Olive Palpation, Sonography and Barium Study in the Diagnosis of Hypertrophic Pyloric Stenosis: Decline in Physician's Art

Background/ Hypertrophic pyloric stenosis (HPS) is the commonest indication of pediatric surgery in neonatal period and early infancy. There are some clinical and radiological methods for the diagnosis of HPS. As an example, a positive "olive sign" in the abdominal examination is diagnostic; however, it seems that performing physical examination for the detection of this sign has been abandoned and that this practice has been replaced by sonography and other paraclinical tests. The aim of this study was to assess the ability of our physicians in finding the palpable olive in clinical examination and the accuracy of sonography and the true positive rate of barium study.Patients and We evaluated 84 patients admitted to our hospital during a 7-year period in which the final surgical report was HPS. Clinical examination for the right upper quadrant (RUQ) olive like mass, barium study and ultrasound findings of HPS were evaluated. Pediatric residents (junior and senior residents) examined all these cases. Twenty-one patients had a barium study and 81 had a sonography, which was performed by an attending radiologist. Data were evaluated for the diagnostic yield (DY) of all these diagnostic tools. The mean age of the patients was 36.1 days on admission and the male/female ratio was 5.4/1. All the patients had a clinical examination, in which the olive sign was detected in only 13 cases (DY= 15.5%, 95% CI: 12%-19%); 81 patients had a sonography, in 71 of whom HPS was detected (DY = 87.7%, 95% CI: 85%-92%); barium study revealed HPS in 16 of 21 patients (DY = 76.2%, 95% CI: 71.4%-82%). Sonography was more precise than clinical examination and barium study in detecting HPS. Due to the crying baby and the distended stomach, less time is spent for clinical examination. Therefore, paraclinical studies such as imaging become the first step in diagnosis and are requested earlier and even as the first diagnostic study on admission. This leads to reduction of doctors'' experience in finding the olive sign.