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Abdomen » Gastrointestinal
Acute gastric outlet obstruction due to an iatrogenic cause
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Presentation A 1.7 kg female neonate born at 36 weeks gestation presented at birth with cyanosis. The Apgar score was 8 at 1- 5 minutes. A cardiac echo showed tetrology of Fallot, for which prostaglandin therapy was started on the first day of life.The neonate developed projectile vomiting after feeds at the age of 4 weeks. The cumulative dose of PGE 1 had reached 1650 microgram per kg at that time. An abdominal ultrasound was performed.
 
 
 
Caption: Longitudinal sonographic image of gastric antrum
Description: There is undulation and thickening of the gastric mucosa and the submucosal folds.
 
 
 
Caption: Transverse sonogram of gastric antrum
Description: This image shows a thickened gastric mucosal layer with the characteristic alternate hyperechoic and hypoechoic pattern.
 
 
 
Caption: Scan after fluid distention of the stomach
Description: This image also demonstrates a thickened gastric mucosa and submucosa.
 
Differential Diagnosis Hypertrophic pyloric stenosis, eosinophilic gastroenteritis, hyperplastic antral polyps
 
Final Diagnosis Acute gastric outlet obstruction following the administration of prostaglandin PGE 1
 
Discussion An  infusion of prostaglandin E 1 is used to maintain the patency of the ductus arteriosus in neonates with ductal-dependent cyanotic congenital heart disease. In 1992, Peled et al. first reported gastric outlet obstruction from antral mucosal hyperplasia associated with prostaglandin E1 administration in five neonates. (3) In the initial and follow-up publications, most of patients with ultrasound confirmed gastric mucosal changes had received a cumulative dose of PGE 1 exceeding 1560 microgram per kg. (2) Ultrasonography is a very useful tool in the diagnosis and monitoring of prostaglandin induced foveolar hyperplasia.

Ultrasound findings correlate well with the pathological features:
- increased height of the mucosal layer correspond to the papillary hyperplasia of the gastric foveolae,
- alternate echogenic and hypoechoic pattern of the gastric mucosa represent dilated mucosal glands in the thickened foveolae and interfoveolar mucin products,
- thickness of the muscular layer is in the normal range. (1, 2)
 
Case References 1. A. Joshi, WE. Berdon, A. Brudnicki et al. Gastric thumbprinting: diffuse gastric wall mucosal and submucosal thickening in infants with ductal-dependend cyanotic congenital heart disease maintained on long-term prostaglandin therapy.  Pediatr Radiol 2002; 32: 405-408.
2. N. Kobayashi, N. Aida, G. Nishimura et al. Acute gastric outlet obstruction following the administration of prostaglandin: an additional case. Pediatr Radiol 1997; 27: 57-59.
3. N. Peled, O. Dagan, P. Babyn et al. Gastric-outlet obstruction induced by prostaglandin therapy in neonates. N Engl J Med 1992; 327: 505-510.
 
Follow Up The clinical and ultrasound findings of antral mucosal hyperplasia resolved with cessation of prostaglandin E-1 therapy.
 
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