In a child of one month age with history of nonbilious vomiting and no weight gain with palpable epigastric lump, first investigation to be done is
Barium study
Ultrasonography
Endoscopy
CT scan
Ans. b (Ultrasonography) (Ref. Bailey and Love 25th/pg. 79)CONGENITAL HYPERTROPHIC PYLORIC STENOSIS (CHPS/IHPS)# Increased incidence in firstborn male child with M:F ratio 4:1. Incidence of hypertrophic pyloric stenosis is approximately 2-5 per 1,000 births per year.# Most commonly affects boys aged 2-8 weeks# Characterised by projectile vomiting after feeds# Gastric peristalsis can be seen and a lump felt# Inherited as dominant polygenic trait.# Ultrasound (investigation of choice)The diagnosis can be confirmed by an ultrasound scan, which shows the thickened pyloric muscle.# Pyloric muscle wall thickness 2.5-3 mm# Pyloric volume > 1.4 cm3# Pyloric length > 1.2 cm# Pyloric transverse diameter 13-16 mm with pyloric channel closed.- Target Sign: Hypoechoic ring and hypertrophied pyloric muscle around echogenic mucosa centrally (transverse scan).- Cervix sign and antral-nipple sign: indentation of muscle mass on fluid-filled antrum (longitudinal scan).Normal values:# Pyloric canal length: < 15 mm# Muscle wall thickness: < 3 mm# Pyloric width: < 7 mm# Contrast radiology (*Barium study) is now not necessary.# Upper Gl Imaging (barium study) -features- Elongation and narrowing of pyloric canal (2-4 cm length) with string sign, double/triple track sign, diamond sign/twining recess, pyloric teat/teat sign, beak sign/antral beaking, umbrella/kirklin/mushroom sign and caterpillar sign may be seen.# Treatment:- Ramsted's Pyloromyotomy (splits the hypertrophied muscle leaving the mucosa intact).Additional Educational points:ULTRASOUND is investigation of choice for diagnosing:# Initial test of choice (Screening) for blunt trauma abdomen (Focused Assessment by Sonography for Trauma), focal liver lesions, obstructive jaundice or acute abdomen.# Hydrocephalus in infants, Neonatal cerebral hemorrhage# To differentiate cystic and solid nodule in thyroid# Screening of rotator cuff injury# Pleural effusion# Gallstones, CHPS, ascitis (Minimal), Pelvic abscess# Developmental dysplasia of hip (DDH)/ CDH# Scrotal lesions
G.I.T.