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In a retrospective study of 84 Ghanaian infants with hypertrophic pyloric stenosis seen over a 15-year period between 1974 and 1988, the male/female incidence ratio was 9:1. First-born infants constituted 23.8% of the patient population. The incidence of associated congenital anomalies and jaundice were 10.7% and 3.6% respectively. About 33.3% of the infants started vomiting within the first week of life. The peak-age of presentation and diagnosis was between the second and sixth weeks of life. The operative mortality was 3.6%.

Eight cases of Infantile Hypertrophic Pyloric Stenosis collected in 10 years (1980-1989) in the Pediatric Surgery Unit of the Surgical Clinic of Dakar are reported. The rarity of this pathology among Blacks and a male predominance are noted. The clinical onset occurred after an average period of 3,25 weeks marked by food vomiting. At the start of the surgical management the age of patients was 6 weeks. X-ray examination following a barium meal showed no passage of contrast in 3 cases. However a narrowed and elongated pyloric canal was noted in 5 cases. Abdominal sonography was used in 3 cases and showed gastric stasis with a hypertrophy of pyloric muscle. A rammstedt pyloromyotomy was performed after a period of few hours to 13 days of resuscitation. A duodenal perforation complicated the operation twice and was subsequently repaired. In the post operative period, two patients died within 2-3 days. One of them had duodenal perforation. Six patients made a good recovery.

This is a world-wide disease, more common in Caucasians and probably on the increase. The aetiology remains very poorly understood. Presentation is between 2 and 8 weeks with vomiting, classically projectile, in an otherwise well hungry child. The diagnosis can confidently be made in most cases by a careful test feed; ultrasound and barium meal examinations are only required for difficult cases. Intravenous fluid replacement is essential prior to surgery and 24 h or longer may be required to correct acid base disturbances and enable safe general anaesthesia. Pyloromyotomy (Ramstedt's operation) remains the only satisfactory treatment, our mortality rate for this is 0.4%. Occasional vomits occur postoperatively in over half of patients but we are sceptical of the value of graded postoperative feeding regimens. There are no known long-term sequelae to surgery and this remains a most rewarding paediatric surgical condition to treat.

Treated were 193 patients with pyloroduodenal ulcer complicated by stenosis of gastric outlet. Compensated stenosis was noted in 14 (7.2%) patients, subcompensated--in 147 (76.2%), decompensated--in 30 (15.5%), gastric tetany--in 2 (1.04%). Studied were the immunologic indices, peripheric blood flow by means of a roentgenologic method under conditions of double contrasting and artificial hypotony, gastric and duodenal function, bioelectric activity--by the method of duodenokinesiography. Gastric resection was performed in 87 patients, vagotomy with drainage operation and without it--in 82, gastroenterostomy--in 14, antrum resection with vagotomy--in 12, Roux resection of the stomach--in 2. The postoperative lethality was 1%. Good and excellent results after gastric resection were noted in 82.1%, after vagotomy--in 88.4% of the patients.

A 38-yr-old Haitian male with a longstanding history of peptic ulcer disease presented with persistent vomiting and weight loss. Barium studies and upper endoscopy revealed gastric outlet obstruction with prepyloric ulcerations. Endoscopic biopsies were consistent with chronic gastritis. The patient did not respond to intensive medical management, including total parenteral nutrition, intravenous cimetidine, and nasogastric suctioning. At the time of surgery, large celiac lymph nodes were noted surrounding the pylorus and the first portion of the duodenum. Biopsies of the wall of the stomach and lymph nodes demonstrated necrotizing granulomas. Cultures for acid-fast bacilli subsequently grew Mycobacterium tuberculosis. A search for foci outside the gastrointestinal tract was negative. Primary gastric tuberculosis remains an extremely uncommon clinical entity; the definitive diagnosis is made by biopsy and positive culture for the organism.

The authors describe a pyloric obstruction due to a mucosal diaphragm in a 16 months old child. They review the literature, and emphasize on the rare frequency on this affection, the steps of its diagnosis, and its surgical removal.

Experience in the treatment of 70 patients with stenotic duodenal ulcer by surgery is generalized. In addition to SPV the patients underwent duodenoplasty as a draining operation. There were 61 (87.1%) males and 9 (12.9%) females. Their ages ranged from 18 to 70 years. The stenosis was compensated in 21 (30%), ++non-compensated in 32 (45.7%), and decompensated in 17 (24.3%) patients. To determine the possibility of performing SPV, the maintenance of the gastric contractile activity was studied by noninvasive methods: computed peripheral electrogastrography and computed gastro-scintigraphy. Involvement of the pylorus into the cicatricial-ulcerous inflammatory infiltration is the main contraindication for duodenoplasty. In view of that, intensive 2-3 week preoperative antiulcer therapy acquires particular significance; it removes or reduces significantly the inflammatory infiltration in most cases and raises the possibility of conducting duodenoplasty. Only intraoperative inspection of the pyloroduodenal segment allows the possibility and type of pylorus -preserving duodenum draining operation to be determined. This operation can be undertaken if the proximal boundary of the stenotic cicatricial-ulcerous deformity is at a distance of at least 1 cm from the pyloric sphincter, whatever the degree and length of the narrowing. A total of 43 operations form the Heineke-Mikulicz Mikulicz duodenoplasty, 17 for Finney's pyloroplasty, and 10 for bulbo-duodenostomy were carried out. The authors consider excision of the duodenal ulcer to be expedient and safe only when it is located on the anterior wall; it was carried out in 9 cases.(ABSTRACT TRUNCATED AT 250 WORDS)

