Search

Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht.

Background: Crohn's disease is a chronic inflammatory condition that can affect the gut from mouth to anus. Gastroduodenal involvement is seen in less than 5% of all patients with Crohn's disease. Among those cases, isolated gastric Crohn's disease is even rarer. Although most patients with isolated gastric involvement have nonspecific complaints, very few of them do develop features of pyloric obstruction. There is a paucity of data on specific management of gastric Crohn's disease owing to its rarity and its frequent coexistence with colonic or ileal disease. We report a case of a patient who had pyloric stenosis as a manifestation of isolated gastric Crohn's disease responding to intralesional steroid injection and balloon dilation., Case Presentation: A previously healthy woman presented with recurrent postprandial vomiting, epigastric discomfort, and unintentional weight loss over 6 months. She had no diarrhea or extraintestinal manifestations. Clinically, she was pale and dehydrated. Examination of systems was unremarkable except for mild epigastric tenderness. Her initial laboratory findings were normocytic normochromic anemia, high inflammatory markers, and hypokalemia. Esophagogastroduodenoscopy revealed an inflamed pyloric mucosa with features of pyloric obstruction. Furthermore, magnetic resonance enterography confirmed the pyloric stenosis. Histopathological examination of a biopsy from the pylorus revealed noncaseating granuloma with superficial ulceration. Tuberculosis and sarcoidosis were excluded by appropriate investigations, and a diagnosis of gastric Crohn's disease was made. Following the initial resuscitation, intralesional steroid injection and controlled radial expansion balloon dilation of the pylorus were carried out. The patient was commenced on azathioprine as a maintenance treatment, which led to a successful dilation and remarkable symptom improvement., Conclusion: Symptoms of pyloric obstruction as a manifestation of isolated gastric Crohn's disease are extremely unusual in clinical practice, awareness of which would facilitate early appropriate investigations and treatment.

A 17-year-old female was referred to our hospital with worsening dietary intake and abdominal bloating. She had epigastric fullness, but no abdominal pain. Gastrointestinal endoscopy revealed food residue and pyloric stenosis. A contrast-enhanced radiograph also showed pyloric stenosis, and gastrografin was not passed well through her pylorus. Computed tomography revealed similar findings. The biopsy results indicated hyperplasia of the gastric glands. The patient was diagnosed with a benign lesion, and underwent endoscopic balloon dilation several times. However, her stenosis worsened and we decided to perform surgery. In consideration of the cosmetic outcome, we performed laparoscopic distal gastrectomy. The postoperative course was good, and the patient was discharged on postoperative day 10. The final diagnosis was pyloric stenosis caused by heterotopic glands. No malignant lesions were found. Since gastric stenosis caused by heterotopic glands has not been reported previously, we consider this to be a very rare case.

Differentiation between pseudoneoplastic regenerative epithelium and gastric carcinoma can be challenging. In cases with pseudoneoplastic regeneration, so-called lateral expansion of tubules and changing of nuclear rows within one gland should not be present. The gastritis status is of particular significance as gastric cancer is a rare occurrence without Helicobacter pylori infections.

Background: The abnormal presence of the pancreatic tissue in other digestive organs is rare but sometimes is the cause of some surgical diseases., Material and Method: This retrospective study is focussed on heterotopic pancreas cases diagnosed in 2nd Surgical Clinic of "Sf. Spiridon" Emergency Hospital from Iaşi between Jan. 1986 and Dec. 2008., Results: 22 patients (15 males/68.2% and 7 females/31.8%) aged between 23 and 76 years were grouped in A group--clinical symptomatic cases (3 patients/13.6%), group B--coincidental cases (17 patients/77.3%) and group C--incidental cases (2 patients/9%). Group A patients presented with obstructing prepyloric polypoid tumors and recquired antrectomy and gastroduodenal anastomosis. 13 patients of group B (76.4%) recquired surgery for pyloroduodenal stenosis and in 4 cases of this group with severe upper-GI bleeding, a subtotal gastric resection (3 patients) or antrectomy (1 case) was performed. In group C patients jejunal HP was histopathologically diagnosed during extensive intestinal resection for colonic malignancies (ascendant colonic and transverse colonic cancers) with jejunal invasion. HP cases were categorized as type I in 40.9% cases (ducts, acini and pancreatic islets), type II in 45.4% cases (ducts and acini) and type III (exclusively with ducts) in 13.6% cases. In 76% patients HP was localized in mucosal and submucosal layers, in 16% intramucosal and in 8% in subserous layer., Conclusion: HP is most often an unexpected symptomless coincidental diagnosis during gastrointestinal surgical diseases.

