Pylorosthenosis
Pylorostenosis is the narrowing of the lumen of the ventricular outlet - the gatekeeper. A narrow gatekeeper prevents the passage of food masses into the 12-colon, there is a delay in food in the stomach, with its overflow begins profuse vomiting. At first, it brings relief, but in the future there is a significant expansion of the stomach, its elasticity is lost, food stagnation is aggravated. Consuming normal portions of food, people at the same time live half-starving, because the food masses do not go through the proper cycles of digestion and assimilation. The expressed pyloric stenosis becomes an obstacle even for liquids, therefore it is dangerous because of the growing depletion of the organism, aggravated dehydration.
Pylorostenosis can occur as a result of secondary damage to the doorkeeper, but it can also be a congenital malformation, in which case he declares himself a certain symptomatology already in infancy and happens in girls less often (about four times) than in boys. The hereditary dependence is traced: the presence of pyloric stenosis in one of the parents increases the risk of inheriting it tenfold.
Acquired pyloric stenosis develops primarily as a consequence of a prolonged course of duodenal ulcer, chronic ulcer or stomach tumor, chemical burns of the digestive tract, pylorospasm. The causes of congenital narrowing of the pylorus are not completely clarified.
Causes of pyloric stenosis
Congenital pyloric stenosis begins to form long before the birth of the child (presumably at the very beginning of the third month of gestation), at the same time the pyloric walls thicken, their elasticity gradually diminishes, the lumen narrows, and the pylorus becomes like a deformed tube that can not fully reduce and create waves of peristalsis. Thickening of the pyloric wall is mainly due to the muscular layer consisting of smooth muscle bundles. They thicken, increase in size, i.e. hypertrophy, in the future between them begins to grow connective tissue until the formation of cicatricial changes. Other layers of the pyloric wall also suffer, the serous membrane also becomes denser, thickens, the mucosa on the contrary, becomes thinner, dystrophic phenomena develop, ulceration may even occur. It is proved that pyloric stenosis is accompanied not only by the manifestations of tissue hypertrophy, but also by innervation disorders, which aggravate the anatomical changes of the pylorus. Why such changes occur in the walls of this part of the stomach - until it is reliably established, but many authors associate it with intrauterine infection.
Pylorosthenosis - sealing the walls of the outlet of the stomach and narrowing the lumen - this is a significant obstacle to the passage of food; it is not completely evacuated from the stomach, part remains until the next feeding, gradually the residual quantity increases, the child begins plentiful regurgitation, then abundant vomiting develops. Without treatment, pyloric stenosis leads to significant disturbances in metabolic processes, can cause dehydration, and in particularly severe cases can lead to death.
Pylorostenosis in adults is always a complication of some other disease. For example, in the area of the gatekeeper there is a chronic ulcer for a long time, it inevitably leads to granulating inflammation and development of sclerotic changes in surrounding tissues. Spreading further and further, the compaction of tissues will capture a significant part of the wall, pyloric stenosis will occur. Approximately the same development of pyloric stenosis in the lesion of the outlet of the stomach tumor.
Direct damage to the mucous and muscle layers can occur with acid and alkaline burns, healing in such cases occurs with the formation of scar tissue, eventually also develops pyloric stenosis. With chemical burns of the digestive tract, pyloric stenosis can immediately begin in subcompensated or even severe form, this is facilitated by the depth of tissue damage and severe healing of injuries of this genesis, in addition, pyloric stenosis in such cases is most often combined with lesions of other departments (eg, esophageal stricture).
Difficult evacuation of food leads to a gradual stretching of the stomach, increasing its size, the contractile capacity of the muscle layer weakens, it weakens, its atony develops. This contributes to the further stagnation of food until its decay. Without treatment, pyloric stenosis can lead to serious consequences.
Symptoms and signs of pyloric stenosis
Congenital pyloric stenosis makes itself felt from the first weeks of the child's life, but there is always a gap that goes without any symptoms, the baby looks strong and healthy, eats well. The presence of such a happy period is explained by very small portions of food eaten in the first or second week after birth, it manages to pass through the narrow aperture of the gatekeeper between the feedings. Then there is quite abundant regurgitation, which is of no particular concern, since it is common for many children. But in a short time pyloric stenosis passes into a phase of obvious manifestations, regurgitation turns into vomiting. It is plentiful, the food masses fly out with a tight jet, the amount of vomit in some cases does not exceed the amount of food taken, but sometimes there may be more eaten volume, because the stomach was not emptied between the feedings. In vomit masses there is no impurity of bile, it can not get into the stomach due to the same constriction of the pylorus. The appetite of a child is not disturbed, even increases, as he does not receive enough food because of vomiting.
