History

Fact Explanation
An adult patient, commonly a male. Adult type pyloric stenosis can differ from pediatric component from very subtle ways. Even though there is not a prominent male predominance as in pediatric component of it, adult pyloric stenosis has been found to have a male to female ratio of 3:1. [1] [2]
Vomiting Vomiting of pyloric stenosis is copious, projectile, nonbilious, contains undigested food, and usually follows soon after eating. In adult kind, vomiting has an insidious onset of a few months and it progresses into the characteristic type slowly. Vomiting is unrelated to the type of food. Hematemesis and malena are not to be seen in vomitus unless complicated with gastritis or peptic ulceration. [3] Diarrhea and fever are not commonly associated. [1] [2] [3] [4] [5] [6] [7] [8] [9]
Feeling of fullness in the upper abdomen The patients commonly complain of a feeling of fullness in the epigastrium due to the blockage. [2] Eating aggravates the discomfort. [3] [9]
Weight loss There can be a significant weight loss due to copious vomiting and poor feeding. [1] [2] [3] [4] [9]
Burning epigastric pain and with cramps In some instances, adult pyloric stenosis is associated with peptic ulcers and gastritis. [3] [5] [9]
Several times treated as dyspepsia By the time they present with full blown obstruction, they might have had several times of hospital admissions and misdiagnosed as dyspepsia and treated for it, with no clinical improvement. [1]
Other underlying causes for pyloric stenosis Adult pyloric stenosis can be secondary to another illness, such as Crohn's disease, peptic ulcer disease, hernia, chronic gastritis associated with Helicobacter pylori, or even a malignant growth. [7] [9] [10] [11] [12] [13] Prostaglandin is also known to cause foveolar hyperplasia and secondary pyloric obstruction. [14] [15]
References
  1. SALMO NA, MAKKI NT. Adult hypertrophic pyloric stenosis. Postgrad Med J [online] 1969 Apr, 45(522):298-301 [viewed 03 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2466569
  2. GRAADT VAN ROGGEN JF, VAN KRIEKEN JH. Adult hypertrophic pyloric stenosis: case report and review. J Clin Pathol [online] 1998 Jun, 51(6):479-80 [viewed 03 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9771452
  3. KNIGHT CD. Hypertrophic Pyloric Stenosis in the Adult Ann Surg [online] 1961 Jun, 153(6):899-910 [viewed 03 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1614008
  4. RUNYEON W. K., HOERR S. O., HAZARD J. B.. Hypertrophic Pyloric Stenosis in the Adult: Discussion of Etiology and Report of a Case. Cleveland Clinic Journal of Medicine [online] 1955 April, 22(2):76-82 [viewed 03 August 2014] Available from: doi:10.3949/ccjm.22.2.76
  5. DAS A. K.. Adult pyloric stenosis--a forgotten entity. Age and Ageing [online] 2006 July, 35(4):448-448 [viewed 03 August 2014] Available from: doi:10.1093/ageing/afl021
  6. CHRISTIANSEN KJELL H.. Idiopathic Hypertrophic Pyloric Stenosis in the Adult. Arch Surg [online] 1962 August [viewed 03 August 2014] Available from: doi:10.1001/archsurg.1962.01310020037008
  7. PAPAZIOGAS BASILIOS, LAZARIDIS CHARALAMBOS, SOUPARIS ANASTASIOS, KOUTELIDAKIS IOANNIS, GRIGORIOU MARIOS, DRAGOUMIS DIMITRIS, ATMATZIDIS KONSTANTINOS. Idiopathic Hypertrophic Pyloric Stenosis Combined with Left Paraduodenal Hernia in an Adult. Med Princ Pract [online] 2007 December, 16(2):151-154 [viewed 03 August 2014] Available from: doi:10.1159/000098370
  8. SELZER DON, CROFFIE JOSEPH, BRECKLER FRANCINE, RESCORLA FREDERICK. Hypertrophic Pyloric Stenosis in an Adolescent. Journal of Laparoendoscopic & Advanced Surgical Techniques [online] 2009 June, 19(3):451-452 [viewed 03 August 2014] Available from: doi:10.1089/lap.2008.0276
  9. BOYBEYI ÖZLEM, KARNAK İBRAHIM, EKINCI SANIYE, CIFTCI ARBAY OZDEN, AKçöREN ZUHAL, TANYEL F. CAHIT, ŞENOCAK MEHMET EMIN. Late-onset hypertrophic pyloric stenosis: definition of diagnostic criteria and algorithm for the management. Journal of Pediatric Surgery [online] 2010 September, 45(9):1777-1783 [viewed 03 August 2014] Available from: doi:10.1016/j.jpedsurg.2010.04.014
  10. DANIKAS D, GEIS WP, GINALIS EM, GORCEY SA, STRATOULIAS C. Laparoscopic Pyloroplasty in Idiopathic Hypertrophic Pyloric Stenosis in an Adult JSLS [online] 2000, 4(2):173-175 [viewed 03 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3015380
  11. ELLIS H. Stenosis due to duodenal ulceration. Postgrad Med J [online] 1966 Dec, 42(494):778-782 [viewed 03 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2466120
  12. YUSUF TONY E, BRUGGE WILLIAM R. Endoscopic therapy of benign pyloric stenosis and gastric outlet obstruction. Current Opinion in Gastroenterology [online] 2006 September, 22(5):570-573 [viewed 03 August 2014] Available from: doi:10.1097/01.mog.0000239874.13867.41
  13. GISBERT J. P., PAJARES J. M.. Helicobacter pyloriinfection and gastric outlet obstruction - prevalence of the infection and role of antimicrobial treatment. Aliment Pharmacol Ther [online] 2002 July, 16(7):1203-1208 [viewed 03 August 2014] Available from: doi:10.1046/j.1365-2036.2002.01275.x
  14. LACHER M., SCHNEIDER K., DALLA POZZA R., SCHWEINITZ D. V.. Gastric Outlet Obstruction after Long-Term Prostaglandin Administration Mimicking Hypertrophic Pyloric Stenosis. Eur J Pediatr Surg [online] 2007 October, 17(5):362-364 [viewed 03 August 2014] Available from: doi:10.1055/s-2007-965422
  15. GOLDMAN GIDEON. Prostaglandin E2 in Pyloric Stenosis. Arch Surg [online] 1989 June [viewed 03 August 2014] Available from: doi:10.1001/archsurg.1989.01410060096020

