BILIOUS VOMITING IN THE NEWBORNSHayssam Rashwan pediatric surgery dep.

Bilious vomiting in newborns is an

URGENT CONDITION thatrequires the immediate involvement of a team of pediatric surgeons and neonatologists for perioperative management

BILIOUS VOMITINGResuscitation* History, age of onset and associated symptoms

IMMEDIATELY after birth; abdominal distention, bilious vomiting

Few hours after birth; bilious vomiting, no distention

Within 24 hours of birth; vomiting, abdominal distention

At 3 to 7 days; bilious vomiting, rapid deterioration with volvulus

10 to 12 days after birth; distention, vomiting, bloody stools

Abdominal film;Distention Air-fluid levels Sweat test Groundglass sign

Abdominal film,doublebubble sign

Abdominal film:air fluid level

Ultrasound; Upper GI spiral sign - Abnormal location of the superior mesenteric vessels

Abdominal film;Distention Pneumatosis Air in the aortal vein

Meconium Ileus

Duodenal Atresia

Jejunoileal atresia

Malrotation with volvulus

Necrotizin g Ileus

Meconium Ileus

Duodenal Atresia

Jejunoileal atresia

Malrotation with volvulus

Necrotizin g Ileus

Gastrografin enema plus IV fluids, Enterostomy if complicated

Resection(s) and anastomosis

Resection of necrotic bowel and enterostomy

Diamond-shaped duodenoduodenostomy

Ladd's procedure

I. Preoperative Management:Place infant in an incubator for close observation and temperature control

Place nil by mouth Nasogastric or orogastric catheter should be placed for gastric decompression to prevent further vomiting and aspirationEstablishment of an intravenous line should follow for administration of fluid, electrolytes and nutrition

Protein (plasma) correct sepsis if present

II. Postoperative:Same as preoperative plus nasogastrotube is inserted until passing of the stool or present of intestinal sound and then start oral feeding

Malrotation & Volvulus

Malrotation

Early volvulus

Late volvulus

Clinical Picture1. Bilious Vomiting2. Acute symptoms of: Intermittent abdominal pain Diarrhoea Constipation Haematochezia

3. Symptoms of bowel ischemia: Peritonitis Abdominal distention Bloody stools Haemodynamic instability Intermittent pain Intermittent vomiting Malabsorption Failure to thrive

4. Chronic symptoms of:

Investigations1. Plain x-ray abdomen Double bubble sign

2. Ultrasound 3. Contrast study

Plain x-ray

Ultrasound

Reversal of the normal superior mesenteric artery (SMA)/superior mesenteric vein (SMV) relationship

Whirlpool sign of malrotation shows whirling bowel and associated mesenteric vasculature

Contrast Study

A paucity of small-bowel gas

Malrotation with midgut volvulus and duodenal obstruction. The position of the duodenojejunal junction is abnormal.

Typical radiographic findings of malrotation.

Corkscrew appearance

Ladds Procedure

A. B. the

The abdomen is opened The small intestines are seen first and appear to hide colon. The entire intestinal mass is delivered out of the abdomen

C. D.

The intestinal mass is rotated to reduce the volvulus The intestines are re-positioned in the abdomen

E. It shows the appearance of the intestines at the end of surgery

Duodenal Atresia

COMPLAINT

Greenish persistant/ intermittent vomiting few hours after birth

Resuscitate untill hemodynamically stable RESUSCITATION early (few hours after birth) bilious vomiting No abdominal distension (may have but uncommon) No passage of meconium (may have in incomplete type) Associated symptom : Down syndrome in 1/3 of patient 20% have congenital heart VACTERL

EXAMINATION

INVESTIGATION

Plain X-ray -double bubble sign -absent of gases

Contrast study: - Gastrographin meal (diagnose the incomple type) Bypass surgery: -duodenodeuodenostomy -duodenojejunostomy

TREATMENT

Preoperative measure

Jejunoileal Atresia

Types

CLINICAL PICTUREBilious vomiting Absent bowel sounds No meconium Abdominal distention

INVESTIGATIO NS1. Plain x-ray Thumb-sized loops of bowel with air-fluid levels 2. Barium enema Define microcolon

TREATMEN TPreoperative Operative: 1. Resection and primary anastomosis of atretic segments 2. Tapering enteroplasty (limited bowel length)

Meconium Ileus

After birth, infants fail to pass meconium in the first 12 to 24 hours

SIGNS OF INTESTINAL OBSTRUCTI ON Bilious emesis Abdominal distention Palpable loops of small intestine

INVESTIGATION S 1. Plain x-ray distended intestine, absence of airfluid levels, "soap bubble" appearance 2. Contrast enema 3. Investigations of cystic fibrosis

A. Illustration of intestine blocked by meconium. B. Abdominal x-ray of a newborn infant with meconium ileus showing dilated loops of bowel.

TREATMENTNONOPERATIVE[Evacuation of meconium] 1. Multiple enemas 2. Dilute Gastrograffin with N-acetylcysteine

OPERATIVE

3. Hyperosmolar solutions(1% acylcysteine)

Necrotizing Enterocolitis

Clinical PictureGastrointestinal

Systemic

Feeding intolerance Abdominal distention Abdominal erythema & tenderness Emesis Occult/gross blood in stool Abdominal mass

Lethargy Apnea/respiratory distress

Temperature instabilityHypotension Acidosis Glucose instability DIC Positive blood cultures

Investigations Plain x-ray abdomen1. Pneumatosis intestinalis

(pathognomic) Linear streaking pattern

Bubbly pattern

2. Portal venous gas

3. Pneumoperitoneum

Pneumatosis IntestinalisNote the air visible in the bowel wall. The air dissects the bowel wall giving it a double lined appearance (railroad tracks without the ties)

Portal Venous Gas

Pneumoperitoneum

Treatment1. Preoperative preparations 2. Operative: Resection of necrotic bowel andenterostomy

Indications: Absolute indication: pneumoperitoneum Clinical deterioration despite medical management Positive paracentesis Fixed intestinal loop on serial x-rays Erythema of abdominal wall

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