Pyloric stenosis

Introduction The pyloric sphincter is highly hypertrophic, hard like cartilage, shaped like an olive, and the pyloric tube is severely narrow, resulting in significant mechanical obstruction. Congenital hypertrophic pyloric stenosis is a common disease in the neonatal period. The success of the treatment of pyloric stenosis is one of the great achievements of surgery in this century. There are different morbidity rates depending on geography, seasonality and ethnicity. The European and American countries are higher, about 2.5 to 8.8 , and the Asian region is relatively low. The incidence rate in China is 3 . Mostly male, the ratio of male to female is about 4 to 5:1, and even as high as 9:1. More common in the first child, accounting for 40 to 60% of the total number of cases.

Cause

The cause of pyloric stenosis:

Mostly congenital, the cause is unknown.

The cause of this disease has not been satisfactorily explained so far. It is currently recognized that there may be dysplasia or deficiency of the plexus between the pyloric muscles, resulting in poor relaxation of the pyloric sphincter, which causes compensatory hypertrophy of the pyloric muscle of the stomach. Its pathological features are hypertrophic hyperplasia of the pyloric sphincter, hard like cartilage, shaped like olives, severe stenosis of the pyloric tube, resulting in obvious mechanical obstruction.

In order to clarify the etiology and pathogenesis of pyloric stenosis, a lot of research work has been carried out over the years, including pathological examination, establishment of animal models, detection of gastrointestinal hormones, virus isolation, genetic research, etc., but the cause is still inconclusive.

an examination

Related inspection

Gastrointestinal meal imaging 14C breath test

(1) Ultrasound examination: The diagnostic criteria for the three indicators reflecting the pyloric mass are pyloric muscle thickness 4 mm, pyloric tube length 18 mm, and pyloric tube diameter > 15 mm. 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). It can also be seen that the stomach is dilated, the gastric peristalsis is enhanced, and the pyloric mouth is closed, which is "bird-like", and the gastric emptying is delayed. 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.

Differential diagnosis

Differential diagnosis:

Should be differentiated from other parts of obstruction. Colonic obstruction: Colonic obstruction can occur anywhere in the colon, but in the left colon. Cancerous obstruction often has typical chronic colonic obstruction, such as constipation, diarrhea, pus and bloody stool, bowel habits and shape changes; abdominal pain in right colon obstruction in the right and middle abdomen, left abdominal obstruction and abdominal pain in the left lower abdomen . Chronic obstruction can develop gradually or suddenly into acute obstruction. Beal suggested that progressive bloating and constipation in the elderly are typical colon cancer obstructions. Normal people have 10% to 20% ileocecal valve insufficiency, part of the colon content can return to the intestine to cause small intestine dilatation, gas accumulation, fluid, easily misdiagnosed as low intestinal obstruction. If the ileocecal valve function is good, a closed bowel segment is formed between the ileocecal part and the obstruction part; at this time, the gas and liquid in the ileum continuously enter the colon, causing the colon to swell, the abdominal distension is obvious, and the exhaust and defecation are completely stopped, but still No vomiting. In addition to abdominal distension during the examination, intestinal type or sputum and lump can be seen, and digital rectal examination and X-ray examination should be performed. In the abdominal fluoroscopy or abdominal plain film, the proximal intestinal fistula showed obvious expansion, and the distal intestinal fistula showed no gas. The standing position showed fluid level in the colon. Barium enema helps to identify, and at the same time it can play an important role in establishing the site of obstruction and the cause. Buechter reported a diagnosis rate of 97% and 94% for abdominal X-ray and barium enema, respectively.

Closed intestinal obstruction: refers to the simultaneous obstruction of both ends of the small intestine and the mesenteric vessels, so that the intestinal obstruction is accompanied by a blood supply disorder of the obstructed intestine (ie, closed hernia).

Low intestinal obstruction: Low intestinal obstruction is a clinical manifestation of intestinal obstruction. Intestinal obstruction (ileus) refers to the intestinal contents being blocked in the intestine.

Symptoms of gastric torsion obstruction: Stomach torsion, also known as gastric reversal, the rotation of the stomach itself caused by the large curvature of the stomach and the small anatomical position of the stomach is a rare disease, accounting for about 2% of the stomach surgery. The gastric torsion may be that the large curvature of the stomach is turned up along the longitudinal axis of the stomach (organ axis), or the pyloric region may be reversed along the transverse axis of the stomach (the retina axis) to the cardia region, the degree of which may be different, clinically causing obstruction and Blood disorder. Stomach torsion is not common, its acute type develops rapidly, the diagnosis is not easy, and the treatment is often delayed. If the torsion exceeds 180°, acute upper abdominal pain and severe vomiting occur, requiring emergency surgery. The symptoms of chronic type are not typical and are not easy to find in time.

diagnosis:

More than the second or third week after birth, pyloric obstruction showed: a. nausea and vomiting, immediately after or 10 minutes after eating, vomiting was jetting, spit without bile, and early cases showed galactorrhea.

b. It can be seen that the gastric peristaltic wave moving from the left rib to the right disappears to the right upper abdomen.

c. pyloric mass, about 90% of cases, can be in the right upper abdomen (generally between the lower edge of the liver and the outer edge of the rectus abdominis), can touch a 2 × 1cm size, the edge is clear, hard as the cartilage is spindle-shaped, surface A smooth lumps are best checked when the sick child is asleep or sucking.

d. Checking the meal, mixing the sputum into the milk, and seeing after eating, the lower end of the stomach is conical, with strong and deep peristaltic waves, suddenly disappearing in the pylorus, and few sputum into the duodenum. The agent is elongated in the pyloric cavity, and the gastric emptying is slow.

The eB type ultrasonic probe presents a hypoechoic mass (substantial dark area), which is located inside the gallbladder, in front of the right kidney and outside the pancreatic head in the lateral scan. The longitudinal scan is located behind the gallbladder. The diameter of the mass is about 1 cm, and the center has a round shape. Or a star-shaped image.

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.

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