Examination

Fact Explanation
Tenderness in the upper abdomen Some patients report a tenderness in the epigastrium and right hypochondrium. This could be due to obstruction or peptic ulcers. [1]
Features of dehydration. i.e. dry mucus membranes, reduced sweating. Due to copious amount of vomiting. [1] [2] [3] [4]
Evident weight loss Due to feeding intolerance and dehydration. [1] [4] [5] [6]
References
  1. KNIGHT CD. Hypertrophic Pyloric Stenosis in the Adult Ann Surg [online] 1961 Jun, 153(6):899-910 [viewed 03 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1614008
  2. SALMO NA, MAKKI NT. Adult hypertrophic pyloric stenosis. Postgrad Med J [online] 1969 Apr, 45(522):298-301 [viewed 03 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2466569
  3. GRAADT VAN ROGGEN JF, VAN KRIEKEN JH. Adult hypertrophic pyloric stenosis: case report and review. J Clin Pathol [online] 1998 Jun, 51(6):479-80 [viewed 03 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9771452
  4. BOYBEYI ÖZLEM, KARNAK İBRAHIM, EKINCI SANIYE, CIFTCI ARBAY OZDEN, AKçöREN ZUHAL, TANYEL F. CAHIT, ŞENOCAK MEHMET EMIN. Late-onset hypertrophic pyloric stenosis: definition of diagnostic criteria and algorithm for the management. Journal of Pediatric Surgery [online] 2010 September, 45(9):1777-1783 [viewed 03 August 2014] Available from: doi:10.1016/j.jpedsurg.2010.04.014
  5. DANIKAS D, GEIS WP, GINALIS EM, GORCEY SA, STRATOULIAS C. Laparoscopic Pyloroplasty in Idiopathic Hypertrophic Pyloric Stenosis in an Adult JSLS [online] 2000, 4(2):173-175 [viewed 03 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3015380
  6. DAS A. K.. Adult pyloric stenosis--a forgotten entity. Age and Ageing [online] 2006 July, 35(4):448-448 [viewed 03 August 2014] Available from: doi:10.1093/ageing/afl021

