A 3-week-old male infant presents with projectile non-bilious vomiting after every feed. On examination, an olive-shaped mass is felt in the right upper quadrant during a test feed. Ultrasound confirms pyloric muscle thickness of 5 mm and pyloric channel length of 20 mm. What is the correct management sequence?
- A Immediate Ramstedt pyloromyotomy without any preoperative preparation
- B Correct electrolyte abnormalities (hypochloremic hypokalemic metabolic alkalosis) before Ramstedt pyloromyotomy ✓
- C Atropine infusion as the primary medical treatment to avoid surgery
- D Emergency laparotomy as this is a surgical emergency requiring immediate intervention
Explanation
Hypertrophic pyloric stenosis (HPS) presents in the 2nd-6th week of life with projectile non-bilious vomiting leading to hypochloremic, hypokalemic metabolic alkalosis (from loss of HCl and potassium in vomit). Immediate surgery is contraindicated — the metabolic alkalosis must be corrected first with IV 0.9% saline + KCl (targeting Cl >100 mmol/L, urine Cl >20 mmol/L). Surgery (Ramstedt pyloromyotomy — open or laparoscopic) is then performed after metabolic correction. This is a medical urgency, not a surgical emergency. Atropine sulfate can be used non-surgically in some centers but is not the standard approach.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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Written and medically reviewed by the StethoPrep medical team.