Improvements in infant surgery (4) – Good diagnosis

Poor diagnosis and arrogant manners are by far the two most frequently heard complaints from the parents of pyloric stenosis babies.  As I write this post I am following a TV program about parents taking their sick children to (cop this) chiropractors!  One Australian chiro on the show told us that 1/3 of his patients are children.

And why?

Chiropractor_smallBecause many parents find doctors take no time for their patients, and especially not for children and their complaints.  So (in Australia at least) growing numbers of parents are asking their friendly chiropractor about asthma, autism, colic and reflux.  And chiropractors are setting up specialist pediatric clinics.  Wow!

I have often posted about the large of number of parents who air on the web their deeply felt grievances about the pediatrican they consulted about a very sick baby, and about the simple things both doctors and parents should remember and do better.

I recently read a “good news” post on this subject, from a doctor (“Casey”) in Broome, a town of 15,000 located on the coast of NW Australia.  He wrote about the challenge of recognizing a pyloric stenosis baby when so many sick babies are brought to his clinic.  What he says about the diagnosis is far from rocket science: I have often mentioned the short list of easily understood and quite recognizable symptoms.

Remind yourself of these basics . . .

Picking the baby with pyloric stenosis from all the refluxing, positing and normal kids can be tricky.  In GP land this is a really common presentation: a new mum with a kid who “spews” after feeding.  We know that the vast majority of these kids will have no pathology, but you really don’t want to  miss an important diagnosis like hypertrophic pyloric stenosis (HPS) or a more sinister GI obstruction, sepsis or other badness.  So I thought I would tell you all about my all time favourite PS diagnosis and have a look at the recent evidence for the diagnosis and management of HPS.

This baby ticked all the boxes :

  • he was a boy (~80 % of HPS in males),
  • His symptoms started around 4 weeks age, and presented at 5 weeks (classic age)
  • he was a few weeks premature (commoner in premmy babies – and they present relatively younger),
  • his mother described a progressive history of increasingly voluminous and forceful vomiting over the past week, this was non-bilious.
  • He was constantly hungry and wanting to feed immediately after spewing.
  • He had lost weight i.e. was not thriving as is often the case in overfed babies who get “overflow” vomits

My practice with the neonate presenting with vomiting is to observe a test feed in the ED or the rooms and watch to see what happens – usually you see a palmful of milky posit come up and can be reasonably reassured that this is likely normal “mum badge” production.

  • This little boy had a test feed and within 3 minutes he erupted like a volcano with a full feed being thrown about a foot in the air over mum, me and the bed – convincing.

The classical triad of HPS is:

  • a palpable “olive” or “tumour” in the RUQ, 48% of cases
  • visible peristalsis ~ 25 % of cases
  • Hypochloremic (hypokalemic) metabolic alkalosis
    • Interestingly hemetemesis was present in 16% at diagnosis – not a traditional symptom of HPS
    • Seeing one component of the triad is common, seeing all 3 is pretty rare – so do not rule out if your patient hasn’t a full deck of signs.

This triad is becoming a rare beast.  Taylor et al (from Westmead in Sydney) published this paper in Journal of Paediatric Child Health in Jan 2013.  They showed that clinical diagnosis is now uncommon – less than 10%, with more reliance on imaging such as Ultrasound and Barium studies.  Only about half had a “tumour” – which might be due to deskilling in us, or just earlier diagnosis?  Ultrasound seems like a good initial investigation as it is painless, non-invasive and has high sensitivity and specificity…   This remains a technically tricky modality – so not one I would do myself in the Emergency Dept and hang my hat upon.

The story continues:

So our little guy – what did examination show?  Well, I could not feel a mass, the vomiting was very convincing….. but technology sealed the diagnosis!  The little guy’s grandfather was an anaesthetist [in a hospital on the other side of the country], who just happened to be doing a list for a paediatric surgeon that morning.  Mum had videoed a clip of “visible peristalsis” after his morning feed and emailed it from her iPhone to her father, who showed it to the surgeon, who then called me just as I was observing the impressively projectile vomiting.  Slam dunk diagnosis!

So I placed an IV and took some blood for VBG and electrolytes.  Resuscitation and electrolyte correction are the cornerstones of initial management…

So now – here is the conundrum.  This boy needs to get to a surgeon to have his pyloromyotomy soonish, yet he is at risk for apnoeas.  So when is it safe to transfer him?

Can we predict who might have apnoeas? …  I think in the really small and premature babies the risk would be higher – so you might need a super-specialist advice on that one.

Alright – that is all I know about pyloric stenosis.  It can be tough to pick the true PS out of the crowd of spewing kids.  Our classical triad is not the norm, however I would advocate the use of Ultrasound early as it is pretty good and there is no real downside.

There was one Comment on Casey’s Post, and I found it significant as it added to Casey’s theme –

Great case Case!  Saw a suspected case with a GP registrar when I was an intern, he only had the olive and not impressive vomiting.

Since then, plenty of garden variety vomiting kids.  Have stopped asking about the nature of vomiting though.  While working as a paeds reg for a few months in town, every child was described as having ‘projectile’ vomiting.  The classic “how far across the room does it go?” might be more differentiating?

I like the use of video technology too.

Dr Casey’s Post gives no indication of his attitude to his patients, but he makes clear that unlike many of his colleagues he is alert to the obvious signs of pyloric stenosis.  This (sadly) seems remarkable.  If only more doctors were as alert, aware, sensible and “grounded” as this one!

2 thoughts on “Improvements in infant surgery (4) – Good diagnosis

  1. Wendy

    I really enjoyed this post. The use of the video to show the troubled peristalsis was amazing! That video added the crucial evidence to the triad. The doctor seemed empathetic, certainly. In any case, it’s exciting to see how a clinic these days handles possible PS babies. An eye-opener!

  2. Fred Vanderbom Post author

    Thanks for your response, Wendy. This doctor’s piece was one of the more encouraging personal experience posts I have seen from the medical profession.


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