Transcript NEONATAL INTESTINAL OBSTRUCTION

Health-Process-Evidencebased Clinical Practice
Guidelines
Acute Abdomen in Newborns
Rommel Q. De Leon, M.D.
Maria Cecilia T. Leyson, M.D.
Operational concept of acute abdomen in
newborn
any abdominal condition from various
causes involving the intra-abdominal
organs that requires immediate/urgent
intervention in newborn (1-28 Day of
Life)
The two general categories of acute
abdomen in newborn
Acute Surgical abdomen –
requiring immediate operative
intervention
Acute Non-Surgical Abdomen –
requiring immediate non-operative
intervention
What are common causes of acute
surgical abdomen in newborn?
Non-Trauma
– G.I. Obstruction
– G.I. bleeding
– G.I. Perforation
– Abdominal Wall defects
Trauma
What are the more common causes of
acute non-surgical abdomen?
Non-trauma
– Ileus
– Diarrhea
NEONATAL INTESTINAL
OBSTRUCTION
What are reliable signs and symptoms
(more than 90% certainty) that a
newborn patient has intestinal
obstruction?
Patient with imperforate anus
Patient with perforate anus with :
– Abdominal distention
– Persistent vomiting
– Non-passage of meconium within the first
24 hours of life or non-passage of stool
within 24 hours
Types of Intestinal Obstruction
Mechanical
no recent history of systemic illness
prior to the presentation of intestinal
obstruction
Non Mechanical
recent history of systemic illness prior
to the presentation of intestinal obstruction
Causes of mechanical intestinal
obstruction
High Obstruction
– Gastric outlet obstruction 1:1,000,000 live
births
pyloric atresia
Pyloric stenosis
Antral web
– Duodenal obstruction
Duodenal atresia
Duodenal stenosis
Annular pancreas
Preduodenal portal vein
Malrotation
– Jejunal obstruction
Atresia
Jejunal stenosis
Causes of mechanical intestinal
obstruction
Low Obstruction
– Distal small bowel
Ileal atresia
Meconium ileus
– Uncomplicated
– Complicated
– Colonic obstruction
Dysmotility states
– Meconium plug 1:500-1,000 live births
– Small left colon syndrome -- rare
Hirschsprung's disease 1:4,000 live births
Colonic atresia
Anorectal malformations 1:4,00-8,000
Reliable S/Sx of High Obstruction
Localized distention
– Upper abdomen
Generalized Distention
Algorithm
patient
DRE
Perforate anus
Imperforate anus
Abdominal Distention
Localized
High Obstruction
Generalized/
Diffuse
Low Obstruction
In a newborn patient with suspected neonatal
intestinal obstruction, what is the most costeffective initial procedure?
Ans:
High Obstruction
– Plain abdominal film
– Upper GI series
Low Obstruction
– Contrast Barium
What are reliable signs and symptoms
(more than 90% certainty) that a
newborn patient has intestinal
obstruction that needs operation?
– Signs of peritonitis
– Clinical deterioration
– Unequivocal clinical evidence of
obstruction
– Radiographic evidence of obstruction
Mattei, P. Neonatal Intestinal Obstruction. Surgical Directives: Pediatric Surgery.
2003;313-316
TREATMENT GOALS
Neonatal intestinal obstruction
Identification of cause
Relieve the obstruction
Restore bowel continuity (if stable)
Gastrointestinal Bleeding in
Newborn
Causes of Upper GI Bleeding
Hemorrhagic disease of the newborn
Stress gastritis
– Systemic illness
Causes of Lower GI Bleeding
Hemorrhagic disease of the newborn
Necrotizing enterocolitis
– Presence of systemic illness
In a newborn patient with neonatal
gastrointestinal bleeding, what is the
most cost-effective initial procedure?
Vigilant observation/examination
TREATMENT GOALS
Identification of cause
Control the bleeding
Treatment of Upper GI Bleeding
Hemorrhagic disease of the newborn
– Self-limiting
– Give 1mg Vit K
Swallowed maternal blood
Stress gastritis
– Nasogastric suctioning
– Lavage
– H2-blockers
Treatment of Lower GI Bleeding
Anal fissure
– Stool softners
– Rectal dilatation
Necrotizing enterocolitis
– Antibiotics
– Bowel rest
– TPN
Malrotation with volvulus
– Emergency surgery
Meconium Peritonitis
Perforation
Relaible S/Sx
– No reliable signs of perforation
– Abdominal distention is a clue for perforation
Paraclinical Diagnosis
– Plain abdominal film
Meconium Peritonitis
Is a chemical or foreign-body reaction of
the peritoneum to prenatal perforation of
the intestinal tract
The perforation may sealed off before birth
or it may persists
ETIOLOGY
Meconium ileus, vascular compromise
Atresias or stenosis, intussusception
Volvulus, congenital bands etc.
