Intestinal obstructions - kennedy kachingwe.pdf

Intestinal obstruction

1. Intestinal
obstructions
KENNEDY KACHINGWE
PEDIATRIC CLINICAL SURGICAL QUALITY IMPROVEMENT NURSE
KAMUZU CENTRAL HOSPITAL- PEDIATRIC SURGERY

2. Obstruction
↙ ↘
partial complete
Intestinal obstruction

3. Causes of int. obs
causes
can be acquired or congenital
↓
mechanical functional
peristalsis working against mechanical obstruction non propulsive
bowel
↙ ↓ ↘ ↙ ↓ ↘
Intraluminal intramural extramural neurological mesenteric vascular other
impaction congenital atresia's bands
foreign bodies strictures hernias (strangulated) Hirschplung’s disease infection Ileus
gallstones malignancies volvulus mickel’s diverticulum narcotics
etc. intussusception ↓K
etc. tumors-benign/malignant cystic
fibrosis

4. where?
Obstruction!!
?
►Vomiting -color- white/ undigested food? Green? Fecal? Nature-
projectile/Non projectile? Frequency?
►Distention ?
►No stool – when last??? Bloody? Loose/hard? Offensive? Explosive?
Flatus?
►Pain-Where? Nature-radiating/localized? Sharp? Stabbing? Colicky?
Duration? type - intermittent / constant
►abdomen.-Visible peristalsis ? guarding / rigid / tender / masses /
?bowel sounds- high pitched/ absent
associated symptoms
►Behavior - ? quiet - ? irritable
►appetite - ? hungry -
►gait - ? stooped
►pyrexia- ? swinging / constant /low grade

5. investigations
bloods
-U and E , ? Blood gas
►Proximal small- bowel obstruction results in loss of fluids that
resemble gastric juice and thus produces hypokalemic
and hypochloremic metabolic alkalosis.
►Distal small bowel obstruction - fluid losses are usually
isotonic, so serum electrolytes are normal until sufficient
dehydration results in metabolic acidosis (low serum
bicarbonate levels, and elevated serum chloride values)
❖Radiology
Plain AXR – Gas pattern/fluid level/ dilation
The higher the level of obstruction the less the abdominal
distention and the more rapid the onset of vomiting
distal obstruction abdominal distention may be marked
vomiting is usually a late feature because the bowel takes
time to fill
Upper/lower contrast study to determine level of obstruction
radiology

6. Principles of management
►Decompression-relief- where ? Upper-ngt lower- rectal washout
►? NPO ? Fluids (? Bolus/maintance) what fluid?
►monitor I and O. 2ml/hr how?-diaper/ catheter- make sure not
blocked. Color of urine?
► SURGERY ?

7. pyloric stenosis
circumferential muscle of the pyloric sphincter thicken, resulting in elongation and obliteration of the pyloric channel.
management
- HYDRATION IV fluids 150ml/kg/day
until alkalosis
120ml/kg/
day
-KEEP NBM
-GASTRIC DECOMPRESSION – NG tube
-REPLACEMENT OF N/G LOSSES – IV FLUID BALANCE
-GLUCOSE MONITORING
►Surgery (pyrolotomy- ramstededt-only when
hydration status well.
Post operative care
▪Npo for 6hrs
▪Regrade feeds slowly if ok discharge .
▪Expect some vomiting
▪Wound care
▪Monitor weight gain at home
SYMPTOMS (USUALLY 3WKS AFTER BIRTH)
►VOMITING – INCREASING / PROJECTILE IN NATURE
►HUNGERY AFTER FEEDS
►DEHYDRATION
►WEIGHT LOSS
CLINICAL HISTORY/ PHYSICAL EXAMINATION
►PALPABLE TUMOUR (gold standard)
►BLOODS – metabolic alkalosis
↑ Ph/ bicarbonate/ base excess
↓ chloride
►???ULTRASOUND

8. Atresia's
►Could occur anywhere along the Gut.
►Embryonic Gut segmental differentiation starts as early as 3 weeks’
gestation.
►Proximal obstructions occur earlier in fetal life
►localized intrauterine localized intrauterine vascular accident with
ischemic necrosis of the bowel and subsequent reabsorption of the
affected segment is the favored theory in distal atresia's

