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GASTROINTESTINAL OBSTRUCTION MARIA NAVAL C. RIVAS, M.D. DEPARTMENT OF PEDIATRICS THE MEDICAL CITY.

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Presentation on theme: "GASTROINTESTINAL OBSTRUCTION MARIA NAVAL C. RIVAS, M.D. DEPARTMENT OF PEDIATRICS THE MEDICAL CITY."— Presentation transcript:

1 GASTROINTESTINAL OBSTRUCTION MARIA NAVAL C. RIVAS, M.D. DEPARTMENT OF PEDIATRICS THE MEDICAL CITY

2 Anatomy Esophagus Stomach Small intestines Duodenum Jejenum Ileum Large Intestines Cecum Ascending, Transverse and Descending colon Sigmoid colon Rectum

3 Definition Blockage of the esophagus, stomach, small or large intestines Blockage of the esophagus, stomach, small or large intestines Prevents food and fluids from passing through Prevents food and fluids from passing through

4 Pathophysiology accumulation of food, gas and gastric/intestinal secretions gastric / bowel distention decreased intestinal absorption and increased secretion of fluid and electrolytes fluid and electrolyte imbalance

5 Symptoms / Signs abdominal pain abdominal pain abdominal distention abdominal distention nausea nausea vomiting : bilious vs. non-bilious vomiting : bilious vs. non-bilious symptoms of malabsorption symptoms of malabsorption

6 MECHANICAL OBSTRUCTION Esophageal Atresia Esophageal Atresia  most common congenital anomaly  1: 4,000 neonates  90% assoc with tracheoesophageal fistula  50% assoc with VATER/VACTERL  s/sx : frothing/bubbling of mouth and nose coughing coughing respiratory distress respiratory distress

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8 MECHANICAL OBSTRUCTION Diagnosis : Diagnosis : inability to pass nasogastric or orogastric tube inability to pass nasogastric or orogastric tube early signs of respiratory distress early signs of respiratory distress absence of gas in the stomach absence of gas in the stomach Treatment: Treatment: managing airway managing airway preventing aspiration preventing aspiration surgical intervention surgical intervention

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10 MECHANICAL OBSTRUCTION Gastric Obstruction Gastric Obstruction Hypertrophic Pyloric Stenosis Hypertrophic Pyloric Stenosis Congenital Gastric Outlet Obstruction Congenital Gastric Outlet Obstruction Gastric Duplication Gastric Duplication Gastric Volvulus Gastric Volvulus

11 MECHANICAL OBSTRUCTION Intestinal Obstruction Intestinal Obstruction Duodenal Obstruction Duodenal Obstruction Jejunal and Ileal Atresia Obstruction Jejunal and Ileal Atresia Obstruction Malrotation Malrotation Intestinal Duplication Intestinal Duplication Meckel’s Diverticulum Meckel’s Diverticulum Adhesions Adhesions Intussusception Intussusception

12 HYPERTROPHIC PYLORIC STENOSIS Incidence : 3 / 1000 infants Incidence : 3 / 1000 infants whites > blacks > Asians whites > blacks > Asians male 4x > females male 4x > females associated with other congenital defects e.g. tracheo- esophageal fistula associated with other congenital defects e.g. tracheo- esophageal fistula etiology : unknown etiology : unknown

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14 HYPERTROPHIC PYLORIC STENOSIS abdominal pain abdominal pain abdominal distention abdominal distention nausea nausea vomiting vomiting bilious bilious non-bilious non-bilious others: jaundice others: jaundice sx of malabsorption sx of malabsorption occ peristaltic waves occ peristaltic waves

15 HYPERTROPHIC PYLORIC STENOSIS Diagnosis Diagnosis palpable pyloric mass palpable pyloric mass firm, movable, approx 2 cm length. olive-shaped firm, movable, approx 2 cm length. olive-shaped located above and to the right of the umbilicus (midepigastrium) located above and to the right of the umbilicus (midepigastrium) Ultrasonography Ultrasonography Treatment Treatment Ramstedt pyloromyotomy Ramstedt pyloromyotomy Correction of fluid imbalance Correction of fluid imbalance

16 MECHANICAL OBSTRUCTION Gastric Obstruction Gastric Obstruction Hypertrophic Pyloric Stenosis Hypertrophic Pyloric Stenosis Congenital Gastric Outlet Obstruction Congenital Gastric Outlet Obstruction Gastric Duplication Gastric Duplication Gastric Volvulus Gastric Volvulus

