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Maria Cecilia T. Leyson, M.D.
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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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)
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The two general categories of acute abdomen in newborn
Acute Surgical abdomen – requiring immediate operative intervention Acute Non-Surgical Abdomen – requiring immediate non-operative intervention
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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
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What are the more common causes of acute non-surgical abdomen?
Non-trauma Ileus Diarrhea
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NEONATAL INTESTINAL OBSTRUCTION
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Patient with imperforate anus Patient with perforate anus with :
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
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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
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Causes of mechanical intestinal obstruction
High Obstruction Gastric outlet obstruction 1:1,000,000 live births pyloric atresia Pyloric stenosis Antral web
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Duodenal obstruction Jejunal obstruction Duodenal atresia
Duodenal stenosis Annular pancreas Preduodenal portal vein Malrotation Jejunal obstruction Atresia Jejunal stenosis
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Causes of mechanical intestinal obstruction
Low Obstruction Distal small bowel Ileal atresia Meconium ileus Uncomplicated Complicated
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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
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Reliable S/Sx of High Obstruction
Localized distention Upper abdomen Generalized Distention
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Algorithm patient DRE Imperforate anus Perforate anus Generalized/
Abdominal Distention Generalized/ Diffuse Localized High Obstruction Low Obstruction
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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
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Low Obstruction Contrast Barium
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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;
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TREATMENT GOALS Neonatal intestinal obstruction
Identification of cause Relieve the obstruction Restore bowel continuity (if stable)
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Gastrointestinal Bleeding in Newborn
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Causes of Upper GI Bleeding
Hemorrhagic disease of the newborn Stress gastritis Systemic illness
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Causes of Lower GI Bleeding
Hemorrhagic disease of the newborn Necrotizing enterocolitis Presence of systemic illness
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In a newborn patient with neonatal gastrointestinal bleeding, what is the most cost-effective initial procedure? Vigilant observation/examination
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TREATMENT GOALS Identification of cause Control the bleeding
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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
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Treatment of Lower GI Bleeding
Anal fissure Stool softners Rectal dilatation Necrotizing enterocolitis Antibiotics Bowel rest TPN Malrotation with volvulus Emergency surgery
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Meconium Peritonitis
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Perforation Relaible S/Sx Paraclinical Diagnosis
No reliable signs of perforation Abdominal distention is a clue for perforation Paraclinical Diagnosis Plain abdominal film
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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
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ETIOLOGY Meconium ileus, vascular compromise
Atresias or stenosis, intussusception Volvulus, congenital bands etc. intestinal obstruction Intrauterine intestinal perforation
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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
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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
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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
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Four Pathologic Types TYPE III Meconium Ascites
Perforation occurs shortly before birth Meconium-stained ascitic fluids Fine stripped calcification may be present
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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
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Clinical Presentation:
1 in 35,000 live births Intestinal obstruction is the most common presentation Vomiting may be present on the first or 2nd day of life Plain abdominal x-rays shows intestinal obstruction and intraabdominal calcifications
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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
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GOAL OF MANAGEMENT Remove all devitalized tissue
Preservation of adequate length of bowel Reestablish bowel continuity
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Abdominal wall defects in newborn
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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
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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
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Goals of treatment - close defect - prevent dehydration and electrolyte imbalance - return of bowel function
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Treatment primary abdominal closure prevention of dehydration and electrolyte imbalanve
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Omphalocele congenital defect in which the abdominal viscera remain herniated covered with sac
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Paraclinical X Ray AP/L Lateral – presence of presacral gas
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Paraclinical for GI Bleeding
Hemorrhagic dse Necrotizing Enterocolitis Xray Clinical with a background of a septic px
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Paraclinical for Perforation
Xray Plain abdomen upright
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Etiology -incomplete fetal growth and fusion of the cephalic, lateral and caudal tissue - usually present with congenitak gear dye.
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- prevent dehydration and electrolyte imbalance
Treatment goals -close defect - prevent dehydration and electrolyte imbalance return of bowel function
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Treatment primary closure of the defect
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Abdominal Trauma in Newborn
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25% of total trauma victims are children
Blunt abdominal trauma—most common
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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 -abdominal rigidity
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Abdominal Trauma Most common causes Birth canal trauma
Vehicular accident
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Abdominal Trauma In a newborn patient with suspected blunt abdominal trauma, what is the most cost-effective initial procedure? Ultrasound
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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
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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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