We report a patient with an advanced gastric cancer complicated by pyloric stenosis who was effectively treated by S-1 mono-therapy after gastrojejunostomy. A 62-year-old man consulted a general practitioner for abdominal pain and anorexia. Gastric roentgenography and upper gastrointestinal endoscopy showed gastric cancer(Borrmann Type 3) with pyloric stenosis. He was referred to our department. He underwent laparotomy, which revealed a T4 tumor invading the pancreas head, but neither liver nor peritoneal metastasis. A gastrojejunostomy was made. After the operation, chemotherapy of S-1(120 mg/day, day 1-21)+cisplatin(100 mg/day, day 8)was administered. After 2 courses, level of tumor marker decreased remarkably and abdominal enhanced computed tomography showed a significant size reduction of lymph nodes and that direct invasion to the pancreas was not clear any more. Second laparotomy was carried out and curative surgery was performed. After 4 courses of S-1(120 mg/day, day 1 approximately 28)mono-therapy as adjuvant chemotherapy, bone metastasis was confirmed by scintigram. Then methotrexate+5-FU, irinotecan+cisplatin and cisplatin+paclitaxel were chosen as second-, third-and fourth-line chemotherapy, which were not effective for long. He died 572 a days after the initial surgery. In the past, gastrojejunostomy was regarded as useful palliative treatment for those with gastric outlet stenosis to ameliorate the QOL. As S-1 is taking major role in the chemotherapy for advanced gastric cancer recently, usefulness of bypass surgery for such patients is highlighted even for longer survival time.

We evaluated the efficacy of chemotherapy using S-1 after gastrojejunostomy for unresectable gastric cancer with pyloric stenosis. We performed gastrojejunostomy to relieve obstruction in 40 patients from 1993 to 2007. After gastrojejunostomy, 15 patients were treated with S-1(S-1 group), 12 patients were treated with another anticancer drug(non S-1 group)and the other 13 patients received no chemotherapy. After informed consent was obtained, S-1(80 mg/m(2)day)and another anticancer drug was administered. The mean period of administered was 16(range 2-56)weeks in the S-1 group. In the non S-1 group, 5-FU was used in 1 patient, 5'-DFUR in 2, UFT in 3, FP chemotherapy in 3, CPT- 11/CDDP chemotherapy in 1, and 5-FU/PTX chemotherapy was conducted in 2 patients. The one-year survival rate was 63% and the median survival time was 394 days in the S-1 group, against 33% and 169 days, respectively, in the non S-1 group. Appetite loss of grade 3 was observed in one(7%)patient with nonhematological toxicity, but no patient suffered grade 3 hematological toxicity. We observed the course of all patients on an outpatient basis. In conclusion, S- 1 administration after gastrojejunostomy appears to be an effective treatment modality for far advanced gastric cancer patients with pyloric stenosis in view of toxicities, antitumor effects and QOL of the patients.

Pyloric stenosis and pancreatitis were simulated before and after administration of serotonin and spiperone (5-HT2 receptor blocker). Activation of the serotoninergic system prevented the development of pancreatitis, but led to more severe course of pyloric stenosis.

A 65-year-old female who complained of appetite loss and upper abdominal pain was diagnosed as unresectable advanced gastric cancer with pyloric stenosis and obstructive jaundice by peritoneal and lymph node metastases. After endoscopic balloon dilatation and endoscopic biliary drainage, S-1(80 mg/m(2)/day, days 1-14 with 1 week rest)/pacli- taxel(PTX)(50 mg/m(2)/day, day 1, day 8)combination therapy was done. After one course of the chemotherapy, subjective symptoms were relieved and oral intake was increased. Computed tomography showed that the volume of gastric wall, the size of paraaortic lymph node, and the amount of pleural effusion and ascites were decreased. Grade 1 alopecia, vasculitis and grade 2 neutropenia were observed as adverse reactions to the treatment. S-1/PTX combination therapy after endoscopic intervention was effective in this case of advanced gastric cancer with pyloric stenosis and obstructive jaundice.

Treatment results in 110 patients with stenotic bleeding pyloroduodenal ulcers (SBPU) were analyzed. Correlation dependence of hemorrhage severity and recurrence frequency from the degree of pyloroduodenal stenosis was revealed. Recurrence of ulcer gastroduodenal bleeding - is the main factor that determines lethality at SPBU. The total lethality against a background of SPBU recurrence was 16%, whereas in the absence of recurrence it was 10%. Treatment tactics in patients with SPBU was worked out. The best results were received after urgent operations which had been carried out after short-term preoperative preparation, aimed to blood replacement and correction of water-electrolytic and protein-energy disturbances at pyloroduodenal stenosis.

In the present study authors have analyzed the suitability of the infrared (IR) spectroscopy for diagnosis of morphological and functional changes of the stomach in ulcer pyloroduodenal stenosis. Data obtained from 64 patients have shown that the IR spectroscopic features of the stomach were dependent on the stage of stenosis, secretory function of the stomach and the presence of the Helicobacter Pylori (HP) infection. IR spectroscopy can be a multi-purpose mean of assessment of the morphological and functional properties of the stomach in pyloroduodenal stenosis. IR spectroscopy provides the opportunity to assess the secretory state of the stomach at different stages of the disease. Using IR spectroscopy we were able to reveal the presence of HP in the stomach and the dynamics of its eradication during of conservative treatment and at any time after surgical intervention.

