"Suspicion du stenose du pylore." I read the referral paper then looked at the tiny two week old baby in front of me.  The mom says he's been vomiting for a week.

I ask "What has he been vomiting?" 

Which gets translated into, "He has been vomiting milk, right?" 

Mom says, "Yes."

I ask, "Does he vomit bile? Green vomit?"

Which gets translated into, "He vomits green stuff, right?"

Mom says, "Yes, its green."

Me, "Is it milk or is it green?"

Mom, "He vomits after I feed him."

And so it went...now this "run-around" may not seem like a big deal, but one of the most important things to know in vomiting babies is, "Is the vomit bilious (green) or not?"  Green vomit is often a big emergency. Milk, not an emergency. Despite multiple questioning attempts, I just couldn't get a clear answer but it seemed most likely he had projectile vomiting of milk.  

I decided to move on to physical exam. Of course, a two week old baby isn't going to tell you if it hurts. He just cried. His abdomen felt pretty normal, although I thought I could see his stomach contracting under his skin.

I  briefly recalled my three months of pediatric surgery training at Seattle Children's hospital. I knew the next step for this vomiting baby: ultrasound. In Seattle, I would just order the ultrasound and wait for a report from the pediatric radiologist. It came back with numbers, measurements, and an interpretation: pyloric stenosis- yes, no, or maybe. Those were the days.

But now, it was just me, the antiquated ultrasound machine, and the baby. I laid the baby on the exam table and grabbed the ultrasound probe.  I've never done an ultrasound for pyloric stenosis...but there wasn't anybody else to do it.  I started scanning and eventually I found something that I thought (hoped) looked like an enlarged pylorus.

I found something that looked kind of like this...fuzz and all

I measured it all the while thinking "Hope this is right....what I wouldn't give for a ultrasonographer right now." I admitted him to the hospital to prepare him for the operation and put him on the list for the first case Saturday morning. 

Saturday morning OR list

The next morning, as we put him on the OR table,  I felt the full weight of my decision to operate. What if I was wrong?  What if his pylorus is normal? Then what? What if he doesn't need an operation? What if I am putting him through the risk of an operation for nothing? 

We prayed and I cut. I found his little stomach and followed it down to the pylorus and...breathed a sigh of relief. It was clearly abnormal.  In just a few minutes, I taught my intern how to fix a little baby's hypertrophied pylorus so the milk can once again empty out of the stomach. 

Within twenty-four hours he was breastfeeding without any problem and two days later he is on his way home!