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Pyloric stenosis is the most common disorder causing vomiting in
infancy which requires surgery.
View a video of a laproscopic pyloromyotomy.
The true cause of pyloric stenosis is unknown. It is believed to
begin as the overworked muscle around the outside of the pyloric opening
at the bottom of the stomach grows too thick. This enlarged muscle
blocks the passage of food from the stomach through the pylorus into the
downstream intestine. After the operation, the pyloric muscle becomes
completely normal. Approximately seven percent of infants with pyloric
stenosis are born with other medical problems.
The most typical symptom is the forceful vomiting of formula or milk.
Symptoms usually begin when children are between three and five weeks
old. Some babies may even have small amounts of vomiting before two
weeks of age. Eventually the children vomit almost all feeds. Even after
vomiting the children stay hungry. Although not letting the baby eat or
drink for a short time may let the infant then hold down some clear
liquids, the vomiting returns when milk or formula feedings are resumed.
Infants who have symptoms for more than a few days often lose weight and
becoming dehydrated. Repeated vomiting that persists for several days
may irritate the stomach and lead to mild stomach bleeding.
1: Ultrasound images showing the oval-shaped, enlarged pyloric
muscle in a 5-week-old infant. The pyloric muscle length (X-X) is 18 mm
and the pyloric muscle thickness (+-+) is 5.2 mm. Lengths greater than
14mm and thicknesses greater than 3 to 4 mm are considered to have
pyloric stenosis. (courtesy of Dorothy Bulas, MD.)
After feeding, waves of stomach contractions can sometimes be seen on
the abdomen in infants with pyloric stenosis. Your child's doctor may be
able to feel the thickened pyloric muscle (called an "olive") when
examining the abdomen.
Pyloric stenosis may be confused with other causes of vomiting in
infants. Overfeeding is the most common. Often there is a history of
formula changes because of intolerance to the current formula. Improved
feeding technique, frequent burping, and time are all that is needed for
most of these problems to resolve. Vomiting can also be caused by
pyloric muscle spasm, gastroesophageal reflux, and rarely, other
problems which may require surgery (malrotation of the intestines and
other types of intestinal blockage). Vomiting may also be associated
with severe medical conditions including infections.
An abdominal ultrasound is used on infants when the pyloric
“olive” cannot be felt. The ultrasound can determine if the
pyloric muscle is too large (Figure 1). A barium upper gastrointestinal
(UGI) series is an x-ray test used if the ultrasound is unclear. The UGI
series will show a blocked stomach with a long and narrowed pyloric
opening—the “string sign” (Figure 2).
If an UGI series is needed, a tube might need to be placed down into
your child’s stomach to remove the barium to decrease the risk of
vomiting when they are put asleep for surgery.
2: Upper gastrointestinal study from a 6-week-old infant shows
narrowing of the pyloric channel and the “string sign” in
Repeated vomiting can cause an abnormality in blood tests. Abnormal
blood chemistries will need to be fixed with extra fluid by vein prior
to surgery. Jaundice, or a yellow skin tone, occurs in approximately 2%
of infants with pyloric stenosis and improves by itself after
Before surgery, care is aimed at replacing the fluids lost from
vomiting by giving fluids by vein. Most infants with pyloric stenosis
can then be operated on within a day after admission to the hospital.
Most of the time the infants are not fed before surgery because of
concerns about accidental vomiting during surgery.
3: Operative technique for pyloromyotomy with optional V-shaped
extension of the incision. Note the spreader used to separate just the
muscle while leaving the inside lining intact.
A pyloromyotomy, performed while your baby is asleep
under general anesthesia, is universally accepted as the preferred
operation. The procedure can be done through a variety of incisions. The
most frequently used are 1) the right upper abdomen, 2) around the belly
button, or 3) using laparoscopy with three very small incisions.
Regardless of the approach used, the thickened pyloric muscle around the
outside of the pylorus is cut to relieve the blockage while the inside
lining of the pylorus is left intact. (Figures 3 and 4).
After the operation, fluids by vein are continued until the infant
can take all of their normal feedings by mouth. If the baby is fully
awake from anesthesia, feedings can usually be started 4 hours after
surgery. The amount and concentration of feedings may be gradually
increased until full feeds are reached. Shortly after surgery it is
common to see small amounts of vomiting until the baby’s stomach
has completely recovered from the procedure. Most infants should go home
from the hospital within one or two days after surgery. The results of
pyloromyotomy have been excellent and there is no increased risk of
stomach or intestinal problems later in life.
4: Intraoperative picture of the pylorus before and after the
muscle has been divided. Note that the inside lining of the pylorus is
left intact after the muscle is divided.
Potential complications include bleeding, wound problems like
infection and hernias, incomplete cutting of the pyloric muscle leading
to a return of symptoms and, extremely rarely, developing a leak in the
intestine. The chance of dying from an operation for pyloric stenosis is
less than four in one thousand. These very rare deaths are usually
related to other severe medical conditions.
Article and graphics adapted from O'Neill: Principles of Pediatric
Surgery. © 2003, Elsevier.