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pyloric stenosis

Practice targeted AMC-style multiple-choice questions on pyloric stenosis.

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Pyloric stenosis as seen on ultrasound in a 6 week old
Image by Dr Laughlin Dawes CC BY-SA 4.0 · Source

A 6-week-old male infant presents to the emergency department with a 2-week history of progressively worsening non-bilious vomiting, which has become projectile over the past few days. His parents report he is feeding eagerly but vomits most feeds shortly after completion. He has had fewer wet nappies than usual and appears more lethargic. On examination, he is irritable but consolable. His weight is below the 3rd percentile, having dropped from the 10th percentile at birth. Vital signs are: Temperature 36.8°C, Heart Rate 155 bpm, Respiratory Rate 40 bpm, Blood Pressure 85/50 mmHg, Oxygen Saturation 98% on room air. Capillary refill time is 3 seconds. Abdominal examination reveals a soft, non-distended abdomen with active bowel sounds; no palpable masses are appreciated. Initial blood gas shows pH 7.52, pCO2 40 mmHg, Bicarbonate 32 mmol/L, Na+ 132 mmol/L, K+ 3.0 mmol/L, Cl- 88 mmol/L. A point-of-care ultrasound was performed, and the image provided was obtained. Considering the clinical presentation, the laboratory results, and the findings demonstrated in the image, which of the following represents the most appropriate immediate therapeutic intervention?

A. Intravenous administration of 5% dextrose in 0.45% sodium chloride.
B. Oral rehydration therapy with an electrolyte solution.
C. Urgent surgical consultation for pyloromyotomy without prior fluid resuscitation.
D. Placement of a nasogastric tube for continuous gastric drainage.
E. Intravenous administration of 0.9% sodium chloride with added potassium chloride.
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Pyloric stenosis as seen on ultrasound in a 6 week old
Image by Dr Laughlin Dawes CC BY-SA 4.0 · Source

A 6-week-old male infant presents with increasing frequency of non-bilious vomiting after feeds for the past week. He is otherwise well, afebrile, and has wet nappies. On examination, he is alert and interactive. Abdominal examination is unremarkable. Vitals are stable. You order an ultrasound, which is shown. Based on the clinical presentation and the provided image, what is the most appropriate immediate next step in management?

A. Obtain an upper gastrointestinal barium study.
B. Discharge home with advice on feeding techniques and follow-up.
C. Proceed directly to surgical pyloromyotomy.
D. Initiate intravenous fluid resuscitation and correct electrolyte abnormalities.
E. Prescribe a proton pump inhibitor and trial smaller, more frequent feeds.
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Hypertrophic pyloric stenosis
Image by Adityagupta95 CC0 1.0 · Source

A 6-week-old male infant presents with a 2-week history of progressively worsening projectile non-bilious vomiting after feeds. He has lost weight and appears lethargic. Initial bloods show a hypochloremic, hypokalaemic metabolic alkalosis. After fluid resuscitation, the image is obtained. What is the most appropriate definitive management for this patient?

A. Further imaging with abdominal ultrasound
B. Placement of nasogastric tube for gastric decompression
C. Trial of medical management with atropine
D. Discharge home with thickened feeds and anti-reflux medication
E. Surgical pyloromyotomy
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Pyloric stenosis as seen on ultrasound in a 6 week old
Image by Dr Laughlin Dawes CC BY-SA 4.0 · Source

A 6-week-old male infant presents to the emergency department with a 2-week history of progressively worsening non-bilious vomiting, which has become projectile over the past few days. His parents report he is feeding eagerly but vomits most feeds shortly after completion. He has had fewer wet nappies than usual and appears more lethargic. On examination, he is irritable but consolable. His weight is below the 3rd percentile, having dropped from the 10th percentile at birth. Vital signs are: Temperature 36.8°C, Heart Rate 155 bpm, Respiratory Rate 40 bpm, Blood Pressure 85/50 mmHg, Oxygen Saturation 98% on room air. Capillary refill time is 3 seconds. Abdominal examination reveals a soft, non-distended abdomen with active bowel sounds; no palpable masses are appreciated. Initial blood gas shows pH 7.52, pCO2 40 mmHg, Bicarbonate 32 mmol/L, Na+ 132 mmol/L, K+ 3.0 mmol/L, Cl- 88 mmol/L. A point-of-care ultrasound was performed, and the image provided was obtained. Considering the clinical presentation and the findings demonstrated in the image, what is the most appropriate immediate next step in the management of this infant?

