History

Fact Explanation
Vomiting Patients presents with projectile non-bilious vomiting. Patients feel hungry immediately after vomiting but they vomit soon after meals. This is common after heavy meals. [1,2,4]
Failure to thrive Children with pylorospasm can present with failure to thrive due to recurrent vomiting. The child is always hungry and cries for feeds.
Symptoms of peptic ulcer disease Patients with pylorospasm are susceptible to develop peptic ulcer disease due to prolonged gastric emptying time. Retention of food and acid in the stomach is the causative factor. Patients with peptic ulcer disease presents with burning epigastric pain, which is relieved with food and exacerbated by fasting. [3]
Symptoms of dehydration Increased thirst, reduced urine output, dry skin, altered consciousness are symptoms of dehydration secondary to excessive vomiting.
References
  1. COHEN HL, BLUMER SL, ZUCCONI WB. The sonographic double-track sign: not pathognomonic for hypertrophic pyloric stenosis; can be seen in pylorospasm. J Ultrasound Med [online] 2004 May, 23(5):641-6 [viewed 15 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15154530
  2. COHEN HL, ZINN HL, HALLER JO, HOMEL PJ, STOANE JM. Ultrasonography of pylorospasm: findings may simulate hypertrophic pyloric stenosis. J Ultrasound Med [online] 1998 Nov, 17(11):705-11 [viewed 15 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9805307
  3. DEAVER JB, BURDEN VG. THE SURGERY OF PYLOROSPASM Ann Surg [online] 1929 Oct, 90(4):530-534 [viewed 15 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1399086
  4. BRACKETT AS. The Alleviation of Pylorospasm and Colic in Infants by Reducing the Volume of the Food Intake per Feeding Yale J Biol Med [online] 1946 Dec, 19(2):155-169 [viewed 15 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2602086

Examination

Fact Explanation
Loss of weight Patients with pylorospasm can have loss of weight. Infants often have failure to thrive due to recurrent vomiting. [2]
Irrtabilty Infants with pylorospasm are irritable and crying due to hunger.
Signs of dehydration Reduced skin turgor, dry mucous membranes, sunken eyes, tachycardia and small volume pulse are signs of dehydration. In severe dehydration patient may have reduced blood pressure, postural hypotension or even shock. Sunken fontanelle can be seen in infants. [1]
References
  1. SMITH S. Clinical signs of dehydration in children Emerg Med J [online] 2007 Aug, 24(8):605 [viewed 15 August 2014] Available from: doi:10.1136/emj.2007.049429
  2. COLE SZ, LANHAM JS. Failure to thrive: an update. Am Fam Physician [online] 2011 Apr 1, 83(7):829-34 [viewed 15 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/21524049

Differential Diagnoses

Fact Explanation
Hypertrophic pyloric stenosis (HPS) HPS is congenital disease, where newborns present with projectile vomiting. Pyloromyotomy is the definitive mode of treatment. [1]
Gastroesophageal reflux disease (GERD) GERD can also present with projectile vomiting. [1]
Peptic ulcer disease (PUD) Patients with pyrolospasm can present with symptoms similar to PUD. Development of acid stricture can cause symptoms of gastric outlet obstruction (projectile non-bilious vomiting) as well.
Congenital duodenal webs Congenital duodenal webs occur due to midgut malrotation and affected infants present with projectile bilious vomiting. [2]
Bouveret syndrome Bouveret syndrome refers to very uncommon cause of gastric outlet obstruction which is due to gallstone ileus. A gallstone is impacted in the bile duct creating a cholecystoduodenal fistula into the duodenum. [3]
Pancreatic pseudocysts Pancreatic pseudocysts are another cause of gastric outlet obstruction. Both acute and chronic pancreatitis can lead to the development of a pseudocyst. [4]
References
  1. COHEN HL, BLUMER SL, ZUCCONI WB. The sonographic double-track sign: not pathognomonic for hypertrophic pyloric stenosis; can be seen in pylorospasm. J Ultrasound Med [online] 2004 May, 23(5):641-6 [viewed 15 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15154530
  2. EKSARKO P., NAZIR S., KESSLER E., LEBLANC P., ZEIDMAN M., ASARIAN A. P., XIAO P., PAPPAS P. J.. Duodenal web associated with malrotation and review of literature. Journal of Surgical Case Reports [online] December, 2013(12):rjt110-rjt110 [viewed 15 August 2014] Available from: doi:10.1093/jscr/rjt110
  3. MAVROEIDIS VASILEIOS K., MATTHIOUDAKIS DIMITRIOS I., ECONOMOU NIKOLAOS K., KARANIKAS IOANNIS D.. Bouveret Syndrome—The Rarest Variant of Gallstone Ileus: A Case Report and Literature Review. Case Reports in Surgery [online] 2013 December, 2013:1-6 [viewed 15 August 2014] Available from: doi:10.1155/2013/839370
  4. KHANNA A. K., TIWARY SATYENDRA K., KUMAR PUNEET. Pancreatic Pseudocyst: Therapeutic Dilemma. International Journal of Inflammation [online] 2012 December, 2012:1-7 [viewed 15 August 2014] Available from: doi:10.1155/2012/279476