Differential Diagnoses

Fact Explanation
Peptic ulcer disease Pyloric stenosis can be a result of antral gastritis with ulceration, especially chronic type associated with Helicobacter pylori. On the other hand, with chronic adult pyloric stenosis can give rise to chronic gastritis as well. But since adult type has an insidious onset, even pyloric stenosis without active gastritis can be misdiagnosed as peptic ulcer disease. [1] [2] [3]
Upper gastrointestinal tumor Primary or idiopathic hypertrophy of the pyloric muscle has an uncertain pathogenesis which both clinically and pathologically mimics gastric cancer. Careful thorough investigations will be necessary to differentiate. [4] [5] [6] [7] [8]
Crohn's disease As in chronic gastritis, Crohns disease is also an inflammative and regenerating disorder. [9] [10] [11] Clinical presentations i.e. vomiting, weight loss, epigastric pain; can be similar in both conditions. Relieving of the stenosis does not produce remission from the illness in Crohn's diesease. Histopathological evidence can help in diagnosis. [12] [13] [14]
References
  1. DAS A. K.. Adult pyloric stenosis--a forgotten entity. Age and Ageing [online] 2006 July, 35(4):448-448 [viewed 03 August 2014] Available from: doi:10.1093/ageing/afl021
  2. KNIGHT CD. Hypertrophic Pyloric Stenosis in the Adult Ann Surg [online] 1961 Jun, 153(6):899-910 [viewed 03 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1614008
  3. BOYBEYI ÖZLEM, KARNAK İBRAHIM, EKINCI SANIYE, CIFTCI ARBAY OZDEN, AKçöREN ZUHAL, TANYEL F. CAHIT, ŞENOCAK MEHMET EMIN. Late-onset hypertrophic pyloric stenosis: definition of diagnostic criteria and algorithm for the management. Journal of Pediatric Surgery [online] 2010 September, 45(9):1777-1783 [viewed 03 August 2014] Available from: doi:10.1016/j.jpedsurg.2010.04.014
  4. GURVITS GE, TAN A, VOLKOV D. Video capsule endoscopy and CT enterography in diagnosing adult hypertrophic pyloric stenosis World J Gastroenterol [online] 2013 Oct 7, 19(37):6292-6295 [viewed 03 August 2014] Available from: doi:10.3748/wjg.v19.i37.6292
  5. VAOS GEORGE, MISIAKOS EVANGELOS P.. Congenital Anomalies of the Gastrointestinal Tract Diagnosed in Adulthood—Diagnosis and Management. J Gastrointest Surg [online] December, 14(5):916-925 [viewed 03 August 2014] Available from: doi:10.1007/s11605-009-1124-z
  6. ZARINEH ALIREZA, LEON MARINO E., SAAD REDA S., SILVERMAN JAN F.. Idiopathic Hypertrophic Pyloric Stenosis in an Adult, a Potential Mimic of Gastric Carcinoma. Pathology Research International [online] 2010 December, 2010:1-4 [viewed 03 August 2014] Available from: doi:10.4061/2010/614280
  7. TAOR RE. Adult hypertrophic pyloric stenosis and Crohn's disease. Proc R Soc Med [online] 1976 Mar, 69(3):228 [viewed 03 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1864177
  8. KIM CH, HAN HS, LEE SY, KIM BK, SUNG IK, SEONG MK, LEE KY. Torus Hyperplasia of the Pyloric Antrum J Korean Med Sci [online] 2010 Jan, 25(1):152-154 [viewed 03 August 2014] Available from: doi:10.3346/jkms.2010.25.1.152
  9. SOUCY G, WANG HH, FARRAYE FA, SCHMIDT JF, FARRIS AB, LAUWERS GY, CERDA SR, DENDRINOS KG, ODZE RD. Clinical and pathological analysis of colonic Crohn's disease, including a subgroup with ulcerative colitis-like features. Mod Pathol [online] 2012 Feb, 25(2):295-307 [viewed 03 August 2014] Available from: doi:10.1038/modpathol.2011.120
  10. HALME L, KäRKKäINEN P, RAUTELIN H, KOSUNEN TU, SIPPONEN P. High frequency of helicobacter negative gastritis in patients with Crohn's disease. Gut [online] 1996 Mar, 38(3):379-83 [viewed 03 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/8675090
  11. SHARIF F., MCDERMOTT M., DILLON M., DRUMM B., ROWLAND M., IMRIE C., KELLEHER S., HARTY S., BOURKE B.. Focally enhanced gastritis in children with Crohn's disease and ulcerative colitis. Am J Gastroenterology [online] 2002 June, 97(6):1415-1420 [viewed 03 August 2014] Available from: doi:10.1111/j.1572-0241.2002.05785.x
  12. TAOR RE. Adult hypertrophic pyloric stenosis and Crohn's disease. Proc R Soc Med [online] 1976 Mar, 69(3):228 [viewed 03 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1864177
  13. GRAADT VAN ROGGEN JF, VAN KRIEKEN JH. Adult hypertrophic pyloric stenosis: case report and review. J Clin Pathol [online] 1998 Jun, 51(6):479-480 [viewed 03 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC500756
  14. NAKAMURA HIROKI, YANAI HIDEO, MIURA OSAMU, MINAMISONO YOSHIKAZU, MITANI NOBUYUKI, HIGAKI SHINGO, TADA MASAHIRO, OKITA KIWAMU. Pyloric stenosis due to Crohn's disease. Journal of Gastroenterology [online] 1998 September, 33(5):739-742 [viewed 03 August 2014] Available from: doi:10.1007/s005350050165