9. duodenal Atresia's
presentation
Anatomic association
often associated with other congenital malformations {VACTREAL
syndrome (Vertebral, Anal, Cardiac, Tracheosophageal, Renal
)}and genetic pathologies (21 trisomy down’s syndrome).
► usually no distention
►Vomiting few hrs/24hrs after birth
Newborn Infants with more than 30mls
aspirate 24hrs after birth should be
investigated.
-Color- depends on location. - non
bilious-proximal to ampulla of vater
-If distal – yellowish green/brown
granular matter
-Note baby will pass meconium!
investigations
Radiology
.Plain xray
.Contrast study

10. JUJENAL ATRESIA
Fold that connect small bowel to the back wall of the abdomen is absent. Jejunum twists around the
colonic marginal artery causing an atresia.
P/E
Clinical Symptoms
Poor weight
Abdominal distention
Bilious vomiting
no meconium in first 24 hrs.
rule out hirchplungs!
►Examine abdomen
-Visible loop of bowel
Absent bowel sounds
PR. Rule out distal obstruction
Investigations
-Radiology-
-plain xray- Tripple
bubble
-contrast- microcolon

12. Intuscesception
►Pain-Colicky, severe, and intermittent
►Child is drawing the legs up to the abdomen and
►kicking the legs in the air
►Vomiting
►Initially nonbilious and reflexive ,Becomes bilious
►Currant jelly stools (a mixture of mucus, sloughed
mucosa and shed blood)
►Lethargy
►Diarrhea (an early sign)
Dehydration
Fsgd
Investigations
Plain xray.
– upright and supine
Barium enema (prefably air)
-Quick and reliable
-theraupeutic for reduction
-
Management
Depends with presentation
Ivf, ngt for decompression
Operate only if manual reduction failed/
obvious perforation

13. Malrotation and midgut volvulus
► Symptoms may never occur and a diagnosis is never made
(0.5% at autopsy)
► In others, symptoms may develop at any age
► Symptoms may include:
► Sudden abdominal pain
► Bilious emesis
► Drawing up of the legs
► Abdominal distension
► Severe shock
► Bloody stools

14. ►Management
►Surgery –ladd’s procedure
►e procedure carried out in order to
correct the malrotation is known as a
Ladd’s procedure and consists of
❖     Reduction of the volvulus with a
counter
clockwise rotation
❖     Placing of the small bowel in the right
abdomen
❖     Freeing of Ladd’s bands
❖     Placing of large bowel in left abdomen
❖     Appendicectomy
 
►Investigation
Diagnostic imaging studies to:
►Evaluate the position of the intestine (DJ)
►Determine obstruction
►Plain AXR (fluid levels, gas pattern)
►Upper GI contrast studies- shows bowel
not in right place
►Abdominal Doppler ultrasound (SMA)
►CT Scan

15. Hirchplung’s disease
►Megacolon aganglionosis
Presentation
Delayed meconium (48 hrs after birth)
Distended abdomen- acute
presentation
P/E
PR- Empty rectum, usually a gash of
loose feaces
Investigations
Rectal biopsy- diagnostic
►AXR- multiple of distended colon
management
Decompression-rectal washout- gas/
stools
Laparotomy- colostomy/ileostomy
psychological preparation
Colostomy care.
Pull through surgery- different
techniques devepending on
surgeons experience and
preference.
complications

16. ANAL RECTAL MALFORMATION
imperforate anus
Agenesis and atresia of rectum and anus
Low abnormality high abnormality
Termination of bowel below pelvic floor bowel termination above pelvic floor
covered anus anorectal agenesis associated
Ectopic anus rectal atresia with
Stenosed anus cloaca fistulas
Membranous anus

17. Hx
Meconium? In 1
st
24hrs of life
For anterior ectopic anus- lifelong hx of constipation, paiful
defecation, will require enemas, laxatives
Examination
Association with VACTEREL
Determine if obstruction high /low
-Invertogram
►Urine culture

18. Management
low high
►Covered anus
Open with scissors then regular
dilatation
►Ectopic anus
Plastic surgery
Stenosed anus
Dilatation
Haggar’s dilators
►Surgery- laparotomy for colostomy
►Post sagital antereior rectoplasty.
Bowel mobilized, new passage created on pelvic floor,
close to urethra –anus site then dilated with hagar’s
dilator so bowel can be pulled down and its mucosa
stiched to skin of newly formed anus.
Jet cleaning
Daily dilatation for at least 3 months- tightness
Damage of peritonel body in cloaca cases.