Approach to Neonatal Intestinal Obstruction.pptx

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1. Approach to neonatal intestinal obstruction Presenter : Dr. Bedru M.(GSR-III) Moderator : Dr.Abreham T.(pediatric surgeon )

2. Outline Introduction Initial evaluation Duodenal atresia and stenosis Jejunoileal atresia and stenosis Malrotation Summary Reference 2

3. Introduction Intestinal obstruction in the first month of life Neonatal intestinal obstruction is the most common neonatal surgical emergency Most are result of congenital abnormalities Usually associated with other system anomalies Bilious vomiting is due to a surgical pathology until proven otherwise Classified based on varies criteria Successful management of depends on early diagnosis. 3

4. Etiology 4

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6. Approach to NIO High obstructive lesion HX- prenatal hx Polyhydraminous Vomiting, , bloody failure to pass meconium diarrhea Sign:DHN,scaphoid lower abdo,tenderness,guarding Imaging: Double-bubble, free air,pneumatosis intestinalis,portal gas distal gaslessness,whirlpool,birds beak,corkscrew,ring /y sing Low obstructive lesion Hx - Vomiting , abdo distension,Constipation,,failure to pass meconium,colics , Signs:distended abdomen,visible /palpable pesistalsis , Imaging: distended bowels, soap abubble,stepladder airfluid level ,calcification ,free air ,unused/ micro colon,Tz 6

7. P/E General Condition V/S CVS Abdomen Inspection Abdominal distention Abdominal wall Erythemia Perineal area Palpation Tenderness & guarding Palpable mass Auscultation Bowel Sound 7

8. INVESTIGATIONS Laboratory studies   CBC, BG & Rh, serum e -- , BUN, and creatinine level Plain abdominal X-ray Non Specific Distended bowel loops Specific sign double - bubble sign Contrast radiographs UGI series Enema Vertebral X-ray Abdominal u/s Echocardiography 8

9. Imaging 9

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11. MANAGMENT General Bowel decompression Open IV line Fluid Electrolyte Nutrition Antibiotics Secure air way Specific Depending on the underlying specific pathology 11

12. Duodenal atresia The duodenum is one of the most common sites of NIO It was recognized as disease entities as early as the eighteenth Modern surgical management has resulted in more than 95% survival, Nearly half have associated anomaly 1 in 6,000 to 1 in 10,000 births Although no specific genetic abnormality is known to cause duodenal atresia, 12

13. EMBRIOLOGY The endoderm gives rise to the gut tube beginning in the week of development In the sixth week, the gut epithelium proliferates rapidly, resulting in obliteration of the intestinal lumen The intestine is then gradually recanalized over the next several weeks of development. Errors in recanalization are thought to be the primary cause of duodenal atresia and stenosis 13

14. Classification intrinsic and extrinsic congenital lesions complete (81%) or partial (19%) obstruction of the duodenum Preampullary or postampullary (85%) Gray and Skandalakis classification: Type 1 (92% of cases) Type 2 (1% of cases) Type 3 (7% of cases 14

15. Clinical presentation Maternal polyhydramnios, 30% to 65% of cases is an early clue. The classic “double-bubble” obstructive pattern is usually identifiable on fetal ultrasonography-after 7 month Complet vs incomple and pre or post ampullary Repeated bilious emesis is the characteristic clinical feature A subtle upper abdominal fullness may be noted. Symptoms my first occur later in infancy 15

16. Cont.…. 16

17. Treatment They are initially managed with NGT decompression correction of fluids and electrolyte disturbance Placement of PICC for TPN surgical correction of duodenal obstruction is not emergent. Option of surgical management 17

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19. Transanastomotic feeding tube after an operation for duodenal atresia 19

20. Complication Intraoperative-Incorrect identification of the site of obstruction(windsock deformity) is present multiple area of atresia Post op -Prolonged feeding intolerance is the most common complication -Survival of infants with duodenal obstruction has increased from 45% to 95% over the past half century. 20

21. Jejunoileal atresia They are the most common congenital anomalies of the small intestine The first successful anastomosis for intestinal atresia was achieved by fockens in1911 Survival of children with intestinal atresia in the first half of the twentieth century was dismal. During the past 3 decades, have led to a significant improvement in survival 1 in 5,000 live births High in African American and twins 21

22. Cont … Factors that increase the risk of developing small intestinal atresias 2 times more common than duodenal atresia Male =female Low birth weight ( multiple,prenal diagnosis) Down syndrome and extra intestinal anomaly is not common 22

23. Etiology Bile pigments, squames (? vermix caseosa ), and lanugo hairs are often found distal to atretic segments This implicates that events other than epithelial plugging may cause intestinal atresia and that these perturbating events occur later in utero Studies have showed that most jejunoileal atresias are the result of late intrauterine mesenteric vascular occlusions Often seen in patients with volvulus , intussusception (intrauterine and rarely postnatal), internal hernia, and tight anterior abdominal wall defects 23

24. Cont. The genetic contribution to jejunoileal atresia is unclear Familial cases have been reported for the following 5 types Pyloric atresia Duodenal atresia Multiple atresia syndrome Apple-peel atresia Colonic atresia 24

