25 May 2008

Dear Editor,


We would like to share our experience with you about a patient with infantile hypertrophic pyloric stenosis (IHPS). This 29-days-old male patient presented to us with complaints of projectile vomiting for 12 days along with signs of dehydration. Ultrasound of abdomen revealed pyloric olive, typical of IHPS. The patient was managed by rehydration, and, when he was fit for surgery after 2 days, Ramstedt pyloromyotomy was performed successfully.

The next day, when the patient was allowed oral sips, he again developed vomiting. He was put on conservative therapy of nasogastric placement, intravenous antibiotics and fluid, but, from the next day onwards, he had started having bilious aspirate. The contrast study was done to look for any site of obstruction but it was inconclusive. The patient was then planned for exploratory laparotomy on clinical suspicion of distal to pylorus obstruction. Laparotomy revealed associated malrotation, which was corrected. The patient fared well in the post-operative period. He was allowed orally on the fifth day and discharged in satisfactory condition on the ninth day post operative.

IHPS has been found to be associated with certain malformations like malrotation,1 genitourinary tract abnormalities2 and esophageal atresia,3 but these are probably so less common that they are even missing from the discussion of standard texts.4 We searched extensively for the association of IHPS and malrotation but could get only one study about this association. Most of the work has found that IHPS associated with malrotation is also associated with short bowel,1 which is not like the case of our patient. In other study, IHPS was found secondary to previously diagnosed malrotation or both diagnosed simultaneously.1

Our patient had no evidence of bilious vomiting or bilious aspirate prior to pyloromyotomy, suggesting that probably it was tight enough to prevent bile reflux, which manifested after the operation. Although, as described, IHPS and malrotation have been diagnosed in the same patient, it is probably for the first time that IHPS had preceded the malrotation.

The intent of this information is to let others know that, although rare IHPS can be associated with malrotation and can present in this manner so if any patient operated for IHPS do present like this, immediate reoperation can give excellent result.


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  2. References
  • 1
    Croitoru D, Neilson I, Guttman FM. Pyloric stenosis associated with malrotation. J. Pediatr. Surg. 1991 Nov; 26 (11): 12768.
  • 2
    Atwell JD, Levick P. Congenital hypertrophic pyloric stenosis and associated anomalies in the genitourinary tract. J. Pediatr. Surg. 1981; 16: 102935.
  • 3
    Applegate MS, Druschel CM. The epidemiology of infantile hypertrophic pyloric stenosis in New York State, 1983 to 1990. Arch. Pediatr. Adolesc Med. 1995 Oct; 149: 11239.
  • 4
    Schwartz MZ. Hypertrophic pyloric stenosis. In: GrosfeldJL, O'NeillJAJr, FonkalsrudEW, CoranAG, eds. Pediatric Surgery, 6th edn. Philadelphia: Mosby Elsevier, 2006: 121524.