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Health-Process-Evidence- based Clinical Practice Guidelines Acute Abdomen in Newborns Rommel Q. De Leon, M.D. Maria Cecilia T. Leyson, M.D.

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Presentation on theme: "Health-Process-Evidence- based Clinical Practice Guidelines Acute Abdomen in Newborns Rommel Q. De Leon, M.D. Maria Cecilia T. Leyson, M.D."— Presentation transcript:

1 Health-Process-Evidence- based Clinical Practice Guidelines Acute Abdomen in Newborns Rommel Q. De Leon, M.D. Maria Cecilia T. Leyson, M.D.

2 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)

3 The two general categories of acute abdomen in newborn Acute Surgical abdomen – requiring immediate operative intervention Acute Surgical abdomen – requiring immediate operative intervention Acute Non-Surgical Abdomen – requiring immediate non-operative intervention Acute Non-Surgical Abdomen – requiring immediate non-operative intervention

4 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

5 What are the more common causes of acute non-surgical abdomen? Non-trauma –Ileus –Diarrhea

6 NEONATAL INTESTINAL OBSTRUCTION

7 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

8 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

9 High Obstruction –Gastric outlet obstruction 1:1,000,000 live births pyloric atresia Pyloric stenosis Antral web Causes of mechanical intestinal obstruction

10 –Duodenal obstruction Duodenal atresia Duodenal stenosis Annular pancreas Preduodenal portal vein Malrotation –Jejunal obstruction Atresia Jejunal stenosis

11 Low Obstruction –Distal small bowel Ileal atresia Meconium ileus –Uncomplicated –Complicated Causes of mechanical intestinal obstruction

12 –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

13 Reliable S/Sx of High Obstruction Localized distention –Upper abdomen Generalized Distention

14 Algorithm patient Perforate anus Imperforate anus DRE Localized Generalized/ Diffuse Abdominal Distention High ObstructionLow Obstruction

15 In a newborn patient with suspected neonatal intestinal obstruction, what is the most cost- effective initial procedure? Ans: High Obstruction –Plain abdominal film –Upper GI series

16 Low Obstruction –Contrast Barium

17 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;

18 TREATMENT GOALS Neonatal intestinal obstruction Identification of cause Relieve the obstruction Restore bowel continuity (if stable)

19 Gastrointestinal Bleeding in Newborn

20 Causes of Upper GI Bleeding Hemorrhagic disease of the newborn Stress gastritis –Systemic illness

21 Causes of Lower GI Bleeding Hemorrhagic disease of the newborn Necrotizing enterocolitis –Presence of systemic illness

22 In a newborn patient with neonatal gastrointestinal bleeding, what is the most cost-effective initial procedure? Vigilant observation/examination

23 TREATMENT GOALS Identification of cause Control the bleeding

24 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

25 Treatment of Lower GI Bleeding Anal fissure –Stool softners –Rectal dilatation Necrotizing enterocolitis –Antibiotics –Bowel rest –TPN Malrotation with volvulus –Emergency surgery

26 Meconium Peritonitis

27 Perforation Relaible S/Sx –No reliable signs of perforation –Abdominal distention is a clue for perforation Paraclinical Diagnosis –Plain abdominal film

28 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

29 ETIOLOGY Meconium ileus, vascular compromise Atresias or stenosis, intussusception Volvulus, congenital bands etc. intestinal obstruction intestinal obstruction Intrauterine intestinal perforation

30 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

31 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

32 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

33 Four Pathologic Types TYPE III Meconium Ascites –Perforation occurs shortly before birth –Meconium-stained ascitic fluids –Fine stripped calcification may be present

34 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

35 Clinical Presentation: –1 in 35,000 live births –Intestinal obstruction is the most common presentation –Vomiting may be present on the first or 2 nd day of life –Plain abdominal x-rays shows intestinal obstruction and intraabdominal calcifications

36 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

37 GOAL OF MANAGEMENT –Remove all devitalized tissue –Preservation of adequate length of bowel –Reestablish bowel continuity

38 Abdominal wall defects in newborn

39 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

40 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

41 Goals of treatment - close defect - prevent dehydration and electrolyte imbalance - return of bowel function

42 Treatment primary abdominal closure prevention of dehydration and electrolyte imbalanve

43 Omphalocele  congenital defect in which the abdominal viscera remain herniated  covered with sac

44 Paraclinical X Ray –AP/L –Lateral – presence of presacral gas

45 Paraclinical for GI Bleeding Hemorrhagic dse Necrotizing Enterocolitis Xray Clinical with a background of a septic px

46 Paraclinical for Perforation Xray –Plain abdomen upright

47 Etiology -incomplete fetal growth and fusion of the cephalic, lateral and caudal tissue - usually present with congenitak gear dye. - usually present with congenitak gear dye.

48 Treatment goals - close defect - prevent dehydration and electrolyte imbalance - return of bowel function

49 Treatment primary closure of the defect

50 Abdominal Trauma in Newborn

51 25% of total trauma victims are children Blunt abdominal trauma—most common

52 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 tenderness with at least guarding -abdominal rigidity

53 Abdominal Trauma Most common causes –Birth canal trauma –Vehicular accident

54 In a newborn patient with suspected blunt abdominal trauma, what is the most cost-effective initial procedure? Ultrasound Ultrasound Abdominal Trauma

55 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

56 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


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