We describe a rare case of hyperplastic polyp of the stomach having its clinical origin in the neonatal period and initially stimulating hypertrophic stenosis of the pylorus. After this neoformation, which almost completely obstructed the pylorus, was endoscopically removed, vomiting ceased and a rapid weight gain was observed. It is known that tumors are a rare cause of gastric outlet obstruction if compared with hypertrophic stenosis of the pylorus. However, our experience suggests that in the case of atypical symptoms, the investigations should be extended, especially to endoscopic examination of the upper digestive tract.

Two sibs with Beemer type short rib syndrome, one of them diagnosed in utero, are reported. Both patients had previously unreported additional abnormalities such as pyloric stenosis and short bowels. Dysplasia of pancreatic Langerhans cells was present in one sib.

Forty-nine infants who underwent investigation or surgery for hypertrophic pyloric stenosis (HPS) over a 30-month period were reviewed. Significant weight loss was present in 18 infants, of whom 16 had HPS. A test feed was performed in 46 infants with 1 of 27 false positive and 6 of 29 false negatives. An ultrasound examination was performed in 34 infants with 4 of 23 false positives and 1 of 11 false negatives. It is recommended that if the test feed is positive then surgery should be performed, otherwise an ultrasound examination can be used as a screening test but a positive result should be confirmed by other means before surgery.

The paper reports the case of family in which the mother and sons were affected by hypertrophic pyloric stenosis. Epidemiological, etiopathogenetic and diagnostic aspects of the disease are taken into account.

Infantile hypertrophic pyloric stenosis (IHPS) is a relatively common disease. We report our experience with 24 IHPS infants admitted to the Departments of Pediatrics and Pediatric Surgery of Chang Gung Memorial Hospital in Kaohsiung over 4 years, from 1986 to 1989. Analysis disclosed a high male to female ratio (11:1) and a heavy preponderance of firstborn male (46%). Fifty per cent of our cases had symptoms beginning between the ages of 2-4 weeks. The fact that 67% of the patients had duration of symptoms longer than 2 weeks prior to admission, with a mean interval of 25 days of progressive symptoms, represented that there was delay in diagnosis and treatment in most of our cases. The major clinical manifestations were projectile vomiting (100%), palpable pyloric mass (66.7%) and visible gastric peristaltic waves (41.7%). Of the 18 cases receiving plain supine abdominal roentgenogram, 17 (94.4%) demonstrated typical pictures. A gastric air outline extending below L2 vertebra is the most helpful criteria. Preoperative sonography suggested that the determination of pyloric muscle wall thickness predicted IHPS more accurately than that of pyloric muscle length. All 24 cases received Fredet-Ramstedt pyloromyotomy, with no mortality and short hospitalizations.

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.

To improve the diagnosis of pyloroduodenal stenoses (PDS), it is suggested that persons at high risk for gastrointestinal diseases screened among the polyclinic contingents may be examined. With that purpose in view a specialized gastrofluorographic room was set up at a polyclinic. Gastric fluorography was carried out according to a standardized method based on double opacification. Endoscopy was performed on a random basis depending on the gastrofluorography findings. Over 25,000 investigations were made. 155 cases of PDS were revealed. Of these, 107 were of ulcerous etiology, 38 of tumorous. In 10 cases, PDS was caused by primary injury to the organs adjacent to the stomach. Besides, for the suggested diagnostic program to be more significant, roentgenofluoroendoscopic correlations were made in 106 patients with remarkable clinical manifestations of PDS, that demonstrated its high efficacy. In the authors' opinion, the developed diagnostic program based on the use of gastrofluorography combined with endoscopy is to contribute to an appreciable rise of PDS detectability, particularly at the early stages of the disease.