Investigations - for Diagnosis

Fact Explanation
Barium studies or Fluoroscopy The first line in investigation of choice in suspected gastric outlet obstruction. The Barium meal and follow through will show the site of obstruction, number of sites affected, and details of the luminal surface of the obstructed site. The usual method is to observe whether the Barium meal passes through the pylorus to the small intestine within 3-6 hours of ingestion, and if it delays that that, it is considered to be obstructed. The expected findings are dilated stomach, narrow antral lumen (string sign) which is duplicated due to puckering of the mucosa (double-track sign), pylorus indenting to the contrast-filled antrum (shoulder sign), base of the duodenal bulb (mushroom sign) and entrance to the pylorus being beak-shaped (beak sign). [1] [2] [3]
Ultrasound scan of abdomen It is a non-invasive method of visualizing the pyloric muscle. The radiologists have criteria to diagnose depending on the thickness of the muscle layer. i.e. 3mm cut off value. [4] [5] [6]
Endoscopy of upper gastrointestinal tract It allows better visualization of the pyloric muscle. [7] [8] It also allows the surgeon to take biopsies of hypertrophies areas.
Histopathological examination Gross hypertrophy of the muscle layer is expected. Importance is it excludes the malignancies and inflammatory lesions. [9] [10] [11] [12] [13]
References
  1. DANA ER. Food-Barium Meal of Value in Diagnosing Gastric Outlet Obstruction Calif Med [online] 1971 Aug, 115(2):68 [viewed 03 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1518012
  2. AMINI B et al. Pyloric stenosis. [web] [viewed 03 August 2014] Available from: http://radiopaedia.org/articles/pyloric-stenosis
  3. LEVIN A.A., LEVINE M.S., RUBESIN S.E., LAUFER I.. An 8-year review of barium studies in the diagnosis of gastroparesis. Clinical Radiology [online] 2008 April, 63(4):407-414 [viewed 03 August 2014] Available from: doi:10.1016/j.crad.2007.10.007
  4. COSTA DIAS SíLVIA, SWINSON SOPHIE, TORRãO HELENA, GONçALVES LíGIA, KUROCHKA SVITLANA, VAZ CARLOS PINA, MENDES VASCO. Hypertrophic pyloric stenosis: tips and tricks for ultrasound diagnosis. Insights Imaging [online] December, 3(3):247-250 [viewed 03 August 2014] Available from: doi:10.1007/s13244-012-0168-x
  5. KNIGHT CD. Hypertrophic Pyloric Stenosis in the Adult Ann Surg [online] 1961 Jun, 153(6):899-910 [viewed 03 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1614008
  6. SAID M. et al. Ultrasound Measurements in Hypertrophic Pyloric Stenosis: Don’t Let the Numbers Fool You. Perm [online] J 2012 Summer;16(3):25-27. [viewed 03 August 2014] Available from: https://www.thepermanentejournal.org/issues/2012/summer/4805-hypertrophic-pyloric-stenosis.html
  7. FIORI ENRICO, LAMAZZA ANTONIETTA, DEMASI ERCOLE, DECESARE ALESSANDRO, SCHILLACI ALBERTO, STERPETTI ANTONIO V.. Endoscopic stenting for gastric outlet obstruction in patients with unresectable antro pyloric cancer. Systematic review of the literature and final results of a prospective study. The point of view of a surgical group. The American Journal of Surgery [online] 2013 August, 206(2):210-217 [viewed 03 August 2014] Available from: doi:10.1016/j.amjsurg.2012.08.018
  8. GURVITS GE, TAN A, VOLKOV D. Video capsule endoscopy and CT enterography in diagnosing adult hypertrophic pyloric stenosis. World J Gastroenterol [online] 2013 Oct 7, 19(37):6292-5 [viewed 03 August 2014] Available from: doi:10.3748/wjg.v19.i37.6292
  9. LANE-ROBERTS PA. Pathology of Infantile Hypertrophic Pyloric Stenosis Proc R Soc Med [online] 1959 Dec, 52(12):1022-1023 [viewed 03 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1869792
  10. GRAADT VAN ROGGEN JF, VAN KRIEKEN JH. Adult hypertrophic pyloric stenosis: case report and review. J Clin Pathol [online] 1998 Jun, 51(6):479-480 [viewed 03 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC500756
  11. ZARINEH ALIREZA, LEON MARINO E., SAAD REDA S., SILVERMAN JAN F.. Idiopathic Hypertrophic Pyloric Stenosis in an Adult, a Potential Mimic of Gastric Carcinoma. Pathology Research International [online] 2010 December, 2010:1-4 [viewed 03 August 2014] Available from: doi:10.4061/2010/614280
  12. KEYNES WM. Simple and complicated hypertrophic pyloric stenosis in the adult Gut [online] 1965 Jun, 6(3):240-252 [viewed 03 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1552288
  13. MEDINA E., ORTI E., TOMé A., MARTINEZ A., CANELLES P., QUILES F.. Hypertrophic Pyloric Stenosis in the Adult. Endoscopy [online] December, 21(05):215-216 [viewed 03 August 2014] Available from: doi:10.1055/s-2007-1012951