A. Administer intravenous ondansetron and observe for improvement in vomiting.
B. Discharge home with instructions for smaller, more frequent feeds and review by the general practitioner in 24 hours.
C. Insert a nasogastric tube for continuous drainage and commence total parenteral nutrition.
D. Obtain an urgent upper gastrointestinal contrast study to confirm the diagnosis and assess for malrotation.
E. Initiate intravenous fluid resuscitation with 0.9% sodium chloride and potassium chloride supplementation, and arrange urgent surgical consultation.
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Hypertrophic pyloric stenosis
Image by Adityagupta95 CC0 1.0 · Source

A 6-week-old male infant presents to the emergency department with a 5-day history of progressively worsening non-bilious vomiting, which has become projectile over the past 48 hours. He is exclusively formula-fed and his parents report decreased wet nappies and increased irritability. On examination, he is alert but appears slightly lethargic. His weight is below his birth weight. Capillary refill time is 3 seconds. Vitals are: HR 150 bpm, RR 40 bpm, T 37.2°C, BP 85/50 mmHg. Abdominal examination is soft, non-distended, and no masses are definitely palpable. Initial blood gas shows pH 7.52, pCO2 40 mmHg, HCO3 32 mmol/L, Na+ 130 mmol/L, K+ 3.0 mmol/L, Cl- 85 mmol/L. Urea and creatinine are mildly elevated. An imaging study was performed, shown above. Considering the clinical presentation and the findings on the imaging study, which of the following is the most critical immediate management step?

A. Initiate intravenous fluid resuscitation with 0.9% sodium chloride and potassium supplementation.
B. Insert a nasogastric tube for gastric decompression.
C. Administer intravenous ondansetron to control vomiting.
D. Arrange for urgent surgical consultation for pyloromyotomy.
E. Obtain a paediatric surgical ultrasound of the abdomen.
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Pyloric stenosis as seen on ultrasound in a 6 week old
Image by Dr Laughlin Dawes CC BY-SA 4.0 · Source

A 6-week-old male infant presents to the emergency department with a 2-week history of progressively worsening non-bilious vomiting, which has become projectile over the past few days. His parents report he is feeding eagerly but vomits most feeds shortly after completion. He has had fewer wet nappies than usual and appears more lethargic. On examination, he is irritable but consolable. His weight is below the 3rd percentile, having dropped from the 10th percentile at birth. Vital signs are: Temperature 36.8°C, Heart Rate 155 bpm, Respiratory Rate 40 bpm, Blood Pressure 85/50 mmHg, Oxygen Saturation 98% on room air. Capillary refill time is 3 seconds. Abdominal examination reveals a soft, non-distended abdomen with active bowel sounds; no palpable masses are appreciated. Initial blood gas shows pH 7.52, pCO2 40 mmHg, Bicarbonate 32 mmol/L, Na+ 132 mmol/L, K+ 3.0 mmol/L, Cl- 88 mmol/L. A point-of-care ultrasound was performed, and the image provided was obtained. Considering the clinical presentation, the laboratory findings, and the abnormality demonstrated in the provided image, which of the following best explains the mechanism leading to the observed electrolyte and acid-base derangements?

A. Loss of gastric acid (HCl) through vomiting, leading to compensatory renal hydrogen ion excretion and potassium wasting.
B. Increased aldosterone secretion due to dehydration, causing sodium retention and potassium excretion.
C. Excessive sodium and water loss in stool due to malabsorption.
D. Shift of potassium into intracellular space due to metabolic alkalosis.
E. Impaired renal bicarbonate excretion due to decreased glomerular filtration rate from dehydration.
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Pyloric stenosis as seen on ultrasound in a 6 week old
Image by Dr Laughlin Dawes CC BY-SA 4.0 · Source

A 6-week-old infant presents with a 1-week history of increasing frequency of non-bilious, projectile vomiting occurring shortly after feeds. He has lost some weight since his last check-up. Examination is otherwise unremarkable. An ultrasound is performed, shown in the image. Based on the clinical presentation and the provided image, which of the following electrolyte abnormalities is the most likely consequence if this condition remains untreated?

