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Published in Samar Razaq, Difficult Cases in Primary Care, 2021
Pyloric stenosis usually presents in the first few weeks of life as parents report an increasing frequency of vomiting. A congenitally thickened pylorus results in obstruction of outflow of stomach contents. As the condition progresses, projectile vomiting follows, as the vomit no longer trickles down the front of the infant but rather shoots over the shoulder of the anxious parent. The vomitus may become progressively blood stained because of the resulting gastritis. The infant usually feels hungry after vomiting and is keen to feed again. Traditionally the diagnosis is made during examination of the child after a test feed. The physician is able to feel the olive-shaped mass in the right hypochondrium. Peristalsis may be visible as the surrounding muscles contract to push the feed beyond the narrowing. The loss of gastric acid as a result of vomiting leads to hypochloraemia, alkalosis and hypokalaemia. However, pyloric stenosis is usually diagnosed before the classical biochemical hallmarks develop, because of early suspicion and use of ultrasound scanning (Hulka, et al., 1997). Treatment involves a pyloromyotomy, which may be performed laparoscopically.
Pyloromyotomy
Published in Mark Davenport, James D. Geiger, Nigel J. Hall, Steven S. Rothenberg, Operative Pediatric Surgery, 2020
About 10–20 mL of air is introduced into the stomach via the nasogastric tube and then gently milked through the pylorus into the duodenum, and a gauze sponge is dabbed on the incision to detect any bile staining. Any perforation of the mucosa will become obvious at this juncture and should be closed by direct suture with 6/0 polydiaxonone or polyglycolic acid. Some surgeons advocate closing the pyloromyotomy completely and redoing the myotomy on the opposite side of the pylorus. In either case, the important point is to recognize the perforation and to repair any leak found.
General Surgery
Published in Tjun Tang, Elizabeth O'Riordan, Stewart Walsh, Cracking the Intercollegiate General Surgery FRCS Viva, 2020
Rebecca Fish, Aisling Hogan, Aoife Lowery, Frank McDermott, Chelliah R Selvasekar, Choon Sheong Seow, Vishal G Shelat, Paul Sutton, Yew-Wei Tan, Thomas Tsang
How will you manage the condition?Firstly, resuscitate the baby and correct the electrolyte imbalance – hypochloraemic, hypokalaemic metabolic alkalosis due to vomiting with renal compensation.If not corrected, can proceed to ‘paradoxical aciduria’ (to conserve H+ ions in presence of alkalosis, Na−K/H exchange pump works in favour of losing more K+ (further aggravating hypokalaemia). However, when hypokalaemia is extreme, Na−K/H pump attempts to conserve K+ at the expense of H+, hence paradoxical aciduria).I would refer the baby to my paediatric surgical colleagues to have a Ramstedt pyloromyotomy. This can be performed by either an open or a laparoscopic approach.Incise longitudinally (2–3 cm) along the anterior, avascular surface of the pyloric ‘olive’ sparing the submucosaSplit the hypertrophic muscle with a spreader down to the intact submucosa.Risks − incomplete pyloromyotomy and perforation
G-POEM may be an optional treatment for refractory gastroparesis in systemic sclerosis
Published in Scandinavian Journal of Gastroenterology, 2020
Jean-Michel Gonzalez, Brigitte Granel, Marc Barthet, Véronique Vitton
A 40-year-old woman who presented a cutaneous SSc was referred for investigating persistent nausea, early satiety and postprandial fullness. While SSc was diagnosed 10 years ago, her symptoms had appeared for only 6 months. An upper gastrointestinal endoscopy was initially performed showing a gastritis with Helicobacter pylori (HP) infection. An antibiotic therapy was given allowing to achieve HP eradication, but without digestive symptoms improvement. A gastric emptying scintigraphy (GES) was then carried out concluding to a gastroparesis with half gastric emptying time (HGET) of 269 min (normal value less than 150 min in our center), retention percentage at two hours (RP2H) of 80% (normal value less than 60%) and retention percentage at four hours (RP4H) of 52% (normal value less than 10%). Symptoms severity was calculated using the Gastroparesis Cardinal Symptoms Index (GCSI) with a mean total score of 3.4, severe gastroparesis being defined by a GCSI > 2 (maximum value is 5) [21]. After the failure of pharmacological management an endoscopic pyloromyotomy was proposed to the patient. The G-POEM was performed as described above, without any complication. The patient was allowed to resume a gradual oral diet after a fasting period of 48 h. At 3 months of follow-up, the patient reported a clinical improvement, especially interesting bloating, with a mean total GCSI of 1. The GES evaluation at 2 months confirmed the clinical improvement, even if some measured values remained disturbed (HGET of 146 min; RP2H of 77%; RP4H of 17%).
Gastroparesis managed with peroral endoscopic pyloromyotomy
Published in Baylor University Medical Center Proceedings, 2020
Jessica S. Clothier, Steven G. Leeds, Ahmed Ebrahim, Marc A. Ward
Gastroparesis manifests with symptoms of nausea, vomiting, early satiety, and bloating.1,2 Though not especially common (2.4 per 100,000 for men and 9.6 per 100,000 for women3), this is a difficult disease to treat. The etiology of gastroparesis is most commonly idiopathic but can also be due to chronic narcotic use, uncontrolled diabetes, or postsurgical causes such as iatrogenic vagal nerve injury.1 Treatment is both medical and surgical, with the medical options of dietary changes, glycemic control, and gastric promotility medications typically being exhausted before moving on to the more invasive modalities of endoscopic intervention or surgery.2 These more invasive options include pyloric dilation or Botox injections, gastric electrical stimulation, laparoscopic pyloroplasty, and even partial or total gastrectomy.2 Most recently, peroral endoscopic pyloromyotomy (POP) has emerged as a novel and effective option for treating gastroparesis.2 POP is an adaptation of peroral endoscopic myotomy (POEM), which was developed for the treatment of achalasia.4,5 Here we discuss a case where POP was used to treat a patient’s severe gastroparesis refractory to medical treatment.
Current and future treatment management strategies for gastroparesis
Published in Expert Opinion on Orphan Drugs, 2019
Priyadarshini Loganathan, Mahesh Gajendran, Richard McCallum
Endoscopic pyloromyotomy technique could provide an incision-less, less invasive alternative to standard laparoscopic pyloroplasty. In this procedure complete endoluminal dissection of the pylorus is performed via a submucosal tunnel. Khashab et al. reported the first case of gastric per-oral endoscopic myotomy (G-POEM) in a patient with refractory GP [110]. Shlomovitz et al. reported a case series with seven GP patients who underwent endoscopic pyloromyotomy with 85% symptom improvement and 80% of patients with improvement in GE [111]. The smaller case series limits the ability to determine the complication and long-term outcome. In a meta-analysis by Avalos et al., G-POEM showed normalizing GE in two thirds of patients with efficacy approaching 90% at 3, 12 months follow-up. With more frequent usage, increased technical experience, endoscopic pyloromyotomy has the potential to become an important endoscopic management in GP.