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Good Morning!. Morning Report July 6, 2012. Semantic Qualifiers. Illness Script. Predisposing Conditions Age, gender, preceding events (trauma, viral illness, etc), medication use, past medical history (diagnoses, surgeries, etc) Pathophysiological Insult

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  1. Good Morning! Morning Report July 6, 2012

  2. Semantic Qualifiers

  3. Illness Script • Predisposing Conditions • Age, gender, preceding events (trauma, viral illness, etc), medication use, past medical history (diagnoses, surgeries, etc) • Pathophysiological Insult • What is physically happening in the body, organisms involved, etc. • Clinical Manifestations • Signs and symptoms • Labs and imaging

  4. Ultrasound

  5. Predisposing Conditions • 5:1 Male predominance • More common is 1st born (30% of cases) • Caucasian • Typically between the age of 2 weeks – 6 weeks • Family clustering • Erythromycin exposure in 1st 2 weeks of life

  6. Pathophysiology • True etiology unknown • Hypertrophy of the pyloric muscle that leads to gastric outlet constriction • Exposure to erythromycin (less so with other macrolides) • Increases risk 8-fold • Erythromycin interacts with smooth muscle motilin receptors • This causes strong gastric and pyloric contractions • Subsequent hypertrophy of the pyloric muscle

  7. Anatomy • Hypertrophy of the pylorus • Elongation and thickening • Progresses to near-complete obstruction

  8. Clinical Manifestations* • Vomiting • Non-bilious • Forceful/projectile • Progressive (increasing frequency) • Progression • Ravenously hungry  • Dehydrated/weight loss  • Lethargic • FTT • Jaundice • Palpable “olive” (up to 90%) • Peristaltic wave after eating • Electrolyte abnormalities

  9. Electrolytes • Metabolic alkalosis** • Decreased excretion into small intestine (increase in serum) • Decreased total body K+ leads to shift of K+ outside of cell in exchange for H+ • Increased re-absorption by kidney for fluid retentions (due to dehydration) • Hypochloremia* • Hypokalemia* (late finding) • Correction of electrolytes before surgery… • Correct dehydration (often with NS bolus) • If mild-moderate dehydration… • D5 ½ NS at correction rate, KCl once voids

  10. Diagnosis** • Primarily a clinical diagnosis • Ultrasound • Pyloric muscle thickness > 4mm • Pyloric muscle length > 14mm • 85-100% sensitivity and specificity • UGI • 89%-100% sensitive/specific • “string sign”, “double track”

  11. UGI

  12. Pyloromyotomy

  13. Thanks!! Noon Conference… Respiratory Failure by Costa 

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