BACKGROUND:

The predictive factors for a negative outcome in initial intravenous atropine (IA) therapy of infantile hypertrophic pyloric stenosis (IHPS) are unknown. Conservative therapy for IHPS is useful for infants because it does not have the risk of surgical and anesthetic stress, but some cases where patients undergoatropinetherapy result in failure. This study aimed to clarify the predictive markers for a negative outcome in initial atropinetherapy of IHPS.

METHODS:

Seventy-six patients with IHPS who were admitted to our institute from 1998 to 2011 were included in this study. The predictive risk factors of a negative outcome in initial atropine therapy for IHPS were evaluated.

RESULTS:

Thirty-one patients initially underwent non-operative therapy for IHPS during the study period. Of the 31 patients, 18 (58%) ceased projectile vomiting with intravenous and subsequent oral atropine administration. Univariate analysis showed that loss of body weight gain before administration, elevated urine potassium level at admission, and projectile vomiting occurring ≥5 times (PV≥5) for 3 days from IA administration were predictive risk factors for a negative outcome in IHPS. Multivariate analysis revealed that only PV≥5 for 3days after IA was independently associated with failure of atropine therapy for IHPS.

CONCLUSIONS:

PV≥5 for 3days after IAmay be a potentially predictive indicator for a negative outcome of atropine therapy in IHPS patients. Our results provide valuable information for determining whether early surgical intervention for IHPS or initial atropine therapy is the best option.

To investigate the efficacy of surgical management for pyloric stenosis induced by gastrointestinal chemical burn in children.Clinical data of 11 children with pyloric stenosis induced by gastrointestinal chemical burn were analyzed retrospectively. After the failure of medicine, intervention of low balloon expansion and stent placement, they underwent pylorectomy and gastroduodenostomy. The body weight, height, serum albumin, hemoglobin, transferrin were compared between 1 day before and 3 months after operation.There were 10 males and 1 female with a mean age of 4.5 years old. The main cause of serious pyloric stenosis was the wrong intake of hydrochloric acid. Lesions involved the esophagus and stomach in the early stage, and 4 weeks later, the lesion mainly involved the pylorus, which resulted in scarring pyloric stenosis and complete pyloric obstruction. Pylorectomy and gastroduodenostomy was successfully performed. The mean operative time was (134±26) min. The estimated blood loss was (5±2) ml. The postoperative length of stay was (10±3) d. There were no surgical complications. During the follow-up of 3 months, all the patients resumed regular diet. The height, body weight, and intelligence appeared to be normal. They showed significant improvement in weight, serum albumin, globulin, hemoglobin, transferrin at 3 months after the surgery(P<0.05). Six months after surgery, the anastomosis was shown to be nornal in barium follow through exam with no signs of stricture of ulcer.Pylorectomy and gastroduodenostomy is an effective management for pyloric stenosis induced by gastrointestinal chemical burn in children, whose short-term efficacy is good.

To examine the sonographic measurements of pyloric muscle and pyloric thickness in premature infants with hypertrophic pyloric stenosis (HPS) and to correlate these measurements with patients variables. We aimed also to evaluate the clinical features and short-term outcome of HPS in premature compared to term infants.The medical notes and the pyloric ultrasounds of all premature infants (<37 weeks) admitted to the Neonatal Surgical Unit with HPS over a 20-year period (1990-2010) were retrospectively reviewed. Sonographic measurements of the pyloric length, muscle thickness and the pyloric ratio (muscle thickness divided by pyloric diameter) were correlated to weight at presentation, duration of symptoms and corrected gestational age. Multiple regression and correlation analysis was carried out.Seventy-five preterm infants were identified (51M:24F). Median gestational age was 34 weeks. Median weight at presentation was 2.74 kg. Forty-two had an ultrasound (US) before surgery, 37 measurements were analysed. Pyloric length, muscle thickness and pyloric ratio were not affected by weight at presentation (p = 0.67, p = 0.122, p = 0.849), corrected gestational age (CGA) (p = 0.921, p = 0.678, p = 0.076), or duration of symptoms (p = 0.827, p = 0.268, p = 0.281). Mean length of stay was 6 days and overall complication rate was 27 %, both higher than reported in term infants (p < 0.001).Premature infants with HPS have a higher female preponderance than expected. Ultrasound measurements in premature infants with HPS are not affected by weight, corrected gestational age or duration of symptoms. In addition, they have a longer hospital stay and increased complication rate compared to term infants.

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.

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 an association between macrolides and cardiovascular malformations. Exposure in early infancy has been associated with pyloric stenosis and intussusception. This has led to an avoidance in prescribing macrolides to pregnant women in several Scandinavian countries. The Objectives of the present study was to investigate the fetal safety of this class of drug by linking a large administrative database of drug dispensing and pregnancy outcome in Southern Israel. 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 termination data were analyzed. The following confounders were controlled for: maternal age, ethnicity, maternal pregestational diabetes, parity, and the year the mother gave birth or went through medical pregnancy termination. First- and third-trimester exposures to macrolide antibiotics as a group and to individual drugs were analyzed. During the study period there were 105,492 pregnancies among Clalit women that met the inclusion criteria. Of these, 104,380 ended in live births or dead fetuses and 1,112 in 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 [odds ratio (OR), 1.08; 95% confidence interval (CI), 0.84 to 1.38)] or specific malformations, after accounting for maternal age, parity, ethnicity, prepregnancy 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. 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.

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.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.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.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.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.