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Pyloric atresia
Pyioric Atresia By Jacques C. Ducharme and Ari~ L6on Bensoussan Montreal, Canada Pyloric atresia is a rare a n o m a l y often diagnosed late because of the absence of green vomitus. We are reporting here a case o f atresia of the m u c o u s pyloric canal.
CASE HISTORY This 3260-g female baby was referred to Sainte-Justine Hospital at the age of 6 days because o f m u c o u s vomiting, dehydration, and metabolic alkalosis. Pregnancy had been complicated by po!yhydramnios. The a b d o m e n was scaphoid. Gastric peristaltic waves were present 9 X-rays of the a b d o m e n on admission (Fig. I) showed air only in the stomach. Gastric suction yielded a b u n d a n t watery secretions. After correction o f the electrolytic imbalance, a laparotomy was done. The pylorus appeared normal, but a stylet could not be inserted through it from an a n t r o t o m y and a d u o d e n o s t o m y incision 9 These two incisions were joined in one d u o d e n o p y l o r o t o m y 3 cm in length 9 The serosa and muscular layers were present, but the pyloric m u c o s a was absent over a distance of 7 m m . After checking the permeability of the intestines, the posterior mucosal wall was approximated with interrupted 5-0 silk. The anterior wall was closed like a Heineke-Mickulicz pyloroplasty in one layer9 Gastric suction was used for 4 days followed by oral feedings. A barium swallow on the 8th postoperative day demonstrated p r o m p t gastric emptying 9 When last seen, a m o n t h later, the baby was well.
DISCUSSION 9 i 7 Only seven similar cases have been published in the hterature. G r a y and Skandalakis, s in their excellent chapter on pyloric atresia describe five types of this malformation; they called this variety complete solid atresia. Sixty cases o f prepyloric or pyloric d i a p h r a g m s have been described and constitute, by far, the most c o m m o n type of pyloric atresia. The absence of green vomitus suggests to the physician that he is not treating a case of neonatal intestinal obstruction, hence the late diagnosis in this case. Simple x-rays of the a b d o m e n are diagnostic 9 In the complete atresia with discontinuity, a side-to-side g a s t r o d u o d e n o s t o m y is indicated.
Fig. I . Simple x-rays of the abdomen at the age of 6 days. Note absence of air beyond stomach.
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CASE REPORTS
However, when faced with the situation reported here, a Heineke-Mickulicz pyloroplasty is both simple and effective.
REFERENCES I. Metz A R , Houscholder R, De Pree JF: Obstruction of the stomach due to congenital double septum with cyst formation. T r a n s West Surg Assoc 50:242, 1941 2. Burnett H A , Halpert B: Perforation of the s t o m a c h of a new born infant with pyloric atresia. Arch Pathol 44:318, 1947 3. Brown RP, Hertzler JH: Congenital prepyloric gastric atresia. A report of two cases. A m J Dis Child 97:857, 1959 4. Kornfield H J: Pyloric atresia and its repair. Surgery 51:569, 1962
5. Talwalker VC: Pyloric atresia: A case report. J Pediatr Surg 2:458, 1967 6. T h o m p s o n N W , Parker W, Schwartz S, et al: Congenital pyloric atresia. Arch Surg 97: 792, 1968 7. Bronsther B, N a d e a u M R , A b r a m s M W : Congenital pyloric atresia: A report of three cases and a review of the literature. Surgery 69:130, 1971 8. G r a y SW, Skandalakis JE: Embryology for Surgeons. Saunders, 1972
CASE HISTORY This 3260-g female baby was referred to Sainte-Justine Hospital at the age of 6 days because o f m u c o u s vomiting, dehydration, and metabolic alkalosis. Pregnancy had been complicated by po!yhydramnios. The a b d o m e n was scaphoid. Gastric peristaltic waves were present 9 X-rays of the a b d o m e n on admission (Fig. I) showed air only in the stomach. Gastric suction yielded a b u n d a n t watery secretions. After correction o f the electrolytic imbalance, a laparotomy was done. The pylorus appeared normal, but a stylet could not be inserted through it from an a n t r o t o m y and a d u o d e n o s t o m y incision 9 These two incisions were joined in one d u o d e n o p y l o r o t o m y 3 cm in length 9 The serosa and muscular layers were present, but the pyloric m u c o s a was absent over a distance of 7 m m . After checking the permeability of the intestines, the posterior mucosal wall was approximated with interrupted 5-0 silk. The anterior wall was closed like a Heineke-Mickulicz pyloroplasty in one layer9 Gastric suction was used for 4 days followed by oral feedings. A barium swallow on the 8th postoperative day demonstrated p r o m p t gastric emptying 9 When last seen, a m o n t h later, the baby was well.
DISCUSSION 9 i 7 Only seven similar cases have been published in the hterature. G r a y and Skandalakis, s in their excellent chapter on pyloric atresia describe five types of this malformation; they called this variety complete solid atresia. Sixty cases o f prepyloric or pyloric d i a p h r a g m s have been described and constitute, by far, the most c o m m o n type of pyloric atresia. The absence of green vomitus suggests to the physician that he is not treating a case of neonatal intestinal obstruction, hence the late diagnosis in this case. Simple x-rays of the a b d o m e n are diagnostic 9 In the complete atresia with discontinuity, a side-to-side g a s t r o d u o d e n o s t o m y is indicated.
Fig. I . Simple x-rays of the abdomen at the age of 6 days. Note absence of air beyond stomach.
149
1 50
CASE REPORTS
However, when faced with the situation reported here, a Heineke-Mickulicz pyloroplasty is both simple and effective.
REFERENCES I. Metz A R , Houscholder R, De Pree JF: Obstruction of the stomach due to congenital double septum with cyst formation. T r a n s West Surg Assoc 50:242, 1941 2. Burnett H A , Halpert B: Perforation of the s t o m a c h of a new born infant with pyloric atresia. Arch Pathol 44:318, 1947 3. Brown RP, Hertzler JH: Congenital prepyloric gastric atresia. A report of two cases. A m J Dis Child 97:857, 1959 4. Kornfield H J: Pyloric atresia and its repair. Surgery 51:569, 1962
5. Talwalker VC: Pyloric atresia: A case report. J Pediatr Surg 2:458, 1967 6. T h o m p s o n N W , Parker W, Schwartz S, et al: Congenital pyloric atresia. Arch Surg 97: 792, 1968 7. Bronsther B, N a d e a u M R , A b r a m s M W : Congenital pyloric atresia: A report of three cases and a review of the literature. Surgery 69:130, 1971 8. G r a y SW, Skandalakis JE: Embryology for Surgeons. Saunders, 1972