intestinal obstruction
Intrauterine intestinal perforation
INTESTINAL PERFORATION
MECONIUM LEAKS INTO PERITONIUM
PERITONIUM WILL EXHIBIT RAPID
FIBROBLAST PROLIFERATION
FIBROBLASTIC ADHESION
ENVELOPS THE LESION
PSEUDOCYSTS
INCREASE VASCULARITY &
FORMATION OF MATURE COLLAGEN
FOREIGN BODY GRANULOMAS
& CALCIFICATIONDEVELOPS
Four Pathologic Types
TYPE I Meconium Pseudocysts
– Perforation not sealed in utero
– Fibrous cysts wall formed from the
surrounding bowel loops
– Gangrenous segment of the intestine is a
major part of the cysts
– Rest of the intraperitoneal cavity devoid of
adhesions
– Calcifications may lined the walls
Four Pathologic Types
TYPE II Plastic Generalized Meconium
Peritonitis
– Wide spread spillage of meconium throughout
the peritoneum
– Scattered peritoneal calcifications
– Dense fibrous adhesions
– Intestinal obstruction occurs due to adhesions
Four Pathologic Types
TYPE III Meconium Ascites
– Perforation occurs shortly before birth
– Meconium-stained ascitic fluids
– Fine stripped calcification may be present
Four Pathologic Types
TYPE IV Infected Meconium Peritonitis
– Perforation that did not sealed off before birth
– There is colonization of neonatal gut allows
bacterial peritonitis
– Air and meconium present in the peritoneal
cavity
– The most serious type of meconium peritonitis
Clinical Presentation:
– 1 in 35,000 live births
– Intestinal obstruction is the most common
presentation
– Vomiting may be present on the first or 2nd
day of life
– Plain abdominal x-rays shows intestinal
obstruction and intraabdominal calcifications
INDICATIONS FOR OPERATION
– INTESTINAL OBSTRUCTION
– PERSITENT INTESTINAL LEAKS
Specific indications
– X-ray evidence of intestinal obstruction and
intraperitoneal air
– Abdominal mass encysted meconium
– Localized or generalized cellulitis of the
abdominal wall
– sepsis
GOAL OF MANAGEMENT
– Remove all devitalized tissue
– Preservation of adequate length of bowel
– Reestablish bowel continuity
Abdominal wall defects in
newborn
GASTROSCHISIS
Congenital defect of the abdominal wall
 right of the umbilicus
 no sac or membrane covering the midgut
OMPHALOCOELE
Congenital defect in which the abdominal
viscera remain herniated
 covered with sac
Etiology
- failure of the lateral portion of the
abdominal wall to join its upper and
lower component
- failure in the muscular migrating from the
dorsal myotomes invade the
splanchnopleura of the embryomic
abdominal wall
Goals of treatment
- close defect
- prevent dehydration and electrolyte
imbalance
- return of bowel function
Treatment
primary abdominal closure
prevention of dehydration and electrolyte
imbalanve
Omphalocele
 congenital defect in which the abdominal
viscera remain herniated
 covered with sac
Paraclinical
X Ray
– AP/L
– Lateral – presence of presacral gas
Paraclinical for GI Bleeding
Hemorrhagic dse
Necrotizing Enterocolitis
Xray
Clinical with a background of a septic px
Paraclinical for Perforation
Xray
– Plain abdomen upright
Etiology
-incomplete fetal growth and fusion of the
cephalic, lateral and caudal tissue
- usually present with congenitak gear
dye.
Treatment goals
-close defect
- prevent dehydration and electrolyte
imbalance
- return of bowel function
Treatment
primary closure of the defect
Abdominal Trauma
in Newborn
25% of total trauma victims are children
Blunt abdominal trauma—most common
Abdominal Trauma
What are reliable signs and symptoms (more than
90% certainty) that a patient with abdominal
trauma needs urgent operation?
Ans:
-hemodynamic instability
-definite (persistent, progressive) direct
tenderness with at least guarding
-abdominal rigidity
Abdominal Trauma
Most common causes
– Birth canal trauma
– Vehicular accident
Abdominal Trauma
In a newborn patient with suspected
blunt abdominal trauma, what is the
most cost-effective initial procedure?
Ultrasound
Clinical Questions
9. What are reliable symptoms and signs (more than 90%
certainty) that a patient has perforated abdominal viscus
that needs urgent operation?
Ans:
-definite (persistent, progressive) direct tenderness
with at least guarding
-abdominal rigidity
References
Baucke VL; Failure to Pass Meconium: Diagnosing Neonatal Intestinal
Obstruction, American Family Physician, vol 60, 1999
Irish MJ, Pearl; Pediatric Surgery for the Primary Care of Pediatrician,
The Approach to Common Abdominal Diagnoses In Infants and
Children; Pediatric Clinics of North America, vol 45, 1990
Jona J; Advances in Neonatal Surgery, Neonatology Update, Pediatric
Clinics of North America, vol 95, 1998
Kimura K; Bilious Vomiting in the Newborn, Rapid Decision of Intestinal
Obstruction; American Family Physician vol 61, 2001
Schulman MH; Imaging of Neonatal Gartrointestinal Obstruction, Radiologic
Clinic of North America, vol 37, 1999