A. Hypernatremic metabolic acidosis
B. Hyponatremic respiratory alkalosis
C. Hypochloremic metabolic alkalosis
D. Hypokalemic respiratory acidosis
E. Hypercalcemic metabolic alkalosis
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Pyloric stenosis as seen on ultrasound in a 6 week old
Image by Dr Laughlin Dawes CC BY-SA 4.0 · Source

A 6-week-old male infant presents with a 1-week history of progressively worsening non-bilious vomiting, often projectile, occurring shortly after feeds. His parents report he is constantly hungry and irritable but has had poor weight gain. On examination, he is alert but appears thin. Vital signs are stable. Abdominal examination is soft, non-tender, with no palpable mass. An abdominal ultrasound is performed, the image of which is shown. Considering the clinical presentation and the findings depicted, what is the most appropriate initial management strategy?

A. Referral to a paediatric gastroenterologist for further investigation
B. Discharge home with advice on smaller, more frequent feeds
C. Urgent upper gastrointestinal contrast study
D. Surgical pyloromyotomy after fluid and electrolyte correction
E. Trial of antiemetic medication and thickened feeds
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Hypertrophic pyloric stenosis
Image by Adityagupta95 CC0 1.0 · Source

A 5-week-old male infant presents with a 10-day history of non-bilious, forceful vomiting after every feed. His parents report decreased wet nappies and lethargy. On examination, he is pale, weighs 3.2 kg (birth weight 3.5 kg), has sunken eyes, and poor skin turgor. Vital signs: HR 170, RR 45, Temp 37.0, BP 80/50. Initial bloods show Na 132, K 3.1, Cl 88, HCO3 30. An imaging study is performed, shown in the image. Considering the clinical presentation and the findings demonstrated in the imaging study, what is the most appropriate immediate management priority for this infant?

A. Administer intravenous ondansetron to control vomiting.
B. Arrange urgent surgical consultation for definitive operative management.
C. Initiate intravenous fluid resuscitation with 0.9% sodium chloride and potassium supplementation.
D. Obtain a repeat imaging study using abdominal ultrasound.
E. Insert a nasogastric tube for gastric decompression and feeding.
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Pyloric stenosis as seen on ultrasound in a 6 week old
Image by Dr Laughlin Dawes CC BY-SA 4.0 · Source

A 6-week-old infant presents with a 1-week history of increasing non-bilious projectile vomiting after feeds. He is otherwise well, afebrile, and has wet nappies. Examination is unremarkable. An ultrasound is performed, shown in the image. Considering the clinical presentation and the findings in the provided image, what is the most appropriate definitive surgical intervention for this condition?

A. Antrectomy
B. Laparoscopic Nissen fundoplication
C. Ramstedt pyloromyotomy
D. Gastrostomy tube insertion
E. Pyloric dilatation
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Pyloric stenosis as seen on ultrasound in a 6 week old
Image by Dr Laughlin Dawes CC BY-SA 4.0 · Source

A 6-week-old male infant presents with a 1-week history of progressively worsening non-bilious vomiting, often projectile, occurring shortly after feeds. His parents report he is constantly hungry and irritable but has had poor weight gain. On examination, he is alert but appears thin. Vital signs are stable. Abdominal examination is soft, non-tender, with no palpable mass. An abdominal ultrasound is performed, the image of which is shown. Considering the clinical presentation and the findings depicted, what is the most appropriate definitive management strategy after initial fluid and electrolyte correction?

A. Trial of antiemetic medication
B. Laparoscopic pyloromyotomy
C. Barium meal study
D. Discharge home with feeding advice
E. Endoscopic balloon dilation
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