Neonatal intestinal obstruction

1. Neonatal intestinal obstruction HASHEM AL-MOMANI SENIOR CONSULTANT PEDIATRIC SURGEON JORDAN UNIVERSITY HOSPITAL

2. Introduction • Neonatal intestinal obstruction is one of the common pediatric emergencies. • Neonatal intestinal obstruction has an incidence of 1 in 2000 live births. • A wide range of congenital anomalies may result in neonatal bowel obstruction.

3. Causes of intestinal obstruction in the neonatal period • Congenital atresia and stenosis constitute the majority of cases. • Other causes include • Malrotation • Volvulus • Meconium ileus • Hirschsprung disease • Anorectal malformations

4. Causes of intestinal obstruction in the neonatal period • Gastric • Early pyloric stenosis • Pyloric web or atresia • Epidermolysis bullosa pyloric atresia syndrome • Duodenum • Stenosis • Atresia • Malrotation • Annular pancreas • Jejunum-Ileum • Stenosis • Atresia • Malrotation • Meconium ileus • Vitello-intestinal duct remnant • Intussusception • Milk curd obstruction • Colonic • Stenosis • Atresia • Imperforate anus • Poorly developed colon e.g. • megacystis microcolon intestinal • hypoperistalsis syndrome • Global • Duplication anomalies • Internal hernia or inguinal hernia • Volvulus with or without (e.g. about a • Meckel’s band) malrotation • Neoplasm

5. Etiology113 etiologies in 106 patients

6. Presentation • “A neonate with bilious vomiting or aspirate is considered to have intestinal obstruction until proved otherwise.” • The presenting symptoms could be any combination of the following: • Bilious vomiting • Abdominal distension • Delayed passage of meconium • Sepsis

7. Prenatal sonography • Echogenic bowel • Dilated bowel • Polyhydramnios

8. Bilious vomiting • Bilious vomiting is synonymous with intestinal obstruction, be it functional or mechanical.

9. Examination • dehydration • abdominal distension • Visible and palpable bowel loops • Erythema and tenderness of abdominal wall • The presence of a normal anus • Associated anomaly

10. A newborn withmarked abdominal distension • suggesting • distal obstruction • necrotizing enterocolitis • sepsis • The more marked the abdominal distension, the more distal is the obstruction

11. Perineal Examination • Absent anus • Rectal stimulation

12. Vomiting • Vomit produced by a neonate should be classified carefully into one of two groups: • Non-bilious vomit: Colorless or milky if a feed has been taken. • Bilious vomit: Dark green . Freshly produced bile of golden color has been acted upon by stomach acid to produce the green color. • Neonatal bilious vomiting should be considered to be a surgical emergency until proved otherwise.

13. Constipation • A term neonate should pass meconium within 24 h of life.

14. Passage of meconium • is absent in complete duodenal and small intestinal obstruction • meconium passage may be present in anomalies of rotation and fixation • delayed in Hirschsprung’s disease • Occurs by an abnormal route (by a fistula or micturition) or not at all in anorectal malformations

15. Abdominal Radiology • The simplest and most informative radiological procedure is the plain abdominal X-ray. • confirmation of bowel obstruction with some information about the level of the obstruction.

16. Imaging Studies • Plain x-ray abdomen: • supine film • lateral decubitus • Invertogram or a prone cross-table lateral film for anorectal malformations

17. Plain abdominal X-ray • The extent and position of bowel gas • Presence or absence of gas in the rectum • Degree and level of distended loops • Air fluid levels • Evidence of free gas would confirm perforation. • “Football sign”, • The rigler sign, also known as the  double wall sign

18. Intestinal air progression

19. Abdominal x-ray showing dilatation of bowel loops with air–fluid level

20. single air bubble

21. Plain abdominalx-ray • Dilated stomach with air distally suggesting partial duodenalobstruction

22. Complete duodenalobstruction

23. Triple bubbles

24. Pneumo-peritoneum • Free air due to perforation from any cause is suspected on supine film when • “football sign” : a large pocket of air overlying liver and the ligamentumteres • Rigler sign: the bowel wall is sharply delineated (pencil lining).

25. Football sign

26. Rigler sign

27. Lateral decubitus • Lateral decubitus film with the right side uppermost should be used to see air above the liver.

28. Free air above the liver

31. Ileal atresia with volvulus

32. Calcification • Calcification of meconium implies long-standing stasis and may be identifiable outside of the bowel loops, which would suggest previous perforation.

33. Diffuse calcifications

34. Contrast Studies • The first enema a neonate receives should be a contrast enema. • The contrast enema acts not just a diagnostic tool but works as a therapeutic measure in cases of: • meconium plug • meconium ileus • Hirschsprung’s disease

35. Lower contrast study showing small left colon syndrome

36. Lower contrast study showing Hirschsprung’s disease

37. Lower contrast study showing meconium plug syndrome

38. A lower contrast study: small unused colon suggesting small bowel obstruction or total colonic hirschprung’s disease.

39. Contrast upper gastrointestinal (GI) studies • If malrotation is suspected • Sometimes to characterize the duodenal obstruction

40. Malrotation

41. Malrotation

42. Volvulus neonatorum- spiral twist of the bowel

43. Upper contraststudy showing congenitalduodenal obstruction.

44. Remember While Doing the Contrast Study • Use water soluble contrast • Make sure the baby is well hydrated • Make sure the radiology suit temperature is warm enough for the baby. • Avoid using Foley catheter with the baloon inflated. • Perform the study using image intensifier.

45. Ultrasound • To look for other associated anomalies • Helps to diagnose free or loculated intra-abdominal fluid collection denoting perforation or a meconium cyst. • In malrotation if the arrangement of the superior mesentric vessels is reversed, then malrotation should be suspected - operator-dependent and is not widely used.

46.  Transverse ultrasound scan through the upper abdomen

47. “whirlpool” configuration of thesuperior mesenteric vessels

48. Treatment • The success of treatment of neonates with intestinal obstruction depends on several factors: • Early diagnosis • Proper preoperative stabilization • The right choice of surgical procedure • Good postoperative care

49. Principles of Treatment • This is individualized according to the diagnosis but certain principals remain common. • The baby is cared for in the NICU with regulation of temperature and adequate monitoring. • The baby should receive broad spectrum antibiotic cover • The baby should be transported in an incubator to and from the operating room (OR). • The OR temperature should be kept high and measures should be taken to keep the baby warm during surgery. • Warm saline is used during the procedure and all the fluids given to the baby are warmed appropriately.

50. Preoperative care: • Once the diagnosis of neonatal intestinal obstruction is made, the patient should be fully resuscitated. • Fluid resuscitation. • Gastric decompression via an orogastric or a nasogastric tube. • The use of umbilical lines should be avoided because of the increased risk of infection and because they interfere with the incision for laparotomy. • Vitamin K is given intramuscularly. • Broad-spectrum antibiotics are given intravenously. • Control of temperature to avoid hypothermia.