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CASE REPORT
Hypertrophic Pyloric Stenosis and
Severe Marasmic Type Malnourishment in a Month-Old Boy
ITRO!"CTIO
Hypertrophic pyloric stenosis (HPS), also known as infantile hypertrophic
pyloric stenosis (IHPS), is the most common cause of infant gastrointestinal
obstruction that requiring surgery in the first months of life.
1,
It is characteri!e" by a
marke" hypertrophy of the pylorus muscle, which lea"s to a blockage of the gastric
outlet an" pro#okes increasingly se#ere episo"es of pro$ectile #omiting.,% &he
inci"ence of IHPS is appro'imately two to fi#e per 1, births per year in most white
populations, although it #aries with the geographic area an" the time perio" being
re#iewe". Pyloric stenosis appears to be more common in infants of caucasian
"escent an" is less common in In"ia an" among black an" sian populations, with a
frequency that is one*thir" to one*fifth that in the white population. +,,-&here is male*
to*female ratio of +1, with reporte" ratios ranging from ,1 to ,1.1,+,
Hypertrophic pyloric stenosis ten"s to run in families, howe#er, the e'act pattern of
inheritance is unclear. &he inci"ence rate is 1 in 1+ if the father is affecte", the rate is
e#en higher if the mother is affecte".1/irst*born chil"ren ha#e been note" to be more
likely affecte", an" a familial link is seen with a greater than fi#efol" increase in the
risk in first*"egree relati#es.,-
Infants classically present at to - weeks ol" with gra"ually progressi#e
#omiting that becomes pro$ectile an" remains nonbilious. Infants remain #igorous
with a ra#enous appetite. &hey rapi"ly finish an entire fee"ing, only to regurgitate the
entire #olume in a pro$ectile fashion. In the later stages of the "isease, chil"ren may
e'hibit #isible wa#es of ab"ominal peristalsis in response to intense contractions
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against an obstruction. 0hil"ren in the later stages of "isease may e'hibit marasmus
(protein*calorie malnutrition) as a result of impaire" nutrient absorption.1,+,-
lthough its etiology remains unknown, our un"erstan"ing of the clinical
manifestation an" treatment of HPS has un"ergone a remarkable e#olution. In
patients in whom clinical e'amination is unsuccessful, mo"ern imaging techniques
are highly accurate in facilitating the "iagnosis.+&he "iagnosis of HPS is ascertaine"
after obtaining an appropriate history an" by the palpation of a pyloric calle" oli#e
sign2. &he "iagnosis may be establishe" by ultrasonography (3S4) of the pylorus.
0hil"ren may ha#e a palpable pylorus, commonly referre" to as an oli#e in the right
epigastrium, on ab"ominal e'amination. Placement of a nasogastric tube an"
emptying the stomach or placement of the infant in the prone position often facilitates
palpation.1,5,6
7ost chil"ren probably are best manage" with hospital a"mission for
rehy"ration, correction of electrolyte abnormalities an" also for management of the
marasmus. Hypertrophic pyloric stenosis can be "iagnose" or e'clu"e" by using
3S4. &hus, infants presenting with nonbilious #omiting shoul" be "irecte" to un"ergo
3S4 if HPS is a consi"eration. Hypertrophic pyloric stenosis may be confirme" by
ultrasonography or upper gastrointestinal series. 3ltrasonography is the "iagnostic
mo"ality of choice because it is simple, rea"ily a#ailable, an" without serious
complications such as aspiration. 8ith both mo"alities, reporte" accuracy is greater
than 9:. 3ltrasonography e'amination re#eals a thickene" pylorus, which is
"iagnostic. characteristic string sign,2 reflecting passage of contrast material
through the narrowe" pyloric sphincter, can be seen in the upper gastrointestinal
tract. In a"#ance" stages with complete obstruction at the pylorus, plain films may
re#eal an enlarge" bo"y of the stomach an" pylorus. 1,+,-,5 If the patient has HPS, the
appropriate surgical referral is ma"e rapi"ly an" accurately. If the sonogram
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"elineates a normal pylorus, a search for other causes, may allow i"entification of
preampullary "uo"enal stenosis or hiatal hernia. 3pper gastrointestinal (34I)
e'amination may be performe" if further e#aluation for these con"itions is
warrante".1,+,5
Surgical correction of pyloric stenosis is not an emergency, an" therefore the
electrolyte "isturbances can an" shoul" be meticulously correcte" before operation.
