Pyloric muscle hypertrophy

Introduction The pylorus is the exit of the stomach and a "level" to the intestines. Due to thickening of the pylorus muscles, hypertrophy, edema, the food leading to the intestines cannot enter the intestines smoothly. The muscles of the stomach wall contracted strongly, and since the milk block entered the intestines with great resistance, it returned from the mouth. In this way, the sick child is in a state of "hunger" and is bound to become increasingly thin. Laboratory tests can find that infants with clinically dehydrated water have varying degrees of hypochlorine alkalosis, elevated blood Pco2, elevated pH and low serum chlorine. It must be recognized that metabolic alkalosis is often accompanied by low potassium, and the mechanism is still unclear. A small amount of potassium is lost with the gastric juice. When the sputum poisoning, the potassium ions move into the cells, causing high potassium in the cells, while the extracellular potassium is increased, and the potassium in the renal distal convoluted epithelial cells is increased, so that the blood potassium is lowered.

Cause

Causes of pyloric muscle hypertrophy:

Due to thickening of the pylorus muscles, hypertrophy, edema, the food leading to the intestines cannot enter the intestines smoothly.

an examination

Related inspection

Gastrointestinal CT examination of gastrointestinal diseases by ultrasonography

Examination and diagnosis of pyloric muscle hypertrophy:

Clinical manifestations:

Mainly manifested as high gastrointestinal obstruction symptoms, such as vomiting, gastric peristalsis in the upper abdomen and pyloric mass touching the hypertrophy.

1. Vomiting: the first symptom of this disease. Generally, children with congenital hypertrophic pyloric stenosis are asymptomatic after birth, and the milk and urine are normal. More than 2 to 3 weeks after birth, vomiting occurs. A few cases are vomiting after birth, and occasionally vomiting is 7-8 weeks later. Premature babies have a late onset. Start with edema after eating, occasionally vomiting, gradually increasing the number, and eventually vomiting after each milk. Vomiting occurs many minutes after the milk, from general vomiting to jetting. When it is severe, it can be sprayed to a few feet away, often from the mouth and nostrils. Vomiting is more common in immature children with pyloric stenosis, which is general vomiting and non-injective. The vomit is milk and gastric juice or milk clot, does not contain bile, and may be brown (3% to 5%) when vomiting is severe. Later, due to the gradual expansion and relaxation of the stomach, the milk stays in the stomach for a long time, the number of vomiting is less than before, sometimes not vomiting 1 or 2 times after the milk, but the amount of spit after the next milk is often more than the amount of entry, 2 times The amount is spit out together, containing more milk clots and having a sour taste. Although vomiting is frequent, there is still a strong appetite after vomiting, showing hunger, such as re-feeding, can suck as usual. Heavier vomiting, reduced stool, 1 bowel movement for several days, dry stool, hard. The amount of urine is also reduced.

2. Gastric peristaltic wave: The abdominal examination shows that the upper abdomen is bulging, and the lower abdomen is flat and soft. About 95% of the children showed gastric peristaltic waves in the upper abdomen, which moved from the left rib, moved to the right upper abdomen, and then disappeared. Sometimes two waves appeared, especially after feeding. Sometimes tapping the abdominal wall with your hand can also cause the appearance of gastric peristaltic waves. Gastric peristalsis is common in congenital hypertrophic pyloric stenosis, but it is not a unique sign. It is usually seen when feeding or after eating. Premature babies are also seen under normal conditions and cannot be used as a basis for diagnosis.

3. Abdominal mass: The olive-like mass in the right upper abdomen is a unique sign of pyloric stenosis. If you can touch and combine the history of typical vomiting, you can determine the diagnosis. However, this mass is not always easy to reach, and the detection rate of the mass is related to the examiner's experience, especially the degree of patience. It is best to check if the sick child is asleep or when feeding in the mother's arms. At this time, the child sucks hard and the abdominal wall is slack. The doctor is standing on the right side of the sick child. At the outer edge of the rectus abdominis of the right upper abdomen, gently massage the deep finger with the middle finger to touch the hard pyloric mass of the olive. Sometimes the location of the tumor is deep, covered by the liver, and it is not easy to touch. At this time, put the left hand on the back of the sick child and hold it up. The right middle finger will push the liver edge up and then touch it to the deep part. As long as you patiently and carefully check it repeatedly, Almost all cases can touch the mass. Premature infants have poor abdominal muscle development, and the abdominal wall is thin and easy to reach.

4. Dehydration and malnutrition: due to progressive exacerbation of vomiting, insufficient intake, often dehydration. The initial weight does not increase, and then quickly declines, and the day is thin. For children who have not been treated for 2 to 3 weeks, their body weight can be about 20% lower than the birth weight, showing a malnutrition appearance. The subcutaneous fat is reduced, the skin is loose, dry, wrinkled, the elasticity disappears, the front sputum and the eye socket are sunken, and the cheek fat disappears, showing the face of the elderly.