Investigations - Fitness for Management

Fact Explanation
Complete blood count To exclude presence of an infection or anemia prior to surgery. [1] [2] [3] [4]
Liver function tests i.e. Serum transaminases, bilirubin, gamma-GT, albumin and total protein. To exclude liver disease prior to surgery. [5] [6] [7]
Renal function tests i.e. serum electrolytes, urine full report, serum creatinine. To exclude renal disorders prior to surgery. [7]
Chest X-ray To exclude respiratory illness prior to surgery. [8] [9]
Fasting blood sugar To look for diabetes as a risk factor for embolism and to exclude it prior to surgery. [10]
Lipid profile To look for dyslipidemia as a risk factor for embolism and to exclude lipid disorder prior to surgery. [11]
12 lead electrocardiogram To exclude presence of atrial fibrillations a causative factor for embolism. [12] [13]
Echocardiogram To exclude the presence of luminal thrombus. [14] [15]
References
  1. BILLER J., FEINBERG W. M., CASTALDO J. E., WHITTEMORE A. D., HARBAUGH R. E., DEMPSEY R. J., CAPLAN L. R., KRESOWIK T. F., MATCHAR D. B., TOOLE J. F., EASTON J. D., ADAMS H. P., BRASS L. M., HOBSON R. W., BROTT T. G., STERNAU L.. Guidelines for Carotid Endarterectomy : A Statement for Healthcare Professionals From a Special Writing Group of the Stroke Council, American Heart Association. Circulation [online] 1998 February, 97(5):501-509 [viewed 19 July 2014] Available from: doi:10.1161/​01.CIR.97.5.501
  2. MCCRORY DC, GOLDSTEIN LB, SAMSA GP, ODDONE EZ, LANDSMAN PB, MOORE WS, MATCHAR DB. Predicting complications of carotid endarterectomy. Stroke [online] 1993 Sep, 24(9):1285-91 [viewed 19 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/8362419
  3. APIRO MARTIN F.. Diagnostic Decision: The Complete Blood Count and Leukocyte Differential Count: An Approach to Their Rational Application. Ann Intern Med [online] 1987 January [viewed 08 June 2014] Available from: doi:10.7326/0003-4819-106-1-65
  4. BLUMENREICH MS. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition [web]; Chapter 153, The White Blood Cell and Differential Count. [viewed 08 June 2014] Available at http://www.ncbi.nlm.nih.gov/books/NBK261/
  5. AHMAD NZ. Routine Testing of Liver Function Before and After Elective Laparoscopic Cholecystectomy: Is It Necessary? JSLS [online] 2011, 15(1):65-69 [viewed 19 July 2014] Available from: doi:10.4293/108680811X13022985131291
  6. SHAHBAZI S, PANAH A, SAHMEDDINI MA. Evaluation of factors influencing liver function test in on-pump coronary artery bypass graft surgery. Iran J Med Sci [online] 2013 Dec, 38(4):308-13 [viewed 19 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24293784
