Pylorosthenosis( stenosis of the pylorus) - Causes, symptoms and treatment. MF.

Pylorostenosis is a scar deformity of the pyloric part of the stomach in the area of ​​its pyloric, which can occur in both adults and children. Pylorostenosis must be distinguished from pylorospasm, since in the former case irreversible replacement of normal muscle tissue with dense scar tissue occurs, and in the second case, dysfunction of the pylorus is caused by functional changes in the tone of his muscles.

Pylorus is a part of the digestive tract, located between the stomach and duodenum, represented by a well developed layer of circular muscles in the form of a sphincter. The function of the sphincter is the closing of the lair of the gatekeeper during the digestion of food in the stomach, the opening at the time of evacuation of food gruel from the stomach into the 12-colon, and the closing when digesting food in the small intestine. Such a well-coordinated mechanism of the pylorus's operation, which is under the control of the autonomic nervous system, provides a distinction between different environments - the acid medium in the stomach and the alkaline in the small intestine. This is important in order that the acidic gastric juice does not irritate the mucosa of the duodenum, and also so that there is no reverse transfer of contents from the intestine to the stomach( reflux).

With pyloric stenosis, the pyloric sphincter can not relax and contract because the scar tissue does not have such properties, unlike the muscle. As a result, the passage of the food lump is broken through the digestive tract, food is delayed in the stomach for a long time, and in severe cases even the minimum volume of liquid is unable to overcome the barrier in the form of dense formation instead of the pylorus. This leads to significant digestion disorders - a reduction in absorption and assimilation of vital nutrients.

Causes of pyloric stenosis.

In adults, pyloric stenosis develops gradually in the presence of diseases such as gastric ulcer and bulb of duodenum, chronic gastritis, stomach polyps in the outlet, malignant tumors of the stomach and small intestine. These diseases with progression involve the mucous membrane of the pyloric section, as a result of which normal tissues are replaced by a dense scar, unable to move food into the intestine.

In children, the disease is more often congenital, its causes are not fully understood. Predisposing factors can be considered heredity, viral infections suffered by the mother in the first trimester, toxicosis in the early stages, the presence in a pregnant woman of an endocrinological or other pathology requiring medications. More often such a developmental disorder occurs in boys, is detected in 6-30 children per 10000 newborns. In some cases, pyloric stenosis in children is combined with other malformations( heart defects, polycystic kidney disease, syndactyly, etc.).

Symptoms of pyloric stenosis.

In adult , the symptoms of pyloric stenosis appear gradually. In the development of the disease, the phases of compensation, subcompensation and decompensation of the are isolated. With the of the first two , the general condition of the patient suffers insignificantly, signs of gastrointestinal lesions are more marked - a decrease in appetite, a severe bloating, a lack of stool for several days, a frequent eructation with putrefactive odor and vomiting of food eaten two to three days before. On examination, especially in lean people, the visible boundaries of the enlarged stomach are determined.

In the phase of decompensation of , besides abundant frequent vomiting with stagnant contents, there are pronounced violations of all kinds of metabolism - significant weight loss, hair loss, decreased skin elasticity caused by dehydration, pallor and weakness due to anemia. There is a convulsive syndrome, which developed as a result of a gross violation of the exchange of electrolytes - potassium, calcium, magnesium.

The appearance of such symptoms on the background of a stomach ulcer, polyps or a tumor should alert the patient and encourage him to see a doctor as soon as possible for examination.

In children, the disease is usually manifested in the second week of life. The child often regurgitates, and then symptoms develop for several days, such as frequent vomiting of the fountain up to ten times a day or more, and vomit, represented by curdled milk, have an unpleasant, sour smell, blood veins or brown staining of vomit. In the absence of treatment during this period, hypotrophy, or lack of body weight, a decrease in the number of urination and the volume of urine output, a decrease in skin elasticity, a westernization of the large fontanel, a prolonged absence of stool develop. With further progressing, violations of the water-salt balance are noted, and convulsions may develop. During the examination, parents can notice the baby's contractions of a crowded stomach under the skin of the abdomen, and with a massage of the tummy determine the presence of a dense tumor-like formation in its upper right.

