GI Emergencies in the NICU

1. GI Emergencies in the NICU Christy Cummings, MD, CLC Neonatology Yale New Haven Hospital

2. Objectives • Case-based learning • Discussion of open abdominal wall defects and their treatment • Discussion of closed abdominal wall defects and their treatment • Q&A

4. Gastroschisis • Full-thickness defect of abdominal wall exposing intestinal contents • Generally a small defect (3-6 cm) located right, lateral to the umbilicus • 1 : 40,000 births, Male> female • Infants are generally preterm or SGA • Malrotation affects all infants • Generally seen on U/S • Survival rate is higher than omphalocele, 95%

6. Gastroschisis - Treatment • Gastric decompression • Gut rest • Antibiotics • Silo suspension • Sealed plastic device surgically attached to infant and suspended above infant • Allows the bowel to return to normal size • Infants commonly have underdeveloped abdominal capacity, not allowing for primary closure • Daily decompression allows for stretching of the abdominal tissue and minimizes intestinal damage, respiratory decompensation • Primary closuregenerally for small defects or those term infants with adequate abdominal tissue

9. Omphalocele • Failure of the intestines to return from the umbilical cord into the abd cavity resulting in a transparent membrane that encapsulates intestinal tissue • 1 :5,500 births, Male > female • Frequently associated (50% - 77%) with other syndromes such as trisomies, CHD, CDH • Defects range from 2-15 cm on average • Smaller defects may be overlooked • Larger defects may include spleen and liver also • Most defects are clearly visible on U/S prenatally • Survival rates are high (75% - 95%) • But not as high as gastroschisis (higher incidence anomalies)

11. Omphalocele - Treatment • Gastric decompression • Antibiotics • Gut rest and delayed feedings are important to allow inflamed intestinal lumen to return to normal size • Antibiotics • Surgical repair is generally reserved for the most severe cases and involves using gortex flaps to cover the transparent sac. • An unfortunate result of non-surgical closure is malrotation

13. Duodenal Atresia • Result of incomplete recanalization of the lumen • 1 : 6,000 - 10,000 births • 25% associated with Trisomy 21 • Other associated anomalies: TEF, malrotation, VACTERL and renal anomalies • Polyhydramnios is the # 1 identifying risk factor • 70% of infants do not pass meconium • Proximal atresias/obstruction generally results in vomiting within the first few hours of life • Distal atresias/obstruction results in emesis longer after delivery • Classic “double bubble” on xray; gasless pattern after the atresias • Survival rate 65%-84% with early intervention • Treatment: Gastric decompression, surgical removal of the atresia area with a side to side anastomosis

15. Esophageal Atresia (EA) • Failure of the trachea to differentiate from the esophagus • Different types of disorder: • 85% have EA and a TE fistula • 8% have EA without any connection to the trachea • 1% have esophageal fistula and no connection to the stomach • 4% are an H type fistula • 1 : 4,500 births • VATER and VACERL association is common • 20%-30% are preterm • Clinical signs: excessive oral secretions, inability to pass OG/NG, aspiration, chronic pneumonias • survival rates 97% with intervention • Mortality is associated with associative disorder • Surgery depends on the type of disorder

25. Necrotizing Entercolitis (NEC) • Necrosis of the mucosal/submucosal layer of intestinal lining • Any portion of the GI tract can be affected • Etiology is still a debate… • Selective bowel ischemia? • Delayed or lack of proper bacterial establishment? Infection? • The effects of feedings, medications, RBCs? • Osmolarity of certain formulas and the lack of feeding EBM play large roles in increasing the risk of NEC • Early EBM feeding decreases risk of NEC by 65% in premies • 65%-92% of infants affected with NEC are preterm infants • Most commonly seen in infants 3-21 days post delivery

26. Necrotizing Entercolitis (NEC) • Signs/symptoms: • Abdominal distention, dusky abdomen, feeding intolerance, increased emesis, bloody stools, VS instability • Xray: • Dilated loops, abnormal gas patter, thickened bowel wall • Pneumatosis (tiny lucent soap bubbles) • Treatment: • Bowel rest • NPO, Replogle to suction for 10-14 days • Prevention of progressive injury • NPO, Fluid management, antibiotics • Serial KUBs to monitor status

31. Intestinal Perforation • Spontaneous rupture of intestine/colon allowing leakage of air into the abdominal cavity (pneumoperitoneum) • Most associated with NEC and ischemic bowel • Most common risk factors: • NEC, sepsis, mechanical ventilation, prematurity, long term steroid usage, postoperative abdominal complications • Survival is directly related to how quickly the staff is able to identify clinical changes

32. Intestinal Perforation • KUB: (A/P and left-lateral decubitus) • Pneumoperitoneum, Football Sign, Rigler Sign, Ligament Sign • Treatment involves: • Surgery immediately • Bowel rest—NPO for 10-14 days • Gastric decompression • Prevention of progressive injury • NPO, Fluid management, antibiotics • Placement of abdominal drain +/-

35. Congenital Diaphragmatic Hernia (CDH) • Herniation of intestinal contents into thoracic cavity • Results in pulmonary hypoplasia leading to respiratory distress • 1 : 4,000 births • Signs/symptoms: • Cyanosis, respiratory distress, scaphoid abdomen • Usually seen during routine prenatal U/S • L:H ratio, presence of liver or other organs in chest • Post delivery xray reveals intestinal loops in chest cavity • Immediate intubation and gastric decompression is essential to higher survival rates • Intubation should be performed by most experienced team member

36. Congenital Diaphragmatic Hernia (CDH)