Database analysis of oral atropine treatment of infantile hypertrophic pyloric stenosis. A ten-year single-center experience

Dragana Vujović; Marija Lukač; Aleksandar Sretenović; Jelena Pejanović; Branislav Jovanović; Polina Pavićević; Tamara Krstajić; Goran Trajković; Vedrana Pavlović; Djordje Topličić; Sanja Sindjić-Antunović

doi:10.2298/VSP190204047V

Dragana Vujović University Children's HospitalFaculty of Medicine University of Belgrade
Marija Lukač University Children's HospitalFaculty of Medicine University of Belgrade
Aleksandar Sretenović University Children's HospitalFaculty of Medicine University of Belgrade
Jelena Pejanović University Children's HospitalFaculty of Medicine University of Belgrade
Branislav Jovanović University Children's HospitalFaculty of Medicine University of Belgrade
Polina Pavićević University Children's HospitalFaculty of Medicine University of Belgrade
Tamara Krstajić University Children’s Hospital, Belgrade, Serbia
Goran Trajković Faculty of Medicine University of BelgradeInstitut for Medical Statistics and Informatics
Vedrana Pavlović Faculty of Medicine University of BelgradeInstitut for Medical Statistics and Informatics
Djordje Topličić University Children’s Hospital, Belgrade, Serbia
Sanja Sindjić-Antunović University Children's HospitalFaculty of Medicine University of Belgrade

DOI: https://doi.org/10.2298/VSP190204047V

Keywords: atropine;, infant;, muscarinic antagonists;, pyloric stenosis, hypertrophic;, risk factors;, surgical procedures, operative;, treatment outcome

Abstract

Background/Aim. Infantile hypertrophic pyloric stenosis (IHPS) is the most common cause of surgery in newborns and young infants. Conservative treatment of IHPS is of great importance because it spares the newborn from stress caused by surgery and general anesthesia. The aim of this study was to evaluate the impact of various oral administration regimens of atropine on its efficacy in treating IHPS. Methods. The study included 45 patients with IHPS, conservatively treated by atropine sulfate in the period from 2006 to 2016. Clinical examination, laboratory analysis, and ultrasonography were performed on all patients on admission. The efficacy of treatment with different oral dosage regimens was analyzed and potential predictive factors of the negative outcome were defined. The evaluation of the success of the treatment was statistically analyzed by the method of the multivariate logistic regression model. Results. Out of 45 patients, 36 (80%) were successfully cured (p = 0.0008, without the need for surgery and without any complications. Gender prevalence, age, birth weight, body weight on admission, duration of symptoms, pyloric muscle thickness, and length had no statistically significant individual effect on the success of the atropine treatment. Patients who received a progressively increased dose of atropine had an 18 times higher risk of surgery, patients with hypochloremic alkalosis (HCA) had a 15 times higher risk, while others, with more than 5 vomitings within the first three days of the therapy, were 9 times more likely to be surgically treated. Conclusion. High success rate and no side effects represent an orally administered atropine treatment as a valid alternative choice for non-operative management of IHPS. Administration of initially high doses was shown to be more effective in relation to gradually increased oral doses of atropine sulfate. HCA and continued vomiting are considered as potential predictive factors of negative outcomes of the atropine treatment.

References

Aspelund G, Langer JC. Current management of hypertrophic pyloric stenosis. Semin Pediatr Surg 2007; 16(1): 27‒33.

Ross A, Johnson P. Infantile hypertrophic pyloric stenosis. In: Ameh EA, Bickler SW, Lakhoo K, Nwomeh BC, Poenaru D, edi-tors. Paediatric surgery: A comprehensive text for Africa. Se-attle: Global Help; 2016; p. 12.

Kawahara H, Imura K, Nishikawa M, Yagi M, Kubota A. Intrave-nous atropine treatment in infantile hypertrophic pyloric ste-nosis. Arch Dis Child 2002; 87(1): 71‒4.

Kawahara H, Imura K, Yagi M. Antropyloroduodenal manom-etry in patients with infantile hypertrophic pyloric stenosis: evidence of pylorospasm. JPN J Pediatr Surg 1997; 29: 1317‒23.

Krogh C, Fischer TK, Skotte L, Biggar RJ, Øyen N, Skytthe A. Familial aggregation and heritability of pyloric stenosis. JAMA 2010; 303(23): 2393‒9.

Hernanz-Schulman M. Infantile Hypertrophic Pyloric Stenosis. Radiology 2003; 227(2): 319‒31.

Mohamed A. Eltomey M, Ghareeb HA. Postoperative ultraso-nography changes of the pylorus in infants with hypertrophic pyloric stenosis. Egypt J Radiol Nucl Med 2014; 45: 897‒902.

Ramstedt C. Zur operation der angeborenen pylorus-stenose. Med Klin 1912; 8: 170‒5.

Shaw A. Ramstedt and the centennial of pyloromyotomy. J Pediatr Surg 2012; 47(7): 1433‒5.

Hall NJ, Eaton S, Seims A, Leys CM, Densmore JC, Calkins CM, et al. Risk of incomplete pyloromyotomy and mucosal perfo-ration in open and laparoscopic pyloromyotomy. J Pediatr Surg 2014; 49(7): 1083‒6.

