Presentation
Persistent hiccups, vomiting (post prandial) and upper gastrointestinal bleed.
Patient Data
Diffusely hypertrophied and hypoechoic pyloric muscularis propia musculature spanning an antero-posterior diameter of 14.5 mm with an increased pyloric diameter of 36.3 mm and resultant elongated channel length of 47.9 mm is noted. Real-time dynamic scanning of the pylorus with water up-take by the patient demonstrates visible luminal and muscular spasms proximally which partially distends. The distal pyloroduodenal compartment barely dilates and there is delayed emptying vide the channel (as much of the air-fluid content swirls to and fro superiorly back into the gastric lumen). Attendant Hepato-splenomegaly (splenic index = 130.80 cm²) and ascites is evident.
Case Discussion
Hypertrophic adult pyloric stenosis (HAPS) is quite rare with very few cases having been documented. The normal adult pyloric muscular wall thickness ranges from 3 to 8 mm¹. In this presentation, the muscular layer amounts up to a mean of 15 mm. During real-time feeding, a normal pylorus is expected to transit the air-fluid content with optimally rapid emptying of its content into the duodenum which was not the case in this particular exam with the sonographic features compatibly favoring pyloric stenosis.
No clinical signs of gastrointestinal (GI) tract malignant process save for the upper GI endoscopic finding that revealed diffuse hypertrophic antral mucosal layer and which pointed towards idiopathic or possibly congenital sequel as the etiological cause.
Other differential diagnoses that may be considered:
- pressure obstruction from pancreatic or other extrinsic tumors
- gastric syphilis or neurosyphilis
- pylorospasm without organic lesion
- psychic vomiting
- gastric or duodenal polypi,
- malignancy or ulcer of the pylorus with spasm
- duodenal ileus
- diverticulosis of the duodenum
- esophageal diverticulum
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