GASTROINTESTINAL OBSTRUCTION MARIA NAVAL C. RIVAS, M.D. DEPARTMENT OF PEDIATRICS THE MEDICAL CITY

GASTROINTESTINGASTROINTESTINALAL

OBSTRUCTIONOBSTRUCTIONMARIA NAVAL C. RIVAS, M.D.MARIA NAVAL C. RIVAS, M.D.

DEPARTMENT OF PEDIATRICSDEPARTMENT OF PEDIATRICS

THE MEDICAL CITYTHE MEDICAL CITY

AnatomyAnatomy

EsophagusEsophagusStomachStomachSmall intestinesSmall intestines

DuodenumDuodenumJejenumJejenumIleumIleum

Large IntestinesLarge IntestinesCecumCecumAscending, Ascending, Transverse and Transverse and Descending colonDescending colonSigmoid colonSigmoid colon

RectumRectum

DefinitionDefinition

Blockage of the esophagus, Blockage of the esophagus, stomach, small or large intestines stomach, small or large intestines

Prevents food and fluids from Prevents food and fluids from passing throughpassing through

PathophysiologyPathophysiology

accumulation of food, gas and gastric/intestinal secretions

gastric / bowel distention

decreased intestinal absorption and increased secretion of fluid and

electrolytes

fluid and electrolyte imbalance

Symptoms / SignsSymptoms / Signs

abdominal pain abdominal pain abdominal distentionabdominal distention nausea nausea vomiting : bilious vs. non-biliousvomiting : bilious vs. non-bilious symptoms of malabsorptionsymptoms of malabsorption

MECHANICAL OBSTRUCTIONMECHANICAL OBSTRUCTION

Esophageal AtresiaEsophageal Atresia most common congenital anomaly most common congenital anomaly 1: 4,000 neonates1: 4,000 neonates 90% assoc with tracheoesophageal fistula90% assoc with tracheoesophageal fistula 50% assoc with VATER/VACTERL50% assoc with VATER/VACTERL s/sx : frothing/bubbling of mouth and noses/sx : frothing/bubbling of mouth and nose

coughingcoughing

respiratory distressrespiratory distress


Diagnosis : Diagnosis : inability to pass nasogastric or orogastric inability to pass nasogastric or orogastric

tubetube early signs of respiratory distressearly signs of respiratory distress absence of gas in the stomachabsence of gas in the stomach

Treatment:Treatment: managing airwaymanaging airway preventing aspirationpreventing aspiration surgical interventionsurgical intervention


Gastric ObstructionGastric Obstruction Hypertrophic Pyloric StenosisHypertrophic Pyloric Stenosis Congenital Gastric Outlet Congenital Gastric Outlet

ObstructionObstruction Gastric DuplicationGastric Duplication Gastric VolvulusGastric Volvulus


Intestinal ObstructionIntestinal Obstruction Duodenal ObstructionDuodenal Obstruction Jejunal and Ileal Atresia ObstructionJejunal and Ileal Atresia Obstruction MalrotationMalrotation Intestinal DuplicationIntestinal Duplication Meckel’s DiverticulumMeckel’s Diverticulum AdhesionsAdhesions Intussusception Intussusception

HYPERTROPHIC PYLORICHYPERTROPHIC PYLORIC STENOSISSTENOSIS

Incidence : 3 / 1000 infantsIncidence : 3 / 1000 infants whites > blacks > Asianswhites > blacks > Asians male 4x > femalesmale 4x > females associated with other congenital defects associated with other congenital defects

e.g. tracheo-esophageal fistulae.g. tracheo-esophageal fistula etiology : unknownetiology : unknown


abdominal pain abdominal pain abdominal distentionabdominal distention nausea nausea vomitingvomiting

biliousbilious non-bilious non-bilious

others: jaundiceothers: jaundice

sx of malabsorptionsx of malabsorption

occ peristaltic wavesocc peristaltic waves


DiagnosisDiagnosis palpable pyloric masspalpable pyloric mass

firm, movable, approx 2 cm length. firm, movable, approx 2 cm length. olive-shapedolive-shaped

located above and to the right of the located above and to the right of the umbilicus (midepigastrium)umbilicus (midepigastrium)

UltrasonographyUltrasonography TreatmentTreatment

Ramstedt pyloromyotomyRamstedt pyloromyotomy Correction of fluid imbalanceCorrection of fluid imbalance


