NEONATAL BOWEL OBSTRUCTION

NEONATAL BOWEL
OBSTRUCTION
Humberto Lugo-Vicente MD FACS FAAP
Professor Pediatric Surgery
UPR School of Medicine
NEONATE
FAILURE TO PASS MECONIUM
BILIOUS VOMITING
ABDOMINAL DISTENSION
PYLORIC,
DUODENAL or
JEJUNAL
atresia/stenosis
NEC
SIMPLE ABDOMINAL FILMS
dilated bowel loops
dilated bowel loops with calcifications,
gasless abdomen with eggshell
calcification
CONTRAST ENEMA
microcolon
Air-fluid levels
NO microcolon
NO air-fluid levels
ground-glass appearance
MECONIUM PERITONITIS
GIANT CYSTIC MECONIUM PERITONITIS
Transitional zone
barium retention past 24
hours
MECONIUM PLUG SYNDROME
INTESTINAL ATRESIA
HYPOPERISTALSIS SYNDROME
MECONIUM ILEUS
Rectal biopsy
HIRSCHSPRUNG’S
LEFT HYPOPLASTIC COLON
Congenital bowel obstruction
• Triad
– Bilious vomiting
– Retained meconium
– Abdominal distension
• Pathologic types
– 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
• gastroduodenostomy
• Pyloric stenosis
Pyloric stenosis
•
•
•
•
•
•
•
Concentric muscle hypertrophy
Males:female 4:1
Post-prandial non-bilious
vomiting
Metabolic hypochloremic
alkalosis
Dehydration
Palpable pyloric muscle
Diagnosis
– US
– UGIS
•
Management
– hydration
– Pyloromyotomy
– Periumbilical approach
Duodenal lesions
• Bilious vomiting
• Types
–
–
–
–
Atresia
Stenosis
Annular pancreas
Ladd’s bands
• Diagnosis
– KUB
– Colon contrast study
• Associated anomalies
– Cardiac
– Down’s syndrome
Duodenal atresia
• KUB
– Double bubble
• Down’ syndrome
– 30%
• Management
– Duodenoduodenostomy
Case 1
5 days-old-male
with intermittent
bilious vomiting
and no abdominal
distension.
Meconium passed
at birth.
Duodenal stenosis
• KUB
– Double-bubble
– Scanty air distally
• Causes
– Pure stenosis
– Annular pancreas
– Ladd’s bands
• Management
– Depends on cause
Case 2
10 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
– 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
Case 3
2 days-old
baby-girl
with bilious
vomiting,
obstipation
and no
abdominal
distension
Intestinal atresias
• Intrauterine vascular
accident
• Types
• Diagnosis
– Bilious vomiting
– 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
• Resection/anastomosis or
enterostomy
• KUB
– Calcifications
• Associated
– Cystic fibrosis
Case 4
2 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
• Management
– Medical
• Gastrograffin enema
• Pancreatic enzyme
replacement
– Surgical
• Enterostomy
• evacuation
Meconium plug syndrome
• Grey impacted
meconium
• Distal obstruction
• Remove manually
• R/O
– aganglionosis
Case 5
2 days-old full-term
male with
abdominal
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
– 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
• Management
– anoplasty
– Initial colostomy
– PSARP
Bowel Duplications
•
•
•
•
Rare
Distal ileum
Cystic or tubular
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
– Thrombocytopenia, metabolic
acidosis
– Portal vein air
• Stage 3: Advance
– Pneumoperitoneum
– Intractable metabolic acidosis
NEC: Initial Tx
• Volume replacement
• Respiratory support
• Correct
electrolytes/ABG
• Antibiotherapy
• Stop feedings
• Monitor
– CBC, SMA-6
• KUB (cross-table)
NEC: Surgical principles
• Drain, patch &
wait
• Resect
gangrenous
bowel
• Avoid massive
resections
• Exteriorize
bowel