To the Editor:
I was a little disappointed to see in your editorial (Pediatric Annah. 1993;23:181-182) that you said the best time to palpate a pyloric mass is after the baby has vomited. After the baby has vomited, the stomach is far from empty. The baby vomits because the stomach is over-distended. To empty the stomach, one needs to insert a nasogastric tube and evacuate the stomach with a syringe. Obviously, this insults the infant and he or she will cry vigorously. However, the baby retains his or her appetite and can be satisfied by offering a bottle of sugar water. When the baby relaxes from the bottle of sugar water; that is the time to palpate the pyloric mass. If one is patient, this can be felt about 9 times out of 10.
I absolutely agree that this is a pediatrician's diagnosis, and unfortunately, pediatricians believe that it is a radiologist's diagnosis. The current argument among pediatricians is whether this should be done by sonogram or contrast study. I am afraid that the majority of pediatricians are too busy in the office to take the time to empty the stomach and feel the mass. It is much more expethent to ship the baby off to the x-ray department.
Ralph L. Swank, U, MD
The Editor responds:
Dr Swank's point is well taken. While the pyloric muscle is easier to feel immediately after vomiting because it is contracted and that portion of the stomach that overlies it is less full (or empty), this does not mean that it is always palpable. In situations in which it is not, the stomach can be emptied using a nasogastric tube. I must confess that I have never done this, but now I certainly will whenever I suspect the diagnosis of pyloric stenosis and cannot feel the olive-size mass after the baby is fed and vomits.
I hope that pediatricians will use these simple methods to make the diagnosis, rather than resorting to sonograms or contrast studies.
Robert A. Hoekelman, MD