Gastric ObstructionGastric Obstruction Hypertrophic Pyloric StenosisHypertrophic Pyloric Stenosis Congenital Gastric Outlet Congenital Gastric Outlet

ObstructionObstruction Gastric DuplicationGastric Duplication Gastric VolvulusGastric Volvulus


Intestinal ObstructionIntestinal Obstruction Duodenal ObstructionDuodenal Obstruction Jejunal and Ileal Atresia / ObstructionJejunal and Ileal Atresia / Obstruction MalrotationMalrotation Intestinal DuplicationIntestinal Duplication AdhesionsAdhesions Intussusception Intussusception





DUODENAL OBSTRUCTIONDUODENAL OBSTRUCTION

DUODENAL OBSTRUCTIONDUODENAL OBSTRUCTION

CausesCauses congenital duodenal atresiacongenital duodenal atresia annular pancreasannular pancreas Ladd’s bands of malrotationLadd’s bands of malrotation

CONGENITAL DUODENAL ATRESIACONGENITAL DUODENAL ATRESIA

Etiology : failure to recanalize the duodenal Etiology : failure to recanalize the duodenal lumen after the lumen after the

solid phase of intestinal solid phase of intestinal development during 4development during 4thth to to

55thth week of gestation week of gestation

Incidence : 1 in 10,000 birthsIncidence : 1 in 10,000 births

25-40% of all intestinal atresias25-40% of all intestinal atresias

50% are premature50% are premature

Other associated congenital anomaliesOther associated congenital anomalies Down’s syndromeDown’s syndrome 20-30%20-30% MalrotationMalrotation 20%20% Esophageal atresia 10-20%Esophageal atresia 10-20% congenital heart disease 10-15%congenital heart disease 10-15% anorectal and renal anomalies 5%anorectal and renal anomalies 5%

Diagnosis : “double – bubble sign” on plain Diagnosis : “double – bubble sign” on plain abdominalabdominal

radiographsradiographs

: readily detected by fetal : readily detected by fetal ultasonographyultasonography

: echocardiogram: echocardiogram

: radiography of chest and spine: radiography of chest and spine

Treatment : nasogastric / orogastric Treatment : nasogastric / orogastric decompressiondecompression

intravenous fluidsintravenous fluids

surgery - duodenoduodenostomysurgery - duodenoduodenostomy

ANNULAR PANCREASANNULAR PANCREAS

rare conditionrare condition 22ndnd part of duodenum is surrounded part of duodenum is surrounded

by a ring of pancreatic tissueby a ring of pancreatic tissue complete / incomplete obstructioncomplete / incomplete obstruction Diagnosis: abdominal ultrasound & Diagnosis: abdominal ultrasound &

radiographradiograph Treatment: duodenoduodenostomy Treatment: duodenoduodenostomy




sx of malaborptionsx of malaborption

JEJUNAL AND ILEAL JEJUNAL AND ILEAL OBSTRUCTIONOBSTRUCTION

JEJUNAL AND ILEAL JEJUNAL AND ILEAL OBSTRUCTIONOBSTRUCTION

CausesCauses congenital jejuno-ileal atresiascongenital jejuno-ileal atresias meconium ileusmeconium ileus Hirschsprung diseaseHirschsprung disease

CONGENITAL JEJUNOILEAL CONGENITAL JEJUNOILEAL ATRESIAATRESIA

attributed to intrauterine vascular accidents attributed to intrauterine vascular accidents

leadingleading

to ischemic necrosis of the bowel and to ischemic necrosis of the bowel and resorption resorption

of the affected segmentsof the affected segments associated with prematurity, polyhydramnios, associated with prematurity, polyhydramnios,

monozygotic twins, failure to pass meconiummonozygotic twins, failure to pass meconium

CONGENITAL JEJUNOILEAL ATRESIACONGENITAL JEJUNOILEAL ATRESIA

Diagnosis: prenatal sonograms Diagnosis: prenatal sonograms

air-fluid levels on plain radiographsair-fluid levels on plain radiographs

contrast studies contrast studies

ultrasoundultrasound Treatment: resection of dilated proximal portion of Treatment: resection of dilated proximal portion of

bowelbowel

followed by end to end anastomosisfollowed by end to end anastomosis

CONGENITAL JEJUNOILEAL ATRESIACONGENITAL JEJUNOILEAL ATRESIA TypesTypes

I – mucosal obstruction caused by an I – mucosal obstruction caused by an intraluminal intraluminal membrane with intact bowel membrane with intact bowel wall and mesenterywall and mesentery