25. Classification Type I (19%) Mucosal (membranous) atresia with intact bowel wall and mesentery -Has a normal length of intestine Type II (31%) Blind ends are separated by a fibrous cord Has a normal length of intestine Type IIIa (?20%) Blind ends are separated by a V-shaped (gap) mesenteric defect Associated with a shorter bowel length caused by resorption of the fetal gut after a vascular accident 25

26. Cont. Type IIIb (11 – 30%) Apple-peel atresia or Christmas-tree deformity Characterized by Proximal atresia near the ligament of Treitz , a large mesenteric defect, and foreshortened bowel Blood supply to the distal bowel is precariously supplied in a retrograde fashion by arcades from the ileocolic , right colic, or IMA Associated with a familial pattern Patients typically are premature (70%), of low birth weight (70%), have a high rate of malrotation (54%), and are associated with an increased number of congenital anomalies 26

27. Cont. Type IV Multiple atresias ( string of sausages ) Associated with a foreshortened intestinal length, prematurity, and a high mortality A diffuse inflammatory process has been proposed as a contributing factor Genetic components have been found 27

28. Diagnosis 28

29. Cont …. Prenatal -it is suspected when US reveals multiple distended loops of proximal bowel with vigorous peristalsis - it is also suspected in fetuses with gastroschisis and marked intestinal dilatation 29

30. Cont. Jejunal atresia Ileal atesia 30

31. Treatment A 10-Fr orogastric or nasogastric sump tube ( Replogle tube) is placed Intravenous access is secured, and a laboratory workup is obtained Close monitoring of the patient’s fluid balance, significant fluid loss from the nasogastric tube should be replaced intravenously. the neonate is taken to the operating room for an abdominal exploration a right supraumbilical transverse incision 31

32. Steps in the operative procedure Approach can be:- Supra umbilical transverse incision or Umbilical factor Identify the type and site of the atresia Confirm the patency of distal bowel with saline injection. Resection of the proximal bulbous atretic segment Limited distal bowel resection 5. Accurate measurement of residual bowel length proximal and distal to the anastomosis. 6. Single or double layer end-to-end or end-to-back anastomosis, In the presence of established peritonitis The fashioning of proximal or distal stomas are indicated . 32

33. Cont … 33

34. Post op care baby is kept warm Maintaining fluid and electrolyte balance is a key component of postoperative care. Intravenous fluids (10% dextrose in 0.25% normal saline along with 2 to 3 mEq /kg/day of potassium chloride) are administered, with a total fluid volume goal of approximately 100 mL/kg/day. If the gastric output is clear and greater than 30 mL/kg/day, it is replaced with 0.45% normal saline. If the output is bilious, it is replaced with lactated Ringer solution. An output of 1.5 to 2 mL/kg/h 34

35. Cont … Nutrition –TPN with in 24 hrs then enteral feeding The approach to introducing feeds varies, depending on both the institution and the physician The quantity with which to initiate feeds ranges from 5 mL to 15 mL goal is to provide the nutritional requirements sufficient for growth 120 calories/ kg/day. 35

36. Morbidity and Mortality Infections are the most common causes of early death Functional intestinal obstruction and anastomotic leak are the two most significant postoperative complications and mortality rate of 15% factors affecting morbidity and mortality include - type and site of atresia -the presence of associated anomalies, - prematurity, -respiratory distress, - short-bowel syndrome -postop bowel obstruction risk stratification 36

37. Normal Rotation and Fixation 37

38. Introduction The term malrotation refers to all abnormalities of intestinal position and attachment Atypical malrotation results when the ligament of Treitz is to the left of midline, defined by the vertebral body, or below the gastric outlet on upper GI contrast studies The term nonrotation is used for failure of the first stage The terms incomplete rotation and mixed rotation are used for abnormalities of the second stage 38

39. Cont. Reverse rotation is a rare anomaly in which the duodenum and colon rotate clockwise in relation to the SMA and vein ( 90 o clockwise ) The transverse colon eventually lies behind the vessels, which may result in acute or chronic colonic obstruction Malrotation is an integral part of congenital diaphragmatic hernia and all abdominal wall defects 39

40. Associated anomalies Associated anomalies are found in 30% to 60% of patients with malrotation Duodenal atresia Jejunal atresia Mesenteric cysts Whether this is a primary anomaly or results from lymphatic obstruction due to chronic volvulus is not clear Malrotation is rarely associated with HSD and ARMs 40

41. Clinical features Acute or chronic midgut Volvulus Duodenal obstruction secondary to congenital bands Reverse rotation with colonic obstruction Internal hernia Cecal volvulus Incidental finding 41

42. Acute Midgut Volvulus The narrow pedicle formed by the base of the mesentery in malrotation predisposes the midgut to clockwise twisting from the duodenum to the transverse colon Excessive length of the mesentery or a point of adhesion at the convexity of the loop may act as an axis for a twist The actual inciting mechanism is unknown But various possibilities have been suggested including unusual movement of the torso, abnormal intestinal peristalsis, or segmental bowel distention 42

