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    Neonatal Intestinal Obstruction EPSGHAN PDF

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    Robert Christeven
    Neonatal intestinal obstruction can have various causes such as congenital anomalies like intestinal atresia or malrotations. Clinical signs include vomiting, abdominal distension, and failure to pass meconium. Diagnosis involves abdominal x-rays and contrast studies. Management depends on the specific condition but may involve surgery to repair atresias or correct malrotations. Long-term outcomes are generally good but can include issues like short bowel syndrome.

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    Neonatal Intestinal Obstruction EPSGHAN PDF

    Uploaded by

    Robert Christeven
    106 views77 pages
    Neonatal intestinal obstruction can have various causes such as congenital anomalies like intestinal atresia or malrotations. Clinical signs include vomiting, abdominal distension, and failure to pass meconium. Diagnosis involves abdominal x-rays and contrast studies. Management depends on the specific condition but may involve surgery to repair atresias or correct malrotations. Long-term outcomes are generally good but can include issues like short bowel syndrome.

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    Neonatal intestinal obstruction can have various causes such as congenital anomalies like intestinal atresia or malrotations. Clinical signs include vomiting, abdominal distension, and failure to pass meconium. Diagnosis involves abdominal x-rays and contrast studies. Management depends on the specific condition but may involve surgery to repair atresias or correct malrotations. Long-term outcomes are generally good but can include issues like short bowel syndrome.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    106 views77 pages

    Neonatal Intestinal Obstruction EPSGHAN PDF

    Uploaded by

    Robert Christeven
    Neonatal intestinal obstruction can have various causes such as congenital anomalies like intestinal atresia or malrotations. Clinical signs include vomiting, abdominal distension, and failure to pass meconium. Diagnosis involves abdominal x-rays and contrast studies. Management depends on the specific condition but may involve surgery to repair atresias or correct malrotations. Long-term outcomes are generally good but can include issues like short bowel syndrome.

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    of 77

    Neonatal Intestinal

    Obstruction
    Prof. R.A. Brown
    Exomphalos Major + chromosomal
    defect
    ‘Red Flags’
    • Respiratory distress – rapid, laboured,
    cyanosis
    • Excessive salivation
    • Vomiting – green, persistent
    • Abdominal distension / mass
    • Failure to pass meconium in 1st 24hrs
    • Convulsions / lethargy
    • Jaundice with pale stools
    Special Problems / Ethical dilemmas
    • Multiple congenital anomalies
    • Prematurity – at risk
    • Delayed diagnosis & delayed surgery
    • Jaundice
    • Coagulation disorders – give vitamin K
    • Metabolic – hypoglycaemia / hypocalcaemia
    • Infection prone – reduced immunity ++HIV
    • Hypothermia
    • IV fluids – beware too much
    • GIT decompression – NGT prox, bowel washout
    • Nutrients
    VACTERL
    vertebral, anorectal, cardiac, trachea-esophageal, renal, limb
    Oesophageal Atresia and Tracheo-
    oesophageal fistula
    Presentation and recognition
    • Prevents normal swallowing
    • Polyhydramnios in 33% with a distal fistula
    100% without fistula
    • Often premature, IUGR
    • Drooling and excessive oral secretions
    • When suckling the baby appears to choke
    and may have difficulty maintaining airway
    • Significant respiratory distress may result
    • May have the seal-bark cough that indicates
    tracheomalacia
    • Unable t insert tube more than 10-11 cm
    from the lips
    Oesophageal atresia
    Tracheoscopy – type c (proximal
    atresia and distal TOF)
    Oesophageal Atresia and Tracheo-
    oesophageal fistula
    Basic concepts of surgery
    • Thoracotomy
    • Primary anastomosis
    • Ventilate for 5 days if tension
    • ICD to assess for leak

    • If gap too long: gastrostomy,


    replogle on suction, ‘grow’
    the child
    • Then: Anastomosis or graft
    interposition

    • Post op: Omeprazole, No


    feeds for 1 week, check
    contrast swallow day 7 to 10,
    slowly introduce feeds
    Ramsted’s pyloromyotomy
    Pyloric stenosis – visible peristslsis,
    forceful (projectile) milk vomits
    Contrast meal
    Stomach peanut
    shaped

    Delayed emptying

    ‘tit’ sign

    Beak

    String sign

    Umbrella/mushroom
    Neonatal bowel obstruction
    green vomit, abdominal distension & failure to
    pass meconium
    Duodenal Atresia and Stenosis
    Pathology
    • Duodenal atresia - complete
    obliteration of the lumen
    • Duodenal stenosis is incomplete
    obstruction of the duodenal
    lumen and may present at
    various ages - clinical findings
    depend on the degree of Atresia
    stenosis (pinhole to mild
    narrowing)
    • Annular pancreas occurs when
    pancreatic tissue surrounds the
    2nd portion of the duodenum, it
    may be associated with complete
    or incomplete duodenal
    obstruction Stenosis
    Duodenal Atresia

