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\def\makelabel##1{\upshape ##1}}% } {\end{list}\end{raggedright}} \newenvironment{specHead}[2]% {\vspace{20pt}\hrule\vspace{10pt}% \phantomsection\label{#1}\markright{#2}% \pdfbookmark[2]{#2}{#1}% \hspace{-0.75in}{\bfseries\fontsize{16pt}{18pt}\selectfont#2}% }{} \def\TheFullDate{2013-05-15 (revised: 15 May 2013)} \def\TheID{\makeatother } \def\TheDate{2013-05-15} \title{Infantile Hypertrophic Pyloric Stenosis: Presentation and Outcome in Khartoum Teaching Hospital} \author{}\makeatletter \makeatletter \newcommand*{\cleartoleftpage}{% \clearpage \if@twoside \ifodd\c@page \hbox{}\newpage \if@twocolumn \hbox{}\newpage \fi \fi \fi } \makeatother \makeatletter \thispagestyle{empty} \markright{\@title}\markboth{\@title}{\@author} \renewcommand\small{\@setfontsize\small{9pt}{11pt}\abovedisplayskip 8.5\p@ plus3\p@ minus4\p@ \belowdisplayskip \abovedisplayskip \abovedisplayshortskip \z@ plus2\p@ \belowdisplayshortskip 4\p@ plus2\p@ minus2\p@ \def\@listi{\leftmargin\leftmargini \topsep 2\p@ plus1\p@ minus1\p@ \parsep 2\p@ plus\p@ minus\p@ \itemsep 1pt} } \makeatother \fvset{frame=single,numberblanklines=false,xleftmargin=5mm,xrightmargin=5mm} \fancyhf{} \setlength{\headheight}{14pt} \fancyhead[LE]{\bfseries\leftmark} \fancyhead[RO]{\bfseries\rightmark} \fancyfoot[RO]{} \fancyfoot[CO]{\thepage} \fancyfoot[LO]{\TheID} \fancyfoot[LE]{} \fancyfoot[CE]{\thepage} \fancyfoot[RE]{\TheID} \hypersetup{citebordercolor=0.75 0.75 0.75,linkbordercolor=0.75 0.75 0.75,urlbordercolor=0.75 0.75 0.75,bookmarksnumbered=true} \fancypagestyle{plain}{\fancyhead{}\renewcommand{\headrulewidth}{0pt}} \date{} \usepackage{authblk} \providecommand{\keywords}[1] { \footnotesize \textbf{\textit{Index terms---}} #1 } \usepackage{graphicx,xcolor} \definecolor{GJBlue}{HTML}{273B81} \definecolor{GJLightBlue}{HTML}{0A9DD9} \definecolor{GJMediumGrey}{HTML}{6D6E70} \definecolor{GJLightGrey}{HTML}{929497} \renewenvironment{abstract}{% \setlength{\parindent}{0pt}\raggedright \textcolor{GJMediumGrey}{\rule{\textwidth}{2pt}} \vskip16pt \textcolor{GJBlue}{\large\bfseries\abstractname\space} }{% \vskip8pt \textcolor{GJMediumGrey}{\rule{\textwidth}{2pt}} \vskip16pt } \usepackage[absolute,overlay]{textpos} \makeatother \usepackage{lineno} \linenumbers \begin{document} \author[1]{Gamar Elanbia Elnour Abdalla} \affil[1]{ Sudan Medical Specialization Board(SMSB)} \renewcommand\Authands{ and } \date{\small \em Received: 12 April 2013 Accepted: 30 April 2013 Published: 15 May 2013} \maketitle \begin{abstract} Background/Aims : Infantile hypertrophic pyloric stenosis (IHPS) is a common cause of gastric outlet obstruction in infants, and presents as one of the most common surgical conditions of infancy. Although there were many published studies about IHPS worldwide; there was very few published study in our local literature. So we conduct this study to investigate IHPS in form of, presentation, management and overall outcome.Methodology : In this prospective cross -sectional, hospital based study; 42 patients with IHPS, were admitted in Khartoum Teaching hospital department of Pediatric Surgery in the period between Aug. 2011 and May. 2013. Patients were referred from all parts of Sudan. \end{abstract} \keywords{pediatric surgery, infantile hypertrophic pyloric stenosis (IH PS), ramsted?s pyloromyotomy.} \begin{textblock*}{18cm}(1cm,1cm) % {block width} (coords) \textcolor{GJBlue}{\LARGE Global Journals \LaTeX\ JournalKaleidoscope\texttrademark} \end{textblock*} \begin{textblock*}{18cm}(1.4cm,1.5cm) % {block width} (coords) \textcolor{GJBlue}{\footnotesize \\ Artificial Intelligence formulated this projection for compatibility purposes from the original article published at Global Journals. However, this technology is currently in beta. \emph{Therefore, kindly ignore odd layouts, missed formulae, text, tables, or figures.