Reliability of Roentgen Examination in Hypertrophic Pyloric Stenosis in Infants

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Abstract
Hypertrophic pyloric stenosis is the most common condition requiring surgical treatment in the first few months of life (1). Clinical recognition is usually considered accurate and sufficient for the diagnosis. Projectile vomiting is the first symptom in most cases, but this may occur in other diseases. The observation of peristaltic waves is a significant but not reliable sign, since these may also be seen in pyloric spasm. It is generally agreed that a palpable tumor is pathognomonic of pyloric stenosis. The technic of palpation is best done following Seeger's description (2). Figures given in the literature as to the presence of a palpable tumor vary markedly. Brown (3) felt the tumor in 44 per cent of his cases; Rinvik (4) in 72 per cent; Tallerman (5) in 94 per cent; Donovan (6) in 100 per cent; Ladd, Ware, and Picket (7) in 98 per cent. In a series of 277 cases of pyloric stenosis seen at the Milwaukee Children's Hospital, the records show that the tumor was felt in 63 per cent (8). Several physicians however, with considerable experience, felt the tumor in about 90 per cent of their cases. Schaefer and Erbes (8) report that occasionally a tumor was reported by the examining physician but was not present at operation. There is therefore a considerable percentage of cases which, after exhaustion of clinical diagnostic measures, remain questionable or need prolonged observation before a reliable diagnosis can be made. The greatest aid in the reduction of operative mortality rates during the past decade has been early diagnosis and adequate preoperative care (Schaefer and Erbes, 8). During the past eleven years the diagnosis was made and operation was performed for pyloric stenosis in 214 consecutive cases at the Milwaukee Children's Hospital, without a single death. It is at present almost generally accepted in the United States that the treatment of choice is early surgery, and operation is usually advised as soon as an adequate diagnosis is made. The statistics of medical therapy coming from Europe, mostly from the Scandinavian countries, are discouraging compared with the results of surgical treatment reported in this country. Roentgen examination, in our experience, is the most accurate and reliable means of diagnosis of pyloric stenosis, and furnishes one of the earliest pathognomonic signs. Although several authors had written about the x-ray diagnosis of pyloric stenosis in preceding years, it was Meuwissen and Sloof (9) who, in 1932, first established a satisfactory roentgenologic technic of direct demonstration of the narrowed elongated pyloric canal. Their work was confirmed by many Scandinavian roentgenologists and pediatricians (Rinvik, 4; Runström and Wallgren, 10; Frimann-Dahl, 11) and by Hefke in America (12).
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