5. Alkali poisoning: due to long-term vomiting, loss of a large amount of gastric acid and potassium ions, can cause low-chlorine, low-potassium alkalosis, clinical manifestations of shallow breathing. Due to the decrease of free calcium ions in the blood, it can cause low calcium sputum, which is manifested as hand, foot, throat, and tonic convulsions. However, if the child has severe dehydration, renal function is low, acid metabolites are retained in the body, and some alkaline substances are neutralized, so it is rare to have obvious alkalosis. A small number of advanced cases are mainly characterized by metabolic acidosis, which is manifested as apathetic, antifeedant, and pale complexion.

6. Astragalus: 2% to 3% of children with jaundice, mainly indirect bilirubin increased, jaundice gradually disappeared after surgery. Causes of jaundice and calorie deficiency, dehydration, acidosis affect the glucuronyltransferase activity of hepatocytes, and delay in stool discharge increases intestinal blood circulation; sometimes direct bilirubin increases, and hypertrophic pyloric compression of the common bile duct produces mechanical obstruction ; autonomic imbalance, causing sputum in the common bile duct; dehydration-induced bile concentration and siltation.

diagnosis:

According to the typical clinical manifestations, three major signs such as gastric peristalsis, sputum and pyloric mass and jet vomiting can be seen, and the diagnosis can be confirmed. The most reliable diagnosis is based on a pyloric mass. If the lumps are not accessible, a real-time ultrasound or barium meal check can be performed to help confirm the diagnosis.

(1) Ultrasound examination: Diagnostic criteria for pyloric hypertrophy: pyloric tube long diameter > 16 mm, pyloric muscle thickness 4 mm, pyloric tube diameter > 14 mm, if the above three criteria are not simultaneously achieved, only one or two The standard is based on an ultrasound scoring system [2]. A score of 4 is diagnosed as CHPS, 2 is negative, and = 3 is recommended for further examination. Ultrasound images of CHPS: The hypertrophic pyloric ring muscles are substantially medium or low echogenic masses with clear outlines, clear borders, strong echoes in the central mucosal layer of the pyloric tube, and a silent line in the pyloric lumen. A small amount of fluid can be seen through the pyloric tube when the stomach motility is strong. A stenosis index of more than 50% has been proposed as a diagnostic criterion. Can also pay attention to observe the opening and closing of the pyloric tube and food passage, it was found that a few cases of pyloric tube open normal: called non-obstructive pyloric hypertrophy, follow-up observation of the mass gradually disappeared.

(B) barium meal examination: the main basis for diagnosis is pyloric lumen growth (> 1cm) and narrow (<0.2cm). The gastrointestinal fluoroscopy showed that the anterior pyloric area was "bird's beak-like" prominent, and the pyloric tube was slender and "line-like". The antrum and stomach cavity are enlarged, and the stomach is filled with the light spots of the contents and the darkness of the liquid dark area. The phenomenon of gastric peristalsis is enhanced and sometimes, and signs of reverse peristaltic waves and delayed gastric emptying are sometimes seen. Some patients followed up and reviewed the cases after pyloric muscle incision. This sign has been seen for several days. Later, the pyloric tube becomes shorter and wider, and may not return to normal. After the examination, the expectorant should be aspirated through the gastric tube and washed with warm saline to avoid vomiting and aspiration pneumonia.

During abdominal examination, the patient should be placed in a comfortable position. The abdomen should be fully exposed. Under the bright light, when feeding the sugar water, the stomach type and peristaltic wave can be seen. The waveform appears under the left costal margin and slowly passes over the upper abdomen. One or two waves advance and finally disappear to the right side of the umbilicus. The examiner is located on the left side of the baby. The technique must be gentle. The left hand is placed on the outer edge of the rectus abdominis of the right costal margin. Press the rectus abdominis with the index finger and the ring finger. Use the middle finger to gently touch the deep part to touch the olive. Smooth and hard pyloric mass, 1 to 2 cm in size. After vomiting, the stomach is emptied and the abdominal muscles are temporarily relaxed. Occasionally, the tail or right kidney of the liver is mistaken for a pyloric mass. However, if the abdominal muscles are not slack or the stomach is dilated, it may not be able to be removed. After the stomach tube is emptied, the sugar water is fed while sucking and checking. It is necessary to check repeatedly with patience. According to experience, most cases can reach the mass.

Laboratory tests can find that infants with clinically dehydrated water have varying degrees of hypochlorine alkalosis, elevated blood Pco2, elevated pH and low serum chlorine. It must be recognized that metabolic alkalosis is often accompanied by low potassium, and the mechanism is still unclear. A small amount of potassium is lost with the gastric juice. When the sputum poisoning, the potassium ions move into the cells, causing high potassium in the cells, while the extracellular potassium is increased, and the potassium in the renal distal convoluted epithelial cells is increased, so that the blood potassium is lowered.

Differential diagnosis

Differential diagnosis of pyloric muscle hypertrophy:

Pyloric fistula: the junction between the lower end of the stomach and the duodenum is called the pylorus. If the pyloric function is temporarily dysfunctional in the newborn, it will cause pyloric muscle tension. This is the pyloric sputum. The symptom is that jet vomiting occurs shortly after feeding, and a large amount of milk is spit out. And milk clots, mostly intermittent attacks. Although there is vomiting but not serious, there is no need to operate, and a little antispasmodic will slowly heal itself.

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