Pyloric stenosis: Possible cause of reflux
I read a few articles regarding gastric reflux and could really relate to these individuals' stories. However, I noticed that there was no mention of a congenital problem called pyloric stenosis. Could you discuss this as a possible cause of reflux?
Question:Robert Steele
Robert W. Steele, MD, is a board certified pediatrician at St. John's Regional Health Center in Springfield, MO. He graduated from medical... Read more
As many parents know, "spitting up" or reflux can be quite a common occurrence particularly in the first few months of life. However, as you know, there is a severe form of it caused by a blockage at the end of the stomach called pyloric stenosis. This blockage becomes progressively worse (usually over the first six weeks of life) until absolutely everything that is ingested comes right back up. The blockage is actually caused by a circular muscle (the pylorus) at the end of the stomach that opens and allows the food to pass into the intestines. We have known for a long time that when this muscle gets too big, it keeps the food from moving forward. However, the reason why this muscle gets too big has only been known for about the last five years.
It turns out that there is a signal that allows for the pylorus muscle to relax. This signal is the chemical, nitric oxide which is normally present in the body. Children who have pyloric stenosis lack the normal receptors on the pylorus muscle which recognize nitric oxide. In other words, the nitric oxide is present, but the pylorus doesn't know it because it doesn't have the correct sensors. And since the muscle can't recognize it, it can't relax. Just like a body builder who builds large muscles quickly because he trains hard, the pylorus muscle gets bigger because it is almost always contracting. Eventually, this circular muscle gets so big that food can't get through it. So, when the stomach starts normally churning the food during digestion, the contents of the stomach go the wrong way.
It takes around 5 weeks for the pylorus muscle to become thickened enough to cause complete blockage to the exit of the stomach. However, these children generally begin their spitting up much earlier than this. The spitting up eventually becomes much more forceful until the child has the characteristic "projectile vomiting." These children generally begin vomiting after every feeding and remain hungry after throwing up.
The diagnosis comes by an experienced hand examining the abdomen or by simply visualizing the pylorus muscle with an ultrasound. The treatment for pyloric stenosis is surgical which, thankfully, is a relatively minor procedure. A small incision is made in the skin (usually an inch and one-half or less) and the pyloric muscle is cut in a way to loosen its tight grip at the end of the stomach. The child usually is kept from eating for the first 24 hours and then slowly fed over the next couple of days.
I certainly appreciate your pointing out pyloric stenosis as cause of reflux. It is an important problem that can cause an infant to become quite ill if not recognized and treated early.
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