Journal of Pediatric Surgery Case Reports (Mar 2024)
Recurrent hypertrophic pyloric stenosis in a 7 weeks old boy male: A case report
Abstract
Introduction: Recurrent pyloric stenosis poses unique diagnostic challenges, particularly in discerning authentic recurrence from post-pyloromyotomy scarring on ultrasound imaging. Case presentation: A male infant began experiencing projectile non bilious vomiting nine days following birth. Upon initial clinical examination, no evidence of pyloric olive or signs of dehydration were detected. However, an abdominal ultrasound examination unveiled a thickened pyloric wall measuring 4.5 mm, along with a pyloric canal length of 17 mm, indicating the presence of pyloric stenosis. Consequently, an uncomplicated supra-umbilical open pyloromyotomy was performed when the patient was 20 days old. Twenty-three days after being discharged, the patient presented to the emergency for a 24-h history of vomiting after every third bottle. On physical exam, a palpable pyloric olive was discovered. The patient had gained 410 g in 23 days (about 18 g/day). An abdominal ultrasound showed a pyloric muscle length of 21 mm and a muscle thickness of 4.5 mm. A multidisciplinary reunion was conducted between the pediatric gastroenterology and pediatric surgery department deciding to perform a second pyloromyotomy. This was executed through the same supra-umbilical incision. A healed incision scar was found along the complete length of the pyloric muscle on the anterior side. The decision was made to perform a second pyloromyotomy approximately 5 mm more dorsal from the first myotomy. There was a small perforation of the mucosa on the duodenal side which was sutured with a PDS 6/0. The progression unfolded without incident, with an improvement in symptoms and weight gain. Follow-up ultrasounds showed a gradual decrease in the length of the pyloric muscle. Conclusion: Recurrent pyloric stenosis is challenging to differentiate from postoperative edema. Particularly, the pyloric length on ultrasound can help distinguish and indicate whether a second pyloromyotomy should be performed or not.