The patient was a 63-year-old male who came to our hospital with the chief complaints of dyspepsia and abdominal fullness. Endoscopic findings showed Type 3 gastric cancer with pyloric stenosis. CT examination revealed a large amount of peritoneal fluid, invasion to the pancreas, peritoneal dissemination and paraaortic lymph node metastasis. Intraperitoneal administration of weekly CDDP 10 mg/body was in vain, and combined chemotherapy of paclitaxel and 5-fluorouracil was carried out. Ascites was significantly reduced and oral intake became possible two courses after this regimen. The tumor decreased in size after 3 courses, and the tumor markers returned to within normal limits. The patient was then discharged, and followed as an outpatient thereafter. Endoscopic examination showed improvement in narrowing of the antrum. However,tumor invasion to pancreas, peritoneal dissemination and lymph node metastasis relapsed. He died one year and one month after the onset.

Purpose: This study evaluated the impact of laparoscopic pyloromyotomy since it came into use at our institution in March 1999., Materials and Methods: The recovery profiles and intraoperative and postoperative complications of 170 infants who underwent laparoscopic, semicircumumbilical incision, or right upper quadrant incision pyloromyotomies between March 1999 and April 2005 were analyzed., Results: Eighty-one (48%) of operations were undertaken laparoscopically, 51 (30%) by traditional right upper quadrant incision, and 38 (22%) by semicircumumbilical incision. Patient group demographics were similar across all groups. There was no significant difference in overall complication rate between procedures: laparoscopic group, 12.3% (10/81); semicircumumbilical incision group, 18.4% (7/38); and right upper quadrant incision group, 9.8% (5/51). Early in the laparoscopic series there were 2 inadequate pyloromyotomies and 2 conversions to open procedures due to perforation (n = 1) and poor visibility (n = 1). Infections were more common with open surgery: laparoscopic, 1.2% (n = 1), right upper quadrant incision, 7.8% (n = 4), and semicircumumbilical incision, 13.2% (n = 5). Operative correction was required for herniation at 3 laparoscopic incision sites (3.6%), 2 semicircumumbilical incision sites (5.3%), and 2 right upper quadrant incision sites (3.9%). Patients who underwent laparoscopy returned to full feeds faster (laparoscopic, 18.1 hours; right upper quadrant incision, 28.1 hours; and semicircumumbilical incision, 28.9 hours) (P < 0.05), required less analgesia (laparoscopic, 2.1 doses; right upper quadrant incision, 4.0 doses; and semicircumumbilical incision, 4.3 doses) (P < 0.05), and had less emesis (laparoscopic, 1.6 episodes; right upper quadrant incision, 2.9 episodes; and semicircumumbilical incision, 3.5 episodes) (P < 0.05), resulting in faster discharge (laparoscopic, 2.0 days; right upper quadrant incision, 3.1 days; and semicircumumbilical incision, 3.2 days) (P < 0.05)., Conclusion: Laparoscopic pyloromytomy is as effective and safe as open procedures and is associated with an improved recovery profile. We conclude that, where laparoscopic skills exist, laparoscopy should be the management of choice for hypertrophic pyloric stenosis.

Pylorostenosis was modeled by putting a slightly compressing ligature in the boundary between the antral part of the stomach and the duodenum. Subcompensated pylorostenosis developed on the 10th day; decompensated pylorostenosis developed on the 15th day.

We report a rare case of pyloric stenosis as a presenting symptom of Crohn's disease. Clinical improvement and long-term relief of pyloric obstruction were obtained following a short course treatment of corticostroids and total parenteral nutrition. In contrast to most of the cases described previously in the literature, surgical treatment was not required.

Bifurcation of the femur and tibial agenesis are rare anomalies and have been described in both the Gollop-Wolfgang Complex and the tibial agenesis-ectrodactyly syndrome. We report on two patients with bifurcation of the femur and tibial agenesis. Hand ectrodactyly was seen in one of these patients. Both patients had unusual additional anomalies. The first patient had in addition proximal focal femoral deficiency, the other patient had a tracheo-esophageal fistula and pyloric stenosis. Clinical and genetic aspects are discussed., ((c) 2005 Wiley-Liss, Inc.)