Yamataka A, Tsukada K, Yokoyama-Laws Y, Murata M, Lane GJ, Osawa M, et al. Pyloromyotomy versus atropine sulfate for infantile hypertrophic pyloric stenosis. J Pediatr Surg 2000; 35(2): 338‒41; discussion 342.

Lauriti G, Cascini V, Chiesa PL, Pierro A, Zani A. Atropine Treatment for Hypertrophic Pyloric Stenosis: A Systematic Review and Meta-Analysis. Eur J Pediatr Surg 2018; 28(5): 393‒9.

Agata Bizzocchi A, Metz D. Treating Pyloric Stenosis Medically in a Resource Poor Setting. Ann Pediatr Child Health 2016; 4(1): 1095.

Vanderwinden JM, Mailleux P, Shiffmann SN, Vanderhaeghen JJ, DeLaet MH. Nitric oxide synthase activity in infantile hyper-trophic pyloric stenosis. N Engl J Med 1992; 327(8): 511‒5.

Kusafuka T, Puri P. Altered messenger RNA expression of the neuronal nitric oxide synthase gene in infantile hypertrophic pyloric stenosis. Pediatr Surg Int 1997; 12(8): 576‒9.

Nagita A, Yamaguchi J, Amemoto K, Yoden A, Yamazaki T, Mino M. Management and ultrasonographic appearance of infantile hypertrophic pyloric stenosis with intravenous atropine sul-fate. J Pediatr Gastroenterol Nutr 1996; 23(02): 172‒7.

Brown JH. Atropine, scopolamine and related anti-muscarinic drugs. In: Gilman AG, Rall TW, Nies AS, Taylor P, editors. Goodman and Gilman’s pharmacological bases of therapeu-tics. Tokyo: Pergamon Press; 1990; p. 150‒65.

Montana M, Evers A. Anesthetic Neurotoxicity: New Findings and Future Directions. J Pediatr 2017; 181: 279‒85.

Andropoulos DB. Effect of Anesthesia on the Developing Brain: Infant and Fetus. Fetal Diagn Ther 2018; 43(1): 1‒11.

Alain JL, Grousseau D, Terrier G. Extramucosal pyloromyoto-my by laparoscopy. Surg Endosc 1991; 5(4): 174‒5.

Cubas RF, Longshore S, Rodriguez S, Tagge E, Baerg J, Moores D. Atropine: A Cure for Persistent Post Laparoscopic Pyloromy-otomy Emesis. J Neonatal Surg 2017; 6(1): 2.

Owen RP, Almond SL, Humphrey GM. Atropine sulphate: res-cue therapy for pyloric stenosis. BMJ Case Rep 2012; 2012. pii: bcr2012006489.

Chiu SS, Gilbert JC. Recurrent pyloric stenosis: a form of the incomplete pyloromyotomy. J Pediatr Surg Case Reports 2018; 29: 14‒7.

Gumayan RL, Sandoval JA. Operative Management of Recur-rent Hypertrophic Pyloric Stenosis: A Case Report and Re-view of the Literature. SM Min Inv Surg 2017; 1(1): 1004.

Hukeri A, Gupta A, Kothari P, Dikshit V, Kekre G, Patil P, et al. Our experience of laparoscopic pyloromyotomy with ultra-sound-guided parameters. J Minim Access Surg 2019; 15(1): 51‒5.

Elnaggar IA, Elbatarny AM, Khiralla MG, Mewally MF. Laparo-scopic pyloromyotomy in infantile hypertrophic pyloric steno-sis using a myringotomy knife. Ann Pediatr Surg 2018; 14(2): 60‒6.

Kasuko O, Yuko Y, Santoshi H, Motoko M, Sigetaka S, Makiko O. Oral treatment of atropine sulphate for hypertrophic pyloric stenosis. J Jap Fed Soc 2001; 105: 22‒8.

Singh UK, Kumar R, Prasad R. Oral atropine sulfate for infan-tile hypertrophic pyloric stenosis. Indian Pediatr 2005; 42(5): 473‒6.

Wu SF, Lin HY, Huang FK, Chen AC, Su BH, Li CI, et al. Ef-ficacy of Medical Treatment for Infantile Hypertrophic Pylo-ric Stenosis: A Meta-analysis. Pediatr Neonatol 2016; 57(6): 515‒21.

Koike Y, Uchida K, Nakazawa M, Inoue M, Kusunoki M, Tsu-kamoto Y. Predictive factors of negative outcome in initial at-ropine therapy for infantile hypertrophic pyloric stenosis. Pe-diatr Int 2013; 55(5): 619‒23.

Fan J, Shi Y, Cheng M, Zhu X, Wang D.Treating idiopathic hy-pertrophic pyloric stenosis with sequential therapy: A clinical study. J Paediatr Child Health 2016; 52(7): 734‒8.

Rasmussen L, Hansen LP, Pedersen SA. Infantile hypertrophic pyloric stenosis: the changing trend in treatment in a Danish county. J Pediatr Surg 1987; 22(10): 953‒5.

Hayashi AH, Giacomantonio JM, Lau HY, Gillis DA. Balloon catheter dilatation for hypertrophic pyloric stenosis. J Pediatr Surg 1990; 25(11): 1119‒21.

Braegger CP, Schwöbel M, Känel J, Werner ER, Thöny B, Blau N. Tetrahydrobiopterin in the treatment of infantile hypertrophic pyloric stenosis. Biochem Mol Med 1997, 62(1): 101‒5.