Infantile Hypertrophic Pyloric Stenosis (IHPS)

(1)

= Abstract=

~~~011A-l 3::~ Jil- {lAt~ °1%~ y~ +

*~-¥-~ 5:71 ~§l-

Infantile Hypertrophic Pyloric Stenosis (IHPS)

-Early postoperative changes of pylorus after pyloromyotomy using ultrasonogram in patients with IHPS-

Hong-Kyu Baik, M.D., Poong-Man Jung, M.D. and Yong-Soo Kim, M.D.*

Department of General Surgery, Division of Pediatric Surgery and Radiology*

College of Medicine, Hanyang University Kun', Korea

The length, diameter and muscle thickness of the pylorus were measured by ultrasonograms in 15 infants with infantile hypertrophic pyloric stenosis(lHPS). These measurements were compared to assemble measurements of infants who came in for the routine vaccination and underwent ultrasonogram. This study also studied by ultrasound the changes in the pylorus of patients who underwent pyloromyotomy 4 weeks and 8 weeks postoperatively. According to Carver

⁵,

the pyloric muscle volume(PMV) and pyloric muscle index(PMI) were calculated in each case. The pyloric muscle volume, PMI and the thickness of pyloric muscle proved to be a more reliable guide to diagnose IHPS than length and diameter of pylorus. The pyloric muscle length, diameter, thickness and pyloric muscle volume were not normalized at 4 and 8 weeks after pyloromyotomy. However, pyloric muscle index was normalized at 4 weeks postoperatively perhaps as the result of rapid weight gain after pyloromyotomy.

Index Words: Infantile hypertrophic pyloric stenosis, Postoperative ultrasonogram

Correspondence; Poong Man lung, M.D., Departmelll oj General Surgery, College of Medicine, Hanyang Uni- versity Hospital, 17 Haengdang-dong, Sungdong-Ku, Seoul 133-792, Korea

i":- -1':-i:-.g.. 1998';1.£ 6~ 3lJ-T--"] <>1] A~ 7ij~]

Jt!

A1]14"t

cJl

~S:.ot.2.]3!j--q.~ <>1] A~

-l'-0J 5Oj'3i

%.

(2)

°aO} tl]~""j %~ ~.?,{%.g. 191

pd

Ramstedt7]-

-H-¥-lf-

-c~ ~7~~~ ""]"~{I- o]t:.ll, T~ ~ tl]~ B %~lf-91 -c~o] A(hJ~s- ~]~Bq.Jl ~i"l1~

ql. T~ ~ ~.A}%9-] (i:PJ~~ ~t?101]A~91 9l~

!1f!-~ o}y2-j- t-l-%01] q~ ~~s- 7~~~% ""]"~-o}

~ %

uJl

*~lf-91 ;<;,l7~ If-Sfi-c 7191 ~o} ~ T 'id%

AjSOs- !<10l

%~lf-91 -c~o] ~~-o] ~""J~

s- ~]-c ?;!~s- ~2-~ A~

9J q.

~ ~T-C T~ ~ 4"1"-9J- 8"1"-91 *~lf- li"J9l-~

~%nj- 7,=J A}S- ~~ -o}o~ AcJ-AJ ~s-

!<1

~ A]71, %OJ

% ~A}-o}.Jl T~ ~ tl]4-B %~lf- 3-7]9J-9-] AJ

t!-

B-1I]~ ~0}~7] Sfi{l- ~~~s- .Jl~~]Siq.

1997\1 6-%!lf-E~ 12-%!7J}.A] 77~-%! %~ °ao} tl]

4-""j %~ ~.?,{(IHPS)~s-

Zlt(!-

~.Jl T~ ~.g.

~.A} % T~ 4- 37~-%! o]""J ~7] 4-~ 7,=JA}7} B 15?~1~ qVJ~s- -o1-~q. qj~T~s- 12"1"- lJl~91 oj]Bcl-~%% Sfi5~ 1-l1~{1- Aj""J 0}7]%~ ~~-o}~

q. 0]% qj~T.g.

£¥

^'?JAJ~~s- 91 u] ~-c

T

£91 ~?;jo] 'idSiq. ~.A}%.g. 5.0-MHz 1t~.A}~

o]%-o}~ ~gnj- 7,=JA}~ T~~, T~ 4- 4"1"-,8

~-o}~E_[)o] o]~ o]%-o}o~ Okorie %291 BJ'il~5'_

%~-c %~(PMV; pyloric muscle volume) ~ %

~-c .A] T(PMT; Pyloric muscle index)~ -=rL-o}

91 1:1- .

