NEONATAL BOWEL OBSTRUCTION

							     NEONATAL BOWEL
      OBSTRUCTION
Humberto Lugo-Vicente MD FACS FAAP
    Professor Pediatric Surgery
      UPR School of Medicine
                                     FAILURE TO PASS MECONIUM
    NEONATE                               BILIOUS VOMITING
                                       ABDOMINAL DISTENSION
                                                                            PYLORIC,
                                                                            DUODENAL or
                                                                            JEJUNAL
                                       SIMPLE ABDOMINAL FILMS               atresia/stenosis
                                                                            NEC

         dilated bowel loops
                                                      dilated bowel loops with calcifications,
                                                          gasless abdomen with eggshell
                                                                   calcification
         CONTRAST ENEMA

                                                           MECONIUM PERITONITIS
                                                     GIANT CYSTIC MECONIUM PERITONITIS
     microcolon                 NO microcolon

                                                                      Transitional zone
                          NO air-fluid levels                     barium retention past 24
    Air-fluid levels
                       ground-glass appearance                             hours

                                         MECONIUM PLUG SYNDROME
                                                                      Rectal biopsy
    INTESTINAL ATRESIA
HYPOPERISTALSIS SYNDROME
                        MECONIUM ILEUS                              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
  – Duodeno-
    duodenostomy
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