17 MECHANICAL OBSTRUCTION Intestinal Obstruction Intestinal Obstruction Duodenal Obstruction Duodenal Obstruction Jejunal and Ileal Atresia / Obstruction Jejunal and Ileal Atresia / Obstruction Malrotation Malrotation Intestinal Duplication Intestinal Duplication Adhesions Adhesions Intussusception Intussusception

18 abdominal pain abdominal pain abdominal distention abdominal distention nausea nausea vomiting vomiting bilious bilious non-bilious non-bilious others: jaundice others: jaundice sx of malabsorption sx of malabsorption DUODENAL OBSTRUCTION

19 Causes Causes congenital duodenal atresia congenital duodenal atresia annular pancreas annular pancreas Ladd’s bands of malrotation Ladd’s bands of malrotation

20 CONGENITAL DUODENAL ATRESIA Etiology : failure to recanalize the duodenal lumen after the solid phase of intestinal development during 4 th to solid phase of intestinal development during 4 th to 5 th week of gestation 5 th week of gestation Incidence : 1 in 10,000 births 25-40% of all intestinal atresias 25-40% of all intestinal atresias 50% are premature 50% are premature

21 Other associated congenital anomalies  Down’s syndrome20-30%  Malrotation20%  Esophageal atresia 10-20%  congenital heart disease 10-15%  anorectal and renal anomalies 5%

22 Diagnosis : “double – bubble sign” on plain abdominal radiographs radiographs : readily detected by fetal ultasonography : readily detected by fetal ultasonography : echocardiogram : echocardiogram : radiography of chest and spine : radiography of chest and spine Treatment : nasogastric / orogastric decompression intravenous fluids intravenous fluids surgery - duodenoduodenostomy surgery - duodenoduodenostomy

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24 ANNULAR PANCREAS  rare condition  2 nd part of duodenum is surrounded by a ring of pancreatic tissue  complete / incomplete obstruction  Diagnosis: abdominal ultrasound & radiograph  Treatment: duodenoduodenostomy

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26 abdominal pain abdominal pain abdominal distention abdominal distention nausea nausea vomiting vomiting bilious bilious non-bilious non-bilious others: jaundice others: jaundice sx of malaborption sx of malaborption JEJUNAL AND ILEAL OBSTRUCTION

27 Causes Causes congenital jejuno-ileal atresias congenital jejuno-ileal atresias meconium ileus meconium ileus Hirschsprung disease Hirschsprung disease

28 CONGENITAL JEJUNOILEAL ATRESIA  attributed to intrauterine vascular accidents leading to ischemic necrosis of the bowel and resorption to ischemic necrosis of the bowel and resorption of the affected segments of the affected segments  associated with prematurity, polyhydramnios, monozygotic twins, failure to pass meconium

29 CONGENITAL JEJUNOILEAL ATRESIA  Diagnosis: prenatal sonograms air-fluid levels on plain radiographs air-fluid levels on plain radiographs contrast studies contrast studies ultrasound ultrasound  Treatment: resection of dilated proximal portion of bowel followed by end to end anastomosis followed by end to end anastomosis

30 CONGENITAL JEJUNOILEAL ATRESIA Types Types I – mucosal obstruction caused by an intraluminal membrane with intact bowel wall and mesentery II – small diameter solid cord connects the proximal and distal bowel IIIA – both ends of bowel end in blind loops IIIB – extensive mesenteric defect that causes distal ileum to coil around the ileocolic artery IV – multiple segments of bowel atresia

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32 MECONIUM ILEUS  last 20-30cm of ileum is collapsed and filled with pale-colored stool, above which is a dilated bowel of varying length obstructed by meconium with thick syrup consitency  80-90% has cystic fibrosis

33 MECONIUM ILEUS  Diagnosis: plain radiograph shows hazy appearance on the R lower quadrant  Treatment: Gastrografin enema resection of ischemic bowel resection of ischemic bowel

34 HIRSCHSPRUNG DISEASE  Congenital Aganglionic Megacolon  absence of ganglion cells in the bowel wall beginning in the internal anal sphincter extending variably to proximal the internal anal sphincter extending variably to proximal intestines intestines  5% involves terminal ileum  1 : 5,000 live births  male : female (4:1)

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36 HIRSCHSPRUNG DISEASE  Clinical Manifestation  delayed passage of meconium  chronic constipation  palpable fecal mass in LLQ  empty rectal vault