}} \end{textblock*} \let\tabcellsep& \section[{Introduction}]{Introduction}\par nfantile hypertrophic pyloric stenosis (IHPS) is a common cause of gastric outlet obstruction in infants, and presents as one of the most common surgical conditions of infancy. The lesion is characterized by gastric outlet obstruction and multiple anatomic abnormalities of pyloric antrum.\par The etiology of (IHPS) is obscure but probably is a multifactorial, involving genetic predisposition and environmental factors. Typically; infants with IHPS are clinically normal at birth, but during the first few weeks of postnatal life; they develops non bilious forceful vomiting described as "projectile" \hyperref[b0]{(1)} .\par The clinical diagnosis hinges on the palpation of the thickened pylorus or "olive " Abdominal examination is accurate but not always successful, depending on factors such as the experience of the examiner ,the presence of gastric distention and , a calm infant. \hyperref[b1]{(2)} Surgical treatment is curative. The classical operation is a Ramsted's Pyloromyotomy; which may also be performed laparoscopically Current imaging techniques, particularly sonography, are noninvasive and accurate for identification of (IHPS) \hyperref[b2]{(3)} .\par There was very few published study in our local literature. So we conduct this study to investigate IHPS in form of, presentation, management and overall outcome. \section[{II.}]{II.} \section[{Methodology}]{Methodology}\par In this prospective cross -sectional, hospital based study; 42 patients with IHPS, were admitted in Khartoum Teaching hospital department of Pediatric Surgery in the period between Aug. 2011 and May. 2013. Patients were referred from all parts of Sudan. Study variables included were age, gender, and residence, presenting symptoms, clinical sign and postoperative outcomes. Data was collected using a structured, pretested questionnaire and analyzed using a computer program-Statistical Package for Social Sciences (SPSS) version 20. Results were presented in tables and graphs. \section[{III.}]{III.} \section[{Results}]{Results}\par Forty two patients were admitted in Khartoum Teaching hospital, department of Pediatric Surgery, from Aug 2011 to May2013; with IHPS. Clinically 42(100\%) of the patients presented projectile vomiting; which found to be non bilious in 41(97.6\%) patients. 34(81.0\%) of the patients had marked weight loss while 24(57.1) of them present with constipation.\par Regarding clinical examination 37(88.1\%) of the patients were dehydrated, 38(90.5\%) had palpable epigastric olive like mass while just 29(69.0\%) of them had visible peristaltic wave. With 24(57.1) of the patient had abdominal distension.\par Thirty (71.4\%) patients had normal Hb level, 24(57.1\%) showed low serum K + level compared to 18(42.9) with low serum Na + . 8(19\%) of the patient had high blood urea level, while just one (2.4\%) had elevated serum creatinine.\par Abdominal U/S done for all patient; which confirm the diagnosis in 41(97.6\%) of the patients, while contrast study was needed to confirm the diagnosis just in one (2.4\%) patient.\par All the 42 patients received open surgical intervention, and Ramsted's pyloromyotomy was done successfully to all patients; with only 4.8\% complication, and 2.4\% mortality Twenty five (59.5\%) of our patients had an average postoperative stay of 48 hours. \section[{IV.}]{IV.} \section[{Discussion}]{Discussion}\par Although there were many published studies about IHPS worldwide; there was very few published study in our local literature. So we conduct this study to investigate IHPS in form of, presentation, management and overall outcome.\par In our study we reviewed 42 patients; admitted in Khartoum Teaching hospital department of Pediatric Surgery with IHPS; from Aug. 2011 to May. 2013. Comparison of our study with the AC Paul, etal \hyperref[b5]{(6)} , Frieda Hulka, etal \hyperref[b7]{(8)} , Jlidi S, etal \hyperref[b8]{(9)} , Taylor, etal \hyperref[b3]{(4)} , and ?smet Faruk ÖZGÜNER, etal {\ref (7)} revealed several similar results and many important differences.