PMV-c i'r~lf-~ ~~OJo]2l 7j1j-o}Jl ~"1"- %~l 01] A~

%1llf-

%~ % .~ ?;! 0]9 IHPS T~ ~ 7.1]

%

91 ~ 7} 9J- Aj ;<J% {}~-o}o~ %1]-71] s-

t-l--iI:-

?;! 0 j PMroj9 -=:L~ l:iL} 7Jq_ o]Acl91 Lj-Lj-9-]

&'%1

!(iT

%% paired t-tests- 7a~-o}~q.

IHPS~A l5 t!jj 9-] T~ ~ %~lf- 3"~%nj- 7a)'} 9J- qj~T l5t!jjo1] qj{l- 7,=JA}9-] ~i!j--c -=:L~ 2, 3

~ K l:iL} {{q. 317cl.g. qj~To1]A~ 1.04-1.83 cm

L

•

^{( \}^I^V^,

Fig. 1. Definition of pyloric muscle volume.

Table 1. Result of Measurements of Pylorus by Ultrasound Examination

Measurement Group Range Mean S_D Significance

Diameter NormaJ(N = 15) 1_04-1_83cm 1_28cm 0_24cm N-S IHPS(N= 15) 1_30-1.60cm lA2cm 0_12cm

Thickness Normal 0.13-0_21cm 0_18cm 0_03cm p (0.001

IHPS OAO-0_62cm 0_52cm 0_05cm

Length Normal 0_91-L50cm 1.16cm 0.16cm N-S

IHPS 1 AO-2AOcm 1_96cm 0_25cm

PMV Normal

o

.50-1_04cm ^J O_72cm ^:1 0_14cm^J p (0_001 IHPS 2.02-3 _61cm ^:1 2_87cm ^:1 0_54cm ^J

PMI Normal 0_10-0_27 0_15 0_04 p (0_001

IHPS 0_52-L21 0.78 0_18

Abbreviations: PMV; pyloric muscle volume. PMI; pyloric muscle index. N-S; not significant

(3)

(mean ± SD, 1.28 ±0.24 em), ~:A}-roJ]Ai 1.30-/.60 em(mean±SD, 1.42±0.12 em)~ .!t.o:j

-fT-9.J"'cjo]

\ii

;ct.2-9,

-fT--li':--¥-

~o] ~A] q1.~-roJ]Ai 0.91-l.S0 em (mean±SD, 1.16±0.16 em), ¥l:A-roJ] Ai 1.40- 2.40em(mean 1.16±0.16em)£

-fT-9.J"'cjo]

\ii;ctq.

0]01] l:I]i5}o:j

-fT--li':-

,!f7JI]-c t:J1~-r 0.13-0.21 em (mean±SD, 0.18 ±0.03 em), ¥l::A}-r 0.40-0.62 em (mean±SD, 0.S2±0.OS em).2-£

-fT-9.J "'cj

0] 'U;ctq (p<O.OOl).

-fT--li':-c

%~ i!j-

-fT--li':--2-

:A] 'T-c t:J1 ~-roJ] Ai O.So- 1.04 em³(mean ± SD, 0.72 ±0.14 em\ 0.10-0.27(mean

±SD, O.lS±O.04), ¥l:;;<.}-r<>1]A-j 2.02-3.61 em³(mean± SD, 2.87±0.S4 em\ 0.S2-1.21(mean±SD, 0.78 ± 0.18)£ .!8-7-l]~~

%9.J "'cjo]

'U;ctq (p<O.OOl).

..

E

=

~ >

3.0

~ 2.0

'"

E

=

"

·C Q

~ 1.0 .j..

'.

"' ... '"

Normal

.'

:' . .'

:.

IHPS

PMV=;r TL(D-1)

Fig. 2. Pyloric muscle volume of normal and IHPS infants.

E 3.0

~ 2.5

1.5

1.0 0.5

Length

t ..

....

'.'

Diameter Thickness

. s

^',

ti'oUo' , - ,

, - ,

..---,

Normal IHPS Normal IHPS Normal IHPS

Fig. 3. Value of length, diameter and thickness of pyloric muscle in normal and IHPS infants.

