What is the treatment for an infant with pyloric stenosis?

Treatment of Infantile Pyloric Stenosis

Surgical pyloromyotomy (open or laparoscopic) is the definitive treatment for infantile hypertrophic pyloric stenosis, but it should never be performed emergently—preoperative medical resuscitation to correct fluid and electrolyte abnormalities must always come first. 1, 2

Preoperative Medical Management (Always Required First)

Correction of metabolic derangements is mandatory before any surgical intervention:

• Fluid resuscitation and electrolyte correction are the true medical emergencies in pyloric stenosis, not the surgery itself 1, 2
• Infants typically present with hypochloremic, hypokalemic metabolic alkalosis from persistent vomiting 1, 2
• Surgery should be delayed until adequate hydration is achieved and electrolytes are normalized 1, 2
• This preoperative optimization significantly reduces perioperative morbidity and mortality 1, 2

Definitive Surgical Treatment

Pyloromyotomy (Ramstedt procedure) remains the gold standard:

• Both open and laparoscopic approaches are effective, with laparoscopic techniques gaining wider acceptance 2, 3
• The procedure involves incising the hypertrophied pyloric muscle down to the submucosa without entering the mucosa 2, 3
• Outcomes are excellent with contemporary surgical care when proper preoperative resuscitation is performed 1, 3

Surgical Complications to Monitor

• Duodenal perforation occurs in approximately 4% of cases and should be recognized intraoperatively 4
• Incomplete pyloromyotomy is uncommon but requires reoperation if diagnosed 4
• Wound infection rates are less than 1% 4
• Postoperative vomiting occurs in approximately 3% and usually resolves with expectant management, but if it persists beyond 5 days, radiologic evaluation is warranted 4

Medical Management Alternative (Limited Role)

Intravenous atropine therapy has been studied as a non-surgical alternative but has significant limitations:

• One study showed 87% success rate with IV atropine (0.01 mg/kg 6 times daily) followed by oral atropine 5
• However, this approach requires prolonged hospitalization (median 13 days) and extended oral medication (median 44 days) 5
• Given the excellent surgical outcomes and shorter hospital stays, atropine therapy is not considered standard of care and should only be considered in exceptional circumstances where surgery poses prohibitive risk 5, 3

Important Caveat About Atropine

• An association exists between oral erythromycin (not atropine) and infantile hypertrophic pyloric stenosis in infants under 6 weeks of age 6
• Infants treated with erythromycin should be monitored for signs and symptoms of developing pyloric stenosis 6

Diagnostic Confirmation

Before proceeding with treatment, diagnosis must be confirmed:

• Ultrasound is the most appropriate initial imaging modality when pyloric stenosis is suspected based on forceful, nonbilious vomiting 7, 2
• Physical examination by an experienced examiner may reveal a palpable "olive" (2 × 2 cm mass) in the right upper quadrant, ideally performed after gastric decompression 8, 7
• The absence of a palpable mass does not exclude pyloric stenosis—ultrasound should be performed when clinical suspicion remains high 8

Clinical Pitfalls to Avoid

• Never rush to surgery without correcting metabolic abnormalities first—this is the most critical error 1, 2
• Do not confuse pyloric stenosis management with gastroparesis treatments (gastrojejunostomy, balloon dilatation)—these are not appropriate for the hypertrophied pyloric muscle 7
• Recognize that mortality should be near zero with proper perioperative care; the single reported death in one large series was due to delayed diagnosis of concurrent Hirschsprung's disease, not the pyloric stenosis itself 4