Abstract

Background: Congenital hypertrophic pyloric stenosis (CHPS), first described in 1888 by Harald Hirschsprung, is one of the most common cause of gastric outlet obstruction in infants. The incidence is approximately 1–4 per 1000 live births although the incidence differs in various regions and communities. It is usually seen in first born male infants and is characterized by projectile or forceful vomiting due to high pressure generated by the hypertrophied gastric muscles. No exact etiological cause is known but genetic and environmental factors are thought to be involved in etiopathegenesis. The diagnosis is usually established by ultrasonography which shows increased pyloric muscle thickness, length and diameter. Ramstedt's pyloromyotomy introduced in 1912, still remains the operative procedure of choice for management of CHPS. There is little published data regarding this condition in our setting hence we conducted this study to describe the clinical presentation, Ultrasound findings, post-operative complications and outcome in infants having CHPS.

Aims and Objectives: (1)To study the incidence and demographic characteristics of patients with CHPS. (2) To study clinical presentation like projectile vomiting, palpable lump, jaundice and dyselectrolytemia in these patients. (3) To study USG findings like pyloric canal length and wall thickness. (4) To study operative outcomes in terms of cessation of vomiting. (5) To study complication like wound gaping, persistent vomiting and aspiration.

Materials and Methods: This was a prospective cohort study comprising of 30 patients with CHPS. For this study infants presenting with non-bilious vomiting and ultrasonography features of CHPS were screened and included depending upon inclusion and exclusion criteria. All patients underwent detailed history, clinical examination, investigation and surgical treatment and they were studied for clinical features, investigation, management and morbidity and mortality patterns. The data was studied using complex statistical software.

Results: The study comprised of 50 infants with congenital hypertrophic pyloric stenosis. Out of the 30 studied cases 20 were males and 10 were females with a M: F ratio of 1: 0.5. Predominantly first born children were affected (70%) while CHPS was found in 9 cases (30%) who were second by order of birth. The most common age of presentation was 4-8 weeks (56.7%) followed by within 4 weeks (33.3%) and 8-12 weeks (10%). The analysis of children with respect to their expected weight revealed that 23 (76.6%) infants had normal weight while 7 (23.4%) infants had weight less than expected foe their age. As expected in CHPS all infants had non bilious vomiting. There was no patient with associated congenital anomalies. In 2 (6.7%) infants there was a family history of CHPS in 1st or 2nd degree relatives. Jaundice and constipation was present in 5 (16.67 %) and 3 (10 %) patients respectively. On clinical examination abdominal distension, palpable epigastric lump, visible peristalsis and was present in 22 (73.3%), 14 (46.7%) and 8 (26.7%) infants respectively. All patients had some form of dehydration. Mild and moderate dehydration was present in 22 (73.3%) and 8 (26.7%) patients respectively. Hyponatremia and hypokalemia was present in 7 (23.3%) and 9 (30%) patients respectively. Ultrasound examination of the cases revealed that pyloric thickness was more than 4 mm in 24 (80%) infants and pyloric length was more than 16 mm in 29 (96.7%) cases. The sensitivity of ultrasound examination for diagnosis of CHPS was found to be 97%. Isolyte P alone (50%) or in combination with DNS (13.3%) or RL (36.7%) was used to correct electrolyte imbalance before surgery. In post-operative period a combination of Isolyte P and Ringers lactate was used in majority (53.3%) of the infants. Ramstedt's pyloromyotomy was done in all the infants with CHPS. In majority of the infants (79.3%) feeding was started within 72 hours after surgery. The most common postoperative complications seen in studied cases were respiratory tract infection (20%) followed by vomiting (16.7%) and wound gaping (10%). 14 (46.7%) patients remained under follow up while 16 (53.3%) were lost to follow up. Growth and development was found to be satisfactory in infants who were brought for regular follow up.

Conclusion: Congenital hypertrophic pyloric stenosis is most common cause of infantile gastric outlet obstruction with most common age of presentation between 4 to 8 weeks of life with a male preponderance. The condition can be diagnosed by ultrasonography and Ramstedt's pyloromyotomy is still procedure of choice for treatment of these patients.

Keywords: Congenital hypertrophic pyloric stenosis, Ultrasonography, Surgical management, Ramstedt's pyloromyotomy, outcome.