[HPS'T~

.:f %-li':--¥-9-]

ltl,~%

::t%S1\-

{JA}£

'T

~

.:f

421"-, 821"- ,!f 5:}2'l] ~A] i5}:ct.2-9 J 7,§A-c 'T~

.:f

4"roJ]

-fT--li':--2-

,!f7JI]-c 0.20-0.34 em (mean 0.281 em), 8"ro1] 0.lS-0.30em (mean 0.221 em)~ .!t.

:ct q .

%-li':--¥- 31 :rcJ31 }

~ 01';::' 4"roJ] 1.20-l.60 em (mean 1.36 em), 0.9-1.7 em(mean 1.46 em), 89-011

31 :rcJ

0.99-1.50 em(mean 1.24 em), ~

°

1 0.87-l.80 em

(mean 1.34 em):ct q.

%-li':--2-

%~::. 4"ro11 0.63-2.34 enl(mean 1.38 em\ 89-011 0.62-l.92 em³(mean 0.98 em³)

P1:l

4), -fT-~c .7-1'T-c 49-011 0.12-0.36(mean 0.26), 821"-011 0.06-0.19(mean 0.15):ct q.

%-li':-c

.7-1

'T

£ .!t.'U-%

uJl

~ ¥l:.7-}<>1Vi 'T~

.:f

49-<>11 A(FJ-~~

£ *-1l~];ctq

P1:l

5).

Thickness (mm) 6.0

5.0 4.0 3.0

2.0 1.0

.... .

::a ...

.. .

',' ~

.

~.

,---, ,---, ,---,

Preoperative Postop. 4 weeks Postop. 8 weeks

Fig. 4. Change of pyloric muscle thickness after pyloromyotomy.

..

1.5 PMI=;r TL(D-1)/ WI.

'tl

..

.S

..

1.0

<l

'" ..

=

E

....

"

·C

~ . ..

~ 0.5

.. .. ..

::s. ...

_...

_:

_.... ^~.

. .:.-: .:. .

Normal IHPS IHPS IHPS Preop. Postop.4wks Postop.8wks Fig. 5. PMI changes at preop, postop 4 weeks and 8 weeks of IHPS infants.

(4)

OJ 01- til

~Ad *~lj'-

'tl :t{(IHP S)oJl

t:1j ~ *~-2-

~7H~ ~ tll~-8 *~lj'-9.1 4=-~ ~ ~~}oJl

t:1lt-}

oj Wollsteinlol ?-lg2-.£ lj'-7a% %t-}oj

tll~-8

*~-2-°1 ~AJ:§:j-~';::' ~c.1~~ Jl~oJ1J.-l tll~91

~cl~~ -tl-~JJt *~-'f-91 4=-~ ~ ~:§:j-oJl

t:1lt-}oj

~JIt-}~q.

&gn} ?,:jJ..}7}

5!-~:§:j-~'?1J..1

Tell, Smith37}

~ t!~

:;-'?1oJIJ.1 IHPSoJl

t:1l~

&gn}

7aJ.}~

?-lg2- .£

~JIt-}~q. '.:L~ 4=-~ ~

*{tlj'-91

~:§:j-oJl t:1l~

&% n} 7,:jJ..}.£

tll~-8

-2--&-S1

£li>~(retroplasia)oJl

t:1l

~ l'i~ ~JI7} ~::dq2,4-7 ~-2-9.1

a:jcl 'i1T

⁹-lO

oJl J..1

5!-~01

IHPS ';::'

-l!':-~~ ~~.g. ~.fii17171 ~~71

~ ~~ ~ 4=-~~~ ~~~~ *~-2- ~~~.g.

%~ tll4=-~~

;;.Ili -;roJl J..1-5:_ til

~

-2--&-0 I

~~ ~

~

7l{loJl 7;;l,7;j £1

i>~t-}~ ~¥!-0l

q4.

4=-~ ~

IHPS91

~t!~

:;-'?1oJ1 J.1 &g:rrJ- ?,:jJ..}

91 °1%.g. IHPS ¥!-0}S1

~;<d~~ ~i2;j, ~~~7,:!

