A 5-week-old exclusively breastfed boy presents with non-bilious projectile vomiting for 10 days. Examination shows visible gastric peristalsis and a firm mobile olive-shaped mass in the right hypochondrium. Biochemistry reveals hypochloraemic hypokalaemic metabolic alkalosis with mild dehydration. What is the correct sequence of management?

• A Immediate Ramstedt pyloromyotomy followed by intravenous fluids
• B Endoscopic balloon dilatation of the pylorus
• C Switch to thickened feeds and observe for 48 hours
• D Correction of dehydration and electrolytes with normal saline and potassium before surgery ✓

Explanation

Pyloromyotomy (Ramstedt procedure) is curative but it is never an emergency. The infant must first be resuscitated with isotonic saline and potassium to correct the hypochloraemic hypokalaemic metabolic alkalosis, because anaesthesia in an alkalotic, hypokalaemic, dehydrated infant risks post-operative apnoea and arrhythmia. Surgery proceeds once hydration and electrolytes are normal, usually within 24 to 48 hours. Diagnosis here is clinical, so imaging or endoscopic intervention adds nothing.

Reference: Bailey and Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.