NSAIDs, Nonsteroidal anti-inflammatory drugs.
Treatment of pyloric stenosis includes IV fluid and electrolyte resuscitation followed by surgical pyloromyotomy.Before surgery, dehydration and hypochloremic alkalosismust be corrected, generally with an initial normal salinefluid bolus followed by infusions of half-normal salinecontaining 5% dextrose and potassium chloride whenurine output is observed. In pyloromyotomy (often by laparoscope), the pyloric muscle is incised longitudinally torelease the constriction. Care is taken not to cut into the mucosa itself.
Acid-related injury can occur in the esophagus, stomach, or duodenum. Table 128-2 lists risk factors for peptic ulcer disease in children. Helicobacter pylori is responsible for more thanhalf of ulcers in the stomach and duodenum in adults. H. pyloriplays a significant but lesser role in childhood ulcer disease. Riskfactors for acquisition of H. pylori are low socioeconomic status and poor sanitation, with the highest incidence in developing countries. Nonulcer dyspepsia includes upper abdominalsymptoms (pain, bloating, nausea, early satiety) in the absenceof gastric or duodenal ulceration. Nonulcer dyspepsia is not associated with H. pylori infection. GER (see Chapter 128) allows acidic gastric contents to injure the esophagus, resultingin esophagitis. Esophagitis is characterized by retrosternal andepigastric burning pain and is best diagnosed by endoscopy. Itcan range from minimal, with only erythema and microscopicinflammation on biopsy, to superficial erosions and finally tofrank ulceration.
Typical symptoms are listed in Table 128-3. The presenceof recurrent burning epigastric and retrosternal pain is arisk factor for esophagitis. With duodenal ulcers, pain typically occurs several hours after meals and often awakenspatients at night. Eating tends to relieve the pain. Gastriculcers differ in that pain is commonly aggravated by eating,
Table 128-3 Peptic Disorders, Symptoms, and Clinical Investigation SYNDROME AND ASSOCIATED SYMPTOMS CLINICAL INVESTIGATION ESOPHAGITIS
Retrosternal and epigastric Endoscopy location Therapeutic trial of acid-blocker Burning pain therapy Sensation of regurgitation pH probe study Dysphagia, odynophagia
Upper abdominal location Endoscopy Fullness Therapeutic trial of acid-blocker Bloating therapy Nausea Upper GI series to ligament of
Treitz—rule out malrotation CBC, ESR, amylase, lipase, abdominal ultrasound “Alarm” symptoms Weight loss Hematemesis Melena, heme-positive stools Chronic vomiting Microcytic anemia Nocturnal pain Other symptoms—same as for esophagitis and nonulcer dyspepsia Endoscopy—mandatory with alarm symptoms Test for Helicobacter pylori CBC, ESR, amylase, lipase, abdominal ultrasound
CBC, Complete blood count; ESR, erythrocyte sedimentation rate; GI, gastrointestinal.
resulting in weight loss. GI bleeding from either can occur.Many patients report symptom relief with antacids or acidblockers.