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Abdomen » Gastrointestinal
Congenital hypertrophic pyloric stenosis at 5 weeks
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Author(s) :
Shlomo Gobi  |  Chaitali Shah, FRCR
Presentation A 5 week old male child presents with projectile vomiting after feeds for a day. An abdominal ultrasound was performed.
Caption: Sagittal image of the pyloric region
Description: The pyloric channel appears significantly elongated and the thickened, hypoechoic muscular layers are well appreciated. The pyloric lumen is reduced and the apposed echogenic mucosal layers of both sides are noted.
Caption: Sagittal image of the pyloric region
Description: The thickened muscular wall of the pylorus is again well appreciated in this image.
Caption: Sagittal image of the pyloric region
Description: This image shows the sonographic double track sign that is created due to redundant mucosa in the narrowed pyloric channel creating two mucosal outlines.
Caption: Transverse image of the pyloric canal
Description: The target sign or the donut sign is seen in this image.
Differential Diagnosis Congenital hypertrophic pyloric stenosis, pylorospasm
Final Diagnosis Congenital hypertrophic pyloric stenosis
Discussion This case demonstrates well the ‘antral nipple sign’, which results due to prolapse of the redundant mucosa into the antrum. The ultrasonic ‘double track sign’ is also appreciated here; however it is not specific for pyloric stenosis and can be seen in infantile pylorospasm as well. 

A ‘pyloric cervix sign’ has also been demonstrated and refers to the appearance of hypertrophied pyloric musculature in longitudinal section impinging upon a fluid filled antrum.
Case References 1. Hernanz-Schulman M, Dinauer P, et al. The antral nipple sign of pyloric mucosal prolapse: endoscopic correlation of a new sonographic observation in patients with pyloric stenosis. J Ultrasound Med. 1995 Apr; 14(4):283-7.
2. Cohen HL, Blumer SL, et al. The sonographic double-track sign: not pathognomonic for hypertrophic pyloric stenosis; can be seen in pylorospasm. J Ultrasound Med. 2004 May; 23(5):641-6.
3. Ball TI, Atkinson GO Jr, Gay BB Jr. Ultrasound diagnosis of hypertrophic pyloric stenosis: real-time application and the demonstration of a new sonographic sign. Radiology. 1983 May; 147(2):499-502.
4. Reid Janet. Hypertrophic Pyloric Stenosis.
Follow Up This child was operated upon and the diagnosis confirmed.
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