Differential Diagnosis between Volvulus and Necrotizing Enterocolitis ---Critical to Outcome

1. Differential Diagnosis between Volvulus and Necrotizing Enterocolitis---Critical to Outcome 趙亮鈞 陳肇真 國立成功大學醫學院附設醫院 小兒外科

2. Identification • Name: 張XX之女 B • Gestational age: 30+2 weeks • Birth: 2010/6/15 11:41am via C/S • Apgar score: 69

3. Clinical course N-CPAP FiO2: 25%, CXR 06/15 06/17 07:30 Abdominal distension, KUB Vital sign unstable  Intubation, Abdominal distension Hb:13.19.2, WBC:9400, Platelet:235K, PH:7.3 PCO2 39.7 HCO3 19.2 BE -6.7 CXR Consult PEDS at 12:53 (Dr. Shih) 06/17 12:35 Operation: Spontaneous bowel perforation s/p peritoneal drainage (14:30-14:45) OP finding：massive dark red fluid 06/17 14:20 Massive bloody ascites was noted from Penrose drainage Exploratory laparotomy was suggested 06/17 15:10

4. Clinical course Operation: Bowel perforation secondary to volvulus s/p bowel resection and ileostomy (19:25-20:35) OP finding：Volvulus with bowel ischemia and perforation 06/17 19:10 HFV FiO2: 100% Survanta irrigation 06/17 21:30 PH: 6.86 PCO2: 120.1 HCO3: 21.4 PO2: 16.2 Bradycardia CPCR 06/18 00:09 06/18 00:41 Expire

5. Differential diagnosisVolvulus v.s. NEC

6. Clinical presentation of volvulus • Acute small bowel obstruction • Physical examination • Distention of the abdomen • Diffuse tenderness with or without peritoneal signs • Bloody stool • Bilious vomiting

7. Clinical presentation of volvulus • Vascular compromise Ischemia and necrosis Third space fluid loss and sepsis Cardiovascular compromise • Plain firm • Multiple continues intestinal dilatation • Partial duodenal obstruction • Free air or air-fluid level

8. Clinical presentation of NEC • Metabolic acidosis, Bradycardia, Hypotension • Physical examination • Abdominal distension • Occult blood、Hematochezia • Peritonitis • Hematologic • Neutropenia • Thrombocytopenia • DIC

9. Clinical presentation of NEC • Plain firm • Bowel dilatation, ileus • Ground glass pattern • Pneumatosisintestinalis • Portal vein gas • Pneumoperitoneum, fixed bowel pattern

10. Review of clinical course N-CPAP FiO2: 25% 06/15 06/17 07:30 Abdominal distension Still vital sign unstable, Abdominal distension Hb:13.19.2, WBC:9400, Platelet:235K, PH:7.3 PCO2 39.7 HCO3 19.2 BE -6.7 Consult PEDS at 12:53 06/17 12:35 Relative normal WBC and platelet when vital sign unstable, not like the nature course of NEC Operation: Spontaneous bowel perforation s/p peritoneal drainage OP finding：massive dark red fluid 06/17 14:20 The drainage of NEC is most bile content or dirty material, not bloody ascites Massive bloody ascites was noted from Penrose drainage Exploratory laparotomy was suggested 06/17 15:10 Vascular integrity impairment with venous oozing

11. Duodenal obstruction Stack bowel loop pattern

12. Treatment of bowel perforation in ELBW infant Exclude the possibility of mechanical obstruction related Segmental necrosis? No Yes Stable? (Vital sign, skin, CBC, platelet, X ray) Peritoneal drainage Yes No Laparotomy Peritoneal drainage Laparotomy if stable Poor outcome if still unstable

13. Treatment of volvulus • Cardiopulmonary resuscitation • Gastric decompression tube • Broad-spectrum antibiotics • Proceed directly to laparotomy

14. Conclusion • Adequate assessment by physical examination • More accurate differential diagnosis • Relative vital signs • CBC (WBC, Platelet) • KUB • Output and color of peritoneal drainage

15. Thanks for your attention

16. Abnormal bowel loop pattern

17. Stack bowel loop pattern