    Presentation and Recognition


    • Incidence is 1:3400 live births
    • Incidence equal in males and female
    • Growth retardation and
    polyhydramnios (in 40%)
    • 50% are born prematurely
    • Bile-stained vomit in neonates aged 24
    hours or younger is typical. Minimal
    duodenal obstruction in mild stenosis
    or membrane may have few symptoms
    • In a few cases, the atresia is proximal
    to the ampulla of Vater and the vomit
    is free of bile
    Duodenal Atresia
    Associated conditions
    • Most commonly associated
    with trisomy 21 in 30%
    • 50% of patients have some
    form of anomaly: cardiac,
    anorectal, genitourinary
    • Oesophageal atresia and
    the VATER syndrome have
    been associated
    • All neonates with duodenal
    atresia should be assessed
    for concomitant
    malformations
    Duodenal Atresia
    Radiology
    • Double-bubble appearance with no distal gas
    • Distal bowel gas indicates stenosis, incomplete
    membrane, or a hepatopancreatic ductal anomaly
    • No oral contrast materials are necessary
    • Use air if more definition required
    Duodenal Atresia

    Outcome
    • Duodenoduodenostomy is
    performed when child is
    stable
    • Average time to full feeds is
    10 days
    • Most do well and need no
    further procedures
    Classification of types of intestinal atresia
    Intestinal atresia – operative findings

    Type 1 Type 3b or apple peel Type 3a with antenatal


    volvulus
    X-ray and contrast enema
    jejunal atresia
    Jejunal and Ileal Atresia

    Outcome
    • Most do well post op(90%)
    • Short bowel syndrome
    occurs if there has been
    multiple atresias and the
    residual bowel length is
    75cm or less
    • Anastomotic strictures or
    breakdown is rare
    • Exclude cystic fibrosis
    Midgut volvulus
    • Acute Midgut • Chronic Midgut
    Volvulus Volvulus
    – Clockwise twisting – Older age (2>)
    – Most under 1 month – Chronic vomiting
    – Bilious vomiting – Intermittent pain
    – Colicky abdominal – Diarrhoea
    pain – Hematemesis
    – PR bleeding – Chyle ascitis
    – Hypovolemia – Malabsorption
    – Shock Asymptomatic
    Corrective surgery is indicated at
    – Tenderness & any age
    peritonitis
    Midgut volvulus
    3 yr. old with sudden onset of abdominal pain and
    vomiting. Past history of recurrent abdominal cramps
    Hirschsprung’s Disease

    Functional obstruction of the


    intestine resulting from the
    congenital absence of
    parasympathetic ganglion cells in
    the myenteric plexus of the distal
    bowel.
    Incidence 1:5000
    M:F 4:1
    2% premature ( 37weeks)
    Genetic and
    Microenviromental factors
    Familial predisposition (2.4%-
    9%)
    Genes Implicated RET (10)
    EDNRB (13)
    Endothelin 3
    (20)
    Associated abnormalities
    21% (11-30)

    12% Chromosomal ( Downs 6%, Waardenburg)


    8 % Git
    6% CNS
    6% UGS
    6% CVS
    Site of aganglionosis
    70% rectosigmoid

    10% total colonic


    (familial 50%)

    Internal Sphincter involved- abn relaxation


    Diagnosis
    History:
    Delay of passage of mec 24h
    Abd distension/bile stained vomiting
    Hirschsprungs associated enterocolitis
    Chronic constipation in older children
    Radiology
    AXR- Air fluid levels in dilated colon
    Dilated small intestine

    Ba enema- Dilated proximal colon


    Funnel shaped narrowing
    Narrow distal colon
    Hirschsprung’s Disease
    2 day old male with abdominal distension, green
    vomit & failure to pass meconium. Normal anus.

    At operation a transition is clearly visible


    between the contracted aganglionic distal bowel &
    Contrast enema showing a patent obstructed proximal sigmoid colon
    colon but narrower rectum than sigmoid
    Histology
    • Absence of ganglion cells in Auerbachs
    and Meissners plexus.

    • Enlarged peripheral nerve trunks

    • Increased acetyl cholinesterase on


    staining
    Management

    Relieve obstruction with definitive surgery


    Defunctioning colostomy in ganglionated bowel
    Initial
    Temporary decompression with saline washouts

    Final Resection of aganglionic segment


    Pullthrough of ganglionated bowel and
    anastomosis to anorectal canal
    Complications
    Early - Anastomotic problems
    - Sepsis
    - Stenosis

    Late - Constipation (9%)


    - Obstructive symptoms
    - Enterocolitis
    - Stricture
    - Incontinence
    Anorectal Malformations
    Types, frequency, concept of
    level
    sacrum
    • Clinical classification: the level Muscle
    of the rectum in relation to the complex
    puborectalis muscle
    • High lesions don't pass
    through this muscle complex,
    more likely to elicit long-term
    continence problems. A
    rectourethral fistula usually
    present
    Anorectal Malformations
    • Low lesions traverse this muscle complex, have a better prognosis
    and are more likely to have perineal or posterior fourchette fistulas
    • Associated maldevelopment of the sacrum impairs innervation of
    both anal and urethral musculature leading to bladder and bowel
    dysfunction