\par Most of our patients (61.9\%) were between 3-6 weeks of age group. That's goes with the results of in comparison studies \hyperref[b3]{(4,}\hyperref[b5]{6,} {\ref 7,}\hyperref[b7]{8,}\hyperref[b8]{9)} .\par In our study there is a male gender dominance (78.6\%), with a male to female ratio of (3.7:1); and that's goes with all the above mentioned studies \hyperref[b3]{(4,}\hyperref[b5]{6,} {\ref 7,}\hyperref[b7]{8,}\hyperref[b8]{9)} , with a male to femal ratio ranging from (3.8:1) in Jlidi S, etal \hyperref[b8]{(9)} to (10:1) in AC Paul, etal \hyperref[b5]{(6)} study.\par With regards AC Paul, et al \hyperref[b5]{(6)} study, he found among 70 male, 49(70\%) were a first born male child, and that's goes with our results as (50\%) of our patients were a first born male.\par Regarding the clinical presentation, 42 (100\%) of the patients presented with projectile vomiting; which found to be non bilious in 41 (97.6\%) patients. (81.0\%) of the patients had marked weight loss while (88.1\%) of the patients were dehydrated, (90.5\%) had palpable epigastric olive like mass and (69.0\%) of them had visible peristaltic wave. That's comparable to most of the previously mentioned studies; (83.6\%) of the patients had the typical history of projectile vomiting and the typical findings of visible peristalsis after a "test meal" and a palpable pyloric tumor in ?smet Faruk ÖZGÜNER, etal {\ref (7)} study, and palpable olive like epigastric mass was found in up to (92\%) of patents in Sapkota. S \hyperref[b4]{(5)} study,while olive' was palpated on examination in 48\%, and visible peristalsis seen in 25\% in Taylor, etal \hyperref[b3]{(4)} study. And that variation is most probably due to patients built; as these sign more obvious in thin wasted patients, beside that the state of gastric fullness also affect the examination finding; as full stomach make a peristaltic wave visible, while an empty stomach facilitate palpation of an olive like epigastric mass.\par Thirty (71.4\%) patients had normal Hb level, 24(57.1\%) showed low serum K + level compared to 18(42.9) with low serum Na + . Eight (19\%) of the patient had high blood urea level, while just one (2.4\%) had elevated serum creatinine. (Table4).\par Abdominal U/S done for all patient; which confirm the diagnosis in 41(97.6\%) of the patients, while contrast study was needed to confirm the diagnosis just in one (2.4\%) patient.\par All patients received open surgical intervention, and Ramsted's pyloromyotomy was done successfully to all patients; with only 4.8\% complication; in form of inadvertent simple mucosal perforation; repaired with 4/0 vicryl, and wound dehiscence for 1 (2.4\%). We had a 1 (2.4\%) mortality. Over all outcome of our study is comparable to the international results, for example; AC Paul, etal \hyperref[b5]{(6)} had Inadvertent mucosal perforation occurred in 1 case during procedure and Superficial wound infection found in 3 cases (03.89\%), Twenty five (59.5) had average postoperative stay of 48 hours, AC Paul, etal \hyperref[b4]{(5)} had 65 (84.41\%) patients were discharged on 3 rd to 4th postoperative day. \section[{Volume XIII Issue IV Version I}]{Volume XIII Issue IV Version I}\begin{figure}[htbp] \noindent\textbf{1}\includegraphics[]{image-2.png} \caption{\label{fig_0}I 1 .