Although the surgical treatment of hypertrophic pyloric stenosis is well established, its management and main complication after surgery, postoperative vomits, are subject to constant revisions. In this study, we sought a prognostic factor that indicates the occurrence of this complication.We analyzed different parameters listed in the medical histories of 169 patients treated at a tertiary hospital between 2000 and 2009, both inclusive, ruling out those who suffered some type of complication (n = 17) and those who followed a different pattern of reintroduction of feeding (n = 43).The decrease in the time interval between surgery and the first shot does not influence the outcome of patients. However, we found a negative correlation between the chlorine level in blood measured by the number of postoperative vomits. The time required to reach a correct tolerance, influenced by the degree of metabolic disorder, does influence both the number of vomits and the time required to achieve a proper tolerance. Other parameters analyzed, such as surgical time and ultrasound measurements of the pyloric olive, do not seem to influence the postoperative course of patients.Just the degree of metabolic disturbance and blood levels of chlorine seem to influence postoperative outcome, detected by the time required to reach a correct tolerance and the number of postoperative vomits.

Introduction:Macrolide antibiotics are largely used in pregnancy for different bacterial infections. Their fetal safety has been studied by several groups, yielding opposing results. In particular, there have been studies claiming association between macrolides and cardiovascular malformations. Exposure in early infancy has been associated with pyloric stenosis and intussusception. This has led to avoidance of macrolides in several Scandinavian countries. The Objectives of the present study was to investigate the fetal safety of this class of drug by linking large administrative database of drug dispensing and pregnancy outcome in Southern Israel.

Methods:

A computerized database of medications dispensed from 1999 to 2009 to all women registered in the "Clalit" health maintenance organization in Southern Israel, was linked with two computerized databases containing maternal and infant hospitalization records. Also, medical pregnancy terminations data were analyzed. The following confounders were controlled for: maternal age, ethnicity, maternal pre gestational diabetes, parity and year of birth or medical pregnancy termination. First and third trimester exposures to macrolide antibiotics as a group, and to individual drugs was analyzed.

Results:

During the study period there were 105,492 pregnancies among Clalit women that met the inclusion criteria. 104,380 of them ended up in live or dead fetus and 1,112 by abortion due to medical reasons. In the first trimester of pregnancy 1,033 women were exposed to macrolides. There was no association between macrolides and either major malformations [OR 1.08 (95% CI 0.84-1.38)], or specific malformations, after accounting for maternal age, parity, ethnicity, pre pregnancy diabetes and year of exposure. During the third trimester of pregnancy 959 women were exposed to macrolides. There was no association between such exposure and perinatal mortality, low birth weight, low Apgar score or preterm delivery. Similarly, no associations were demonstrated with pyloric stenosis or intussusception.

Conclusions:

Use of macrolides in the first trimester of pregnancy is not associated with an increased risk of major malformations. Exposure in the third trimester is not likely to increase neonatal risks for pyloric stenosis or intussusception in a clinically meaningful manner.

Gastric lipoma is considered a rare condition that may constitute a challenging diagnosis. A 51-year-old woman presented dysphagia and abdominal pain, and an upper digestive endoscopic study disclosed a gastric tumor located in the submucosa of the pyloric antrum. Conclusive diagnosis was established after repeated endoscopic biopsies, and the patient was subjected to an atypical gastrectomy, which evolved into a pyloric stenosis. This complication was appropriately corrected and the patient remains symptomless, under outpatient surveillance.

Pyloric stenosis, the most common infant gastrointestinal disease, has no known etiology and clinically presents as abnormal gastric emptying with evidence of pyloric muscle hypertrophy. Whether abnormalities in gastric muscle contraction and/or relaxation have a role in this condition are poorly known, but gastroparesis is commonly observed in association with delayed gastric emptying in adults. Therefore, we evaluated the tetrahydrobiopterin(BH4)-deficient newborn mouse model of this disease (hph-1) and hypothesized that their gastric muscle properties are impaired, when compared with wild-type control animals. In vitro studies evaluating the age-dependent gastric fundus muscle contraction and relaxation potential were conducted. As compared with wild-type mice, the hph-1 stomach content/body weight ratio was significantly increased in newborn, but not juvenile or adult animals, confirming abnormal gastric emptying. Gastric tissue neuronal nitric oxide synthase(nNOS) protein expression was upregulated in both newborn and adult hph-1 mice, but in the former there was evidence of enzyme uncoupling and higher tissue superoxide generation when compared with same age control animals. The newborn hph-1 gastric muscle carbachol, but not thromboxane A2 analogue U46619-induced contraction and nNOS-dependent relaxation were significantly reduced (P<0.01), when compared with same age wild-type animals. These group differences were not present in juvenile or adult mice. Pre-incubation with BH4 significantly enhanced the newborn hph-1, but not wild-type control gastric muscle contraction. In conclusion, changes compatible with gastroparesis are present in the newborn mouse model of pyloric stenosis. The role of BH4 deficiency and possibly associated gastroparesis in the pathogenesis of infantile pyloric stenosis warrants further investigation.

BACKGROUND:

Functional gastrointestinal disorders (FGIDs) are common digestive conditions characterized by chronic or recurrent symptoms in the absence of a clearly recognized gastrointestinal etiology. The biopsychosocial model, the most accepted concept explaining chronic pain conditions, proposes that the interplay of multiple factors such as genetic susceptibility, early life experiences, sociocultural issues, and coping mechanisms affect children at different stages of their lives leading to the development of different pain phenotypes and pain behaviors. Early life events including gastrointestinal inflammation, trauma, and stress may result in maladaptive responses that could lead to the development of chronic pain conditions such as FGIDs.