  7. MATHEW A, ELIASZIW M, DEVEREAUX PJ, MERINO JG, BARNETT HJ, GARG AX, FOR THE NORTH AMERICAN SYMPTOMATIC CAROTID ENDARTERECTOMY TRIAL (NASCET) COLLABORATORS. Carotid Endarterectomy Benefits Patients with CKD and Symptomatic High-Grade Stenosis J Am Soc Nephrol [online] 2010 Jan, 21(1):145-152 [viewed 19 July 2014] Available from: doi:10.1681/ASN.2009030287
  8. DA ROSA MP, SCHWENDLER R, LOPES R, PORTAL VL. Carotid Artery Stenosis Associated with Increased Mortality in Patients who Underwent Coronary Artery Bypass Grafting: A Single Center Experience Open Cardiovasc Med J [online] :76-81 [viewed 19 July 2014] Available from: doi:10.2174/1874192401307010076
  9. GUILBERT MARIE-CHRISTINE, ELKOURI STEPHANE, BRACCO DAVID, CORRIVEAU MARC M., BEAUDOIN NATHALIE, DUBOIS MARC JACQUES, BRUNEAU LUC, BLAIR JEAN-FRANçOIS. Arterial trauma during central venous catheter insertion: Case series, review and proposed algorithm. Journal of Vascular Surgery [online] 2008 October, 48(4):918-925 [viewed 19 July 2014] Available from: doi:10.1016/j.jvs.2008.04.046
  10. JOOB B, WIWANITKIT V. Fasting blood sugar for diagnosis of diabetes mellitus in patients with tuberculosis Lung India [online] 2012, 29(1):90 [viewed 19 July 2014] Available from: doi:10.4103/0970-2113.92379
  11. TOLONEN H, FERRARIO M, KUULASMAA K, WHO MONICA PROJECT. Standardization of total cholesterol measurement in population surveys--pre-analytic sources of variation and their effect on the prevalence of hypercholesterolaemia. Eur J Cardiovasc Prev Rehabil [online] 2005 Jun, 12(3):257-67 [viewed 19 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15942425
  12. KLEMM HANNO U., VENTURA RODOLFO, ROSTOCK THOMAS, BRANDSTRUP BENEDIKT, RISIUS TIM, MEINERTZ THOMAS, WILLEMS STEPHAN. Correlation of Symptoms to ECG Diagnosis Following Atrial Fibrillation Ablation. J Cardiovasc Electrophysiol [online] 2006 February, 17(2):146-150 [viewed 19 July 2014] Available from: doi:10.1111/j.1540-8167.2005.00288.x
  13. PLATONOV PG. Atrial conduction and atrial fibrillation: what can we learn from surface ECG? Cardiol J [online] 2008, 15(5):402-7 [viewed 19 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/18810714
  14. KAWABORI MASAHITO, YOSHIMOTO TETSUYUKI, ITO MASAKI, FUJIMOTO SHIN, MIKAMI TAISEI, MURAKI MUTSUKO, KANEKO SADAO, NAKAYAMA NAOKI, KURODA SATOSHI, HOUKIN KIYOHIRO. Spontaneous Echo Contrast and Thrombus Formation at the Carotid Bifurcation After Carotid Endarterectomy. Neurol. Med. Chir.(Tokyo) [online] 2012 December, 52(12):885-891 [viewed 19 July 2014] Available from: doi:10.2176/nmc.52.885
  15. CRIADO ENRIQUE, WALL PHILLIP, LUCAS PAUL, GASPARIS ANTONIOS, PROFFIT TRENT, RICOTTA JOHN. Transesophageal echo-guided endovascular exclusion of thoracic aortic mobile thrombi. Journal of Vascular Surgery [online] 2004 January, 39(1):238-242 [viewed 19 July 2014] Available from: doi:10.1016/j.jvs.2003.07.017

