What is pyloric stenosis?
stenosis is a narrowing of the pylorus, the opening from the stomach, into the
small intestine. This type of blockage
is also referred to as a gastric outlet obstruction. Normally, food
passes easily from the stomach into the duodenum through a valve called
the pylorus. In pyloric stenosis, the
muscles of the pylorus are abnormally thickened, which prevents the stomach
from emptying into the small intestine and food backs up into the esophagus.
The cause of the thickening is unknown, although genetic factors may play a
role. The condition is usually diagnosed by the time a child is 6 months old.
Vomiting is the first symptom in
- Vomiting may occur after every feeding or only after
- Vomiting usually starts around 3 weeks of age, but may
start any time between 1 week and 5 months of age
- Vomiting is forceful (projectile vomiting) and the
vomit itself is usually clear or has the appearance of partially digested
- The infant is hungry after vomiting and wants to feed
Other symptoms generally appear
several weeks after birth and may include:
- Abdominal pain
- Constant hunger
- Dehydration (gets worse with the severity of the
- Failure to gain weight or weight loss
- Wave-like motion of the abdomen shortly after feeding
and just before vomiting occurs
The condition is usually diagnosed
before the baby is 6 months old. A physical exam may reveal signs of
dehydration. The doctor may detect the abnormal pylorus, which feels like an
olive within the abdomen, when pressing over the stomach. An ultrasound of the
abdomen may be the first imaging test performed. Other tests that may be done
include a barium X-ray to show the shape of the stomach and pylorus.
The first form of treatment for
pyloric stenosis is to identify and correct any changes in body chemistry using
blood tests and intravenous fluids. Pyloric
stenosis is always treated with surgery, which almost always cures the
condition permanently. The operation, called a pyloromyotomy, divides the thickened
outer muscle, while leaving the internal layers of the pylorus intact. This opens a wider channel to allow the
contents of the stomach to pass more easily into the intestines.
A minimally invasive approach to
abdominal surgery, called laparoscopy is generally the first choice of surgery
for pyloric stenosis. To perform laparoscopic
surgery, the surgeon inserts a rigid tube (called a trochar) into the abdominal
cavity through a small incision (cut). The
tube allows the surgeon to place a small camera into the abdomen and observe
the structures within on an external monitor. The abdomen is inflated with carbon dioxide
gas, which creates room to view the contents of the abdomen and to perform the
operation. Additional rigid tubes are
placed through small incisions and used to insert small surgical instruments
into the abdomen. These instruments are
used together with the camera to perform the operation. Tubes and instruments are removed when the
operation is finished and the incisions are closed with sutures (stitches) that
are absorbed by the body over time.
Laparoscopic pyloromyotomy generally involves the use of two or three
trochars, and therefore usually requires two or three small incisions.If the surgeon decides that a laparoscopic
operation is not the best way to treat the problems that are found in the
operating room, then the operation will be changed (converted) to use an older
surgical technique. Conversion to a
non-laparoscopic operation (also called an “open procedure”) is rare and
requires a larger incision, which may take longer to heal.
In general, patients who receive
surgical treatment for pyloric stenosis have an excellent recovery and very few
suffer any long-term problems as a result of the disease.After surgery, your baby may be fed special
fluids for one or two feedings and then breast milk or formula within 24 hours.
stay following a pyloromyotomy is typically one or two days and the decision to
discharge a patient is typically based on how well the child is recovering:
specifically, if the baby is able to drink breast milk or formula without
vomiting, and has pain that can be controlled by medications taken by
is normal for a baby to vomit small amounts during the first day or two after
surgery, but this should gradually improve. If your baby continues to vomit
after you return home, call your doctor, because this may indicate continued
blockage that is preventing the stomach from emptying normally.
Following all operations, parents or caregivers will
be provided with a list of instructions, including specific warning signs that
require communication with the surgical team or the attention of a doctor
(either in an Emergency Department or a pediatrician’s office). Parents and other caregivers should refer
first to written discharge instructions and use the telephone numbers provided
to reach the Pediatric Surgery team to discuss any problems. These instructions are provided for specific
patients after considering their medical conditions, the operation performed
and how well the patient is recovering.
Therefore, the instructions received at the time of discharge (or
afterward over the phone or in the Pediatric Surgery clinic) are the best
resource for parents and caregivers if questions arise. In general, the following findings should
cause concern and require a patient to be seen by a doctor
The patient cannot
move his or her bowels. Some medications
cause constipation, so the surgical team may prescribe stool softeners or mild
laxatives to help with bowel movements.
If these treatments are ineffective, there may be a more serious
- Fever greater than 101.3F by oral
or rectal thermometer
- Spreading redness, drainage
(leaking fluid) from the surgical wounds that looks like pus.
- Increased bloody drainage from
wound. Small amounts of yellow, pink, or
blood-streaked drainage that is absorbed by the wound’s dressing is normal, and
should go away in three to five days.
- Increasing pain that does not
improve with medications prescribed at discharge.
- Nausea and vomiting that prevents
the child from drinking clear fluids – this can be associated with certain
kinds of pain medication or antibiotics and may improve if these medications
are taken with food.
of Pediatric General Surgery at Johns Hopkins Children's Center treats pyloric stenosis.