Incidence is 1.5 to 4 per 1000 births. Infants usually present at 3-4 weeks after birth. However, many babies are even presenting at 7 -10 days of life, these are attributed by many authors due to increased use of formula feed. The disease shows a male predominance with male: female ratio ranging from 2:1 to 5:1. Pyloric stenosis is common in first born males.

The disease is considered multifactorial with no certain aetiology proven so far.

Hereditary, genetic, cow milk allergy, exposure to certain antibiotics, and abnormal innervation of pyloric muscles have been suggested by various authors.

Abnormal hypertrophy of the pyloric muscles leading to gastric outlet obstruction and thereby causing projectile non-bilious vomiting often leading to severe dehydration, electrolytes, and acid-base imbalance.

• Usually, an infant that tolerated feeds previously or with minor regurgitation followed by rapid progression to projectile vomiting after each feed

• Infant typically hungry after each feed

• Infants < 4 weeks old with progressive Projectile non bilious vomiting - SUSPECT PYLORIC STENOSIS.

• Pyloric Atresia.

• Antral web.

• Foveolar Hyperplasia.

• Gastric Duplications.

Pyloric atresia may be associated with Epidermolysis bullosa an association known as Carmi syndrome.

• Abdominal Examination: Look for visible gastric peristalsis.

• Palpable olive-like mass diagnostic: To palpate the mass techniques like suctioning the stomach via NG tube, flexing the hips to relax rectus abdominis, allowing baby suck on drops of glucose water helps to relax the baby using your index and middle fingers.

• Assess hydration; if dehydrated Bolus with Normal Saline (NS) 20ml/kg.

• Following bolus – start 5% dextrose (D5) + ½ NS +20mEq KCl/L at 150ml/kg/day (add K+ only after urine output established).

• Gastric decompression by anesthesiologist with a large bore orogastric tube in theatre prior to induction.

• Check electrolytes (watch for alkalosis).

• Consider bilirubin if infant appears to have jaundice.

Hypokalemia, hypochloremia, metabolic alkalosis, paradoxical aciduria, hyperbilirubinemia.

• Imaging of choice is ultrasound. It is accurate, avoids radiation. Pyloric muscle thickness >4 mm is diagnostic and most commonly used criterion. Other criteria – pyloric canal length >16mm, pyloric diameter >12mm etc.). Smaller premature babies may not meet this threshold.

• Upper G.I contrast if results of USS are ambiguous.

Preoperative

• Continue D5 ½ NS with 20mEq KCl/L @ 150 ml/kg/day (add K+ only after urine output established) Venous Blood gases and electrolytes If bicarbonate is > 30 mEq/L, K < 3mEq/L, Cal < 9mg/L Continue resuscitation and repeat electrolytes in 8 hours

• Target is Bicarbonate <30mmol/L, Chloride >100 mmol/L

• Because the compensatory mechanism for metabolic

alkalosis is hypoventilation/respiratory acidosis, correction is necessary to prevent postoperative apnea

• Open Pyloromyotomy

- Supraumbilical cosmetic incision

- Right upper quadrant

• Laparoscopic Pyloromyotomy: Adequate length of pyloromyotomy is essential to avoid recurrence

If iatrogenic mucosal perforation:

• Give antibiotics, repair, turn 180 degrees, re-do pyloromyotomy, leave NG insitu and feed as tolerated.

• No role for any routine post-operative antibiotics

• IV + PO fluids: D10 1/2 NS with 20 mEqKCl/L at 100ml/kg/day.

• NPO X 4 hours.

• Graded feeding regimen (can vary according to local institute protocol) Make sure that the child has fully recovered, alert and active.

• Start with clears (glucose water or ORS) 30 ml q2h X 2

• Half strength formula 30 ml q2h X 2 or start breast milk slowly.

• Advance as tolerated to oral feeds.

• If clinically significant emesis, withhold feeds one cycle and restart at previously

• Role of atropine is controversial; not recommended by most.

• Redo Pyloromyotomy

It is sometimes required in children with persistent

vomiting after surgery.

• Persistent vomiting after pyloromyotomy should bec onservatively managed for at least 48-72hrs and then re-evaluated by USG to see the persistent thickness of pyloric muscle to rule out incomplete pyloromyotomy.

• An upper GI contrast study is also suggested by a few authors in case diagnostic dilemma.

• Incomplete myotomy - occurs on gastric side.

• Perforation - occurs on duodenal side.

• If iatrogenic mucosal perforation:

repair and keep NPO x 24 hours - advance directly to pyloric feeding.

• No role of any routine post-operative antibiotics

• IV fluids

• NPO for 6 hours.

• NG tube is removed post-op by some; while used for graded NG feeds by some

• Graded feeding regimen (can vary according to local institute protocol) Make sure that the child has fully recovered, alert and active.

• Advance as tolerated to oral feeds.

In sub-Saharan African settings, the understanding and management of pyloric stenosis face unique challenges due to limited healthcare resources, delayed diagnosis, and variable access to surgical interventions. Awareness campaigns, improved diagnostic tools, and accessible treatment options are critical to reducing morbidity. Integrating these with local healthcare systems can significantly improve outcomes, emphasizing the importance of early detection and culturally sensitive care approaches tailored to the region's specific needs.