.J2}

t:1~~ ul!~

%-.B..-e;}nj til

~01~~ ~AJg,

5!-

°1';::' 784-y- *lj'-

'6ff-~ ~~ *t-}.;::. AJ~JoJIJ..1

~g~ ~}.}£ s:.%~ ~% ~ ~-ctJl ~q. ~

IHPS ¥!-7} %-

{lA~O}

3':,71oJl

~A~~ 78~Y- .:Q:.~

~

"<l 01 71 Y-J.1

~A~ ~ 78~, ~?J ~ ~

IHPS

~AJ

01

tll::;::~-

q;:,

tll'8-~Ad T£~¥!-~91 ~~~t!

oJl

~ ~

J.1 & g:rrJ- 7a A} .£ Z1 t!t-I

4=-~a:j

lj'-

~ ~ ~

~

4=-

~q.

-3178 JJt -2--&-91 .!f-7J11 S'.,.!f- :;-

~

5 1! J..1

~

01 15 mm ol AJ, .!f-7J11 4 mm oVJ2-.£

A;;l,~£1::d.Q..y-3.7.1I, *~

-2-91 .!f-7J11 7} 4mm 7 .:js:.°l '?1 *lj'-oJIJ..1 "fJ711 %ff-7}

~~

£1 E...£ Stunden ;

12 ~

91

0

1

~.;::.

*{t-'f- -2--&-

.!f-7J1I~

2.5 mm °VJ2-.£

5!-~.Q..nj *~lj'-91 ~01

:;-7.:j 01 ¥!-A} -;rJJt t:1l3'::-;roJl J..1

-l!':-~ ~

?-}01

~

5!-

~

qJl

t-}~2-Y-,

Ludke %42, Torgersen -2--&-.g.

A.:j AJ~.Q...£ {lA~0}71~

71Y-'?1 Acl7-Jol "i:l4'-E...£ 4=-

~ ~ 4'-~

7,:jA}oJ1J..1 &g n} 7,:jJ..}.£

*~lj'-91 ~

°1S1

~~ ~ ~-2{~

71JI7}

~

-8C\'Jl

t-}~q. ~

~ToJ1J.1s:.

3::g n}

:;-~Al

7}7-J

~ ~4=-7}

-3178.J2}

7Jo l9.1

~~7} {l~

;;;!°lnj,

~t!~ ~'?1oJIJ.1s:.

* {tlj'- -3178.J2}

~01';::' ~AJ

t:1l 3'::-;r.J2}

tll.iilt-}o~

%111

3"j

9.1\]171- \1~::dJl,

Q-71

~ ~oJl ~11'\5--'6'-7}oJl 91~

*~-2-

7.14=-

7} %1113"j~ 9.lol~

'--l-sl\.W:dq.

*

{t!f-

9.1

B11!f-~3"j, A~cl~3"j ~7cJAd-

78T gc'.1

tl

~19.}

Sfl .:g-*(gastric emptying)on

Lc]--e-

-3172,

~

°171- ~t}E..'£ :;-

::z.:jA171,

~7.:jA}, ~1PU-'ji:joJl TLj--e-

?-}017}

1)

t}el- . ° 1.£

~ t-}o~

3::71 oJl

~ t!~

71

~01

~JIA1-o}c\, ~-5;J;ef5 ~~~ :;-~% ~t-}a:jJ..1';::' 7}-'6'-~ ~ ~

91 &%:rrJ- 7a A}

~

'J9.17} :;-

~

5 11 o):t-l- Jl

*~lj'-

&%Ii} ?,:jJ..}

~oJl tll~-tl-% ~~t-}oq

SfloJl '6 0}

~J';::'

highly echogenic milk

curds~

A il 71t-}Jl %g,

~.;::.q,

01.£

~t-}a:j

clear acoustic

window~ '?i~J..1 *~!f-91

S'.,0Jol &gn}.£

-tl-~

01 %olt ll

~q.

7.:jAJo}71

~ 4=-~ ~ 4~, 8~oJl A15~t-}';::' *~lj'-9.1

3::gIIj-7,:jA}';::' 7a

^A} ~oJl

3)lZl-

~s:.91

.:g-*A1Z1% .!f-Jl

:;-~-31~ ~FJ-%% ~~

q.

£%% ~It! o}71%~ ~*~ ~Al~ ~J~~

4=-

~q.

