Tag Archives: symptoms

Pyloric stenosis: its infant and adult forms

This blogsite has mentioned several times that pyloric stenosis (“PS”) afflicts adults as well as infants.

Pain01Recently I devoted a post to the adult form, passing on the stories of several people who had related these on one of the Facebook PS Groups’ pages.  By using the “Categories” box at the top right of this site, interested readers can locate several posts that deal with adult PS.

The stories of adult PSers vary even more than those about the infant form of the condition.  However, the basic cause is the same: high gastric acidity.

In the infant disease, the high gastric acid level over-stimulates the pylorus (the circular muscle valve at the stomach’s exit, causing it to thicken, toughen and choke the muscle’s ability to relax and pass food. Peptic ulcer3

Adult PS is also caused by high acidity and often a virus, Helicobacter pylori. The acid erodes the stomach lining and creates conditions which enable the virus to trigger the eruption of gastric ulcers, which then scar the stomach and pylorus, ultimately narrowing and blocking the stomach outlet.  These ulcers can also give rise to cancer.

These differences do not affect the name of the condition: “pyloric stenosis” means “narrowing” of the pylorus (which means “gate”).  The term “hypertrophic” means “enlargement” and is only used of the infant form.  The effect of PS is also the same: the blockage of the narrow exit valve, starvation and vomiting.

The difference in the development of the two forms of PS explains why the relatively simple “fixes” for infant PS (medication or surgery to relax the pyloric ring) do not relieve the adult form of the condition.  The PS baby’s problem is the thickening of the pyloric passage’s muscular outer, whereas the adult’s blockage occurs inside the pylorus or at the antrum, the tapered part of the stomach closest to the pylorus.

Scared_DoctorThe main post mentioned above reflects the range of symptoms that adult PSers may suffer and the various treatments which are offered by GI specialists: unhappily adult PS is more complex in its causes, symptoms and available treatment.  All treatment options are far from assured of success and they tend to have unwanted and significant physical side-effects, far more often so than the great majority of infant PS survivors report.

Infant PSers have a much higher risk of a list of abdominal complaints after their early surgery and in later life.  One of the risks is of developing gastric ulcers – and the other form of PS.  Deja-vu!

But today, thanks to effective antibiotic treatment, H. pylori infection is usually quite easily dealt with, and so gastric ulcers are now much less common than they were in my younger years.

The next post will continue the stories of adults with PS.

The difference between GERD and Pyloric Stenosis

Four of my blogs during the past six weeks have dealt with the sadness and/or anger of far too many parents the world over because the diagnosis of their baby’s malady was by any standard less than respectful and thorough.

I have observed in several blogs that all the parents and medical professionals concerned with this issue could improve their consultation process in particular ways, possibly in many ways.

During the past week I heard a radio program about the number of parents who take their sick children to the local hospital’s Emergency Department.  Some went there with urgent and serious conditions but we were told that many went with minor ailments of infancy that could easily have been taken care of in other ways: by checking the web or a book at home, consulting a family member, or calling on their local pharmacist or the local health clinic.

What completely amazed me however, was the comment of the health professional and educator being interviewed that in Australia and most other developed countries most hospitals do not use an evidence-based diagnosis procedure!  That is: a list of the symptoms, questions, and tests that need to be worked through to arrive at as accurate and prompt a diagnosis as possible. And that most health workers do not have one either.

Every medical worker is like everyone of us: we all have strong and weak areas.  Not every family doctor is a whiz at diagnosis or sports medicine, not every surgeon is a good communicator, not every nurse has a good manner with children, and not every hospital CEO is a born negotiator.  We all need to recognise and remember that.

This is all the more reason to ask why every hospital “emergency room” (ER) must not have a formal set of diagnostic procedures!  My body and its working and defects is very, very complex, and thus diagnosing a problem can sometimes be very difficult.  If we could expect every ER to have somebody on duty at all times who is able to cover many cases and who is strong in diagnosis . . . “and pigs will fly!”  Surely every doctor and hospital must have a list of the symptoms, questions, and tests that need to be worked through to arrive at an accurate and prompt diagnosis.

Let me illustrate with a simple example.

Many parents who take their new baby to their doctor or ER because of constant vomiting tell us they were assured the problem is probably gastro-esophageal reflux disease (GERD) or reflux.  Their family history of pyloric stenosis (PS) or their list of symptoms pointing to this was summarily brushed off: “All babies sick up!  New mothers are anxious!”  Just read the recent posts or some of the web-based comments.

In recent blogs I have listed the symptoms of PS.  The following small table makes it easy for parents and all concerned to recognise the clear differences between PS and GERD –

I have seen many tables like this on the web, dealing with many different conditions and symptoms.  They help the general public, and surely such simple information (or fuller versions of them) would also greatly raise the standard of good medical diagnosis.

