16 day old male born via planned C-section due to placenta previa presents due to vomiting. Mother says pt was vomiting in hospital and vomits after every feed. Notably, formula changed at DOL 7 due to inadequate weight gain, born 6 lb 15oz now 8lb. Currently taking 2-3 oz/feed and vomiting about 1 oz after every feed. Had 4 episodes projectile vomiting day of presentation. Still with normal wet diapers and bowel movements. Mother’s brother had history of pyloric stenosis.
Constitutional: no fever.
Respiratory: no cough or respiratory distress.
GI: see HPI
Neuro: normal activity level
VITALS: T 98.0F, P 175, RR 39, 100% on RA
HEAD : anterior fontanelle not sunken or distended
EYE : No conjunctival injection
ENT: No oropharyngeal erythema or exudate, vesicles, or ulcers. Mucous membranes are somewhat dry. RESP: Chest is clear to auscultation b/l. Respiratory effort is unlabored, and there are no subcostal or intercostal retractions.
ABD: Soft/non-distended. No obvious scrotal asymmetry, erythema, or palpable inguinal masses.
EXT: The patient moves all extremities spontaneously.
- What is your differential diagnosis for a vomiting neonate?
- What likely diagnosis is represented by IMAGE 1 below?
- What ultrasound diagnostic criteria are used?
- What is the next step in management...eg lab work, consultants?
- Pyloric stenosis, obstruction, GERD, metabolic disorders, necrotizing enterocolitis, feeding intolerance, milk protein allergy, UTI, toxic ingestion
- Pyloric Stenosis!!!
- Pyloric stenosis is diagnosed if the pylorus muscle thickness (single wall) >3-4mm and/or the pyloric channel length is >14-15mm. (To remember: think of the numerical value of pi - 3.1415) See IMAGE 2 below.
To find the pylorus:
a. Linear probe, start in transverse position and identify gallbladder. Pylorus is medial and posterior to GB (image 2 below). The muscular layer is usually a hypoechogenic thin layer less than 2 mm in thickness. It is important to be aware that tangential views and contractions can produce pseudo-thickening. Visualize the passage of the gastric content through the pylorus, distending the antropyloric region.
b. Oblique positioning and performing ultrasound immediately after feeding can alleviate problems of gas-filled stomach, and a stomach filled with water can act as an acoustic window for pylorus evaluation.
- Hydration, correction of electrolyte abnormalities, surgical consult for pyloromyotomy or alternative more conservative treatments such as placement of an NGT though the pylorus.