1. Neonatal intestinal obstruction

2. General information
Neonatal intestinal obstruction can be due to a variety of causes
Presenting clinical features are often similar
Bile-stained vomiting is never normal in a neonate and implies obstruction
95% of babies pass meconium within the first 24 hours of life
Failure to pass meconium is also a feature of obstruction
The degree of abdominal distension is variable

3. Clinical Features
Triad of : Vomiting, abdominal distension, and failure to pass meconium (constipation)
Manifestation depends on the site of obstruction

4. Principles of Management
GIT decompression
fluid and electrolyte management
Surgical treatment accordingly

5. Diagnosis Antenatal U/S, MRI
Plain X-Ray upright, and supine (Air fluid level)
Contrast material

6. Causes of Neonatal Intestinal obstructions
Atresias – duodenal, jejunal, colonic
Meconium ileus; Meconium plug
Hirschsprung’s disease
Imperforate anus
Malrotation with volvulus

7. Duodenal atresia Occurs in 1 in 5-6,000 live births
Site of obstruction is most commonly in 2nd part of duodenum
Proximal duodenum become hypertrophied
50% are associated with polyhydramnios
60% of such pregnancies are complicated or end prematurely
Can often be diagnosed with antenatal ultrasound

8. Duodenal atresia
30% of babies with duodenal atresia have Down's syndrome
Other associated abnormalities are cardiac anomalies, malrotation and biliary atresia
Postnatally presents with bilious or non-bile stained vomiting
X-ray may show a 'double-bubble' and no gas within the bowel distally

9. Management A nasogastric tube should be passed
Intravenous fluid resuscitation should be given
Major cardiac and other defects should be excluded
Duodenoduodenostomy should be performed when resuscitated

11. Other atresias Atresias of the small bowel and colon are less common
Often associated with polyhydramnios
Bilious vomiting and distension are key features
x-ray will show dilated bowel and a gas-free rectum
A nasogastric tube should be passed
Intravenous fluid resuscitation should be given
At operation, dilated proximal bowel should be resected or tapered
A primary anastomosis may be possible

12. Types (Bowel loss, mesentery)
web (membrane), normal length, normal mesentery.
Type 2
fibrous cord between blind ends of the atretic bowel but have an intact mesentery.
Type 3/A
There is a complete separation of the blind ends of the separated bowel by a v-shaped mesenteric defect.
Type 3/B
Apple peal or Christmas tree deformity.
Type 4
Multiple atresia, string of sausage or string of beads.

13. Type 1
Type 2
Type 3/A
Type 3/B
Type 4

15. Type I Atresia

16. Type IV Atresia

17. Annular pancreas

18. Meconium ileus
Commonest cause of neonatal intraluminal intestinal obstruction
80% cases are associated with cystic fibrosis
Cystic fibrosis occurs in 1 in 2000 live births
Inherited as an autosomal recessive trait
Viscid pancreatic secretions cause autodigestion of pancreatic acinar cells
Resulting meconium is abnormal and putty-like in consistency

19. Meconium ileus Meconium becomes inspissated in the lower ileum
There is a microcolon
Presents with bilious vomiting and distension usually on first day of life
Passage of meconium is delayed
Meconium filled loops of bowel may be palpable
X-ray may show a 'ground-glass' appearance, especially in the right upper quadrant

20. Meconium Ileus (cont) Diagnosis made with contrast enema
Gastrograffin enema with aggressive hydration can be used to treat some
Operative evacuation of meconium
May require ostomy
Proximal bowel dilated and distal bowel may be very small (microcolon) and require time to dilate with use

21. Management Gastrografin enemas may be successful in 50% of patients
If unsuccessful, surgery will be required
Limited resection and stomas may be required

22. Meconium plug
Difference between meconium ileus and meconium plug is site and severity of obstruction
Preterm infants, infants of diabetic mothers, IUGR babies, otherwise ill babies
Treatment with glycerin suppositories and warm saline enemas
May require contrast enema to make diagnosis
Normal stooling pattern should follow evacuation of plug

23. Malrotation
Volvulus

24. Malrotation
Between 4 and 10 weeks of development intestines herniate into umbilical cord
When returned to abdomen they rotate 270 degrees anticlockwise
As a result
Duodeno-jejunal flexure lies to the left of the midline

25. Malrotation Caecum lies in right iliac fossa
Transverse colon lies anterior to the small bowel mesentery
Partial failure of rotation results in malrotation
Commonest abnormality results in caecum lying close to DJ flexure

26. Malrotation
Resulting midgut mesentery is abnormally narrow and liable to volvulus
Fibrous bands may be present between caecum and DJ flexure (Ladd's bands)
Radiological investigations are often unhelpful

27. Clinical presentations
Three clinical presentations
Presents late with intermittent bile stained vomiting and distension
Presents early with collapse and acidosis due to intestinal infarction
Presents as incidental finding on radiological investigation

28. Malrotation & Volvulus (Volvulus Neonatorum)
90% occur first month
Bilious emesis
Abdominal distention, peritonitis
Septic shock
Rectal bleeding
Absolute surgical emergency; detorsion, Ladd
procedure, possible bowel resection

29. Malrotation with volvulus
Can occur in the fetus – large calcified shadow in midabdomen on x-ray
Sudden onset of bilious emesis in infant – requires rule out
Signs of shock and sepsis can be present
Surgical emergency since intestinal viability is at stake.
UGI to evaluate for position of ligament of Treitz

30. Management After resuscitation, early laparotomy may be required
Any volvulus should be reduced
Resection may be required if there has been small bowel infarction
Any Ladd's bands should be divided
The base of the mesentery should be widened
Colon should be placed on the left of the abdomen
Small bowel should be placed on the right
Inversion appendectomy should be performed to prevent future diagnostic uncertainty