NEONATAL BOWEL

OBSTRUCTIONOBSTRUCTION

Humberto Lugo-Vicente MD FACS FAAP

Professor Pediatric Surgery

UPR School of Medicine

FAILURE TO PASS MECONIUMBILIOUS VOMITING

ABDOMINAL DISTENSION

SIMPLE ABDOMINAL FILMS

dilated bowel loops with calcifications, gasless abdomen with eggshell

calcificationCONTRAST ENEMA

dilated bowel loops

NEONATEPYLORIC,DUODENAL orJEJUNAL atresia/stenosisNEC

microcolon

MECONIUM PERITONITISGIANT CYSTIC MECONIUM PERITONITISNO microcolon

Transitional zonebarium retention past 24

hours

Rectal biopsy

HIRSCHSPRUNG’SLEFT HYPOPLASTIC COLON

INTESTINAL ATRESIAHYPOPERISTALSIS SYNDROME

NO air-fluid levelsground-glass appearance

MECONIUM PLUG SYNDROME

MECONIUM ILEUS

Air-fluid levels

Congenital bowel obstruction

• Triad– Bilious vomiting

– Retained meconium

– Abdominal distension

• Pathologic types– Intraluminal– Intraluminal

– Extraluminal

– Functional

• Aids in early dx– Mother history, miscarriage, siblings

– Polyhydramnious

• Investigation– Plain X-ray (KUB or babygram)

– Contrast studies (enema or UGIS)

Gastro-pyloric

anomalies

• Pyloric atresia

– Epidermolysis bullosa

– Management– Management

• gastroduodenostomy

• Pyloric stenosis

Pyloric stenosis

• Concentric muscle hypertrophy

• Males:female 4:1

• Post-prandial non-bilious vomiting

• Metabolic hypochloremic alkalosis

• Dehydration

• Palpable pyloric muscle• Palpable pyloric muscle

• Diagnosis– US

– UGIS

• Management– hydration

– Pyloromyotomy– Periumbilical approach

Duodenal lesions

• Bilious vomiting

• Types– Atresia

– Stenosis

– Annular pancreas

– Ladd’s bands– Ladd’s bands

• Diagnosis– KUB

– Colon contrast study

• Associated anomalies– Cardiac

– Down’s syndrome

Duodenal atresia

• KUB

– Double bubble

• Down’ syndrome

– 30%– 30%

• Management

– Duodeno-

duodenostomy

Case 1

5 days-old-male

with intermittent

bilious vomiting bilious vomiting

and no abdominal

distension.

Meconium passed

at birth.

Duodenal stenosis

• KUB

– Double-bubble

– Scanty air distally

• Causes• Causes

– Pure stenosis

– Annular pancreas

– Ladd’s bands

• Management

– Depends on cause

Case 210 days well-baby develops abdominal distension,

bilious vomiting and metabolic acidosis

Malrotation and Volvulus

• Embryology– Clockwise rotation midgut

– Obstruction 3rd portion duodenum

– Ischemia midgut

• Symptoms– Bilious vomiting– Bilious vomiting

– Abdominal distension

– Metabolic acidosis

• Diagnosis– KUB

– UGIS

– contrast enema

• Management– Ladd’s procedure

– Laparoscopic

Malrotation: Embryology

Volvulus: Dx

• Diagnosis

– UGIS

– Contrast enema

Volvulus: Tx

• Ladd’s procedure

– Counter-clockwise derotation bowel

– Lysis Ladd’s bands

– Incidental appendectomy– Incidental appendectomy

Case 3

2 days-old

baby-girl

with bilious

vomiting, vomiting,

obstipation

and no

abdominal

distension

Intestinal atresias

• Intrauterine vascular accident

• Types

• Diagnosis– Bilious vomiting

– Abdominal distension

– Abdominal distension

• KUB– Dilated bowel

loops

• Contrast enema– Microcolon

• Management– anastomosis

Meconium Diseases

• Meconium peritonitis

• Meconium ileus

• Meconium plug syndrome

Meconium Peritonitis

• Intrauterine bowel perforation

• Types– Simple

• observe

– Complicated– Complicated• Resection/anastomosis or

enterostomy

• KUB– Calcifications

• Associated – Cystic fibrosis

Case 42 days-old-female with bilious vomiting, abdominal distension, no passage of meconium.

Colon contrast: microcolon with intraluminal meconium pellets

Meconium Ileus• Intraluminal obstruction

• Cystic fibrosis

• Types– Simple

– Complicated

• KUB– Multiple dilated bowel loops

– “water-soap” appearance– “water-soap” appearance

• Management– Medical

• Gastrograffin enema

• Pancreatic enzyme replacement

– Surgical• Enterostomy

• evacuation

Meconium plug syndrome

• Grey impacted

meconium

• Distal obstruction

• Remove manually• Remove manually

• R/O

– aganglionosis

Case 5

2 days-old full-term

male with

abdominal

distension and no distension and no

passage of

meconium

or

Hirschsprung’s Disease

• Congenital absence ganglion cells

• Absent cranio-caudal migration neuroblast

• Symptoms– Absent meconium 1st 48 hrs of life

– Painless abdominal distension

– TAGA male

• Diagnosis• Diagnosis– First enema: barium enema

– Suction rectal biopsy

• Management– Laparoscopic Pull-through

– Neonatal > 5 kg weight

– Colostomy• Perforated

• HAEC

• Premature

• No compliance

Imperforate Anus

• Physical exam

• Males vs female defect

• Associated anomalies

– Cardiac

– Renal– Renal

• Management

– anoplasty

– Initial colostomy

– PSARP

Bowel Duplications

• Rare

• Distal ileum

• Cystic or tubular

• Management• Management

– Resection

– anastomosis

NEC: Bells’ Classification

• Stage 1: Suspect– Perinatal asphyxia, abd

distension, blood in stools, gastric residue, ileus in KUB

• Stage 2: Definitive– Cellulitis, edema, pneumatosis – Cellulitis, edema, pneumatosis

– Thrombocytopenia, metabolic acidosis

– Portal vein air

• Stage 3: Advance– Pneumoperitoneum

– Intractable metabolic acidosis

NEC: Initial Tx

• Volume replacement

• Respiratory support

• Correct electrolytes/ABGelectrolytes/ABG

• Antibiotherapy

• Stop feedings

• Monitor

– CBC, SMA-6

• KUB (cross-table)

NEC: Surgical principles

• Drain, patch & wait

• Resectgangrenous gangrenous bowel

• Avoid massive resections

• Exteriorize bowel