Recognising Pylorix isn’t usually rocket science

A very early photo

Having had my pyloric stenosis surgery at the very early age of 10 days is one of the very few things I know about that early chapter of my story.

My parents always batted away my questions, and being a shy and compliant child (my aggression is typically of the “passive” kind) the details of this vital episode of my life have sadly gone to the grave with my dear folks.  But I’m “a brooder” and I have been able to learn a lot about my infant surgery by reading, networking and joining the dots.

The symptoms of infant pyloric stenosis can appear at any time during the first six months (and very occasionally even later), but usually between 3 weeks and 3 months.  Sometimes the symptoms develop over several weeks, and sometimes very quickly.  So having PS surgery at just 10 days means that my case must have been very clear, if not urgent.

In recent blogs I have written about the frustration many parents express about their doctor when the signs of a major problem with their baby were summarily dismissed time after time.  Sometimes their problem was indeed a normal part of getting to know their new baby.  But there are far too many stories of babies suffer professional neglect until their condition was such that the parents were told, “Your baby would have died if you had delayed another day”.  I doubt this happened to me.

Pyloric stenosis is by far the most common condition in a baby that is (usually) dealt with surgically.  It affects 3 – 4 in every 1,000 babies and its symptoms are usually quite clear, whether they take a few days or weeks to become clear and critical.  Even better: you don’t need medical training to recognise and keep a list of these symptoms.  All your doctor has to do then is run a few double-checks, like xray or ultrasound imaging.

  • The first thing to look for is projectile vomiting.  During or up to half an hour after a feed, the stomach turns your baby into a fountain, as the milk is expelled with great force, typically 1 – 4 metres across the room.
  • The second sign is no loss of appetite.  PS babies do not feel sick after their vomiting but feel hungry immediately, and tell you by crying.
  • Weight loss is the third clear sign, so keep a close eye on your baby’s growth.  Babies who cannot process their food cannot maintain their weight, let alone grow.
  • Watch for signs of dehydration.  A clear case of PS means dry nappies (diapers), a dry mouth, crying without tears, and the depression of the soft spot of the skull.  Dehydration also makes the baby less active and more sleepy.
  • With dehydration, the bowel movements also stop or become infrequent and minimal.  There may be mucous and a green colour in any stools.
  • Keep an eye on your baby’s abdomen, especially during and after feeding.  Rhythmic movements from left to right show the stomach muscles are working (in vain) to move the food through the pylorus (“gate” or outlet) to the intestines.
  • You may also be able to feel the swollen pyloric muscle, which in PS is about the size and shape of an olive.  To try this, relax your baby by having it on your lap, keeping it warm and giving it sugar to suck; raise the legs to further relax the bared belly; with warm fingers press gently and feel over the stomach, usually in the middle to left and north of the umbilicus.  But usually it will take a skilled person to feel the swollen pylorus.
  • Having a compelling checklist of all or many of these symptoms will make it far less likely that a doctor or paediatrician will not take your anxiety seriously.  If the information you gather is not very convincing, it should reassure you that the problem is not (yet) PS.  If it is unclear and your baby has not shown wasting, it would be wise to consider trying alternatives such as medical treatment for reflux or PS rather than rushing to the operating room.
  • If the signs are clear for infant pyloric stenosis, a pediatrician must make a formal diagnosis.  You can demand this if your baby shows any of the clearest signs and symptoms of pyloric stenosis.  The doctor who can feel the “pyloric olive” as part of a physical examination will probably still use a variety of tests including ultrasound, X-rays and blood tests.  Ultrasound enables the pylorus to be measured to assess whether it is indeed swollen.  An x-ray will show conclusively whether food is indeed blocked from passing through the exit muscle.  Blood tests are needed to assess the blood chemistry work that is vital for a tiny PS baby to recover from dehydration and starvation, and to survive medical treatment and/or surgery.

Pyloric stenosis like many other faults of the infant abdomen is fatal unless treated.  PS is probably the simplest of these faults to remedy, and it can be treated with medication far more often than the present Western medical world determines!  In my day (1945) PS surgery was still seriously life threatening and deeply traumatic for all concerned.  It is still hugely distressing for all parents, but usually only in passing.

Almost all of us who have had pyloric stenosis and infant surgery are also surviving it.  But this chapter can cause trauma for the infant in later life, which may be why some of you are reading these blogs – and it’s the main reason I’m creating them.

Shoddy diagnosis = parents in pain

Isn’t it just so satisfying when all the pieces of a puzzle come together promptly as well as perfectly?

