Intestinal Obstruction In The Neonate Dr Osama Bawazir Assistant Professor , Consultant Pediatric surgeon FRCSI, FRCS(Ed), FRCS (glas), FRCSC, FAAP,FACS.

Incidence intestinal obstruction is the most common surgical emergency of the newborn. 1 case per every 500-1000 live births. 50% of these neonates will have intestinal atresia or stenosis

Presentation Cardinal signs of intestinal obstruction in neonate Antenatal polyhydramnios Bilious vomiting Delayed passage of meconium (> 24 hrs) Gastric residual > 30 cc Abdominal distention bloody diarrhea indicating bowel ischemia or necrosis.

Imaging Study New born has air within the proximal small bowel within 30 minutes. Air can be identified in the rectum by 6-8 hours. Multiple dilated loops of bowel with “stepladder” air fluid levels on the upright film is the pattern most often seen with distal intestinal obstruction. peritoneal and/or scrotal calcifications which may signify an intrauterine perforation with meconium peritonitis.

contrast enema may be useful to distinguish between causes of distal bowel obstruction Upper gastrointestinal barium studies (not useful) only for bowel rotation. small unused colon

Causes of neonatal intestinal obstruction Common: Malrotation (duodenal obstruction, volvulus, internal hernia) Duodenal atresia, stenosis or annular pancreas Jejunal atresia or stenosis Ileal atresia or stenosis Simple meconium ileus Meconium ileus with perforation Meconium plug syndrome Hirschsprung’s disease Drug-induced ileus Hypertrophic pyloric stenosis Uncommon: Pyloric atresia or web Tumors Intussusception Segmental intestinal dilatation Small left colon syndrome Milk bolus obstruction Colonic atresia Functional Intestinal obstruction Intestinal Psuedo-Obstruction Neuronal Intestinal Dysplasia Megalocystis-Microcolon-Intestinal Hypoperistalsis Syndrome Inguinal hernia

Pathophysiology Proximal intestinal obstruction  loss of H+ ,K+ & Cl‾  Hypochloremic alkalosis Distal intestinal obstruction  fluid loss from emesis & from fluid sequestered into the lumen of dilated bowel loops Fluid shifts and volume depletion  dehydration, oliguria, metabolic acidosis, and inadequate peripheral perfusion. impair diaphragmatic function bowel ischemia and necrosis.

Perioperative Management (1) Fundamental rule: previous losses /maintenance/ongoing needs Urine output best measure of adequate resuscitation ?Need for central monitoring if problematic Recall distribution of various IV solution Bolus: as per PALS (20 cc/kg) Titrate to heart rate, urine output BP ↑ Maintained 25% for each quadrant of abdomen involved

Perioperative Management(2) Antibiotics if any viscus opened, cardiac issues, immunosuppresed (newborn) Steroids: if on previously/deficiency (stress dose physiology) Nasogastric tube (Decompression) Keep patient warm surgery should not be delayed once volume resuscitation is adequate

Two weeks old full term female with bilious vomiting.

Be Aware of Child with Bilious (Green) Vomiting

Malrotation 10th Week of Development rapid growth of intestine which returns to abdominal cavity with rotation 0.5–1% of the population only 1 in 6000 live births will present with clinical symptoms. Problems can occur at any of the 3 stages Duodenal rotation Elongation and fixation of the mesentery Rotation of the colon

spiral or corkscrew cut-off to passage of barium described as a “bird’s beak”

In simple malrotation, the upper gastrointestinal series shows the incomplete rotation of the duodeno-jejunal loop cut-off to passage of barium described as a “bird’s beak” spiral or corkscrew Ultrasound  superior mesenteric vein is normally to the right of the artery

Treatment Midgut volvulus is a surgical emergency. Malrotation without volvulus is a relatively nonemergent condition The operative management (Ladd procedure) Recurrent volvulus 10% after Ladd procedure. 5-6% bowel obstruction secondary to adhesions.

Full term female who was 6 hours old Full term female who was 6 hours old. The pregnancy history was remarkable for polyhydramnios on prenatal ultrasound. Immediately after birth the patient developed bilious emesis.

Duodenal Atresia/ Annular Pancreas Primary problem is one of recanalization of solid duodenum. Obstruction typically at level of common bile duct and pancreas Duodenal obstruction occurs distal to the ampulla of Vater in 80% of cases. Duodenal obstruction can be secondary to intrinsic or extrinsic lesions.

Associated anomalies common: almost 50% Down syndrome 29% malrotation 19% congenital heart disease 17% TEF 7% Others (renal, respiratory, imperforate anus - roughly 10%) surgical treatment of choice is a ‘double diamond’ duodenoduodenostomy

Newborn 36 week premature female with bilious vomiting. polyhydramnios on prenatal ultrasound.

Jejunal & Ileal Atresia Pathology related to late second trimester vascular accident (Barnard) most common gastrointestinal atresia one per 2,000 live births. Associated anomalies rare Classification system

2 month old boy with bilious vomiting and a palpable right lower quadrant mass

Inguinal hernia Indirect 99% 1% to 3% of all children 3% to 5% in preterm baby R 60% L 30% Bilateral 10-15% Males to females ratio is 6:1 Present as bulge in the groin, scrotum, or labia. A reliable history is sufficient to make the diagnosis, even if the hernia cannot identify. An incarcerated inguinal hernia presents as a mass in the labia or scrotum that does not reduce spontaneously.

What embryological events account for this abnormality? Failure of the processus vaginalis to close (it remains patent). What are your recommendations to the parents? The hernia should be repaired electively; the parents should be warned about possible incarceration in the meantime. If at the time of your examination the child were irritable and the mass irreducible, what would be your approach? Attempt manual reduction (use sedation if necessary); emergency surgery if unsuccessful.