The paper reports on the authors' experience used on 164 patients with complicated postbulbar ulcers (12% of the duodenal ulcers) with hemorrhage (52 cases), perforation (9 cases), duodenal stenosis (13 cases), stenosis and penetration (36 cases) and pancreatic-biliary penetrations (36 cases). The frequency of hemorrhagic complication was of 31%. As the hemorrhage due to postbulbar ulcer is favoured by vascular fistula, the severe character of the hemorrhage and the frequency of the recurrence, mainly the cataclysmic one, impose the radical surgery as early as possible. The following were used: large Reichel-Polya's gastrectomy (26 cases with 7 deaths) Péan's gastro-duodenectomy (12 cases), Péan's hemigastrectomy+vagotomy (4 cases), gastrectomy for exclusion with hemostasis in situ and ligature of gastroduodenal artery (8 cases, of which 1 with vagotomy and 2 deaths) and pyloroplasty with vagotomy and hemostasis (2 cases). The postsurgical mortality was of 17%. In 9 cases with perforation: Reichel-Polya's gastrectomy in 5 patients (1 death), Péan's gastrectomy in 2 cases, excision pyloroplasty and suture of the perforation in one case, respectively, were used. In the postbulbar ulcers penetrating into the pancreas or into the hepatic pedicle associated with stenosis (36 cases) the following were performed: Reichel-Polya's gastrectomy (7 cases), Péan's gastrectomy (7 cases of which 2 with vagotomy) gastrectomy for exclusion of ulcer in 19 cases, of which 5 with vagotomy, Péan's hemigastrectomy+vagotomy (3 cases). The 36 cases of ulcers penetrating into pancreas were solved as follows: gastrectomy for exclusion (16 cases of which 5 with vagotomy), Reichel-Polya's gastrectomy (10 cases of which 1 with vagotomy), Péan's gastrectomy (10 cases of which 2 with vagotomy). In 13 patients with stenosed ulcers, Reichel's-Polya's gastric resection (10 cases), Péan's gastrectomy, gastrectomy for exclusion and gastrojejunostomy (in one case each) were performed. The conclusions may be drawn that the postbulbar ulcers are complicated ulcers that require differentiated surgical treatment, as early as possible, for diminishing the postsurgical morbidity and mortality (7.5% mortality).

The authors postulated that volumetric measurement of residual gastric aspirate in neonates and infants with nonbilious projectile vomiting could enable differentiation between patients with hypertrophic pyloric stenosis (HPS) and those with gastroesophageal reflux (GER) and help to determine whether ultrasound (US) or fluoroscopy of the upper gastrointestinal tract would best confirm the diagnosis. In the 38 patients (all but two of whom had been fasting for 3-4 hours), 10 mL or more of nasogastric aspirate was considered indicative of obstruction. HPS occurred in 91.7% of patients with 10 mL of aspirate or more, whereas GER occurred in 85.7% of patients with less than 10 mL. The differences between the two groups were statistically significant. Solely on the basis of residual volume (greater than or equal to 10 mL), the cause of vomiting could be differentiated, prior to standard radiologic studies, 89.4% of the time. It is concluded that patients with projectile vomiting who have 10 mL or more of residual aspirate in the stomach should undergo US for confirmation of HPS; those with less than 10 mL should undergo fluoroscopy for confirmation of GER.

A total of 40 patients with a diagnosis of infantile hypertrophic pyloric stenosis were admitted to Ethio-Swedish Children's Hospital, Addis Ababa, Ethiopia over a period of 6 years (1981-1986). The clinical records of 34 patients could be retrieved and analysed. The incidence rose from 2.7 per thousand admissions in 1981 to 3.6 in 1986. The male to female ratio was 4.7:1. Patients started to vomit at a mean age of 21.5 days with age range from birth to three months. In 26 (76.4%) patients, vomiting started before the first month of life. Their distribution showed a bias towards term infants 97%, males 83.2%, first borns 26.5%, and higher socio-economic class 23.5%. No seasonal variations were observed. A palpable tumor was present in 35.3%. [Each of hematemesis with melena and jaundice were seen in 2.9%]. The treatment was pyloromyotomy; seven patients developed complications but none died.

A study of 58 consecutive Indian infants operated for congenital hypertrophic pyloric stenosis revealed an accentuated male predominance in the incidence of the disease and far less preoperative hemetemesis as compared to that in their Western counterparts. 'Pyloric tumor' was palpable in 89% of cases. Only 34.5% of these infants were first born. Postoperative vomiting occurred in 13.8% of patients and wound sepsis was not encountered. Air contrast radiography confirmed the diagnosis in clinically doubtful cases.

We present 40 patients operated consecutively for pyloric stenosis during an 8-year period (1981-88). The most common symptom was projectile vomiting, which occurred in 92.5% of the cases. On examination only three patients had a palpable hypertrophic pylorus. In 39 patients, a preoperative x-ray examination with contrast was necessary to confirm the diagnosis. A pyleromyotomy was performed in all patients. We discuss the diagnostic routines and the results of our treatment.