Aim: To quantify the chronological sequence of changes in the morphology and immunoreactivity for neurotransmitters in the pylorus of an animal model of infantile hypertrophic pyloric stenosis and phenylketonuria., Method: Thirty specimens of pylorus from hph-1 mice and age/sex matched controls (age range: 10-180 days) were examined using conventional histology and immunohistochemistry for a variety of antigens: protein gene product 9.5, a pan neuronal marker; vasoactive intestinal polypeptide; nitric oxide synthase two antigens coalesced to the same inhibitory neurons in humans; substance P, a potent excitatory neurotransmitter; and calcitonin gene related peptide, a neurotransmitter implicated in the somatic afferent innervation of the stomach. The changes in the morphology of the muscle layers were quantified and statistically analysed for each age group (10, 20, 40, 90 and 180 days)., Results: Between 10 and 90 days of age, all muscle layers of the hph-1 mice were hypertrophied, for example, 10 days, hph-1 longitudinal muscle mean diameter = 3.4, control = 1.8; hph-1 circular muscle width = 11.5, control = 4.7. The hph-1 mice were significantly smaller during this period (40 days, hph-1 weight = 10 g, control = 25 g). There was no change in the pattern of expression of the antigens examined within the hph-1 mice compared with the controls., Conclusion: Hph-1 mice develop a transient smooth muscle hypertrophy of the pylorus attended by gastric distension and failure to gain weight. These changes resolve as the pyloric muscle hypertrophy resolves.

We investigated whether atropine sulfate was an effective, non-surgical method for treating hypertrophic pyloric stenosis (HPS). The study group consisted of 5 patients, all of the patients presented with projectile vomiting. Hypertrophic pyloric stenosis was diagnosed based on abdominal sonographic findings. The age when symptom arose was 30.8 +/- 15.5 (mean +/- SD) days, the age upon admission was 43.2 +/- 9.6 days. The frequency of vomiting was 5.8 +/- 2.3 times per day. After admission, all patients received 10% atropine sulfate 0.01 mg/kg intravenous (i.v.) for 5 minutes q4H (every four hours) before each feeding. Formular milk was started and increased by 10 ml every feeding until full feeding (120 ml/kg/day) was achieved. When vomiting had ceased for a period of one day, i.v. atropine was changed to 0.02 mg/kg oral q4H before each feeding. The patient was hospitalized until full feeding was maintained for more than 2 days. Then oral atropine was tapered by half a dose every 2 weeks. Oral atropine was continued until the thickness of the pyloric muscle had normalized (< 3.5 mm). All five patients were successfully treated with atropine sulfate. The frequency of vomiting was reduced to less than two times per day (1.8 +/- 1.3 days). i.v. atropine was used for 6.4 +/- 3.4 days, and the oral form was used for 30 +/- 9 days. The total number of days of atropine sulfate treatment was 36.4 +/- 9.58 days. Full feeding was achieved at 8 +/- 5.3 days. The hospitalization was 14.6 +/- 6.2 days. The body weight when admitted was 4000 +/- 760.8 gm and the body weight when discharged was 4282 +/- 901 gm. The body weight one month after treatment was 5210 +/- 772.5 gm. The body weight gain one month after atropine treatment was 1262 +/- 441.4 gm. Body weigh range on admission was from <3rd to 25th percentile, and after one month of atropine treatment, the body weight range was from 10th to 75th percentile. Complications included transiently elevated heart rates (180-200 times/min) in two patients and facial flushing after the first dose of IV atropine in one patient. In conclusion, conservative treatment with initially IV atropine in the initial stages instead of oral atropine sulfate is an effective alternative to pyloromyotomy, particularly in infants with major concurrent disease or when parents are unwilling to let their infants undergo surgery. Surgical intervention is not always necessary.

Context: Interstitial cells of Cajal (ICCs) are pacemaker cells, which are of fundamental importance in regulating gastrointestinal motility. Recent evidence suggests that carbon monoxide is a neurotransmitter involved in neurotransmission between ICC and smooth muscle cells. Heme oxygenase-2 (HO-2) is the major physiological mechanism for the generation of carbon monoxide in the enteric nervous system., Objective: To investigate the immunocolocalization of HO-2 and ICCs in the normal pylorus and in infantile hypertrophic pyloric stenosis (IHPS)., Design: Specimens from 18 infants with IHPS and 8 control specimens were examined using double-immunostaining with c-Kit and HO-2 antibodies. The immunolocalization was detected with the help of confocal laser scanning microscopy., Results: Abundant HO-2 immunoreactivity was found in ICCs in the smooth muscle layer of normal pylorus. There was a decrease in the number of ICCs and lack of HO-2 immunoreactivity in ICCs in IHPS., Conclusions: The results of the present study provide the first evidence for the presence of HO-2 in ICCs in the normal human pylorus. The lack of ICCs and HO-2 in IHPS suggests impaired intracellular communication between ICCs and smooth muscle cells, contributing to motility dysfunction in IHPS.