}\end{figure} \begin{figure}[htbp] \noindent\textbf{1} \par \begin{longtable}{P{0.5160714285714285\textwidth}P{0.11130952380952382\textwidth}P{0.10119047619047618\textwidth}P{0.12142857142857141\textwidth}} Age\tabcellsep Male\tabcellsep Female\tabcellsep Total\\ Less than 3 Weeks\tabcellsep 1\tabcellsep 0\tabcellsep 1\\ 3-6 Weeks\tabcellsep 20\tabcellsep 6\tabcellsep 26\\ More than 6 Weeks\tabcellsep 12\tabcellsep 3\tabcellsep 15\\ Total\tabcellsep 33\tabcellsep 9\tabcellsep 42\end{longtable} \par \caption{\label{tab_0}Table 1 :}\end{figure} \begin{figure}[htbp] \noindent\textbf{2} \par \begin{longtable}{P{0.5685064935064934\textwidth}P{0.10487012987012986\textwidth}P{0.17662337662337663\textwidth}} Symptoms\tabcellsep Frequency\tabcellsep Percent (\%)\\ Vomiting\tabcellsep 42\tabcellsep 100\\ Non Bilious vomiting in character\tabcellsep 41\tabcellsep 97.6\\ Projectile vomiting in character\tabcellsep 42\tabcellsep 100.0\\ Loss of wt\tabcellsep 34\tabcellsep 81.0\\ Constipation\tabcellsep 24\tabcellsep 57.1\end{longtable} \par \caption{\label{tab_1}Table 2 :}\end{figure} \begin{figure}[htbp] \noindent\textbf{3} \par \begin{longtable}{P{0.5590604026845638\textwidth}P{0.10838926174496645\textwidth}P{0.1825503355704698\textwidth}} Signs\tabcellsep Frequency\tabcellsep Percent (\%)\\ Abdominal distension\tabcellsep 24\tabcellsep 57.1\\ Dehydration\tabcellsep 37\tabcellsep 88.1\\ Emaciated\tabcellsep 17\tabcellsep 40.5\\ Visible peristaltic wave\tabcellsep 29\tabcellsep 69.0\\ Palpable abdominal olive mass\tabcellsep 38\tabcellsep 90.5\end{longtable} \par \caption{\label{tab_2}Table 3 :}\end{figure} \begin{figure}[htbp] \noindent\textbf{4} \par \begin{longtable}{P{0.34\textwidth}P{0.22543478260869568\textwidth}P{0.28456521739130436\textwidth}} Investigation\tabcellsep Normal\tabcellsep Abnormal (low)\\ Hemoglobin \%\tabcellsep 30 (71.4\%)\tabcellsep 12 (28.6\%)\\ Serum potassium\tabcellsep 19 (45.2\%)\tabcellsep 23 (54.8\%)\\ Serum sodium\tabcellsep 24 (57.1\%)\tabcellsep 18 (42.9\%)\\ Blood urea\tabcellsep 34 (81.0\%)\tabcellsep 08 (19.0\%) high\\ Serum createnine\tabcellsep 41 (97.6\%)\tabcellsep 1 (2.4\%) high\\ P value 0.049\tabcellsep \tabcellsep \end{longtable} \par \caption{\label{tab_3}Table 4 :}\end{figure} \begin{figure}[htbp] \noindent\textbf{5} \par \begin{longtable}{P{0.5080459770114942\textwidth}P{0.07816091954022988\textwidth}P{0.2637931034482759\textwidth}} Outcome\tabcellsep No\tabcellsep Percent (\%)\\ Uneventfully\tabcellsep 39\tabcellsep 92.8\\ Developed complications\tabcellsep 2\tabcellsep 4.8\\ Death\tabcellsep 1\tabcellsep 2.4\\ Total\tabcellsep 42\tabcellsep 100.0\end{longtable} \par \caption{\label{tab_4}Table 5 :}\end{figure} \footnote{© 2013 Global Journals Inc. (US)} \backmatter \begin{bibitemlist}{1} \bibitem[Piroutek et al. (2012)]{b5}\label{b5} \textit{Bilious vomiting does not rule out IHPS Clin Pediatr (Phila)}, M J Piroutek , L Brown , A W Thorp . 2012 Mar. 51 p. . \bibitem[Raveenthiran ()]{b4}\label{b4} ‘Centennial of pyloromyotomy’. V Raveenthiran . \textit{J Neonat Surg} 2013. 2 (8) . \bibitem[Aspelund et al. ()]{b1}\label{b1} \textit{Current management of hypertrophic pyloric stenosis. Seminars in Paediatric surgery}, Gudrun Aspelund , C Jacob , Langer . 2007. 16 p. . \bibitem[8-Tutay et al. ()]{b7}\label{b7} ‘Electrolyte profile of pediatric patients with IHPS’. G J 8-Tutay , G Capraro , B Spirko , J Garb , H Smithline . \textit{Pediatr Emerg Care} 2013Apr. 29 (4) p. . \bibitem[Charles et al. ()]{b6}\label{b6} \textit{Hypertrophic pyloric stenosis .Schwartzs principles of surgery}, F Charles , Dana Brunicardi , Timothy R Kandersen , Billiar , L David , Dunn , Johng , Hunter . 2009. 9 p. . \bibitem[Spicer ()]{b2}\label{b2} ‘Infantile hypertrophic pyloric stenosis’. R Spicer . \textit{Br J Surg} 1982. 69 p. . \bibitem[Mullassery et al. ()]{b3}\label{b3} ‘Negative exploration for pyloric stenosis -Is it preventable’. Dhanya Mullassery , [ ..] Sreelakshmi Mallappa , Colin T Baillie . \textit{BMC Pediatr} 2008. 8 p. 37. \bibitem[9-Sapkota and Shrestha (2010)]{b8}\label{b8} ‘Retrospective Study on Anesthetic Management of Infants with Hypertrophic Pyloric Stenosis’. S* 9-Sapkota , S** Shrestha , S . \textit{PMJN Postgraduate Medical Journal of NAMS} 2010 Jul-Dec (2. 10 p. 19. \bibitem[Hernanz-Schulman ()]{b0}\label{b0} ‘Review Ultrasound (US), in infants and children’. Marta Hernanz-Schulman . \textit{Radiology} 2003. 227 p. . \end{bibitemlist} \end{document}