Infants un"ergoing pyloromyotomy are assume" to ha#e a full stomach an" the
anaesthesiologist shoul" keep this in min". ;oth the anaesthesiologist an" surgeon
shoul" be #igilant "uring the operation to pre#ent aspiration of gastric $uice.,6
&he purpose of this report is to present a rare case of hypertrophic pyloric
stenosis an" se#ere marasmic type malnourishment in a month*ol" boy.
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CASE REPORT
gu"i 8aluyo
Hospital 8lingi because of #omiting. &he parents reporte" that #omiting ha"
starte" since a week before a"mission, non*bilious, non*pro$ectile an" non*
bloo"y, frequency ? 6*1 times@"ay, it happene" ? *1 minutes e#erytime he
finishe" nursing or bottle fee"ing, the amount is ?1*% ml each time an"
sometimes #omiting the entire #olume of his feee", contains milk. fter #omiting
the infant remains hungry an" still eager to fee". Pre#iously patient only ha"
breast fee"ing since he was born, but his mother ga#e him formula milk since ten
"ays before a"mission because he still looke" thirtsy after ha#ing breast
fee"ing. &he breast fee"ing frequency was e#ery one to two hours with the
length of breast fee"ing was 1*% minutes e#ery nursing an" there was no
"ifficulty fee"ing. &he mother ga#e e'tra formula milk about % times "aily with
amount of % ml e#ery bottle. &here is no history of fe#er, upper respiratory
infection (3AI) symptoms, "iarrhea, sei!ure, $aun"ice, hea" in$ury an" no sign of
"ehy"ration. &here is also no history of lump in the ab"omen before starting ha"
#omiting. He is less acti#e than normal. He is making fewer wet "iapers an" less
stool than usual.
Patient e'perience" weight loss since he ha" #omiting. He was born with
birth weight of - grams an" has weight gain of 9 grams when he was
three weeks in age. He loss his weight of + grams at the time when he was
a"mitte" in 8lingi hospital, an" when in the Saiful anwar hospital his bo"y weight
was grams.
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Patient ha" brought to pe"iatrician before by the parents when he ha"
#omiting for three "ays, but the pe"iatrician sai" there is no big problem an" that
was only or"inary #omiting that happene" to mostly baby, then the "octor ga#e
me"ication. ;ecause there is no impro#ement after taking me"ication from the
pe"iatrician for two "ays then the parent took him to another pe"iatrician. &he
secon" pe"iatrician referre" him to >gu"i 8aluyo 8lingi Hospital "ue to
suspecte" of HirschprungBs "isease. &he patient referre" to Saiful nwar Hospital
for further e'amination an" management.
Pasien was the first chil" an" "uring pregnancy there was no history of
blee"ing, #aginal "ischarge, fe#er, "iabetes mellitus, or hypertension of the
mother. She ne#er smoking an" also there is no history of taking "rugs or herbal
me"icine "uring pregnancy. She was routinely ha#ing ante natal care in mi"wife
e#ery month an" ha" 3S4 once in the obstetrician at the 5 months gestational
age. He was "eli#ere" spontaneously at*term by a mi"wife in nnisa Hospital
;litar, crie" spontaneously, weighe" - grams, no history of cyanosis,
respiratory "istress an" $aun"ice. &he amniotic flui" was greenish, then he was
hospitali!e" for "ays an" gi#en antibiotic.
&he mother was % years ol" house wife an" high school gra"uate". His
father was % years ol", high school gra"uate" an" work as employees in an
wel"ing in"ustrial. &here is no history of family with the same complain before.
Patient alrea"y ha" hepatitis ; immuni!ation.
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/igure 1. &he patientBs picture
&he physical e'amination foun" him alert, his weight grams (-,-:
of increament bo"y weight), bo"y length cms, hea" circumference %- cms (*1
stan"ar" "e#iation to mean) an" his weight for length was less than *% stan"ar"
"e#iation (SC).
His a'ilary temperature was %-.6D0, pulse rate 1+ beats per minute
strong an" regular, respiratory rate +- times per minute an" E saturation 99: .