Objective: To evaluate the results of laparoscopic pyloromyotomy in infants with hypertrophic pyloric stenosis (HPS)., Design: Retrospective., Method: Data from medical records were collected on all children who underwent laparoscopic extramucosal pyloromyotomy for hypertrophic pyloric stenosis in the period from 1 October 1993 to 31 March 2001 in the Wilhelmina Children's Hospital of the Utrecht University Medical Centre, the Netherlands., Results: A total of 133 children were operated: 108 boys (81%) and 25 girls (19%). The mean age on the day of operation was 35.3 days (SD: 15.4). Of these children, 17 (13%) were ex-prematures and 8 (6%) were ex-dysmatures, and 40 (30%) had a positive family history for HPS. The mean operating time was 29 min (SD: 10); per surgeon, the first 5 operations required over 30 minutes on average and the following operations lasted an average of 26 minutes. Postoperatively, 84 patients (63%) no longer vomited. Four children required a second operation. The mean period from operation to discharge was 61.6 hours (SD: 46.0). Complications included: perforations of the mucosa (n = 4; 3%), wound infections (n = 4; 3%) and small incisional hernias (n = 5; 4%)., Conclusion: Laparoscopic pyloromyotomy is an efficient and safe operative technique for the treatment of infants with HPS.

Introduction: In spite of the clinical experience about infantil Hypertrophic Pyloric Stenosis (IHPS), its etiopathology remains unknown. Recent studies have been focussed in immunohistochemistry techniques for valuing the neuronal development in the pyloric muscle., Material and Methods: We took biopsy from 10 babies diagnosed of IHPS and 10 babies with similar age, died because of other causes. Immunohistochemical study was performed using monoclonal antibodies: S100 protein, GFAP, enolasa and neurofilaments NF. The results were showed semi-quantitativement as strong (++), moderate (+) and absent (-). Immunotinction of the myenteric plexus (ganglion cells and satellite) and nervous fibers of the muscle layer, were done., Results: We observed a poor immunoreactivity in the muscle layer (longitudinal and circular) in the 60-70% of specimens of pyloric muscle in babies with IHPS. GFAP were absent in the 80% in the myenteric plexus. This poor innervation may be related to the etiopathogenesis of pyloric stenosis and hypertrophy.

Hypertrophic pyloric stenosis (IHPS) is the most common abdominal abnormality requiring surgery in infants. It occurs due to the hypertrophic and hyperplasia of the muscular layers of the pyloric. The usual age of clinical presentation is about three weeks of life. The most important symptom is non bilious emesis, intermittent or after each feeding. From march 1996 to June 2001, 21 infants, 20 males and 1 female, were subjected to ultrasonographic, radiographic exams and after diagnosis to the pyloromyotomy extramucosa. Ultrasonography was the study of choice used to identify hypertrophic pyloric stenosis; the markers to analyse were the length and the overall diameter of the pyloric canal and the muscle thickness of the wall. The results showed that a length of the pyloric canal 20 +/- 6 mm, a diameter 13.6 +/- 2.5 mm and a muscle thickness 4.1 +/- 1 mm are diagnostics for hypertrophic pyloric stenosis.

The authors report on a male infant aged 4(1/2) weeks who underwent a pyloromyotomy for hypertrophic pyloric stenosis. After an uncomplicated postoperative course with normal feeding and weight gain, projectile vomiting reoccurred. The boy underwent a repyloromyotomy for recurrent hypertrophic pyloric stenosis. The underlying cause of a recurrent hypertrophic pyloric stenosis after a successful pyloromyotomy may be explained by the natural history of the disease., (Copyright 2002, Elsevier Science (USA). All rights reserved.)

Hypertrophic pyloric stenosis (HPS) is the most common surgical condition producing vomiting in infants. It has been reported as early as the 1st week of life. We report an infant with HPS seen on prenatal ultrasound. Although infants with HPS usually present between 3 and 5 weeks of life, HPS must be considered as part of the differential diagnosis of newborns with non-bilious vomiting.

The authors present a case of an infant who was treated for recurrent vomiting following pyloromyotomy. Gastroscopic examination showed a polypoid tumour of 4-5 mm in diameter located at the antral region. The patient recovered following re-pyloromyotomy.

Objective: To assess the link between very early erythromycin exposure and pyloric stenosis in young infants., Design: Retrospective cohort study., Participants and Methods: Medicaid or TennCare (Tennessee's program for Medicaid enrollees and uninsured individuals) births in Tennessee from 1985 to 1997. Cases of infants with a hospital discharge diagnosis of pyloric stenosis and an associated surgical procedure code were used. Erythromycin exposure and other antibiotic exposure between 3 and 90 days of life were identified from prescription files., Main Outcome Measures: Hospital discharge diagnosis of pyloric stenosis, and an associated surgical procedure code., Results: Of 933 239 births in Tennessee during the study period, 314 029 were enrolled in Medicaid. Among these infants, 804 (2.6/1000 infants) met the criteria for pyloric stenosis. Very early exposure to erythromycin (between 3 and 13 days of life) was associated with a nearly 8-fold increased risk of pyloric stenosis (adjusted incident rate ratio, 7.88; 95% confidence interval, 1.97-31.57). No increased risk of pyloric stenosis was seen in infants exposed to erythromycin after 13 days of life or in infants exposed to antibiotics other than erythromycin., Conclusions: The significant increase in pyloric stenosis in children with very early exposure to erythromycin is consistent with reports of other investigators. The risks and benefits of erythromycin should be weighed carefully prior to initiating such therapy in young infants.

