Quiz: Newborn patient with a report of non-bilious vomiting after feedings. What would it be?

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Male patient, 27 days old, with a report of non-bilious vomiting after feedings. On physical examination, a patient with poor weight gain, malnourished, dehydrated 2+/4+ and pale 2+/4+ is observed. Examination of the abdomen showing the pyloric olive.

vomiting

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Question 1 of 2

Given the results of the physical exam and the clinical history, what is the first test to order?

To correct

Answer: A

The first test to assess persistent vomiting in the pediatric population is abdominal ultrasound.

Incorrect

Answer: A

The first test to assess persistent vomiting in the pediatric population is abdominal ultrasound.
Question 2 of 2

Given the imaging results, answer: what structure is visualized and its radiological diagnosis?
To correct

Answer: c) pylorus, stenosis hopertrophe pylorus

The pyloric canal was still elongated, measuring 19 mm in the longitudinal axis – yellow arrow.

Hypertrophic pyloric stenosis is a disease characterized by hypertrophy of the circular muscle of the pylorus, resulting in narrowing of the pyloric duct and obstruction of the gastric outlet. Boys are more affected than girls with a ratio of 4-5:1. Patients typically present between two and six weeks with nonbilious vomiting. Clinical diagnosis can be made by palpating an olive-shaped “mass” in the epigastrium (pyloric olive). Fighting gastric peristalsis can also be observed. However, these ectoscopy and clinical examination findings only occur in about 17-53% of patients.

Ultrasound is the imaging test of choice to diagnose this condition. The baby should be breastfed approximately 30 minutes before the exam to fill the pyloric antrum with fluid and allow adequate visualization of the pylorus. In the long axis projections of the pylorus, the thickened pyloric muscle and the elongated pyloric canal are seen. The reference values are as follows: the normal pyloric canal measures up to 12 to 14 mm and the thickness of the normal muscle is up to three millimeters.

References:
- Hernanz-Schulman M, Zhu Y, Stein SM, et al. Hypertrophic pyloric stenosis in infants: ultrasound assessment of the pyloric canal vascularization. Radiology 2003; 229: 389-393.
- Haider N, Spicer R, Grier D. Sonographic diagnosis of infantile hypertrophic pyloric stenosis: determinants of pyloric length and the effect of prematurity. Clin Radiol 2002, 57:136-139.
- Gale HI, Gee MS, Westra SJ, et al. Abdominal ultrasound of the pediatric gastrointestinal tract. World J Radiol 2016;8:656-667.
- Peeters B, Benninga Ma, Hennekam RC. Infantile hypertrophic pyloric stenosis – genetics and syndromes. Nat Rev Gastroenterol Hepatol 2012:9:646-660.
Incorrect

Answer: c) pylorus, stenosis hopertrophe pylorus

The pyloric canal was still elongated, measuring 19 mm in the longitudinal axis – yellow arrow.

Hypertrophic pyloric stenosis is a disease characterized by hypertrophy of the circular muscle of the pylorus, resulting in narrowing of the pyloric duct and obstruction of the gastric outlet. Boys are more affected than girls with a ratio of 4-5:1. Patients typically present between two and six weeks with nonbilious vomiting. Clinical diagnosis can be made by palpating an olive-shaped “mass” in the epigastrium (pyloric olive). Fighting gastric peristalsis can also be observed. However, these ectoscopy and clinical examination findings only occur in about 17-53% of patients.

Ultrasound is the imaging test of choice to diagnose this condition. The baby should be breastfed approximately 30 minutes before the exam to fill the pyloric antrum with fluid and allow adequate visualization of the pylorus. In the long axis projections of the pylorus, the thickened pyloric muscle and the elongated pyloric canal are seen. The reference values are as follows: the normal pyloric canal measures up to 12 to 14 mm and the thickness of the normal muscle is up to three millimeters.

References:
- Hernanz-Schulman M, Zhu Y, Stein SM, et al. Hypertrophic pyloric stenosis in infants: ultrasound assessment of the pyloric canal vascularization. Radiology 2003; 229: 389-393.
- Haider N, Spicer R, Grier D. Sonographic diagnosis of infantile hypertrophic pyloric stenosis: determinants of pyloric length and the effect of prematurity. Clin Radiol 2002, 57:136-139.
- Gale HI, Gee MS, Westra SJ, et al. Abdominal ultrasound of the pediatric gastrointestinal tract. World J Radiol 2016;8:656-667.
- Peeters B, Benninga Ma, Hennekam RC. Infantile hypertrophic pyloric stenosis – genetics and syndromes. Nat Rev Gastroenterol Hepatol 2012:9:646-660.

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Authors):

Graduated in Medicine from the Federal University of Rio de Janeiro – UFRJ. Medical residency in Radiology and Diagnostic Imaging at the Federal University of Rio de Janeiro – UFRJ. Specialization in Pediatric Radiology in 2018. Pediatric Radiologist at the Municipal Jesus Hospital, Instituto Fernandes Figueira (IFF) and Instituto de Puericultura e Pediatria Martagão Gesteira (IPPMG).

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