Management - General Measures

Fact Explanation
Re-hydration and correction of electrolytes The water balance and electrolytes should be restored to normal levels immediately because the patients usually present with copious vomiting for a considerable time. Alkalosis is life threatening and should be paid immediate attention to. [1] [2] [3] [4] [5] [6]
References
  1. AMINI B et al. Pyloric stenosis. [web] [viewed 03 August 2014] Available from: http://radiopaedia.org/articles/pyloric-stenosis
  2. DAS A. K.. Adult pyloric stenosis--a forgotten entity. Age and Ageing [online] 2006 July, 35(4):448-448 [viewed 03 August 2014] Available from: doi:10.1093/ageing/afl021
  3. SCHAER MICHAEL. Therapeutic Approach to Electrolyte Emergencies. Veterinary Clinics of North America: Small Animal Practice [online] 2008 May, 38(3):513-533 [viewed 03 August 2014] Available from: doi:10.1016/j.cvsm.2008.01.012
  4. WEISS-GUILLET EVA-MARIA, TAKALA JUKKA, JAKOB STEPHAN M. Diagnosis and management of electrolyte emergencies. Best Practice & Research Clinical Endocrinology & Metabolism [online] 2003 December, 17(4):623-651 [viewed 03 August 2014] Available from: doi:10.1016/S1521-690X(03)00056-3
  5. LINDEMAN ROBERT D.. Therapy of Fluid and Electrolyte Disorders. Ann Intern Med [online] 1975 January [viewed 03 August 2014] Available from: doi:10.7326/0003-4819-82-1-64
  6. NAKA TOSHIO, BELLOMO RINALDO.Bench-to-bedside review: treating acid-base abnormalities in the intensive care unit--the role of renal replacement therapy . Crit Care [online] 2004 December [viewed 03 August 2014] Available from: doi:10.1186/cc2821

Management - Specific Treatments

Fact Explanation
Pylorotomy The definitive treatment mode is surgical pyloromyotomy,where the pyloric muscle is divided down to the submucosa. This can be performed both open and laparoscopically. The operation is curative and has very low morbidity. [1] [2] [3] [4] [5] [6] [7]
Pyloroplasty Can be performed in the absence of ulceration. Endoscopic pyloroplasty is also available for minimal invasive technique. [8] [9] [10]
Partial gastrectomy When a clear margin is not to be found, or in circumferential thickenings. [11]
References
  1. AMINI B et al. Pyloric stenosis. [web] [viewed 03 August 2014] Available from: http://radiopaedia.org/articles/pyloric-stenosis
  2. KNIGHT CD. Hypertrophic Pyloric Stenosis in the Adult Ann Surg [online] 1961 Jun, 153(6):899-910 [viewed 03 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1614008
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