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Infant Bowel Obstruction

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Presentation on theme: "Infant Bowel Obstruction"— Presentation transcript:

1 Infant Bowel Obstruction
Robert W. Letton, Jr., MD Associate Professor of Surgery Pediatric Surgery Oklahoma University Health Sciences Center

2 Question 1? Why do Pediatric Surgeons always make such a big deal out of a little yellow or green emesis?

3 Answer Because unlike when Stan sees Wendy in Southpark©,
it usually means bowel obstruction or necrosis in our patients!

4 Goals Discuss the work-up and management of the child with potential bowel obstruction Recognize the common causes of bowel obstruction in children Discuss surgical management of common causes of bowel obstruction

5 History Birth History Feeding History Formula intolerance Emesis
Bilious vs non-bilious Bowel Habits passage of meconium

6 History Antecedent episodes Irritable, lethargic
History of inguinal hernia Family history Hirschsprung’s Recent immunization or URI Intussusception

7 Physical Exam General state of hydration Obvious source of sepsis
meningitis, strep throat, otitis, pneumonia, UTI Inspect abdomen scaphoid or distended, discolored Auscultate Palpate masses, tenderness, peritonitis

8 Physical Exam Must remove diaper

9 Physical Exam Must perform rectal exam, not just look!

10 Ancillary Studies CBC, Lytes, UA, +/- Blood Cx, +/- ABG
Acute abdominal series left lateral decub, KUB, CXR Contrast Study From above or below??

11 Initial Management NG or OG to low wall suction (NPO!!)
Hydrate and replace losses 10 cc/kg of crystalloid IS NOT AN ADEQUATE BOLUS!! Antibiotics if suspect perforation or necrosis Consult surgeon and/or transfer to appropriate facility

12 Bowel Obstruction Diagnosis often age specific
Bilious vomiting in the infant and child is a surgical emergency until proven otherwise Difficult to tell when volvulus is present Child may look surprisingly good until it’s too late

13 Etiology of Bowel Obstruction
Atresias Hirschsprung’s Malrotation Volvulus Intussusception Incarcerated Hernia Perforated appendix

14 Atresia Usually presents the first few days of life
Child may feed well for a day or two with distal atresia Duodenal atresia often diagnosed on antenatal U/S Atresias can occur anywhere in GI tract from pharynx to anus

15 Atresias Esophageal: aspirate feeds immediately, OG tube won’t pass (non-bilious, but still bad) Duodenal: bilious vomiting immediately, “double bubble” on KUB with absence of distal gas, Down’s Syndrome Jejunal: usually present 1st 24 hours, large dilated proximal loop or loops

16 Atresias Ileal: may take 24-48 hours before bilious emesis
Colonic: rare, may present with bilious emesis after 2-3 days Anal: should be diagnosed at birth, often a perineal fistula is labeled normal

17 Obvious Obstruction

18 Atresias may be multiple

19 Jejunal Atresia

20 Apple Peel Deformity (IIIb)

21 Imperforate Anus: Anal atresia

22 Hirschsprung’s Disease
Congenital colonic aganglionosis Physiologic obstruction May present first few days to weeks of life Short segment disease often tolerated for months Starts at anus and extends proximally a variable distance

23 Hirschsprung’s Delayed passage of meconium at birth
Meconium plug syndrome, small left colon syndrome, Down’s syndrome Often present with distension and diarrhea at 2-4 weeks of life May or may not have emesis Profoundly distended abdomen with dilated bowel Fever and WBC’s with colitis

24 Hirschsprung’s Rectal exam may seem normal until withdraw finger
“Explosive” release of liquid stool almost diagnostic Barium enema while dilated Irrigate and dilate until decompressed Suction rectal biopsy

25 Hirschsprung’s Disease

26 Barium Enema

27 Treatment NO WAY!

28 Hirschsprung’s Disease

29 Toxic Megacolon Severe enterocolitis
Very rare to get with idiopathic constipation Usually only seen with Hirschsprung’s Disease or Ulcerative Colitis NG decompression, IV fluids, IV antibiotics Mortality 20-30% in some studies

