2. Case Presentation Case Presentation By: Julie Mathew PA-S

3. Case Presentation C/C: “ 5 days of vomiting ”

4. Case Presentation 11/8/00 HPI: One month Hispanic female came into the ER brought in by her mother complaining of vomiting for 5 days after every feeding. She would vomit 1x after 1-2 hrs after her meals. The mother then tried to switch formulas from similac to isomil, but the symptoms continued. Then mother started give the baby water about 10 oz which the baby tolerated. The mother denies projectile vomiting, but noted belching after each feeding. Also the baby would have 5 wet diapers per day, but only 1 today around 11am. The baby also had no changes in stool and has no allergies. The mother stated that her child has no PMH. She was a normal delivery with no complications.

5. Case Presentation In ER PO challenge was attempted – 50% of the milk was vomited after 3 min it was started ER: VS= T =99.6, R= 46, P =140 BP= 80/P Plan: IVF D5 1/3 NS @ 18cc/hr & Labs:CBC w/Diff and U/A/ Admit

6. History & Physical Examination BIRTH Hx: 8lbs 2oz/ NSVD PMH: None FH: Mother asthma PSH:None Injuries/Hospitalization : None Allergies:NKDA Meds: None Immunizations:Hep B 10/5/00

7. Review Of System Positive: Vomiting Rash Diarrhea Belching Mild nasal congestion Negative: Nonprojectile Nonbilious No olive mass Earache/Sorethroat Fever/Cough/No change in weight Sick contact/Trauma

8. Physical Examination VS: T= 99, P=156, R=32, BP=100/49 General:Sleeping comfortably,decreased appetite Skin: Macular rash on the trunk, good turgor HEENT: Moist mucous membrane,mild nasal congestion Heart/Lungs: RRR, S1+S2 normal, no murmurs Abd: soft,ND,NT, +BS, no masses Ext: No edema/ no joint pain Rectal/Gential: No abnormalities noted, no labial fusion

9. Differential DX Gastroenteritis UTI Pyloric Atresia Poor Feeding Practices Hiatal Hernia Congenital Adrenal Hyperplasia ……..# 1 Pyloric Stenosis………..

10. Work –up 11/9/00 Labs: CBC w/ Diff U/A Abd US Stool Guiac

11. Laboratory Values

12. Ultrasound Report Preliminary Report: The pyloric length measures 1.9cm. The muscle thickness is 3mm at the the upper limits of normal. The administration of sterile water PO, the pyloric channel is not noted to open in a normal fashion. Pyloric Stenosis is a strong diagnostic consideration.

13. Case Plan 11/9/00 Upper GI Series Surgery Consult NPO/IVF/NGT

14. Upper GI Series Pyloric canal upward, the base duodenal bulb concave, indicating pyloric stenosis.

15. Pyloric Stenosis 1.What is it? Hypertrophy of the smooth muscle of the pylorus, resulting in the obstruction of outflow 2. Risk Factors? Family Hx,firstborn males,decreased incidence in African-American population. 3. Average Age Usually from 2 weeks after birth to about 2 months.

16. Pyloric Stenosis 3.Symptoms: Increasing frequency of regurgitation /vomiting weight loss, decreasing frequency in stool,belching. 4.Signs: Abdominal mass or olive in the epigastric region,hypokalemia, hypochloremic metabolic alkalosis,icterus,visible gastric peristalsis, paradoxic aciduria,hematemesis.

17. Pyloric Stenosis 5.Diff Dx: Pylorospam, milk allergy hiatal hernia,GE reflux malrotation,duodenal atresia ect. 6.Diagnosis : Hx & Physical Exam US: elongated > 15mm pyloric channel and thickened muscle wall >3.5mm Barium swallow: string sign or double railroad tract sign.

18. Pyloric Stenosis 7.Initial Tx: Hydration & correction of Alkalosis 8.Definitive Tx: Fredet-Ramstedt pyloromyotomy-division of the circular muscle fibers w/o entering the lumen or mucosa. 9.Postoperative Complications: Bleeding, wound infxn, aspiration pneumonia

19. Pyloric Stenosis 10. Appropriate postoperative feeding: Between 6 to 12 hrs postoperative feeding w/sugar water advance to full strength formula over 24 hours. ( Blackbourne 493-494)

21. Bibliography Blackbourne, Lorne H. Surgical Recall. North Carolina: Lippincott Williams & Wilkins., 1998