comprising 2744 cases of malrotation, 5831 of intussusception, 36,499 of HPS, 8564 of IH, and 10,112 of HD. About 58.2% of malrotation cases presented before age 1. Moreover, 92.8% of HPS presented between 3 and 10weeks. For intussusception, 50.3% and 91.4% presented prior to ages 1 and 4years, respectively. Also, 55.8% of IHD cases presented before their first birthday. For HD, 6.5% of cases presented within the neonatal period and 45.9% prior to age 1year.Our findings support generally cited presenting ages for HPS and intussusception. However, the ages at presentation for HD, malrotation, and IH differ from commonly cited texts.