Conference abstract

Medical treatment with atropine for infantile hypertrophic pyloric stenosis when surgery is not an option: a case presentation and literature discussion

Pan African Medical Journal - Conference Proceedings. 2018:9(8).12 Dec 2018.
doi: 10.11604/pamj-cp.2018.9.8.734

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Keywords: IHPS, conservative treatment, atropine
Poster

Medical treatment with atropine for infantile hypertrophic pyloric stenosis when surgery is not an option: a case presentation and literature discussion

Valori Ana Victoria1,&, Lafferty Nadia2

1Médecins Sans Frontières, OCBA, Democratic Republic of Congo, 2Médecins Sans Frontières, OCBA, Barcelona

&Corresponding author
Valori Ana Victoria, Médecins Sans Frontières, OCBA, Democratic Republic of Congo

Abstract

Introduction: infantile hypertrophic pyloric stenosis (IHPS) is common in neonates, affecting approximately 2 to 3.5 per 1000 live births. Surgical pyloromyotomy is proven to be both effective and simple; it is considered the gold-standard treatment. Nevertheless, in resource-limited settings where trained staff is scarce, conservative management with atropine has been described as a useful alternative. We present a case study to explore the potential of this treatment in MSF fields.

Methods: a 7 week old male presented to an MSF-supported hospital in DRC, with a 2 week history of projectile vomiting and weight loss. IHPS was suspected and ultrasound images were compatible. Given the setting and patient instability, transfer was not possible. As no on-site surgical capacity was available, IV atropine was commenced at 0.02mg/kg every 6 hours after a review of available evidence, as no MSF protocol was available. The prescription was switched after 48h to an infusion of 0.5mg atropine/24h added to maintenance fluids, following a case review and discussion among colleagues. After 12 days of irregular vomiting and poor monitoring, the baby developed gastrointestinal bleeding, mixed haemorrhagic/septic shock and subsequently died.

Results: several studies have shown good success rates (75 - 96%) using atropine for pyloric stenosis, with no serious side effects identified. Best results appear to be achieved using IV atropine 0.04 to 0.2mg/kg/day in divided doses for one week, followed by several weeks of oral atropine at double the IV dose. Atropine infusion has not been described in the literature. Projectile vomiting ≥5 times/day in the first 3 days of starting IV atropine has been shown to be a negative predictive factor.

Conclusion: medical treatment with atropine is recommended for pyloric stenosis when surgical treatment is not possible. However, close monitoring and careful dosing are essential, they may also be limiting factors in rural MSF settings with low-qualified staff. Specific MSF protocols for the use of atropine in pyloric stenosis may help to optimise the chances of success.