30 Toxic Megacolon

31 Hirschsprung’s in an 8 year old

32 Malrotation Normal

33 Malrotation Most often presents during the first few months of life
Infant with acute onset of bilious emesis May be diagnosed on UGI for other reasons Malrotation is a surgical urgency due to the possibility of volvulus VOLVULUS IS A SURGICAL EMERGENCY

34 Malrotation Abdomen usually NOT distended AAS usually normal
May show bowel obstruction, double-bubble, or gasless UGI is definitive diagnostic study Infant in extremis resuscitate and operate

35 Malrotation

36 Malrotation

37 Volvulus Malrotation most common condition resulting in midgut volvulus Can have volvulus with normal rotation omphalomesenteric remnant internal hernia Duplication Adhesive small bowel obstruction

38 Midgut Volvulus

39 Small Bowel Obstruction

40 Meckel’s

41 Duplication/Volvulus

42 Duplication

43 Intussusception Inversion of the bowel upon itself secondary to a lead point Juvenile intussusception most often idiopathic Also secondary to Meckel’s Presents 6 months to 2 years of age As early as 1 month

44 Intussusception Acute painful episodes followed by periods of lethargy
When incarcerated progress to continuous lethargy May or may not have “currant-jelly” stool But often stool is heme positive Rule out with a left lateral decubitus film

45 Left-lateral Decubitus Film

46 Intussusception

47 Intussusception

48 Intussusception

49 Intussusception

50 Bad Intussusception

51 Intussusception 7% chance of recurrence after ACE reduction
Usually recur in 48 hours Operative exploration warranted on second recurrence to R/O pathologic lead point Recurrence after surgery rare but possible Post-op intussusception can occur after any surgery

52 Incarcerated Hernia

53 Inguinal/Scrotal Anatomy
From Surgery of Infants and Children, Oldham, et. al., 1997

54 From Atlas of Pediatric Surgery, Ashcraft, 1994
Inguinal Hernia From Atlas of Pediatric Surgery, Ashcraft, 1994

55 Incarcerated Inguinal Hernia

56 Hernia Reduction From Surgery of Infants and Children, Oldham, et. al., 1997

57 Incarcerated Hernia Most can be reduced in clinic or ED
Bowel usually OK if able to reduce Surgical consultation if reduction difficult Repair with 1-2 days of incarceration Beware the “inguinal node’ in females incarcerated ovary

58 Incarcerated Hernia If unable to reduce: urgent operative exploration (NPO) If able to reduce without sedation: urgent surgical referral with repair soon If extremely difficult (sedation, surgical referral): repair next day Watch child for obstructive symptoms

59 Perforated Appendix Children still die from complications of perforated appendicitis Resuscitation is critical Response to surgery variable Often require multiple procedures, hyperalimentation, prolonged antibiotic therapy Diagnosis difficult

60 AAP Guidelines for Pediatric Surgical Referral
Patients 5 years or younger who may need surgical care Infants and children with perforated appendicitis Seriously injured infants and children Infants, children, and adolescents with solid malignancies Minimally invasive procedures Infants and children with medical conditions that increase operative risk

61 Morbidity Incidence of Perforation

62 Perforated Appendix Suspect in children 3-5 years old with history suggestive of appendicitis “Bowel obstruction” in a 3-5 year old without obvious etiology is perforated appendix until proven otherwise Fever > 101.5, WBC > 20 with bands, diffuse abdominal pain, guarding, SBO on AAS

63 Perforated Appendix

64 Perforated Appendix

65 Resuscitation NG tube, NPO
20 cc/kg boluses until UOP > 1 cc/kg/hr and VS stable 1.5-2 times maintenance fluids Broad Spectrum Antibiotics

66 Perforated Appendix

67 ? Summary Atresias Hirschsprung’s Malrotation Volvulus Intussusception
Incarcerated Hernia Perforated Appendix

68 Question 2? Why are Pediatric Surgeons so interested in flatus?
Contrary to popular belief, kids with obstruction can still have bowel movements, but they won’t pass gas!

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