His eyes were not yellowish an" the skin turgor in the forehea" was normal. &he
chest e'amination foun" symmetrical mo#ement, normal with clear breathing
soun"s an" no retractions. Heart auscultation re#eals a regular rhythm an" no
murmur. His ab"omen is slightly "isten"e" with acti#e bowel soun"s. >o
hepatosplenomegaly is note". He looks #ery thin with ol" man face an" baggy
pants. He has no inguinal hernias. 4enitalia are normal. ='tremities are normal.
0olor, perfusion, an" capillary refill are goo". >eurologic e'amination is normal.
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/igure . &he patientBs growth chart
Initial laboratory fin"ings at the time of presentation at Saiful nwar
Hospital are shown in table 1.
&able 1. Initial laboratory tests results (%*%*1)
Hemoglobin 1+.+ gms@"l 0AP .- mg@"F
Feukocytes 1-.9@mm% PP& 11.% secon"s&hrombocytes +++,@mm% P&& %9.6 secon"s
Hematocrits %9 : lbumin +.-- gms@"lCifferential count
=osinofil@;asofil@
>eutrophil@Fymfosit
@7onosit
.-@.+@+5.9@[email protected] So"ium@Potasi
um@0hlori"el@
0alsium@
Phosfor
1-@%.+6@[email protected]@+.%
S4E&@S4P& +-@1+ m3@"l
plain ab"ominal G*ray on 7ay +th1 showe" the "ilatation of gaster.
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/igure %. 0hest G*ray an" plain ab"ominal G*ray , 7ay % th1
;ase" on the anamnesis, clinical signs an" ra"iological fin"ings, the initial
"iagnosis was #omiting "ue to "iffrential "iagnosis with hypertrophy pyloric
stenosis (HPS), gastro esophagal reflu' "isease (4=AC), pylorospasm, pyloric
atresia, an" se#ere marasmic type malnourishment. n ab"ominal 3S4 was
planne" to confirm the "iagnosis. Initial treatment of the patient was o'igenation,
flui" an" nutritional support, antibiotics, an" micronutrient. &hose are nasal
canule o'igen liters per minutes if clinicaly there were "yspneau "ue to
"isplacement by enlarge" stomach, semifowler position %, intra#enous flui"
"rip Ce'trose 1, ,16 >a0l ,9: % ml@"ay, lipi" : ml (, gms@kg bo"y
weight@"ay), aminosteril infant -: 6- ml (1, gms@kg bo"y weight@"ay), ampicillin
%'5mg (1mg@kg bo"y weight@"ay), #itamin 1' I3, #itamin = 1' I3,
#itamin 1'1mg, #itamin 0 1'mg, #itamin ; comple' 1' 1@+ tablet, !inc
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1'1mg, folic aci" 1'1mg an" breast fee"ing - ml gi#en intermitten.Patient also
consulte" to surgery "epartement. &he conclusion from surgery "epartment was
high le#el bowel obstruction "ue to suspecte" hypertrophic pyloric stenosis an"
planne" to ha#e ab"ominal 3S4.
&he b"ominal 3S4 on 7ay th1, foun" thickening of the walls of
the pylorus with the thickness of ?.- cms along the ?1.-9 cms, with the patient
postion tilte" to the right, there were still a little liqui" that passes through the
pylorus. &he conclusion of ab"ominal 3S4 was hypertrophic pyloric stenosis.
/rom surgery "epartement patient planne" to ha#e pylorotomy.
/igure +. b"ominal 3S4, 7ay th1
En June %r"1 the surgery "epartment performe" pyloromyotomy to
patient. Eperation report showe" there were thickeness of pylorus along ?1.-
cms an" thickeness of serous muscularis length ?.- cms.
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!ISC"SSIO
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Hypertrophic pyloric stenosis is the most common cause of infantile
gastrointestinal obstruction beyon" the first month of life. &he first clinical "escription
of HPS was by /abricious Hil"anus in 1-5, but Haral" HirschsprungBs seminal
article in 1666 le" to our mo"ern un"erstan"ing of the con"ition.lthough HPS is the
most common surgical con"ition pro"ucing emesis in infancy,its etiology is unknown.