Pylorysthenosis in newborns quickly leads to the fact that the baby stops gaining weight, then begins to lose weight. The child is less likely to urinate and recover.
At an early stage, pyloric stenosis in children manifests an increased peristalsis of the stomach, which makes efforts to push food masses through a narrow outlet department, this is noticeable by eye - the upper part of the abdomen seems to pulsate. Having stroked the palm in the epigastric region, one can cause an increase in peristalsis and see a constriction resembling an hourglass in shape - a characteristic symptom that allows to suspect pyloric stenosis in infants.
Further pyloric stenosis in newborns leads to dehydration, the child becomes sluggish, inactive, the skin acquires a grayish shade, often with a marble pattern, a decrease in the elasticity of the skin can be so pronounced that wrinkles appear on the child's forehead, and the face looks like a "little old man". Complications in the form of gastric bleeding can develop, vomiting is frequent in the respiratory tract with the development of aspiration pneumonia.
Pylorostenosis in adults is accompanied by complaints of a feeling of heaviness in the epigastrium, bad breath, vomiting, poor health. A mandatory sign of the disease is a gradual decrease in body weight. Due to dehydration, the patient may complain of dryness and flaking of the skin, thirst. Since pyloric stenosis in adults is a complication of another disease, naturally, its symptoms will also be present, in each case different.
Pylorostenosis by severity of manifestations and their severity are divided into three degrees. At the first (compensated) there is a feeling of overflow in the upper abdomen and nausea, vomiting is episodic, bringing relief, the patients associate it with errors in nutrition. Laboratory indicators are slightly different from normal, hypokalemia , moderately elevated ESR index can be observed. In the second (subcompensated) degree, pyloric stenosis is manifested by abundant vomiting stagnant food masses, which were long in the stomach and have a pronounced acidic odor. At laboratory diagnostics to the lowered level of the maintenance of a potassium in blood the deficiency of sodium, chlorine joins. At the third (decompensated) degree, food is almost not evacuated to the intestines, stagnates and rotes in the stomach, causes considerable discomfort and so unpleasant sensations that the patient prefers to induce vomiting on his own, without waiting for her spontaneous onset. Vomit has an extremely unpleasant putrefactive odor, relief from vomiting is negligible. At laboratory blood test low level of potassium, sodium, chlorine, protein will be revealed, the ESR increases significantly, signs of alkalosis are present.
Congenital pyloric stenosis according to the severity of the flow is divided into forms: mild, moderate, severe, the main evaluation criterion is the decrease in body weight. An easy form means a daily weight loss in a child of not more than 0.1%. With a moderate form, this indicator rises to 0.3%. Pylorostenosis in severe form is characterized by weight reduction of up to 0.4% or more.
Diagnosis of pyloric stenosis
Pilocrostenosis in terms of diagnosis of special difficulties does not cause, because it has quite characteristic features. Complaints of an adult patient are reduced to nausea, vomiting, a feeling of heaviness in the upper floor of the abdominal cavity, weight loss. When examined, signs of dehydration are noticeable: dry tongue, overlaid with a gray coating, dry loose skin. Often, you can see an intense peristaltic wave, visible even through the abdominal wall. Percussion of the anterior abdominal wall reveals a significant expansion of the boundaries of the stomach. In the instrumental study, additional data are obtained. Thus, when probing from the stomach on an empty stomach, several liters of stagnant contents are removed, indicating a violation of food progression to the intestine, the nature of stagnant masses is quite clearly indicative of the degree of severity with which pyloric stenosis has reached.
Endoscopic examination allows you to visually confirm the presence of narrowing of the pylorus and dense cicatricial deformation of its walls, indicating pyloric stenosis. X-ray examination reveals a significant expansion of the stomach, a delay in the contrast medium in its cavity, but this method is almost not used, it was replaced by a more pleasant and safe ultrasound for the patient, taking much less time and giving no less accurate results.
Pylorostenosis is often difficult to distinguish from pilorospazma, which manifests similar symptoms. But if the pyloric stenosis is an organic lesion (thickening, compaction) of the outlet part of the stomach, the pylori spasm develops when the innervation of this department is disturbed and manifests itself by a persistent spasm of the normally developed muscular layer of the pylorus. This difference is most often easily detected with ultrasound and endoscopy. If doubts remain, the patient is prescribed a short course of spasmolytic therapy, its effectiveness will be evidence of pilorospasm in the patient, pyloric stenosis does not respond to such treatment, the patient's condition will not improve.