II – small diameter solid cord connects the II – small diameter solid cord connects the proximal proximal and distal bowel and distal bowel

IIIA – both ends of bowel end in blind loopsIIIA – both ends of bowel end in blind loops

IIIB – extensive mesenteric defect that causes IIIB – extensive mesenteric defect that causes distaldistal

ileum to coil around the ileocolic arteryileum to coil around the ileocolic artery

IV – multiple segments of bowel atresiaIV – multiple segments of bowel atresia

MECONIUM ILEUSMECONIUM ILEUS

last 20-30cm of ileum is collapsed and filled last 20-30cm of ileum is collapsed and filled with with

pale-colored stool, above which is a dilated pale-colored stool, above which is a dilated bowel of varying length obstructed by bowel of varying length obstructed by meconium with thick syrup consitency meconium with thick syrup consitency

80-90% has cystic fibrosis80-90% has cystic fibrosis

MECONIUM ILEUSMECONIUM ILEUS

Diagnosis: plain radiograph shows hazy Diagnosis: plain radiograph shows hazy appearance appearance on the R on the R lower quadrantlower quadrant

Treatment: Gastrografin enemaTreatment: Gastrografin enema

resection of ischemic resection of ischemic bowelbowel

HIRSCHSPRUNG DISEASEHIRSCHSPRUNG DISEASE

Congenital Aganglionic MegacolonCongenital Aganglionic Megacolon absence of ganglion cells in the bowel wall absence of ganglion cells in the bowel wall

beginning inbeginning in

the internal anal sphincter extending variably the internal anal sphincter extending variably to proximal to proximal

intestinesintestines 5% involves terminal ileum5% involves terminal ileum 1 : 5,000 live births1 : 5,000 live births male : female (4:1)male : female (4:1)


Clinical ManifestationClinical Manifestation

delayed passage of meconiumdelayed passage of meconium chronic constipationchronic constipation palpable fecal mass in LLQpalpable fecal mass in LLQ empty rectal vaultempty rectal vault


DiagnosisDiagnosis rectal manometry and rectal biopsyrectal manometry and rectal biopsy Radiograph : transition zone (funnel-shaped area) Radiograph : transition zone (funnel-shaped area)

between normal dilated proximal colon and a between normal dilated proximal colon and a smaller-caliber obstructed distal colonsmaller-caliber obstructed distal colon

Treatment : surgicalTreatment : surgical

MALROTATIONMALROTATION incomplete rotation of the intestines incomplete rotation of the intestines

during fetal developmentduring fetal development duodenum fixed to the posterior abdominal duodenum fixed to the posterior abdominal

wallwall right & left colon and mesenteric artery root right & left colon and mesenteric artery root

fixed to the posterior abdomenfixed to the posterior abdomen most common type: failure of cecum to most common type: failure of cecum to

move to R lower quadrantmove to R lower quadrant malposition of ligament of Treitz, superior malposition of ligament of Treitz, superior

mesenteric vein located to the left of the mesenteric vein located to the left of the arteryartery





MALROTATIONMALROTATION

MALROTATIONMALROTATION complication: VOLVULUScomplication: VOLVULUS

twisting of the small or large bowel twisting of the small or large bowel around itselfaround itself

acute presentation of bowel obstructionacute presentation of bowel obstruction Diagnosis: ultrasound and Diagnosis: ultrasound and

contrastradiographic contrastradiographic studiesstudies

1.1. duodenal obstructionduodenal obstruction

2.2. thickened bowel loops to the R of spinethickened bowel loops to the R of spine

3.3. free peritoneal fluidfree peritoneal fluid

MALROTATIONMALROTATION TreatmentTreatment

Malrotation : surgical intervention Malrotation : surgical intervention Volvolus : Volvolus : reduce twisted bowelreduce twisted bowel

free duodenum and upper free duodenum and upper jejenum of any jejenum of any

bands / position in R abdominal bands / position in R abdominal cavitycavity

colon is freed from adhesions colon is freed from adhesions and placed in R and placed in R abdomen with cecum in abdomen with cecum in the L lower quadrantthe L lower quadrant