8hether the con"ition is congenital or acquire" is "ebate".- Infants classically
present at to - weeks ol" with gra"ually progressi#e emesis that becomes
pro$ectile an" remains nonbilious. In general, #omiting in IHPS is pro$ectile, but in
these patients was not foun". Aesearch by San"ra et al foun" only 69: of infants
with HPS showe" manifestation pro$ectile #omiting.1
Infants remain #igorous with a ra#enous appetite.1,Infants classically present
at to - weeks ol" with gra"ually progressi#e #omiting that becomes pro$ectile an"
remains nonbilious.&he cause of pyloric stenosis is unknown. 4enetic, familial,
gen"er, an" ethnic origin can influence the inci"ence rates of HPS.6,11,1 &here is
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e#i"ence both for an" against an increase" inci"ence in the first*born chil", an" there
is familial clustering of HPS, but not in a 7en"elian pattern.,-&here is male*to*
female ratio of +1, with reporte" ratios ranging from ,1 to ,1.1,+,
;ottle*fee"ing has been suggeste" to increase the risk of HPS. Aesearch by
rogh et al an" 7c.teer et al showe" that bottle*fe" infants e'perience" a +.-*fol"
higher risk of pyloric stenosis (PS) compare" with infants who were not bottle*fe".
&he result a""s to the e#i"ence supporting the a"#antage of e'clusi#e breastfee"ing
in the first months after birth.
%,1+
&his is a case that occurre" in infants age" 1 month with onset at age
weeks, present with non bilious an" pro$ectile #omiting. In epi"emiology in
accor"ance with an a#erage age IHPS is *- weeks. Patient is male an" was the
first born chil" but there is no history of HPS in his parents. In these patients from
birth to age weeks "oes not in"icate an abnormality. He starte" ha#ing complain of
#omiting since weeks of age. &his complain note" by her mother since she ga#e
e'tra bottle fee"ing instea" of gi#ing breast fee"ing. ;ase" on the research about
bottle fee"ing is associate" with an increase" risk of HPS, this patient ha" only
breast fee"ing before he starting #omiting. &he mother starte" gi#ing bottle fee"ing
instea" of breast fee"ing because she felt that his baby still look thirsty after ha#ing
nurse" on her. &hat coul" happene" because she "i"inBt know how to gi#e correctly
breast fee"ing since this is the first chil".
Ene of "ifferential "iagnosis of this this patient is 4=AC as the #omiting of
this patient was not pro$ectile. &he results of ab"ominal plain G*ray shows there is
stomach wi"ene", meaning there is probablitiy of obstruction in the stomach.
&he "iagnosis of HPS is initially suggeste" by the typical clinical presentation.
Palpation of the har" muscle mass, or oli#e, is "iagnostic but is often challenging an"
time consuming. In e'perience" han"s an" with a"equate time an" preparation,
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ab"ominal palpation can be successful in 6:L1: of infants.+ 0hil"ren may ha#e
a palpable pylorus, commonly referre" to as an oli#e in the right epigastrium, on
ab"ominal e'amination. Placement of a nasogastric tube an" emptying the stomach
or placement of the infant in the prone position often facilitates palpation.1 If the
pylorus is palpate" by an e'perience" clinician, no further imaging is necessary.
4astric "istension or #isible gastric peristalsis, seen as a wa#e of contraction from
the left upper qua"rant to the epigastrum, may be seen in some cases. &he inability
of a clinician to palpate an oli#e "oes not rule out the "iagnosis of HPS.
,-,6
/rom the patientBs physical e'amination we "i"nBt fin" oli#e sign2, so that we
nee" further e'amination to make the correct "iagnosis. /luoroscopic upper
gastrointestinal contrast stu"y was first propose" in 1916, an" is performe" with the
chil" "rinking from a bottle.In patients with HPS, there is failure of rela'ation of the
prepyloric antrum an" the pyloric canal is outline" by a string of contrast material.
&he thickene" muscle causes an e'ternal impression on the gastric antrum, terme"
the shoul"er sign.2 /luoroscopy can be time consuming an" in#ol#es ra"iation.
