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

2. Anatomy Stomach Small intestines Duodenum Jejenum Ileum
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
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 distention nausea
vomiting : bilious vs. non-bilious
symptoms of malabsorption

6. MECHANICAL OBSTRUCTION
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
respiratory distress

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

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

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

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

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

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

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

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

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

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

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

21. Other associated congenital anomalies
Down’s syndrome 20-30%
Malrotation 20%
Esophageal atresia 10-20%
congenital heart disease %
anorectal and renal anomalies 5%

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

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

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

27. JEJUNAL AND ILEAL OBSTRUCTION
Causes
congenital jejuno-ileal atresias
meconium ileus
Hirschsprung disease

28. CONGENITAL JEJUNOILEAL ATRESIA
attributed to intrauterine vascular accidents leading
to ischemic necrosis of the bowel and resorption
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
contrast studies
ultrasound
Treatment: resection of dilated proximal portion of bowel
followed by end to end anastomosis

30. CONGENITAL JEJUNOILEAL ATRESIA
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

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

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

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

37. HIRSCHSPRUNG DISEASE Diagnosis Treatment : surgical
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
duodenum fixed to the posterior abdominal wall
right & left colon and mesenteric artery root fixed to the posterior abdomen
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

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

41. MALROTATION complication: VOLVULUS
twisting of the small or large bowel around itself
acute presentation of bowel obstruction
Diagnosis: ultrasound and contrastradiographic studies
duodenal obstruction
thickened bowel loops to the R of spine
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
colon is freed from adhesions and placed in R abdomen with cecum in the L lower quadrant

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 24th month
male:female is 4:1

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

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

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

50. INTUSSUSCEPTION Treatment : Prognosis
emergency reduction except if with signs of shock, peritoneal irritation, intestinal perforation or pneumatosis intestinalis
radiologic reduction under fluoroscopic or ultrasonic guidance
Prognosis
fatal if untreated
spontaneous reduction during pre-operative preparation
most recover if reduced within 24 hours
Increase mortality after 2nd 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
2-3% of patients after abdominal surgery
majority are single adhesions
symptoms of obstruction manifest anytime after 2nd
postoperative week
Diagnosis: plain and contrast radiographs
Treatment: nasogastric decompression
IV fluid rescucitation
broad-spectrum antibiotic