Intestinal Obstruction In The Neonate

Dr Osama BawazirAssistant Professor , Consultant Pediatric surgeon

FRCSI, FRCS(Ed), FRCS (glas), FRCSC,FAAP,FACS.

Incidence

intestinal obstruction is the most common surgical emergency of the newborn.

1 case per every 500-1000 live births. 50% of these neonates will have intestinal

atresia or stenosis

PresentationPresentation

Cardinal signs of intestinal Cardinal signs of intestinal obstruction in neonateobstruction in neonate

1. Antenatal polyhydramnios2. Bilious vomiting3. Delayed passage of meconium

(> 24 hrs)4. Gastric residual > 30 cc5. Abdominal distention

bloody diarrhea indicating bowel ischemia or necrosis.

Imaging StudyImaging Study New born has air within the

proximal small bowel within 30 minutes. Air can be identified in the rectum by 6-8 hours.

Multiple dilated loops of bowel with “stepladder” air fluid levels on the upright film is the pattern most often seen with distal intestinal obstruction.

peritoneal and/or scrotal calcifications which may signify an intrauterine perforation with meconium peritonitis.

contrast enema may be useful to distinguish between causes of distal bowel obstruction

Upper gastrointestinal barium studies (not useful) only for bowel rotation.

small unused colon

Causes of neonatal intestinal obstruction

Common:

Malrotation (duodenal obstruction, volvulus, internal hernia)

Duodenal atresia, stenosis or annular pancreas

Jejunal atresia or stenosis Ileal atresia or stenosis Simple meconium ileus Meconium ileus with perforation Meconium plug syndrome Hirschsprung’s disease Drug-induced ileus Hypertrophic pyloric stenosis

Uncommon:

Pyloric atresia or webTumorsIntussusceptionSegmental intestinal dilatationSmall left colon syndromeMilk bolus obstructionColonic atresiaFunctional Intestinal obstructionIntestinal Psuedo-ObstructionNeuronal Intestinal DysplasiaMegalocystis-Microcolon-Intestinal Hypoperistalsis SyndromeInguinal hernia

PathophysiologyPathophysiology

Proximal intestinal obstruction loss of H+ ,K+ & Cl‾ Hypochloremic alkalosis

Distal intestinal obstruction fluid loss from emesis & from fluid sequestered into the lumen of dilated bowel loops

Fluid shifts and volume depletion dehydration, oliguria, metabolic acidosis, and inadequate peripheral perfusion.

impair diaphragmatic function bowel ischemia and necrosis.

Perioperative Management (1)Perioperative Management (1)

Fundamental rule: previous losses Fundamental rule: previous losses /maintenance/ongoing needs/maintenance/ongoing needs

Urine output best measure of adequate Urine output best measure of adequate resuscitationresuscitation

?Need for central monitoring if problematic?Need for central monitoring if problematic Recall distribution of various IV solutionRecall distribution of various IV solution Bolus: as per PALS (20 cc/kg)Bolus: as per PALS (20 cc/kg) Titrate to heart rate, urine output BPTitrate to heart rate, urine output BP ↑ ↑ Maintained 25% for each quadrant of Maintained 25% for each quadrant of

abdomen involvedabdomen involved

Perioperative Management(2)Perioperative Management(2) Antibiotics if any viscus opened, cardiac Antibiotics if any viscus opened, cardiac

issues, immunosuppresed (newborn)issues, immunosuppresed (newborn) Steroids: if on previously/deficiency (stress Steroids: if on previously/deficiency (stress

dose physiology)dose physiology) Nasogastric tube (Decompression)Nasogastric tube (Decompression) Keep patient warmKeep patient warm surgery should not be delayed once surgery should not be delayed once

volume resuscitation is adequatevolume resuscitation is adequate

Two weeks old Two weeks old full term female full term female with bilious with bilious vomitingvomiting..

Be Aware of Child with Be Aware of Child with Bilious (Green) VomitingBilious (Green) Vomiting

MalrotationMalrotation

10th Week of Development rapid 10th Week of Development rapid growth of intestine which returns to growth of intestine which returns to abdominal cavity with rotation abdominal cavity with rotation

0.5–1% of the population0.5–1% of the population only 1 in 6000 live births will only 1 in 6000 live births will

present with clinical symptoms.present with clinical symptoms.