01 784-';::'

tll~-tl-% °1%~

%

~~.Q...£

7,:j

J..}~

"fJ711

~

4=-

~

q7. 019} {t.g. llJ'ji:j.Q...£ '?i

~~

*{tlj'-91 7J01, -3178, -2--&-91

.!f-7J11~

°1%t-}

a:j *{t-2-

%~

%

T~q·

*~-2- %~.g. 4=-~ ~ ~~H1:-

tll.iil t-}.;::.r11 7J1-tl-

~ ~

A l JI71 ·

~

4=-

~.Q..nj, IHPS4=-~ ~ if~ ~

~11

%-

-'6'-7}~

5!-°I';::'C11 01 ul] Ad 7-JoJl n:}-e

~

4=-

~ .!;!../~ t-}71

Sfl t-}a:j

*~lj'- -§-~

% %J?-711.£

L-Hf

* {t-2- 714=-.?_

7cl~~ ~JJt~ ~%

4=-

~lq3-6

IHPS91

~t! 71~oJl ~t:J-~

*{t-2- 714=-oJl t:1l t-}a:j Okorie %2.g. 7.:j AHl

~ ~

0.08-0.28, IHPS ¥!- 7}oJV1 ';::' 0.46-1.26.Q...£

~JIt-}~q.

D avies ;13

~

0.2 ,£

~JI"5}~.Q..nj *~-'f- ~oloJl

.!f-7J1I91 3.641111

~

t:l"5} a:j 25 0VJ ol'?1 IHPSc}

"t}~q. ~ ~T~

.J2}oJ1A1~ ~AJ ~Sfl';::'

0.1-0.2701::d.Q..nj IHPS ¥!-o}

~91

*{t-2- 71 4=-

~~7}

0.52-1.21 .Q...£ q -e

.;::.~

.J2}

tll~~ ~.J2}~ 5!-~q.

4=-~ ~ tll~

-2--&-91

£l5~oJl t:1l"5}a:jJ.l~

Lu- dtke %4.g.

~ 6~oJl

-2--&-9.1

£l5~01 ~u}.£711 ~~\:l

e} Jl

"51·~

q. Bourchier ';','

6

2,

~ 4~oJl

HU}-e

£l5~

% 5!-0lJl 671!-%! 77}71

9P~~Adol ~~y-J.1 ~AJ

t:1l 3'::-;r;;'l oJl

7J-2-~qJl "5}~q.

Sauerbrei %6

~

-31 72:iL} .!f-lJlI 7}

6~

78 oJl

~

AJ.Q...£ *::r1

~q

Jl

"5}~

e}.

A1A}~9.1 ~.J2}';::' 4=-~ ~ *~-2-

.!f-7J11 .;::. 8'1"-77}

A l

~AJ.Q...£ ~*~71 ~~

784-7}

!fl~"5}Jl,

*{t

-2- -3178.J2}

~0191 ~~.;::. 4=-~ ~ 4~, 8~

S'.,.!f-

(5)

~7-l]3cj

9.J O ]7}

~~.2-00j,

iH!!-:C %3cj.g-

T~

-f- 4 9-oJP' 1 89- 7(jo]'i'!

AjAJ.2-~ §p,t~]~Jl, T~

-f- B-Z1

~ 7.1]

'F

~

7}

~

A,PJ%

Jl

t=j"0. %-!C:C

;<.]

T .£

~ ~%

I Lll

T~

-f- 49-

1-11 oj]

Aj AJ.2-'£

~:fl~]

~q.

T~ ~ ~A}oJ]

%A J .9.J 7]Z!-,

~~"']7].2.J- T~

~

:c*.9.J tl] -f-5:..2.J-.9.J

-t!-7-l]~ ~~~

uJl

Ukabiala

.2.J-

Lister

'4 -C :c* .9.J tl]-f-5:..2.J-

IHPS ~).~

'it"']9.J t..j-o],

~.9.J ~).~¥-E1 T~7J}A].9.J

7]{l-JI}9.J AJ-t!- -t!-

7-l]~ t!~t"]

%-!C¥-

^¥-7Jl]^~'il-

o }yc} tl] .f- :C41* .9.J

DNA~<'J=% 1:I].iil.t"}O:j

-t!-7-l1 7} 'id g

% ~uat"}'tt J1., ~ ~T~]"'15:. T~ ~ ~AJ.9.J

7]Z!-JI}

~~",]

7]7} %-!C¥- :c* ^tl] -f- Aj 5:..2.J- -t!-7-l]-c

~ ~

q.