43. Cont. Most patients with midgut volvulus present in the first month of life Majority in the first 7 days of life sudden onset of bilious vomiting in a previously healthy, growing infant Crampy abdominal pain is common As vascular compromise progresses, blood is often passed per rectum 43

44. Cont. Infants with complete obstruction rapidly develop intestinal ischemia Abdominal tenderness varies with the degree of vascular compromise, but signs of peritonitis are invariably present 44

45. Cont. A high index of suspicion for midgut volvulus is based on clinical findings The decision whether to confirm must be based on the condition of the patient and the risk of vascular compromise if there is any delay 45

46. Chronic midgut volvulus This situation is more commonly encountered in children older than 2 years Symptoms Chronic vomiting Intermittent colicky abdominal pain Constipation Diarrhea Hematemesis protein-calorie malnutrition 46

47. Acute duodenal obstruction secondary to congenital bands it results from Ladd bands extending across the third portion of the duodenum The obstruction may be complete or incomplete It may have acute or chronic features It is more common in neonates and infants but can occur later in life as well Volvulus is not a principal finding in these patients In a newborn, symptomatic malrotation with bands is often associated with intrinsic duodenal obstruction 47

48. Reverse rotation with colonic obstruction In this rare abnormality, the duodenum and jejunum lie anterior to the superior mesenteric vessels and obstruct the posteriorly lying transverse colon The transverse colon must pass through a tunnel beneath the mesentery, and this produces a chronic incomplete or complete obstruction of the colon The obstruction is caused by pressure of the vessels and by bands from the mesentery to the small bowel It is usually seen in adults and is rarely reported in children 48

49. Internal hernia Lack of fixation of the mesentery of the right or left colon, or of the duodenum, may result in the formation of potential spaces for hernias The most commonly seen internal hernias are the right and left mesocolic hernias The term mesocolic is preferred to the alternative term paraduodenal 49

50. Cont. Right mesocolic hernia Most of the small bowel is trapped behind the right mesocolon Failure of rotation of prearterial segment of the midgut 50

51. Cont. Left mesocolic hernia Bowel is trapped in the left mesocolon posterior to the IMV Due to failure of small bowel migration to the left superior portion of the abdomen 51

52. Cont. Internal hernias are associated with recurrent entrapment of bowel with partial obstruction This may eventually progress to complete obstruction and strangulation Signs and symptoms are related to recurrent, intermittent bouts of IO characterized by recurrent colic This may lead to constant abdominal pain, vomiting, and, sometimes, constipation The symptoms are often mild and are occasionally thought to be psychologic 52

53. Volvulus of the cecum It is caused by lack of fixation of the cecum , terminal ileum, and proximal ascending colon It is seen most often in patients older than 60 years The main symptoms are acute, severe abdominal pain and nausea associated with right-sided abdominal distention Complete obstruction frequently develops The characteristic x-ray findings A large air-filled loop of colon occupying the LUQ (the convex surface faces the LLQ) Associated with small bowel obstruction 53

54. Malrotation in asymptomatic patient The incidental finding of malrotation on radiography or at the time of an operation Some have symptoms referable to the abnormality The general consensus is that a corrective surgical procedure is indicated at any age 54

55. Diagnosis Plain abdominal x-ray It is often non-diagnostic Some useful signs are occasionally seen The “double bubble” of acute duodenal obstruction The absence of a normal colonic gas pattern in an older patient with a displaced cecum A“gasless ” abdomen in volvulus of the midgut 55

56. Cont. Abdominal U/S it can define vascular flow through the superior mesenteric vessels Some important signs “Whirlpool” flow pattern of the SMV and mesentery around the SMA in patients with midgut volvulus A fluid-filled, distended duodenum and dilated, thick-walled bowel loops located mainly to the right of the spine Identification of position of the duodenum and the SMA SMA/SMV invertion 56

57. Cont. Doppler U/S image of malrotation The abnormal position of the SMV to the left of the SMA can be seen just anterior to the abdominal aorta CT angiography It may also demonstrate a “whirlpool” flow pattern 57

58. Cont. Upper GI contrast study Study of choice The position of the ligament of Treitz is assessed relative to the midline and the level of gastric outlet Normal: ligament of Treitz to the left of the vertebral body and at the level of the gastric outlet Malrotation Typical: the ligament is to the right of midline or absent Atypical: the ligament is midline or to the left and below the gastric outlet The other is cecal position Normal: RLQ Abnormal: somewhere other than RLQ 58

59. Cont. Classification of malrotation based on the location of the ligament of Treitz 59

60. Cont. Normal Abnormal 60

61. Cont.. 61

62. Treatment Pre-op management NG tube Fluid resuscitation Antibiotics Surgery The Ladd procedure corrects the fundamental abnormalities associated with malrotation with or without midgut volvulus 62

63. Ladd procedure 63

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65. Time is bowel in NIO 65

66. Reference Coran's Pediatric Surgery 7th, 2012 Ashcrafts Pediatric Surgery 6th, 2014 Uptodate 2021 internet 66