A newborn child with similar symptoms should be examined immediately by a doctor, as pyloric stenosis, if left untreated, can lead to death due to severe metabolic and dehydration disorders.

Diagnosis of the disease.

Additional diagnostic methods are prescribed to confirm the diagnosis, in addition to routine blood and urine tests:

- Gastroscopy - allows to assess the presence of a causative disease( ulcer, polyp, tumor), to determine the degree of stenosis of the pylorus, expansion of the stomach and its atonic, stretched walls,
-X-ray of the stomach with contrasting barium suspension is carried out immediately after filling the stomach and after a few hours. Violation of the evacuation function of the stomach is considered a delay of contrast in it for more than 8 hours. A delay of 24 hours or more is a sign of decompensated pyloric stenosis.
- MRI or CT of the abdominal cavity allows better evaluation of tumor location, extent of affection of adjoining organs, and also determine the thickness of the walls of the stomach and the thickness of the pylorus.

Treatment of pyloric stenosis.

The treatment of stenosis of the pylorus is only surgical. In the presence of the underlying disease in an adult, surgical removal of a part of the stomach( resection) in the area surrounding the ulcer or tumor is indicated. Polyps showed polypectomy. In parallel with gastric resection, pyloroplasty is performed - longitudinal dissection of the pylorus from the outside with suturing the cut in the transverse direction to widen its lumen. In the case of an inoperable tumor, the gastroejunoanastomosis is superimposed - an anastomosis between the stomach and the gut to ensure food progress.

Children is sufficient to perform pyloroplasty while maintaining the anatomical integrity of the stomach.

Operations are performed under general anesthesia with laparotomy access - with dissection of the anterior abdominal wall. Two to three days before the scheduled intervention, preoperative preparation is performed - gastric lavage, intravenous infusion of electrolytes and protein solutions to correct dehydration and salt metabolism disorders.

Postoperative treatment is limited to strict diet, prescription of antibiotics, taking antiulcer drugs, and in case of cancer of the stomach or intestine, chemotherapy and radiation therapy are indicated.

Lifestyle with pyloric stenosis.

Recommendations on diet and lifestyle for adults and children vary. When treating an adult , a strict diet should be followed for 3-4 days after surgery, with a gradual expansion of the menu. Rinsed soups, low-fat cereals, a steam omelet, stewed vegetables and fruits in baked form or compote are allowed. Two to three weeks after the operation, it is allowed to use sour-milk products, fresh bread, steam cutlets from low-fat meat and fish.
Further recommendations are reduced to a lifelong adherence to the principles of rational nutrition with the exception of "harmful" foods - fatty, fried, smoked foods and salty foods.

Newborn after the operation, it is allowed to feed expressed breast milk every two hours, and on day 5-6 to go on to full-fledged breastfeeding or artificial feeding.

In addition to proper nutrition, to avoid recurrences of diseases of the gastrointestinal tract, adult patients need to avoid stress, more rest and walking outdoors.

Complications.

In children , the period of pyloric stenosis with frequent vomiting can be complicated by the development of asphyxiation( asthma), otitis and aspiration pneumonia. Also, an unfavorable outcome is expected from dehydration, severe hypotrophy, metabolic disorders and associated purulent-septic complications( meningitis, pneumonia, sepsis, etc.).

Adult complication is the complete cessation of absorption of nutrients with the development of dystrophy.
Complications after surgery are rare, including inflammation of the postoperative wound, inconsistency of the joints and bleeding from the wound.

Forecast.

Prognosis in the absence of treatment is unfavorable. With a timely call to the doctor and the time of the operation performed, the forecast is favorable. Children after surgery in physical and psychomotor development do not lag behind their peers, unless there is another serious pathology.

In the tumor nature of pyloric stenosis, the forecast is doubtful.

Doctor therapist Sazykina O.Yu.