Hyperplastic gastric polyps account for the majority of benign gastric polyps and are generally diagnosed by routine gastroscopy as they rarely become symptomatic. We report a 79-year-old woman who presented with intermittent attacks of bloating, belching, nausea and vomiting. Endoscopy showed a pedunculated polyp in the gastric antrum prolapsing through the pylorus, thus obstructing the gastric outlet. The polyp was repositioned with an endoscopic forceps and then removed at its pedicle by endoscopic snare excision. Histologic examination showed a hyperplastic polyp without dysplasia or malignancy. The significance of gastric polyps is discussed from the clinical point of view.

This study aimed to quantify the neural changes in congenital pyloric stenosis in dogs and to study the comparative anatomy between this condition in dogs and that in infantile hypertrophic pyloric stenosis. Eight specimens from the pylorus of dogs with pyloric stenosis and six control specimens were examined using conventional histology and immunohistochemistry for a range of neural antigens. The changes in the proportion of nerves immunoreactive for each antigen were quantified and analysed statistically. The morphology of the nerves in the diseased dogs was similar to that in controls. Only vasoactive intestinal peptide was reduced in expression in dogs (median proportion in control dogs 0.57, in diseased dogs 0.17; P = 0.065). This study demonstrates both morphological similarities and significant differences between closely related conditions in dogs, humans and other species.

Congenital hypertrophic pyloric stenosis (CHPS) is a common condition in infancy associated with smooth muscle hypertrophy and resulting in pyloric outlet obstruction. The final diagnosis of CHPS is based on precise ultrasonographic measurements of length and width of the pyloric muscle. Based on our clinical and sonographic experience, we observed that smaller measurements of the pyloric muscle were obtained in dehydrated infants than in children examined after proper fluid restoration. The clinical importance of these observations was evident because false-negative results could be obtained. An experimental animal work followed, proving our clinical observation to be true. A significant difference of about 30% to 50% was found between measurements of the muscle thickness of the gastric and pyloric muscles in a state of water deprivation, as compared with a state of full hydration (p < 0.05). Based on our preliminary results, we suggest that children with suspected CHPS should be well hydrated before the ultrasound (US) examination is performed, to avoid false-negative results and a consequent delay in treatment.

Background/purpose: Proponents of subspecialization in surgery claim that fellowship training improves the quality of care. Others claim that general training is adequate for most routine surgical procedures. The authors questioned whether there were differences in outcomes when general surgeons (GEN) operate on children and infants with common surgical conditions compared with the care of their pediatric surgical (PED) colleagues., Methods: The authors retrospectively reviewed the Healthcare Investment Analysts North Carolina Information Network database to identify patients who underwent pyloromyotomy for congenital hypertrophic pyloric stenosis in North Carolina during the period from October 1995 through September 1998 (n = 780). Information obtained included demographics, insurance type, hospital, length of stay, total hospital charges, occurrence of mucosal perforation, and type of surgeon (general v pediatric)., Results: Of the 780 pyloromyotomies performed, 363 (48%) were performed by pediatric surgeons. Pediatric surgeons cared for more Medicaid patients than general surgeons (PED, 52% v GEN, 40%; P =.001). Infants treated by pediatric surgeons had a lower incidence of mucosal perforation (PED, 0.5% v GEN, 2.9%; P =.0015), which was associated with decreased overall total hospital charges (no perforation, $4,806 plus minus 79 v perforation, $6,592 plus minus 492; P =.002). When patients with uncomplicated pyloric stenosis were evaluated (96% of cases), those cared for by pediatric surgeons had lower total hospital charges (PED, $4,496 plus minus 95 v GEN, $5,121 plus minus 121; P =.0001) and shorter length of stay (PED, 2.7 plus minus 0.1 days v GEN, 3.1 plus minus 0.1 days; P =.01)., Conclusions: In North Carolina, general surgeons treat more than half the patients who have pyloric stenosis, though fewer with Medicaid. The cost and incidence of mucosal perforation were increased in infants with pyloric stenosis when care was provided by general rather than pediatric surgeons., (Copyright 2002 by W.B. Saunders Company.)

