[Hypertrophic pyloric stenosis].

Sir, I should like to report a case of hypertrophic pyloric stenosis presenting at the age of 2 years 6 months. This male, only child was admitted with a 5-day history of fever and vomiting, which was not bile stained. His past history was normal and he had not vomited in infancy. The vomiting settled within two days and he was discharged to be readmitted 8 days later with a recurrence of his symptoms. The vomiting had become projectile. An abdominal radiograph again showed a gas-distended stomach with residue, suggesting gastric outlet obstruction. Barium meal revealed a narrow pyloric canal which was confirmed by endoscopy. Surgery showed a thick-walled stomach and a pyloric tumour typical ofhypertrophic pyloric stenosis. A coincidental finding was a thick band from the junction of the first and second parts of the duodenum kinking the duodenum at this point and holding up the first part onto the under surface of the liver. There was no evidence of duodenal obstruction or of malrotation. A Ramstedt pyloromyotomy was performed and the band divided. 'Congenital' or 'infantile' hypertrophic pyloric stenosis usually presents in the first weeks of life, symptoms beginning at an average age of 3.5 weeks.' Although the literature contains reports of several older infants presenting with this condition,2'3 it is extremely rare for it to present in children. Hypertrophic pyloric stenosis presenting after thoracic surgery in a boy aged 3 years 6 months has been described.3 These authors2'3 have also found difficulties with diagnosing late onset pyloric stenosis, including reluctance to consider the diagnosis in an older infant or child and episodic presentation with periods of remission. The duodenal band was considered to be a coincidental congenital anomaly and unrelated to the pyloric stenosis. Late presentation of pyloric stenosis is rare but should be considered in the differential diagnosis for older children presenting with recurrent vomiting and weight loss, even if the history is of relatively short duration.