Problems can occur at any of the 3 Problems can occur at any of the 3 stagesstages Duodenal rotationDuodenal rotation Elongation and fixation of the Elongation and fixation of the

mesenterymesentery Rotation of the colon Rotation of the colon

cut-off to passage of barium describedas a “bird’s beak”

spiral or corkscrew

In simple malrotation, the upper gastrointestinal series shows the incomplete rotation of the duodeno-jejunal loop

cut-off to passage of barium described as a “bird’s beak”

spiral or corkscrew Ultrasound superior

mesenteric vein is normally to the right of the artery

Treatment Midgut volvulus is a

surgical emergency. Malrotation without

volvulus is a relatively nonemergent condition

The operative management (Ladd procedure)

Recurrent volvulus 10% after Ladd procedure.

5-6% bowel obstruction secondary to adhesions.

Full term female who was 6 hours old. The

pregnancy history was remarkable for

polyhydramnios on prenatal ultrasound.

Immediately after birth the patient developed

bilious emesis.

Duodenal Atresia/ Annular Duodenal Atresia/ Annular PancreasPancreas

Primary problem is one of Primary problem is one of recanalization of solid recanalization of solid duodenum.duodenum.

Obstruction typically at level of Obstruction typically at level of common bile duct and pancreas common bile duct and pancreas

Duodenal obstruction occurs distal to the ampulla of Vater in 80% of cases.

Duodenal obstruction can be secondary to intrinsic or extrinsic lesions.

Associated anomalies Associated anomalies common: almost 50%common: almost 50% Down syndrome 29%Down syndrome 29% malrotation 19%malrotation 19% congenital heart disease 17%congenital heart disease 17% TEF 7%TEF 7% Others (renal, respiratory, Others (renal, respiratory,

imperforate anus - roughly imperforate anus - roughly 10%)10%)

surgical treatment of choice surgical treatment of choice is a ‘double diamond’ is a ‘double diamond’ duodenoduodenostomyduodenoduodenostomy

Newborn 36 week premature female with bilious vomiting.polyhydramnios on prenatal ultrasound.

Jejunal & Ileal AtresiaJejunal & Ileal Atresia Pathology related to late second

trimester vascular accident (Barnard)

most common gastrointestinal atresia

one per 2,000 live births. Associated anomalies rare Classification system

2 month old boy with bilious vomiting and 2 month old boy with bilious vomiting and a palpable right lower quadrant massa palpable right lower quadrant mass

Inguinal herniaInguinal hernia Indirect 99%Indirect 99% 1% to 3% of all children 1% to 3% of all children 3% to 5% in preterm baby3% to 5% in preterm baby R 60% L 30% Bilateral 10-15%R 60% L 30% Bilateral 10-15% Males to females ratio is 6:1Males to females ratio is 6:1 Present as bulge in the groin, Present as bulge in the groin,

scrotum, or labia.scrotum, or labia. A reliable history is sufficient to A reliable history is sufficient to

make the diagnosis, even if the make the diagnosis, even if the hernia cannot identify.hernia cannot identify.

An incarcerated inguinal hernia An incarcerated inguinal hernia presents as a mass in the labia or presents as a mass in the labia or scrotum that does not reduce scrotum that does not reduce spontaneously.spontaneously.

What embryological events What embryological events account for this abnormality?account for this abnormality?

Failure of the processus vaginalis to Failure of the processus vaginalis to close (it remains patent).close (it remains patent).

What are your recommendations What are your recommendations to the parents?to the parents?

The hernia should be repaired The hernia should be repaired electively; the parents should be electively; the parents should be warned about possible warned about possible incarceration in the meantime.incarceration in the meantime.

If at the time of your examination If at the time of your examination the child were irritable and the the child were irritable and the mass irreducible, what would be mass irreducible, what would be your approach?your approach?

Attempt manual reduction (use sedation Attempt manual reduction (use sedation if necessary); emergency surgery if if necessary); emergency surgery if unsuccessful.unsuccessful.