    Fistula to
    perineum or Rectovestibular
    scrotum fistula
    Anorectal Malformations - male
    1. ‘high’ malformation – anorectal agenesis 1
    with ? recto-vesical fistula, sacral agenesis
    and poor pelvic floor muscles

    2. ‘high’ or ‘intermediate’ anorectal agenesis


    with recto-urethral fistula

    3. ‘low’ anomaly - covered anus with a


    ‘bucket handle’
    No fistula - high

    2
    3
    Anorectal Malformations
    Presentation and recognition
    • Failure to pass meconium
    • Patients with low lesions may be able to defecate via a vestibular
    anus or large fistula to perineum, but over time constipation and
    abdominal distension supervene
    • Patients with anterior ectopic anus may present as children or adults
    with constipation
    • Newborns with high lesions may have meconium at the urethral
    meatus or noted in the urine

    High lesion – no fistula Perineal fistula Bucket handle


    Anorectal Malformations
    • Diagnosis is confirmed by examination of the perineum
    • Flat perineum, short sacrum suggests a high anomaly
    • In males, meconium at the urethral meatus or in urine, or pneumaturia
    suggests a rectourethral or rectovesical fistula. In females, a fistula may
    open at the posterior vestibule
    • A perineal fistula may be small and difficult to detect. Waiting 24 hours
    allows gas or meconium to appear at the perineum
    • A single perineal opening in a female patient implies a cloaca.

    Vestibular anus No fistula Cloaca


    Anorectal Malformations
    Associated conditions and syndromes
    • Occur in 50-60%, especially high anomalies – may be VACTERL
    • Cardiovascular malformations occur in 12-22%
    • Tracheoesophageal abnormalities exist in 10%
    • Vertebral anomalies: Lumbosacral anomalies in approximately 1:3. The
    frequency of spinal dysraphism (the most common is tethered cord)
    increases with the severity of the lesion
    • Urologic abnormalities: vesicoureteric reflux in 50% of patients, renal
    agenesis and dysplasia, Cryptorchidism occurs in up to 20% of males.
    Vaginal and uterine abnormalities are common
    • Limb abnormalities – radial dysplasia

    Lumbar agenesis Reflux Renal dysplasia Tethered cord


    Anorectal Malformations
    Basic concepts of surgery
    • A divided colostomy is performed for patients with high lesions until
    later definitive repair
    • Posterior sagittal correction (PSARP) has been performed as the gold
    standard at 3 to 6 months. Incision in the midline posterior sagittal
    plane identifies the muscle complex and terminal rectum. The fistula to
    the genitourinary tract is corrected. Electrical stimulation of the
    sphincters and levator muscle complex shows correct anal position
    • Cloacal anomalies involve advancing the urethra, vagina and rectum to
    the perineum. They may require a combined abdominal and perineal
    approach
    • Low lesions can undergo a limited posterior sagittal approach to
    transpose the anus to the sphincters
    • The latest approach is a laparoscopic assisted anorectal pullthrough

    Divided colostomy Position Incision Rectum pulled down


    Meconium Disease in infancy
    • Meconium ileus without C.F.
    • Meconium obstruction and the prem infant
    • Meconium plug syndrome
    • Hirschsprung’s Disease
    • Small Left Colon Syndrome
    • Meconium peritonitis
    Meconium ileus in newborn

    Inc. C.F. in USA 1:3000


    15% mec ileus equals 180 pts/ year
    Rare in non Caucasians
    CF gene Chromosome 7 (1985)
    Pathogenesis

    Abn of exocrine mucous secretion


    obstruction of pancreatic duct/ intestinal glands
    Low water content ( 65% vs. 75%)
    in mucus
    Low enzyme levels sucrase/ lactase/
    pancreatic enz.

    Sticky meconium, which obstructs lumen


    Antenatal Perforation

    • Aet: volvulus/ distension


    • Inc: 50%
    • Results in: bowel atresia
    meconium peritonitis
    meconium pseudocyst
    Diagnosis

    • Not antenatally
    • Intest. obstruction in the newborn
    • Doughy abdominal mass
    • Complications : erythema/ oedema of
    ant abdominal wall
    Treatment
    a) Non Surgical
     Hydrostatic enema decompression
     Aim to reflux into terminal ileum
     Repeated enema may be necessary
     60-75% success

    b) Surgical
    Uncomplicated Enterotomy
    Saline
    Relieve obstruction Acetylcysteine
    Complicated Resection
    Anastomosis covered by colostomy
    Drainage and bowel rest, delayed anast 3 weeks
    post op
    XRay

     AXR inconsistent
    ( diff loop size ,meconium mottling, paucity rectal gas)

     Contrast enema (water soluble)


    small unused colon/ terminal ileum

     Biochem
    Sweat test
    Genetic testing
    INGUINAL HERNIA
    AETIOLOGY
    Persistence of processus vaginalis

    (peritoneal tongue accompanying


    descending testis or round ligament)

    M:F 8:1
    Obstruction
    OPERATE FOR
    COMPLICATIONS
    Irreducibility
    Obstruction
    Strangulation

    60% < 6 months


    80% < 1 year

    Operate at diagnosis

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