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This is Pediatrics week one case one and the

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diagnosis under consideration is hypertrophic pyloric stenosis.

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And we're looking at ultrasound images.

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This is the current first line Imaging

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for suspected hypertrophic pyloric stenosis.

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The indication often is repeated vomiting or projectile vomiting

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and in the past we may have used

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fluoroscopic Imaging to evaluate. However, ultrasound

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is Superior in terms of portability. It's

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non-invasive and it's the first

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line Imaging used in almost all places in

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the United States at the current time. So we

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have this pyloric ultrasound here. And the first thing to remember before

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we can evaluate the images is to make

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sure we know what we're looking at and I say that because it's

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very simple to accidentally image The gastroesophageal Junction

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instead of the pyloris the gastric Inlet

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instead of the outlet. They're very close together. These are

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small patients and it is a very simple thing

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especially for an inexperienced technologist to put

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Probe in the wrong place and if you imagine what gastric

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reflux back into the esophagus would

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look like well fluid moving into a narrower structure. What

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is gastric emptying look like fluid moving

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into a narrower structure so you can get fooled the key

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thing to remember is

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where are we in terms of anterior or

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posterior location? The pylorus should be fairly anterior

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in the abdomen tucked just under the

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left lobe of the liver.

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The gastroesophageal Junction is posterior

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Because the esophagus is posterior. So you would expect it to

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be deeper backed by the great vessels backed by the spine. In this

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case. We don't see that we see an anterior structure

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we can feel good that we're actually looking at the pylorus

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and here we can see some shadowing ingested gastric

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contents. And here's the hypoechoic muscle of

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the pyloris. Now, we're going to scroll through and we're going to get some good

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elongated views of the pyloris, which

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is too long and the muscle is too thick good

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rules of thumb would be three and 15 the channel

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shouldn't be longer than 15 millimeters. The wall thickness shouldn't

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be greater than three millimeters. We're gonna put some

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measurements on that here in a minute and we're gonna see that it is indeed

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too long. So here we've got the pyloris

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measuring it approximately 2.3 centimeters.

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We've got complete collapse of

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the Lumen of the pyloric Channel just a little slip of fluid here.

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That's okay. You can still make the diagnosis if a

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few drops of fluid go through but if you're

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seeing a large bowl of material leave the stomach

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Is not hypertrophic pyloric stenosis. So what if it's on

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the border what if you're unsure of your measurements?

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Remember that you can give the child

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something to drink in the bottle. We use electrolyte water

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like Pedialyte and watch in real time

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Imaging while they drink that should stimulate the stomach

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to empty in a normal infant.

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And you can document the passage of materials once

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you've documented a bolus leaving the stomach you're done.

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It's a normal exam. But if you have borderline thickened

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measurements and nothing is leaving the

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stomach you can feel better about calling that hypertrophic pyloric

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stenosis. And that's exactly what we have here the walls

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too thick the muscles too long. Nothing leaves the stomach

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this patient needs to go to surgery for pyloromyotomy. That's

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the end of the case.