Two infants presenting with vomiting were thought to have palpable pyloric tumours. At operation hypertrophic pyloric stenosis was not present, but other conditions causing duodenal obstruction were, and these required surgical treatment. The cases illustrate that other abnormalities may masquerade as pyloric stenosis.

The association of infantile hypertrophic pyloric stenosis with congenital diaphragmatic hernia is rare. We report three cases of infantile hypertrophic pyloric stenosis who had concomitant congenital diaphragmatic hernia.

Infantile hypertrophic pyloric stenosis is a relatively common paediatric condition effectively cured by Ramstedt's pyloromyotomy. Nevertheless, published results demonstrate a residual perioperative morbidity indicating a need for improved management. While technological advances in diagnosis and treatment may contribute to this, attention to the details of perioperative care coupled with a meticulous surgical approach are likely to have a much greater impact.

The currently accepted premise that the diagnosis of hypertrophic pyloric stenosis (HPS) should be made on clinical grounds, with ultrasound (US) and upper gastrointestinal series (UGIS) reserved for those with a negative clinical examination, was tested. Variable clinical skills of initial examiners, including pediatric surgeons, made abdominal palpation no more sensitive or specific than US or UGIS. For those with a negative clinical examination, proceeding directly to a UGIS will result in monetary savings, especially if good clinical performance decreases the probability of HPS among those without palpable pyloric "tumors." The benefits of a "US first" approach (no radiation, better patient and parent acceptance, no contrast medium) are less apparent but no less important and increase as clinical experience declines and performance of US improves. Criteria for the clinical or sonographic diagnosis of HPS should be kept strict to avoid false-positive results; false-negatives and other causes of vomiting should be identified by UGIS.

Clinical and sonographic findings in 27 patients were analysed in a retrospective study in order to find sonographic criteria for the necessity of surgical treatment of infantile hypertrophic pyloric stenosis. Thirteen patients underwent surgical treatment, 14 were cured by conservative management only. Patients did not differ as regards clinical or serological findings when first investigated by means of sonography. On first examination, carried out about three days after the onset of symptoms, most of the patients who necessitated surgical treatment showed 1) a long canal segestorius (greater than 20 mm), 2) a significantly elevated muscle to lumen ratio exceeding 2:1, 3) pathological "target sign" in the medium upper stomach measuring more than 18 mm, 4) no passage of stomach contents to the duodenum on real time sonography examination. However, this constellation of features was also observed in some patients who were treated successfully by conservative management. Thus, although statistically significant differences were found between these two groups of patients, a definitive prospective decision in the individual patient with regard to the necessity of surgical treatment could not be obtained on the basis of the above-mentioned ultrasound signs. Our study suggests that sonographic criteria are helpful in establishing the diagnosis of infantile hypertrophic pyloric stenosis and also in evaluation of the response to therapeutic management, but--at the time of initial investigation--cannot provide accurate prognostic information.

The authors performed the selective proximal vagotomy in combination with the ulcer excision and duodenoplasty in 233 patients in complicated forms of duodenal ulcer disease. The clear indications for this type of intervention have been established. The high effectiveness of the pylorus-preserving operations is noted. Improvement of the techniques for local removal of an ulcer is a reserve for improving the results.

Cystic duplication of the large intestine is a rare anomaly which may give no clinical symptoms. When combined with a nonrotation anomaly it may enhance the symptoms of a high gastro-intestinal obstruction. A case is presented where the combination of these two conditions gave intermittent symptoms simulating a duodenal or a pyloric stenosis.

Abdominal ultrasonic examination was performed in 8 infants with hypertrophic pyloric stenosis, and in 23 control patients of the same age. The average anteroposterior diameter of the pylorus in children with hypertrophic pyloric stenosis measured 17 mm (range 15-20 mm), and 9.6 mm (range 6-12 mm) in the control group. The statistical difference was highly significant (p less than 0.001). In addition, delayed gastric emptying and retroperistalsis of the stomach were demonstrated. The sonographic findings of hypertrophied pylorus correlated well with roentgenologic results and were confirmed during following operation. Abdominal sonography is a rapid, safe and non-invasive method for the identification of hypertrophic pyloric stenosis.

In the complex called vagal indigestion two main types of stenosis can be distinguished, pyloric stenosis and stenosis between the reticulum and omasum or reticulo-omasal stenosis. Laboratory examinations of blood and rumen fluid were carried out in 10 cows with reticulo-omasal stenosis. The results are discussed with respect to the differential diagnoses of pyloric stenosis. In the cows with reticulo-omasal stenosis no metabolic alkalosis occurred and consequently dehydration and uraemia did not develop. For the clinician valuable points of difference were a more prolonged and chronic course and, on physical examination, the absence of serious circulatory disturbances and the absence of an ammoniacal-uraemic odour in the expired air. The clinical picture of reticulo-omasal stenosis strongly resembles a syndrome described as failure of omasal transport.