INTUSSUSCEPTIONINTUSSUSCEPTION

portion of alimentary tract is telescoped portion of alimentary tract is telescoped into an adjacent segment most into an adjacent segment most commonly involving ileocolic and commonly involving ileocolic and ileoileocolicileoileocolic

incidenceincidence 1-4 in 1,000 live births ( 3mos-6yrs)1-4 in 1,000 live births ( 3mos-6yrs) rare in neonatesrare in neonates 60% younger60% younger than 12 monthsthan 12 months 80% of cases occur before 2480% of cases occur before 24thth month month male:female is 4:1male:female is 4:1


EtiologyEtiology most cases unknownmost cases unknown some associated with adenovirussome associated with adenovirus complicates URTI, AGE, otitis media, complicates URTI, AGE, otitis media,

Henoch-Schonlein PurpuraHenoch-Schonlein Purpura theory on swollen Peyer’s patchestheory on swollen Peyer’s patches lead points in 2-8% caseslead points in 2-8% cases

meckel’s diverticulummeckel’s diverticulum intestinal polypintestinal polyp neurofibromaneurofibroma hemangiomahemangioma lymphomalymphoma

INTUSSUSCEPTIONINTUSSUSCEPTION PathologyPathology

intussusceptum invaginates into intussuscipiens dragging mesentery

constriction of mesentery

obstruction of venous return

engorgement of intussusceptum

bloody stools with mucus (currant-jelly stools)

edema and bleeding from mucosa

INTUSSUSCEPTIONINTUSSUSCEPTION Early PhaseEarly Phase

1.1. sudden onset of paroxysmal, colicky painsudden onset of paroxysmal, colicky pain

2.2. accompanied by straining with legs/knees accompanied by straining with legs/knees flexed and loud criesflexed and loud cries

3.3. frequent vomitingfrequent vomiting

4.4. child may play in between paroxysms of painchild may play in between paroxysms of pain Late PhaseLate Phase

1.1. bile-stained vomitusbile-stained vomitus

2.2. little / no flatuslittle / no flatus

3.3. child is progresively weaker and lethargicchild is progresively weaker and lethargic

4.4. fever with shock-like statefever with shock-like state


Physical ExaminationPhysical Examination slightly tender sausage-shaped massslightly tender sausage-shaped mass bloody mucous on rectal exambloody mucous on rectal exam abdominal distentionabdominal distention

DiagnosisDiagnosis plain radiograph : density in the area of plain radiograph : density in the area of

intussusceptionintussusception barium enema : coiled-spring signbarium enema : coiled-spring sign abdominal ultrasound : doughnut or target abdominal ultrasound : doughnut or target

appearanceappearance


Treatment : Treatment : emergency reduction except if with signs of emergency reduction except if with signs of

shock, peritoneal irritation, intestinal shock, peritoneal irritation, intestinal perforation or pneumatosis intestinalisperforation or pneumatosis intestinalis

radiologic reduction under fluoroscopic or radiologic reduction under fluoroscopic or ultrasonic guidanceultrasonic guidance

PrognosisPrognosis fatal if untreatedfatal if untreated spontaneous reduction during pre-operative spontaneous reduction during pre-operative

preparationpreparation most recover if reduced within 24 hoursmost recover if reduced within 24 hours Increase mortality after 2Increase mortality after 2ndnd day day

INTESTINAL DUPLICATIONINTESTINAL DUPLICATION

well-formed tubular structures firmly well-formed tubular structures firmly attached to the intestine with a common attached to the intestine with a common blood supplyblood supply

lining of duplications resembles GI tractlining of duplications resembles GI tract very rarevery rare cause unknown but attributed to defect in cause unknown but attributed to defect in

recanalization during embryological recanalization during embryological developmentdevelopment

signs of obstructionsigns of obstruction

ADHESIONSADHESIONS

fibrous bands of tissue that are a common fibrous bands of tissue that are a common cause of cause of

post-operative bowel obstructionpost-operative bowel obstruction 2-3% of patients after abdominal surgery2-3% of patients after abdominal surgery majority are single adhesionsmajority are single adhesions symptoms of obstruction manifest anytime symptoms of obstruction manifest anytime

after 2after 2ndnd

postoperative weekpostoperative week Diagnosis: plain and contrast radiographsDiagnosis: plain and contrast radiographs Treatment: nasogastric decompressionTreatment: nasogastric decompression

IV fluid rescucitationIV fluid rescucitation

broad-spectrum antibioticbroad-spectrum antibiotic

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GASTROINTESTINAL OBSTRUCTION MARIA NAVAL C. RIVAS, M.D. DEPARTMENT OF PEDIATRICS THE MEDICAL CITY