Pylorostenosis in infants can be detected by palpation, the dense walls of the pylorus are probed to the right of the rectus abdominis muscle. Attentive mothers in the interview will tell you that they noticed the unusual mobility of the abdominal wall in the child, she seems to "walk in waves". During feeding, this symptom increases, so if a child is suspected of pyloric stenosis, a little water or feed should be given to the child during the examination, a surge of peristalsis will help in diagnosis.
Of the additional methods, ultrasound is most commonly used, with lengthening of the pylorus and thickening of its wall (the main sign indicating pyloric stenosis), deviation of these parameters from the norm will be the stronger the severity of the disease. Normally, the wall thickness of the gastric outlet of the newborn does not exceed 1.5 mm, an increase of this index to 2-2.5 mm is already an occasion to suspect pyloric stenosis. Thickening to 3-3.5 mm indicates a mild form of the disease, up to 4-4.5 mm - on the medium-heavy course. Pylorostenosis in severe form can lead to a thickening of the pyloric wall up to 6 mm and even higher.
It facilitates the diagnosis and X-ray examination with the use of contrast medium, while the characteristic signs of pyloric stenosis are visible: enlargement and pronounced peristalsis of the stomach, as if dividing it into two fragments with constriction. The delayed passage of the contrast medium, the constriction of the pylorus, a significant decrease in gases in the intestine are clearly visible, but the X-ray method of examination in children is used extremely rarely, only in the case of inconclusive data for other types of examination.
Pylorostenosis in children and adults leads to violations of water-salt and electrolyte metabolism, which is reflected in laboratory indicators, they reveal a low content of potassium, sodium, chlorine and proteins in the blood, indicate signs of alkalosis.
Pylorostenosis is often difficult to distinguish from pilorospazma, which manifests similar symptoms. But if the pyloric stenosis is an organic lesion (thickening, compaction) of the outlet part of the stomach, the pylori spasm develops when the innervation of this department is disturbed and manifests itself by a persistent spasm of the normally developed muscular layer of the pylorus.
Treatment of pyloric stenosis
Pyloric stenosis is treated mainly by surgical methods, the type of operation is chosen taking into account several factors: the general condition of the patient, the degree of tissue dehydration and the deviation from the norm of laboratory indicators, the presence of individual characteristics.
Children undergo pylorotomy according to Fred-Ramstedt - an operation that maximally preserves the integrity of the digestive tract. During the operation, the serous membrane is dissected, the muscular layer thickened and compacted, the incision is made along the longitudinal axis of the pylorus. The mucous membrane during the operation is not affected, seams on the intersected serous and muscle layers do not overlap. Blurring the dense ring around the output section of the stomach, reduce the pressure on the mucous membrane, it has the opportunity to straighten, the normal diameter of the pyloric lumen is formed, as a result, pyloric stenosis is eliminated. At the same time, a part of the nerve fibers intersects, which also eliminates the spastic component of the disease.
The severity of the child's condition can not be contraindicated to surgery, since without surgical treatment pyloric stenosis ends in a lethal outcome. In severe conditions, a volume preparation for the operation is performed, during which the volume of circulating blood is replenished, rheological indicators are given at least in relative norm. The child subcutaneously and rectally injected fluid, intravenously - saline and glucose, if necessary, produce blood transfusion. After surgery, the child remains in the hospital until his condition is assessed as satisfactory. A course of rehabilitation is being carried out, during which time the portions of food consumed gradually increase. Begin with a couple of spoons of saline and watch the peristalsis of the stomach, if it is within normal limits, the baby is fed a small (20-25 ml) amount of expressed breast milk. Feedings should be frequent, up to ten per day, with each time the amount of milk is slightly increased, after a week they are transferred to maternal feeding, bringing portions to normal age-related nutritional loads.
Pylorostenosis after surgical treatment ends in recovery, the children develop correctly, there is no disturbance from the gastrointestinal tract. After surgery, there may be cases of vomiting, but single, they soon go away by themselves. Long-term follow-up of the operated children shows a complete and lasting recovery.
Pylorostenosis in adults is a consequence of far-reaching cases of other diseases, therefore, operations with pyloric stenosis in adults are conducted taking into account the primary pathology. If pyloroplasty is possible, it is performed. If pyloric stenosis developed as a result of ulcerative or neoplastic lesions of the pylorus, preference is given to partial resection of the stomach followed by plasty (formation) of the outlet, with more significant lesions producing subtotal resection of the stomach with the formation of gastrointestinal anastomosis or gastrostomy.
Pilostenosis in case of untimely diagnosis and delayed treatment can result in death due to massive dehydration and its complications. Timely recognition of the disease with the subsequent rapid restoration of the pyloric patency of the stomach has a favorable outcome.