AIMS:

In this review, we discuss novel findings from studies regarding the long-term effect of early life events and their relationship with childhood chronic abdominal pain and FGIDs.

METHODS:

A bibliographic search of the PubMed database was conducted for articles published over the last 20 years using the keywords: "Functional gastrointestinal disorders", "chronic abdominal pain", "chronic pain", "gastrointestinal inflammation", and "early life events". Forty-three articles were chosen for review.

RESULTS:

Based on the current evidence, events that take place early in life predispose children to the development of chronic abdominal pain and FGIDs. Conditions that have been studied include cow's milk protein hypersensitivity, pyloric stenosis, gastrointestinal infections, and Henoch-Schonlein purpura, among others.

CONCLUSIONS:

Early events may play an important role in the complex pathogenesis of functional gastrointestinal conditions. Timely intervention may have a critical impact on the prevention of this group of chronic incapacitating conditions.

Infantile hypertrophic pyloric stenosis (IHPS) is a common surgical cause of vomiting, which requires surgery in infant. There is the complete or partial obstruction of pylorus due to hypertrophy of circular muscle of the pylorus leading gastric outlet obstruction. The occurrence of IHPS in dizygotic twins is rarer and the theory of genetic origin alone does not explain it. Recent literature points to the association of bottle feeding in singletons to be a major aetiological factor for this condition. Here, we present a rare case of dizygotic twins who were bottle-fed and were affected with IHPS. We review the literature and focus on the question of whether this condition in twins supports a genetic or environmental origin of IHPS.

Here, we report a case of duodenal intramural metastasis from gastric cancer, which is extremely rare.A 72-year-old man was admitted to our hospital with a chief complaint of lack of appetite in 2010. An endoscopic evaluation detected a Borrmann type 2 tumor occupying the lesser curvature of the gastric body and antrum, and pyloric stenosis. The patient underwent total gastrectomy. In an examination of the resected specimen, a type 2 tumor was identified in the middle gastric body and antrum, and a submucosal tumor was detected in the duodenal bulb. A histopathological examination demonstrated that the gastric tumor was not contiguous with the duodenal submucosal tumor. A microscopic examination demonstrated that the gastric tumor was a moderately to poorly differentiated adenocarcinoma and displayed lymphatic permeation. The duodenal submucosal tumor was also found to be an adenocarcinoma and was similar to the gastric tumor; therefore, we diagnosed the duodenal tumor as an intramural metastasis from gastric cancer.The most common route of metastasis from gastric cancer involves hematogenous metastasis, lymph node metastasis, and peritoneal metastasis. Intramural metastasis from gastric cancer is rare and has been reported to be a variant of lymphogenic metastasis. The clinicopathological features of patients with duodenal intramural metastasis from gastric cancer are unclear because only one case of the condition has been reported.Duodenal intramural metastasis from gastric cancer is an advanced form of cancer, and we suggest that it should be treated with surgical resection followed by adjuvant therapy.

Early exposure to oral erythromycin in young infants, particularly in the first 2 weeks of life, has previously been associated with the development of hypertrophic pyloric stenosis. We report a case of an infant who received an abbreviated 4-day course of oral erythromycin for suspected Chlamydia conjunctivitis at 5 days of life then underwent pyloromyotomy for pyloric stenosis less than 2 weeks later. Health care providers should use erythromycin judiciously in neonates because only a few days of exposure to this medication may lead to the development of a surgical condition of gastric outlet obstruction.

BACKGROUND:

Little is known about the direct effect of pneumoperitoneum (PP) on microcirculation and its influence on the quality of tissue perfusion. This study aimed to investigate the intraoperative effects of carbon dioxide (CO2) gas PP on microcirculation density and perfusion in neonates receiving laparoscopic surgery for hypertrophic pyloric stenosis.

METHODS:

In a single-center observational study, the oral microcirculation in 12 neonates receiving laparoscopic pyloromyotomy was investigated. Intraoperative hemodynamic parameters, intermittent buccal mucosa capillary density measurements (pre- and postoperative), and continuous intraoperative sublingual microcirculation measurements (i.e., vessels with a diameter <25 μm) of total vessel density, perfused vessel density, proportion of perfused blood vessels, blood vessel diameters (BVd), and microvascular flow index were obtained before (at baseline), during, and after PP insufflation for all patients using sidestream dark-field imaging for the duration of the complete surgical procedure.

RESULTS:

With the exception of a significantly elevated end-tidal CO2 (34 ± 4-40 ± 8 mmHg; p < 0.05 vs before [baseline], one-way analysis of variance [ANOVA]) during intraoperative insufflation, no significant differences were found between time points for the intraoperative hemodynamic parameters. Pre- and postoperative buccal capillary density showed no significant changes in mucosal perfusion. Analysis of continuous intraoperative sublingual microcirculation parameters exhibited a statistically significant increase in BVd during insufflation (8.8 ± 2.4-9.3 ± 2.5 μm; p < 0.05, one-way ANOVA) and a significant decrease after exsufflation (8.2 ± 2.3 μm; p < 0.01 vs during insufflation and p < 0.05 vs baseline, one-way ANOVA, respectively). No other significant differences were found between time points for the remaining microcirculatory parameters.

CONCLUSION:

The installation of CO2 gas PP during laparoscopic pyloromyotomy procedures regulates microcirculatory perfusion by inducing changes in microvascular diameters but does not alter microcirculation density in neonates.