The Three Ps of Pyloric Stenosis
The back story of pyloric stenosis is fascinating. It is a relatively minor surgical condition today, but the disease had a mortality of 100 percent before 1904, when only five operative cases were known to have been performed in the United States. The dying process was slow and painful, and parents watched their infants slowly starve to death.The pyloromyotomy procedure currently used to treat pyloric stenosis was introduced by Conrad Ramstedt, MD, in 1911 at the Children's Hospital of Munster, and is still called the Ramstedt procedure. Before surgical management was introduced for this gastric outlet obstruction, multiple unsuccessful medical therapies had been attempted, including treating infants with bromides, antipyrine, cocaine, novocain, belladonna, and atropine.Attempts at emergency fluid resuscitation involved administration subcutaneously or as nutrient enemas, the rectal administration of nutrient-containing solutions. Only atropine has shown evidence of success. In fact, a 2005 article by Kawahara, et al., described 45 of 52 patients (86.5%) whose projectile-vomiting was stopped using intravenous atropine. (J Pediatr Surg. 2005;40:1848.) Treatment with intravenous atropine (median of 7 days) was followed by oral atropine (median of 44 days). The median hospital stay was 13 days (6-36 days). The relevance of a medical therapy to us in emergency medicine is the patient who is clinically unstable or has contraindications for immediate surgery. Atropine i...
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