Sensiti#ity as high as 9: is reporte" but "epen"s on e'perience an" skill of the
e'aminer.3ltrasonography is nonin#asi#e, can be performe" quickly an" there is no
ra"iation e'posure. ccuracy approaches 1: in e'perience" han"s, with 99.:
sensiti#ity an" 1: specificity.,-&his woul" normally confirm the presence of a
pyloric tumour2. &he characteristic appearance of pyloric stenosis on ultrasoun" is
that of a "oughnut2 or bullBs eye2 on cross section of the pyloric channel. &he
hypertrophie" pyloric canal may range from 1+ mm to more than mm in length
an" the muscle thickness is #ariable (from % to mm). Aeal time obser#ation of
failure of rela'ation of the pyloric canal is important. &hese limits may be lower in
infants younger than % "ays of age. n e'perience" sonographer will recogni!e
perio"s of rela'ation in infants with pylorospasm, commonly confuse" with pyloric
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stenosis at e'amination.,-,6 &he 3S4 e'amination of this patient we foun" that there
is thickening of the walls of the pylorus with the thickness of ?.- cms along the
?1.-9 cms. &his ab"ominal 3S4 result retaine" HPS.
;efore surgery we ha#e to keep the patientMs general con"ition to remain
stable. ;ecause the patient was also suffering from se#ere marasmic type
malnourishment which is one of the complications of HPS, then we "i" treatment of
malnutrition. 7alnutrition is a pathologic state of #arying se#erity with clinical features
cause" by "eficiency, e'cess, or imbalance of essential nutrients. &he cause may be
primary (in#ol#ing the quantity or quality of foo" consume") or secon"ary (in#ol#ing
alterations in nutrient requirements, utili!ation, or e'cretion). Historically, malnutrition
in chil"ren has been "efine" using the terms marasmus an" kwashiorkor. 7arasmus
"e#elops after se#ere "epri#ation of calories an" is characteri!e" by weight loss an"
wasting of fat an" muscle tissue. Fow weight*for*height an" a re"uce" height*for age
are commonly obser#e". In the chil" with kwashiorkor, protein "eficits outweigh
calorie "eficits. ="ema "ue to #isceral protein "epletion occurs along with muscle
wasting. lthough some "egree of growth failure may be present, weight*forheight
may not be notably low secon"ary to retention of flui" in the e'tra#ascular
compartment. Irritability, apathy, anore'ia, an" fatigue may be seen in both
marasmus an" kwashiorkor.1 &he "iagnosis of se#ere marasmic type
malnourishment from this patient base" on clinical fin"ing an" anthropometric
e#aluation. /rom the anthropometric we foun" that his weight for length was less
than *% SC with percentage of increament bo"y weight was 9,9:. /rom the physical
e'amination patient looks like ol" man face with #ery thin bo"y an" there was baggy
pants. 1-,15
In the stabilisation phase a cautious approach is require" because of the
chil"Bs fragile physiological state an" re"uce" homeostatic capacity. /ee"ing shoul"
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be starte" as soon as possible after a"mission an" shoul" be "esigne" to pro#i"e
$ust sufficient energy an" protein to maintain basic physiological processes. ;ase"
on 8HE the essential features of fee"ing in the stabilisation phase are15
N small, frequent fee"s of low osmolarity an" low lactose
N oral or nasogastric (>4) fee"s (ne#er parenteral preparations)
N 1 kcal@kgs@"ay
N 1*1. grams protein@kgs@"ay
N 1% ml@kgs@"ay of flui" (1 ml@kgs@"ay if the chil" has se#ere oe"ema)
N if the chil" is breastfe", encourage to continue breastfee"ing but gi#e the
prescribe" amounts of starter formula to make sure the chil"Bs nee"s are met.
&his patient ha" problem profuse #omiting "ue to HPS ma"e the enteral
nutrition will barely "ifficult to gi#e, so we ga#e parenteral nutrition (P>) for this
patient. &he time when P> shoul" be initiate" will "epen" both on in"i#i"ual
circumstances an" the age an" si!e of the infant or chil". In the small preterm infant
star#ation for $ust one "ay may be "etrimental an" where it is clear that enteral fee"s
will not be tolerate" soon P> must be institute" shortly after birth. Howe#er in ol"er
chil"ren an" in a"olescence longer perio"s of ina"equate nutrition up to about se#en
"ays may be tolerate", "epen"ing on age, nutritional status, an" the "isease, surgery
or me"ical inter#ention.16
0arbohy"rates are the main source of energy in nutrition an" usually pro#i"e
+L-: of the energy supply in western "iets. &he ma$ority of the carbohy"rate
"eri#e" from a normal "iet reaches the bo"yBs peripheral tissues as glucose. 4lucose
is utilise" by all cells an" ser#es as metabolic fuel for muscle, li#er, heart, ki"neys
an" gut an" as the obligate energy source for brain, renal me"ulla an" erythrocytes.