Recently I read about a woman who was severely worried about her grandson. It was only weeks after his birth that his grandmother decided to get him to her doctor. Her GP could see immediately that the little man was having problems with his food and that he was starting to become dehydrated: he knew instantly what he was seeing and suggested that the baby was suffering with Pyloric Stenosis. The grandmother looked worried until the doctor lifted his shirt and showed her the scar he’d had across his stomach almost since his birth. Grandma urged her daughter to take the baby to her own doctor, suggesting to him what she thought the condition was. The baby was taken in immediately, operated on and is doing well now.

Wave-like motion across the abdomen after feeding and before vomiting is typical of PS

This story would be quite common. After all, pyloric stenosis occurs in one in every 250-300 babies, so there are many thousands of medical workers who like myself would quickly recognise the condition.

Besides this, pyloric stenosis is the most common reason for infant surgery (apart from elective and unnecessary circumcisions) and apart from tonsillectomies, the most common surgery on children under 5. Every pediatrician, family doctor and hospital emergency department in the world will have seen many cases. Almost always, many of the symptoms cannot be ignored: over several days (or very sometimes, weeks) pyloric stenosis gets to a life-threatening stage that demands medical treatment.

Even more significantly, every medical textbook includes the easily understood and quite obvious tell-tale signs that everyone could easily recognise: projectile vomiting, the reduction or complete cessation of bowel and bladder movements, loss of weight, condition, and finally alertness, and often visible muscular movements across the abdomen and an olive-sized and -shaped mass that can be felt over the stomach.
Yet most people have never heard of this common malady. Worse still, many doctors don’t consider it until they’ve ruled out other problems. And even worse than that, there are hundreds of complaints on the web from parents who have been upset or angered by the way their distress and their baby’s trouble were brushed off with (usually) patronising talk of “all babies puke” and “over-anxious parents”.

Here is one mother’s story:

When my youngest was born he was really sick all the time and the doctor kept telling me he had reflux, but I just knew there was something more to it, as the Gaviscon and Infacol didn’t do a thing. I had him at the doctor 3 times in 2 weeks and he just said the same thing. The final straw came when he was only 3 weeks old and I was feeding him and he took half an ounce and brought up about 4, so i took him to the hospital and the little soul had pyloric stenosis and needed to have an operation. If I had kept listening to the doctor he could have ended up seriously malnourished, but because I trusted myself he was in and out of hospital in less than a week.
I say, don’t ever doubt yourself: you know best!

A month ago an Australian blogger posted the horrendous process a friend of hers endured before the severity of her baby’s condition was taken seriously. Anna’s full account is worth reading; it is both infuriating and heart-rending.

Let me highlight the main points here:

  • Anna’s friends had two normal healthy children before their son developed what they first assumed was reflux at two months.
  • As the “reflux” became worse, the mother took her son to a doctor who treated him for a cold.
  • A week later her son had clearly lost condition so she decided to see another doctor, who diagnosed bronchiolitis again, as well as mild reflux. The mother protested that her baby was projectile vomiting after every feed, that he had stopped gaining weight, and that a cousin had had pyloric stenosis. The doctor said little but his manner told the mother he thought she was over-reacting.
  • Not satisfied, the woman then took her son to the local hospital, which also told her the problem was reflux.The infant was now losing weight, he’d become more irritable, his bowel movements were black and his urine output had fallen. He was seen by a third doctor who agreed that his condition was of serious concern. But he also diagnosed the problem as reflux and prescribed a week’s medication.Three days later, the mother steeled herself to see the hospital doctor again, who refused her demand to test the baby for pyloric stenosis, nor did he give any medication; he did make an appointment with a paediatrician for two days later.
  • The following morning, the baby was listless and crying in pain. With the husband’s and grandparents’ support, the baby was taken back to the hospital. The infant was admitted and immediately treated for dehydration; an ultrasound showed his pylorus was enlarged and closed.
  • The local hospital could not do the surgery but then the city children’s hospital refused to recognise the diagnosis; the tests were repeated but again rejected. The children’s hospital then agreed to receive the baby, now a 10 week old whose only intake was coming from an IV drip, but he would have to go through the entire admission and testing process again.
  • Finally transferred to the children’s hospital, the couple saw a surgeon at 3 am who immediately agreed with the pyloric stenosis diagnosis and arranged urgent surgery. He was appalled at the way the family has been dealt with, and commented that most infants with pyloric stenosis do not survive for two weeks and that most cases are diagnosed within a week.

In my next post I want to set out and explore some of the good and bad reasons why so many personal stories about pyloric stenosis babies are not happy ones.

[I am grateful to Ly’ren, Maxine and Anna, the people whose stories I have included here; the web addresses of the blogs referred to are available on request.]