An unusual case of vomiting in a premature baby

Abstract:

Background: We are reporting a case of pyloric stenosis in an extremely preterm male baby of 27 weeks gestation, discovered in the 7^th week of life. To our knowledge, pyloric stenosis has not been reported previously in a preterm baby of 27 weeks gestation or less. 
The presentation of pyloric stenosis in preterm babies is atypical and the diagnosis is often delayed. 

Case Presentation: A male baby was born breech via normal vaginal delivery at an estimated gestation of 27 weeks following a concealed pregnancy. He had a smooth neonatal journey requiring respiratory support. His feeds were commenced and built up with preterm formula according to local guidelines and reached full feeds on day 10 of life. On day 13 he showed signs of feed intolerance with vomiting and distended abdomen. He was treated for suspected sepsis with septic ileus. On day 44 of life (33+1 CGA) he began to have persistent vomiting. Several management strategies were tried including replacement of nasogastric tube, gravity feeding and decreasing feed volume. He continued to be otherwise clinically well with a normal abdominal examination. On day 45 despite still examining well, he was placed NBM and treated for possible NEC. His blood gas at the time showed pH 7.4, CO2 8.7, HCO3 36.6, BE 16.3,Na 138 , K 3.2 ,Cl 92

Investigations: He had a plain abdominal film on D45 which showed non-specific bowel gas pattern with dilated stomach bubble but no signs of NEC and an abdominal ultrasound which showed appearances in keeping with pyloric stenosis. The pyloric muscle was thickened with pyloric length of 1.9 cm muscle thickness of 4 mm.

Treatment: He was taken to theatre for a pyloromyotomy and made a full recovery.

Audience Take Away Notes: 

• The blood gas did show the textbook hypokalaemic hypochloraemic metabolic alkalosis although more subtly than usually described
• Pyloric stenosis should remain a differential diagnosis in preterm neonates with persistent vomiting and feed intolerance
• A contrast study may be needed in order to confirm the diagnosis if the ultrasound findings remain inconclusive

Biography:

Dr. Quratulain Aslam studied Medicine at Pakistan and graduated in 2009. She then completed her postgraduate Training programme in Pakistan and did membership exams for UK. Currently, she is working as a senior clinical Fellow in neonatology in a tertiary neonatal unit of United Kingdom. she is actively involved in different research projects in her  department.