The safety profile of erythromycin is notable for the frequent occurrence of intolerable gastrointestinal effects. One of the more serious of these is infantile hypertrophic pyloric stenosis (IHPS). A recent cluster of IHPS cases prompted an epidemiological investigation which identified oral erythromycin chemoprophylaxis of pertussis as the major risk factor. Evidence suggests an association between early postnatal erythromycin exposure and IHPS. There is no substantive evidence of a risk associated with prenatal exposure, with the single published case-control study to date producing negative findings. The epidemiological investigations of the association with early postnatal exposure have reported significantly elevated odds ratios but have a variety of methodological limitations that prevent definitive conclusions being made. Nevertheless, the concordance of findings across studies increases the strength of evidence favouring an association. The prominent gastrokinetic properties of erythromycin have been postulated as the mechanism behind this phenomenon. A comprehensive assessment of this potential adverse effect should consider its biological plausibility in light of known gastrointestinal physiology, its modulation by erythromycin, and the known pathophysiology of IHPS. Gastrointestinal motor activity in the fasted mammal consists of three phases, phase III being large amplitude contractions called migrating motor complexes (MMC) that can be initiated by motilin and erythromycin. The gastrokinetic effects of erythromycin are variable and complex and include effects on the timing, duration, amplitude and distribution of MMCs. It has been speculated that the motilinomimetic effects of erythromycin on antral smooth muscle function, such as the MMC, may mediate the effect via work hypertrophy. Although intuitively plausible and consistent with hypertrophic obstructive changes similar to IHPS observed in hyperplastic rat ileum after artificially induced mechanical obstruction, there is no direct evidence of this phenomenon. Further complicating the association is the limitations of our knowledge about the pathophysiology of IHPS, including numerous genetic abnormalities, increased parietal cell mass, and gastric hyperacidity. The implications of the reported findings with erythromycin on the benefit-risk profiles of newer macrolides and azalides must be considered. The available data on the comparative gastrokinetic properties of macrolides are significant for the potent gastrokinetic properties and its acid degradation products, the marked variation in gastrokinetic properties associated with macrolide ring size, and the requirement for specific glycosidic linkages at the C-3 and C-5 carbons of the macrolide ring. The variation in gastrokinetic properties associated with variations in molecular structure suggests that if the association between erythromycin and IHPS is causal it may not be a class effect.

Background/purpose: Periodic clusters of phasic pressure waves in the gastroduodenal junction (GDJ) have been seen in patients with infantile hypertrophic pyloric stenosis (IHPS). This study investigated the details of these pressure waves in relation to disturbed transpyloric flow in IHPS., Methods: Manometric study was performed in 11 IHPS patients before and after atropine therapy and 2 non-IHPS infants. Pressure changes in the GDJ were measured with an 8-channel sleeve or a 9-channel sidehole micromanometric assembly under fluoroscopic control for 2 hours., Results: Clusters of phasic pressure waves (365 +/- 42 mm Hg) associated with an increase in basal pressure (10 +/- 3 mm Hg) were intermittently observed in the GDJ in all IHPS patients. Similar observations were not made in the non-IHPS infants. Most antral pressure waves occurred simultaneously with those pressure waves in the GDJ in the IHPS patients. Atropine (0.01 mg/kg) transiently abolished the phasic and tonic pressure waves for 19 +/- 10 minutes. Significantly fewer phasic pressure waves were observed after atropine therapy., Conclusions: Characteristic phasic and tonic contractile activity in the GDJ is uncoordinated with the antral contractions in IHPS patients. Such incoordination may be an important factor in the disturbed transpyloric flow in IHPS., (Copyright 2001 by W.B. Saunders Company.)

Studied among indices for the glutathione system in 99 patients was content of total, oxidized, reduced glutathione. The studies made suggested that in patients beyond 60 years of age there are profound inadequecies in the glutathione system manifested by an apparent reduction in total, reduced glutathione and augmentation of the oxidized form in the blood. Surgical treatment in the above patient population has not been found to be associated with bringing all studied forms of glutathione back to normal, which fact attests to the need for quest of drugs-antioxidants to be employed in the complex of postsurgery curative measures.

Background/purpose: Idiopathic hypertrophic pyloric stenosis (IHPS) is a common infantile disorder characterized by enlargement of the pylorus and gastric outlet obstruction. Its complete etiology is still not fully understood, but recent research has focussed on abnormalities of nerve distribution. The authors used confocal laser scanning microscopy to perform 3-dimensional studies of pylorus biopsy specimens taken from cases of IHPS and present their findings., Methods: Pylorus biopsy specimens obtained at pyloromyotomy from 6 infants with IHPS were studied using confocal microscopy and compared with 6 control pylorus biopsy specimens from patients without gastrointestinal disease. Biopsy specimens were pretreated to enhance nerve expression by using protein gene product 9.5 (PGP9.5) polyclonal antibody to identify enteric nerve system fibers. Double staining immunofluorescence was used to detect alpha smooth muscle actin (SMA), a smooth muscle marker., Results: Control pylorus biopsy specimens showed many thin PGP9.5-positive nerve fibers in the circular and longitudinal muscle layers that communicated with each other to create a 3-dimensional meshlike network. Muscle cells stained by alpha SMA antibody were thin. In contrast, muscle cells from IHPS patients were fat and round. The PGP9.5 staining nerve fibers from IHPS patients formed numerous, thick, and contorted bundles that did not communicate., Conclusions: By using confocal laser microscopy the authors were able to identify abnormally thick contorted nerve bundles in the pyloric muscle layers of infants with IHPS. These anormal nerve bundles have not been described previously because of the limitations of 2-dimensional microscopy. The authors suspect that the etiology of IHPS may be related to these abnormal fibers., (Copyright 2001 by W.B. Saunders Company.)