4lucose is the main carbohy"rate utilise" "uring foetal lifeK about 5 gms@kgs per "ay
(appro'imately mgs@kgs per minute) of glucose crosses the placenta in the last
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trimester of pregnancy. &he ma$or source of non*protein calories in P> is C*4lucose
("e'trose), which is pro#i"e" in the monohy"rate form for intra#enous use. Ce'trose
usually contributes most of the osmolality of the P> solution. Proteins are the ma$or
structural an" functional components of all cells in the bo"y. &hey consist of chains of
amino aci" subun, its $oine" together by pepti"e bon"s. &he chain length ranges from
two amino aci"s to thousan"s, with molecular weights subsequently ranging from
hun"re"s to hun"re"s of thousan"s of Caltons. /rom a nutritional perspecti#e, an
important aspect of a protein is its amino aci" composition. 8HE recommen"e"
gi#ing lipi" emulsions are use" in pae"iatric P> as a non*carbohy"rate source of
energy in a low #olume an" with low osmolarity. Fipi" intake shoul" usually pro#i"e
L+: of non*protein calories in fully parenterally fe" patients.16
;ase" on 8HE recomme"ation we ga#e parenteral nutrition with "e'trosa
1,: ,16 >a0l .9: combine" with lipi" : an" aminosteril infant -:. 8e still
ga#e breest fee"ing as enteral nutrition gi#en by intermitten fee"ing. &he enteral
nutrition gi#en as the patient complient. n" for the se#ere malnutrition we also ga#e
antibiotic an" micronutrient.
&his patient ha#e ha" operation using metho"e of pyloromyotomy by /re"et*
Aamste"t. Curing operation the surgeon foun" pylorus muscle thickening o#er - mm
an" a length of more than 1- mm pylorus. &he surgeon "i" incision e'stramukosal of
serous towar"s mucous without in$uring the mucosa. Surgery remains an option with
a success rate of almost 1:. &herapy with this operation has a mortality rate of
less than .:, morbi"ity between 1*:, an" 1*%: recurrence rate.19,
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/igure Ciagnostic lgorithm for Hypertrophic Pyloric Stenosis6
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S"MMAR#
gu"i 8aluyo 8lingi
Hospital because of #omiting since a week before a"mission, non bilious an" non
pro$ectile, frequency ? 6*1 times@"ay. Pre#iously patient only ha" breast fee"ing
since he was born, then his mother ga#e him formula milk since ten "ays before
a"mission. &here is no history of fe#er, upper respiratory infection (3AI) symptoms,
"iarrhea, sei!ure, $aun"ice, hea" in$ury an" no sign of "ehy"ration. &here is also no
history of lump in the ab"omen before starting ha" #omiting. He is less acti#e than
normal. He is making fewer wet "iapers an" less stool than usual.
Physical e'amination foun" him alert, looks #ery tiny with ol" man face an"
baggy pants. /rom the anthropometric we foun" that his weight for length was less
than *% SC with percentage of increament bo"y weight was 9,9:. His temperature
was %-.6 D0, pulse rate 1+ beats per minute strong an" regular, respiratory rate +-
times per minute. &here was no li#er an" spleen enlargement. Plain ab"ominal G*ray
showe" the "ilatation of gaster. /rom physical e'amination there were no oli#e sign2,
so that we perform 3S4 to make the correct "iagnosis as 3S4 is nonin#asi#e, can
be performe" quickly an" there is no ra"iation e'posure. &he 3S4 e'amination of
this patient we foun" that there is thickening of the walls of the pylorus with the
thickness of ?.- cms along the ?1.-9 cms. &his ab"ominal 3S4 result retaine"
HPS.
&his patient ha#e ha" surgery using metho"e of pyloromyotomy by
/re"et*Aamste"t. Curing operation the surgeon foun" pylorus muscle thickening
o#er - mm an" a length of pylorus more than 1- mm. &he "iagnosis was
hypertrophic pyloric stenosis (HPS) an" se#ere marasmic type malnourishment.
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RE$ERECES
1. 7ark . Hostetler. AosenMs =mergency 7e"icine * 0oncepts an" 0linical
Practice in 4astrointestinal Cisor"ers n"e". 0hapter 15. 1+1-6*165.
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