37 HIRSCHSPRUNG DISEASE  Diagnosis  rectal manometry and rectal biopsy  Radiograph : transition zone (funnel-shaped area) between normal dilated proximal colon and a smaller-caliber obstructed distal colon  Treatment : surgical

38 MALROTATION incomplete rotation of the intestines during fetal development incomplete rotation of the intestines during fetal development duodenum fixed to the posterior abdominal wall duodenum fixed to the posterior abdominal wall right & left colon and mesenteric artery root fixed to the posterior abdomen right & left colon and mesenteric artery root fixed to the posterior abdomen most common type: failure of cecum to move to R lower quadrant most common type: failure of cecum to move to R lower quadrant malposition of ligament of Treitz, superior mesenteric vein located to the left of the artery malposition of ligament of Treitz, superior mesenteric vein located to the left of the artery

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40 abdominal pain abdominal pain abdominal distention abdominal distention nausea nausea vomiting vomiting bilious bilious non-bilious non-bilious others: jaundice others: jaundice sx of malabsorption sx of malabsorption MALROTATION

41 MALROTATION complication: VOLVULUS complication: VOLVULUS  twisting of the small or large bowel around itself  acute presentation of bowel obstruction  Diagnosis: ultrasound and contrastradiographic studies 1. duodenal obstruction 2. thickened bowel loops to the R of spine 3. free peritoneal fluid

42 MALROTATION  Treatment  Malrotation : surgical intervention  Volvolus : reduce twisted bowel free duodenum and upper jejenum of any bands / position in R abdominal cavity bands / position in R abdominal cavity colon is freed from adhesions and placed in R abdomen with cecum in the L lower quadrant

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44 INTUSSUSCEPTION  portion of alimentary tract is telescoped into an adjacent segment most commonly involving ileocolic and ileoileocolic  incidence  1-4 in 1,000 live births ( 3mos-6yrs)  rare in neonates  60% younger than 12 months  80% of cases occur before 24 th month  male:female is 4:1

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46 INTUSSUSCEPTION  Etiology  most cases unknown  some associated with adenovirus  complicates URTI, AGE, otitis media, Henoch-Schonlein Purpura  theory on swollen Peyer’s patches  lead points in 2-8% cases  meckel’s diverticulum  intestinal polyp  neurofibroma  hemangioma  lymphoma

47 INTUSSUSCEPTION Pathology Pathology intussusceptum invaginates into intussuscipiens dragging mesentery constriction of mesentery obstruction of venous return engorgement of intussusceptum bloody stools with mucus (currant-jelly stools) edema and bleeding from mucosa

48 INTUSSUSCEPTION Early Phase Early Phase 1. sudden onset of paroxysmal, colicky pain 2. accompanied by straining with legs/knees flexed and loud cries 3. frequent vomiting 4. child may play in between paroxysms of pain Late Phase Late Phase 1. bile-stained vomitus 2. little / no flatus 3. child is progresively weaker and lethargic 4. fever with shock-like state

49 INTUSSUSCEPTION Physical Examination Physical Examination  slightly tender sausage-shaped mass  bloody mucous on rectal exam  abdominal distention Diagnosis Diagnosis  plain radiograph : density in the area of intussusception  barium enema : coiled-spring sign  abdominal ultrasound : doughnut or target appearance

50 INTUSSUSCEPTION Treatment : Treatment :  emergency reduction except if with signs of shock, peritoneal irritation, intestinal perforation or pneumatosis intestinalis  radiologic reduction under fluoroscopic or ultrasonic guidance Prognosis Prognosis  fatal if untreated  spontaneous reduction during pre-operative preparation  most recover if reduced within 24 hours  Increase mortality after 2 nd day

51 INTESTINAL DUPLICATION  well-formed tubular structures firmly attached to the intestine with a common blood supply  lining of duplications resembles GI tract  very rare  cause unknown but attributed to defect in recanalization during embryological development  signs of obstruction

52 ADHESIONS  fibrous bands of tissue that are a common cause of post-operative bowel obstruction post-operative bowel obstruction  2-3% of patients after abdominal surgery  majority are single adhesions  symptoms of obstruction manifest anytime after 2 nd postoperative week  Diagnosis: plain and contrast radiographs  Treatment: nasogastric decompression IV fluid rescucitation IV fluid rescucitation broad-spectrum antibiotic broad-spectrum antibiotic


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