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Neonatal intestinal obstruction

Neonatal intestinal obstruction. General information. Neonatal intestinal obstruction can be due to a variety of causes Presenting clinical features are often similar Bile-stained vomiting is never normal in a neonate and implies obstruction

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Neonatal intestinal obstruction

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  1. Neonatal intestinal obstruction

  2. General information • Neonatal intestinal obstruction can be due to a variety of causes • Presenting clinical features are often similar • Bile-stained vomiting is never normal in a neonate and implies obstruction • 95% of babies pass meconium within the first 24 hours of life • Failure to pass meconium is also a feature of obstruction • The degree of abdominal distension is variable

  3. Clinical Features • Triad of : Vomiting, abdominal distension, and failure to pass meconium (constipation) • Manifestation depends on the site of obstruction

  4. Principles of Management • GIT decompression • fluid and electrolyte management • Surgical treatment accordingly

  5. Diagnosis • Antenatal • U/S, MRI • Plain X-Ray upright, and supine (Air fluid level) • Contrast material

  6. Causes of Neonatal Intestinal obstructions • Atresias – duodenal, jejunal, colonic • Meconium ileus; Meconium plug • Hirschsprung’s disease • Imperforate anus • Malrotation with volvulus

  7. Duodenal atresia • Occurs in 1 in 5-6,000 live births • Site of obstruction is most commonly in 2nd part of duodenum • Proximal duodenum become hypertrophied • 50% are associated with polyhydramnios • 60% of such pregnancies are complicated or end prematurely • Can often be diagnosed with antenatal ultrasound

  8. Duodenal atresia • 30% of babies with duodenal atresia have Down's syndrome • Other associated abnormalities are cardiac anomalies, malrotation and biliary atresia • Postnatally presents with bilious or non-bile stained vomiting • X-ray may show a 'double-bubble' and no gas within the bowel distally

  9. Management • A nasogastric tube should be passed • Intravenous fluid resuscitation should be given • Major cardiac and other defects should be excluded • Duodenoduodenostomy should be performed when resuscitated

  10. Other atresias • Atresias of the small bowel and colon are less common • Often associated with polyhydramnios • Bilious vomiting and distension are key features • x-ray will show dilated bowel and a gas-free rectum • A nasogastric tube should be passed • Intravenous fluid resuscitation should be given • At operation, dilated proximal bowel should be resected or tapered • A primary anastomosis may be possible

  11. Types(Bowel loss, mesentery) • Type 1 • web (membrane), normal length, normal mesentery. • Type 2 • fibrous cord between blind ends of the atretic bowel but have an intact mesentery. • Type 3/A • There is a complete separation of the blind ends of the separated bowel by a v-shaped mesenteric defect. • Type 3/B • Apple peal or Christmas tree deformity. • Type 4 • Multiple atresia, string of sausage or string of beads.

  12. Type 1 Type 2 Type 3/A Type 3/B Type 4

  13. Type I Atresia

  14. Type IV Atresia

  15. Annular pancreas

  16. Meconium ileus • Commonest cause of neonatal intraluminal intestinal obstruction • 80% cases are associated with cystic fibrosis • Cystic fibrosis occurs in 1 in 2000 live births • Inherited as an autosomal recessive trait • Viscid pancreatic secretions cause autodigestion of pancreatic acinar cells • Resulting meconium is abnormal and putty-like in consistency

  17. Meconium ileus • Meconium becomes inspissated in the lower ileum • There is a microcolon • Presents with bilious vomiting and distension usually on first day of life • Passage of meconium is delayed • Meconium filled loops of bowel may be palpable • X-ray may show a 'ground-glass' appearance, especially in the right upper quadrant

  18. Meconium Ileus (cont) • Diagnosis made with contrast enema • Gastrograffin enema with aggressive hydration can be used to treat some • Operative evacuation of meconium • May require ostomy • Proximal bowel dilated and distal bowel may be very small (microcolon) and require time to dilate with use

  19. Management • Gastrografin enemas may be successful in 50% of patients • If unsuccessful, surgery will be required • Limited resection and stomas may be required

  20. Meconium plug • Difference between meconium ileus and meconium plug is site and severity of obstruction • Preterm infants, infants of diabetic mothers, IUGR babies, otherwise ill babies • Treatment with glycerin suppositories and warm saline enemas • May require contrast enema to make diagnosis • Normal stooling pattern should follow evacuation of plug

  21. Malrotation Volvulus

  22. Malrotation • Between 4 and 10 weeks of development intestines herniate into umbilical cord • When returned to abdomen they rotate 270 degrees anticlockwise • As a result • Duodeno-jejunal flexure lies to the left of the midline

  23. Malrotation • Caecum lies in right iliac fossa • Transverse colon lies anterior to the small bowel mesentery • Partial failure of rotation results in malrotation • Commonest abnormality results in caecum lying close to DJ flexure

  24. Malrotation • Resulting midgut mesentery is abnormally narrow and liable to volvulus • Fibrous bands may be present between caecum and DJ flexure (Ladd's bands) • Radiological investigations are often unhelpful

  25. Clinical presentations • Three clinical presentations • Presents late with intermittent bile stained vomiting and distension • Presents early with collapse and acidosis due to intestinal infarction • Presents as incidental finding on radiological investigation

  26. Malrotation & Volvulus (Volvulus Neonatorum) • 90% occur first month • Bilious emesis • Abdominal distention, peritonitis • Septic shock • Rectal bleeding • Absolute surgical emergency; detorsion, Ladd • procedure, possible bowel resection

  27. Malrotation with volvulus • Can occur in the fetus – large calcified shadow in midabdomen on x-ray • Sudden onset of bilious emesis in infant – requires rule out • Signs of shock and sepsis can be present • Surgical emergency since intestinal viability is at stake. • UGI to evaluate for position of ligament of Treitz

  28. Management • After resuscitation, early laparotomy may be required • Any volvulus should be reduced • Resection may be required if there has been small bowel infarction • Any Ladd's bands should be divided • The base of the mesentery should be widened • Colon should be placed on the left of the abdomen • Small bowel should be placed on the right • Inversion appendectomy should be performed to prevent future diagnostic uncertainty

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