Background/purpose: Increasing evidence suggests that the enteric nervous system is under the control of neurotrophins. Nerve growth factor (NGF), brain-derived neurotrophic factor (BDNF), neurotrophin-3 (NT-3), and neurotrophin-4/5 (NT-4/5), promote differentiation, growth, and survival of various central and peripheral nervous system neurons. The biological effects of neurotrophins are mediated by the interactions with high-affinity tyrosine kinase receptors (TrkA, TrkB, TrkC). Recently, abnormalities of intramuscular innervation have been reported in infantile hypertrophic pyloric stenosis (IHPS). To further understand the reported abnormalities in pyloric innervation in IHPS, the authors analyzed the expression of Trk receptors and the neurotrophins content in IHPS., Methods: Full-thickness muscle biopsy specimens were obtained from 8 IHPS patients (age range, 23 to 41 days) at pyloromyotomy and from 8 age-matched controls without gastrointestinal disease at autopsy performed within 12 hours after death. Indirect immunohistochemistry was performed using ABC (Avidin Biotin peroxidase Complex) method with anti-Trk specific antibodies (A,B,C). Quantitative analysis was performed using sandwich-type ELISA for NGF, BDNF, NT-3, and NT-4/5., Results: The intensity of staining of the myenteric plexus for TrkA, TrkB, and TrkC was similar among IHPS and controls. There was a lack of TrkA-positive nerve fibers in IHPS compared with controls. The quantity of total NGF, NT-3, and BDNF in IHPS was significantly lower than in controls., Conclusions: The reduced production of neurotrophins in IHPS may be responsible for the delay in the functional and structural maturation of pyloric innervation in IHPS. The lack of TrkA-positive nerve fibers in pyloric muscle may explain the abnormal intramuscular innervation in IHPS., (Copyright 2001 by W.B. Saunders Company.)

Introduction: Infantile hypertrophic pyloric stenosis (IHPS) consists of hypertrophy of the muscular layer of the pylorus. Its etiology is still unknown. In the last years only few jobs that studied the extracellular matrix (ECM) in the muscular layer in the IHPS have been reported. Our aim was to investigate the expression of two ECM molecules: chondroitin-sulfate proteoglycan (CSPG) and fibronectin (FN), and fibroblasts., Material and Methods: Full-thickness muscle biopsy specimens were obtained from 33 IHPS patients at pyloromyotomy and 12 controls. Indirect immunohistochemistry was performed using CSPG, FN and fibroblasts monoclonal antibodies. The results were showed by a semiquantitative scale as follows: strong (++), moderate (+), weak (+/-), and absent (-)., Results: We demonstrated that the CSPG immunoreactivity was localized in the connective tissue septa and the expression of FN molecules in the pericellular space. Both molecules were significantly the increased in the muscle layer of the pylorus with IHPS in relation to control pylorus. We also demonstrated a marked increased expression in the number of fibroblasts in the muscle layer of the pylorus with IHPS. Even-though the most striking increase was localized in the septa, we also observed great number of fibroblasts amongst the smooth muscle cells., Conclusions: We suggest that IHPS is characterized, not only by the muscle layer hypertrophy, but also by the increase of several ECM molecules, such as CSPG and FN. We also think that the increase of fibroblast could explain the higher expression of both ECM molecules in the muscle layer of pylorus in IHPS.

The authors present a case of epidermolysis bullosa lethalis (EBL) associated with a double obstruction, one at the pyloric and the other in the anorectal region. Both obstructions could be due to separation of the rectal mucosa during intrauterine life followed by adhesive closure of its wall. Both the gastrointestinal lesions could be part of the generalized denudation process involved in EBL.

Purpose: The aim of this study was to study nitric oxide synthase (NOS) immunohistochemistry in the pyloric muscle and establish the role of nitric oxide in pyloric stenosis., Methods: Pyloric muscle biopsy specimens were obtained from 20 patients with pyloric stenosis during pyloromyotomy. Ten control specimens without pyloric disease were obtained from autopsy performed less than 4 hours after death on age-matched babies who died of other causes. Tissues were fixed in 4% paraformaldehyde immediately. A monoclonal antibody against the neuronal form of NOS (bNOS) was used for immunohistochemistry., Results: Immunohistochemistry showed activity of bNOS in the control specimens and some pyloric stenosis specimens. This shows that NOS is present in the pylorus in normal cases as well as in a few cases of pyloric stenosis., Conclusions: NOS deficiency leading to lack of locally available nitric oxide causes a failure of smooth muscle relaxation. This may account for the cause of pyloric stenosis in infants. However, this study shows that this is true probably only in a subset of cases. The etiology of pyloric stenosis may still be multifactorial. Further investigations are required regarding the etiology of pyloric stenosis. J Pediatr Surg 36:616-619., (Copyright 2001 by W.B. Saunders Company.)