~

7-l1 3cj.2-.£

%.9.J~ ~.g- T~ ~

tl]-f-5:.7}

{l~\:!

7(j.!f-

T~

.f-

§1"6~.9.J

4i'-5:.7}

H~~q. ~td

tl] -f-7}

~~t..j-q1 0]

AJEll.£

%A]~q7} T~

.f-

B-Z1~

§1"6~ ~ ~~q4.

0Jo} tll.f-). j

%~¥- ~~.9.J ~gli}

{ltd ",]

~

td

7]€.2-£~

%-!C¥-

~7(jJI}, ~o]~q-c

¥-7Jl1 7}

~7-l1~3cj.s2..£

%.9.J ). j o]

~~.s2..00j, td~ ~~~q-c

ff-tr-C

%~ ~

01 %

~·n %-~.£ y-~ *~-c

7-1 4- 7 }

~q ~td3cj

7}5.]7}

~~q. T~

.f-

%~:C9.J

~

§.j-oJ] A i %-!C:C.9.J ¥-7Jl].2.J- %-!C:C %3cj.g-

T~.f-

49-oJ]

~).J.s2..£ ~ A] ?J-~A]

'il- %-!C:C

A]

T-C Aj AJ.s2..£

~~q.

1. Wollstein M: Healing of hypertrophic pyloric stenosis after the Fredet-Ramstedt operation.

Am J Dis Child 23: 511-517, 1922

1. Okorie NM, Dickson JAS, Carver RA, Steiner GM: What happens to the pylorus after pyloromyotomy? Arch Dis Child 63:1339-1340, 1988 3. Teele RL, Smith EH: Ultrasound in the diagnosis of idiopathic hypertrophic pyloric stenosis. N Engl J Med 296: 1149-1150, 1977 4. Ludtke FE, Bertus M, Michalski S, Dapper

FD, Lepsien G: Long-term analysis of ultra-

sonic features of the antropyloric region 17-27 years after treatment of infantile hypertrophic pyloric stenosis. J Clin Ultrasound 22: 229-305, 1994

5. Carver RA, Okorie NM, Steiner GM, Dickson JAS: Infantile hypertrophic pyloric stenosis- diagnosis from the pyloric muscle index. Clin Radiol 38: 625-627, 1988

6. Bourchier D, Dawson KP, Kennedy JC : Py- loric stenosis: a postoperative ultrasound study . Aust Paediatr J 21: 189-190, 1985

7. Neilson D, Hollman AS: The ultrasonic diagnosis of infantile hypertrophic pyloric stenosis : technique and accuracy. Clin Radiol 49:

246-247, 1994

8. Kobayashi H, O'Briain DS, Puri P: Selective reduction in intramuscular nerve supporting cells in infantile hypertrophic pyloric stenosis. J Pediatr Surg 29: 651-654, 1994

9. Okazaki T, Yamataka A, Toshino F, Nishiye H, Fujimoto T, Miyano T: Abnormal distribu- tion of nerve terminals in infantile hypertrophic pyloric stenosis. J Pediatr Surg 29:655-658, 1994 10. Vanderwinden JM, Liu H, De Laet MH, Vanderhaeghen JJ: Study of the interstitial cells of Cajal in infantile hypertrophic pyloric stenosis. Gastroenterology 111: 279-288, 1996 11. Grait M, Izchak Y, Avigad I, Strauss S, Ami

TB: The pylorus in infancy: over all sonographic assessment. Pediatr Radiol 14:14-17, 1984

12. Stunden RJ, LeQuesne GW, Little KET : The improved ultrasound diagnosis of hypertrophic pyloric stenosis. Pediatr Radiol 16:200-205, 1986

13. Davies RP, Linke RJ, Robinson RG, Smart JA, Hargreaves C: Sonographic diagnosis of infantile hypertrophic pyloric stenosis. J Ultra- sound Med 11: 603-605, 1992

14. Ukabiala 0, Lister J: The extent of muscle hypertrophy in infantile hypertrophic pyloric stenosis. J Pediatr Surg 22: 200-202, 1987