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A 2,5-month-old boy came to the clinic with complaints of projectile vomiting. Earlier, 2 ultrasounds, which had been made because of similar complaints, had shown signs of borderline pyloric hypertrophy and no signs of pyloric hypertrophy, respectively. A new ultrasound was made; it showed pyloric hypertrophy.

A 39-year-old woman had been investigated elsewhere due to symptomatic hypokalaemia, renal potassium wasting and metabolic alkalosis. Vomiting was considered to be the underlying cause but the patient repeatedly denied this behaviour. After extensive investigations, Bartter's syndrome was finally diagnosed. Eighteen months later the patient was readmitted due to progressive renal insufficiency. On the basis of a very low urinary chloride excretion and the aforementioned laboratory results, it was concluded that the metabolic disturbances were due to vomiting and the diagnosis of Bartter's syndrome was rejected. Upon being confronted with these findings, the patient finally admitted to vomiting, but stated that this happened involuntarily after meals. She had a stenotic ulcer in the pylorus and a gastric biopsy demonstrated the presence of Helicobacter pylori associated gastritis. Eradication therapy was given and the symptoms disappeared. The renal insufficiency was partly accounted for by hypovolaemia and partly by tubulointerstitial nephropathy (demonstrated by kidney biopsy) which was probably due to the chronic hypokalaemia. This case illustrates the difficulty of establishing the differential diagnosis of hypokalaemia, especially in the case of denied vomiting. However, it also shows that in such cases the correct diagnosis can be made if objective parameters are used.

A one-month-old infant was admitted with projectile vomiting due to a hypertrophic pyloric stenosis. A pyloromyotomy was successfully performed.

Objective: To determine if ultrasonography is necessary for the diagnosis of pyloric hypertrophy in children and if in (clinical) doubt the ultrasonographic diagnosis of 'pylori hypertrophy' may constitute the indication for operation., Setting: Leiden University Hospital and Amsterdam Centre for Paediatric Surgery., Design: Retrospective study., Method: In the period 1985-1990, 83 children younger than 4 months were operated on for pyloric hypertrophy (group I; 73 of them had been examined by ultrasonography), while 15 underwent sonography because of suspicion of pyloric hypertrophy (group II), without operation. An attempt was made to find clinical and laboratory data that might be an indication of pyloric hypertrophy, and render supplementary ultrasonography unnecessary., Results: In group I, the combination of projectile vomiting, discernible gastric peristalsis after test meal and metabolic alkalosis was present in 34%, while a tumour in the upper abdomen was palpated in 25%; neither finding was present in group II. The sensitivity of one-time ultrasonography was 74%, that including follow-up examination in case of doubt, 82%. The predictive value of an ultrasonographic result positive for 'pyloric hypertrophy' was 98%, that of a negative finding 52%, the accuracy was 84%., Conclusion: In children younger than 4 months with the combination of projectile vomiting, gastric peristalsis after test meal and metabolic alkalosis, or with a palpable swelling in the upper abdomen, no ultrasonography is necessary to make the diagnosis of 'pyloric hypertrophy'. In case of clinical doubt, the indication for operation may be based on the result of ultrasonography.

Diagnosis and treatment of pyloric stenosis in the dog are described. The most common causes in 47 dogs were hypertrophic and functional pyloric stenosis. These conditions were mostly seen in young, male dogs of brachycephalic breeds. In contrast with the literature no indications were found for a predisposition in miniature breeds. Hypertrophic stenosis was treated successfully with the Fredet-Ramstedt pyloromyotomy. Functional stenosis and hypertrophic gastritis were mainly treated with the Heineke-Mikulicz pyloroplasty; good results were obtained in more than half of the cases.