Investigations - for Diagnosis

Fact Explanation
Ultrasound scan Ultrasound scan is a non-invasive investigation used in making the diagnosis. Presence of double-track sign (false impression of two lumen due to hypertrophied and irregular esophageal musculature), subsequent scans showing changes in pyloric wall thickness, length and diameter and passage of gastric contents in to the duodenum are suggestive of pylorospasm. [1,2]
Barium meal In pylorospasm ingested Barium will slowly empty in to the duodenum and most of the contrast is seen to be retained in the stomach.
References
  1. COHEN HL, BLUMER SL, ZUCCONI WB. The sonographic double-track sign: not pathognomonic for hypertrophic pyloric stenosis; can be seen in pylorospasm. J Ultrasound Med [online] 2004 May, 23(5):641-6 [viewed 15 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15154530
  2. COHEN HL, ZINN HL, HALLER JO, HOMEL PJ, STOANE JM. Ultrasonography of pylorospasm: findings may simulate hypertrophic pyloric stenosis. J Ultrasound Med [online] 1998 Nov, 17(11):705-11 [viewed 15 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9805307

Investigations - Fitness for Management

Fact Explanation
Renal function test Dehydration can lead to acute renal failure. Altered electrolyte balance and raised creatinine can be observed.
References

Management - General Measures

Fact Explanation
Health education Parents should be advised to avoid over feeding the child. Frequent small meals will reduce the incidence of vomiting and help to gain weight. [1]
Rehydration Intravenous fluids should be administrated as oral fluids can precipitate vomiting.
References
  1. BRACKETT AS. The Alleviation of Pylorospasm and Colic in Infants by Reducing the Volume of the Food Intake per Feeding Yale J Biol Med [online] 1946 Dec, 19(2):155-169 [viewed 15 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2602086

Management - Specific Treatments

Fact Explanation
Conservative management Some patients can be managed conservatively. Patients are advised to avoid large meals as this can precipitate pylorospasm. [1,3]
Antispasmodics Antispasmodics can be used in the treatment of pylorospasm. Calcium channel blockers, sildenafil and nitrates are commonly used. [1]
Surgery For the treatment of refractory pylorospasm, Rammstedt division of the pylorus is indicated. Vagotomy is also proven to reduce pylorospasm. [2]
References
  1. COHEN HL, BLUMER SL, ZUCCONI WB. The sonographic double-track sign: not pathognomonic for hypertrophic pyloric stenosis; can be seen in pylorospasm. J Ultrasound Med [online] 2004 May, 23(5):641-6 [viewed 15 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15154530
  2. MAYO CH. DIVISION OF THE VAGI FOR PYLOROSPASM Ann Surg [online] 1928 Oct, 88(4):669-671 [viewed 15 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1398613
  3. BRACKETT AS. The Alleviation of Pylorospasm and Colic in Infants by Reducing the Volume of the Food Intake per Feeding Yale J Biol Med [online] 1946 Dec, 19(2):155-169 [viewed 15 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2602086