NEONATAL INTESTINAL OBSTRUCTION

GENERAL CONSIDERATION
One of the most common and potentially
-------new born surgical emergency.
Successful management depends on both
timely diagnosis and prompt treatment.
Signs and symptoms may not be specific and
may be subtle.
Prenatal diagnosis
Ultrasound:
 polyhydramnios(50% of duodenal
atresia)
 dilated loop of bowel
 whirlpool
 appearance to the bowel and its
mesentery
 echogenic bowel
 dilated proximal esophagus
 bowel in thoracic cavity
 flecks of calcification in peritoneal
cavity.
 ascites
 hydrocephalus,renal disease
non surgical causes of post
natal bowel dysfunction.
 Therefore prenatal diagnosis may directly
improve postnatal outcome by expediting its
surgical management
 PREOP WORK UP

History

 Bilious vomiting
 failure to pass meconium in the first 24
hours
 abdominal distention
 fever
 explosive diarrhoea
 family history: maternal polyhydramnios,
diabetes mellitus, HD, jejunal atresia,
 Down's syndrome
 preterm labour

Physical exam
 Vital signs: signs of dehydration
 abdominal distention
 abdominal tenderness
 abdominal wall erythema
 palpable mass
 visible loop of bowel
 incarcerated hernia
 anterior ectopic anus
 failure to pass NGT
THE PROBLEM MAY BE NON SURGICAL

1.Sepsis with associated ileus.

2.intra cranial lesions
a. hydrocephalus
b.subdural haemorrhage
3.Renal disease associated with uremia
a. renal agenesis
b.polycystic disease
c. other urinary tract abnormalities
associated with severe
hydronephrosis.

INVESTIGATION
1. Hct
2. platelate count
3. WBC
4.U/A
5. imaging evaluation for suspected NIO
a. plain film
* Diagnostic in complete high
intestinal obstruction----no gas in
the distal small bowel
 bouble buble sign in DO
 few gas filled loops beyond
duodenum showing jejunal
atresia
 * Many gas filled loops - low
intestinal obstruction.
 ileal atresia
 meconium ileus
 meconium plug syndrome
 small left colon syndrome
 Hirschsprungs disease
 colonial atresia.
* Non specific in malrotation ----
caecum in upper abdomen (LUQ)
* Calcifications - intraperitoneal----
meconium peritonitis
* Soap-bubble and ground glass
appearance ----MI
* Pneumatosis intestinalis------
necrotizing enterocolitis
b.Contrast enema - differentiates
 Microcolon---complete obstruction
of small bowel
 MP ----intraluminal filling defect
and proximal dilated colon.
 HSD
 cone shaped transition
zone.
 retained barium after 24
hrs.
 spasm,
ulcer,edema(complicatedH
D)
  Small left colon syndrome----colon
dilated to the splenic flexure, then
becomes narrow.
c. Upper GI
 Standard examination for malrotation-----
Findings:
* Birds beak sign
* Incomplete obstruction with
extrinsic compression of duodenum.
* Ligament of Treitz at right of
midline or below pylorus
* position of splenic, hepatic flexures
and cecal position
d.Ultrasound ----for prenatal diagnosis:
confirms the following diagnosis
* Malrotation---SMA lies to the right
or anterior of SMV
* Dilated loops of intestine
* Abdominal mass.
e. Anorectal manometry: In
* HSD---shows absence of internal
sphincter relaxation
f. Rectal biopsy---for HSD, MPS, SLCS
* suction biopsy
* punch biopsy
* full thickness biopsy
 In HSD the biopsy shows
presence of ganglion cells in
submucosa and
 acetylcholinestrase stain shows
abnormal hypertrophic nerve
fibers.

DIFFERENTIAL DIAGNOSIS

1.proximal bowel obstruction

 Malrotation and volvulus
 duodenal atresia
 jejunoileal atresia
 Esophageal atresia,TEF
 IHPS
2. Distal bowel obstruction
 MI
 MPS
 HSD
 Colonic atresia
 Anorectal malformation
3. Non surgical
 Hypothyroidism
 sepsis
 narcotic mother
 electrolyte abnormality: Hypokalemia,
hypermagnesemia
 renal problem
 CNS problem
 MANAGEMENT

1. INITIAL :
 NGT decompression
 IV fluid resuscitation
 IV antibiotics
2. Non operative treatment for: MI, MPS with
 Contrast enema
 saline enema
 NGT gastrograffin
3. Laparotomy:
a. malrotation and volvulus--- load procedure
* Evisceration
* reduction and derotation
* division of bands
* widening of mesentric bands
* release of doudenal obstruction
* incidental appendectomy
b.DA
* resection or by pass of atretic segment
* resection of web
* duodenotomy
c. JI atresia
* resection and primary anastomosis of
atretic segments
* identify all sites of atresia
* reestabilish intestinal motility
d.MI
* 50% respond for non surgical treatment
* diluted gastrograffin with N-
acetylcholine
 risk of perforation---------3-10%
* Surgical
 enterotomy with irrigation of
bowel contents(ileostomy)
 resection with anastomosis
 resection with ileostomy:
mikulicz, Bishop-kopp
* post op treatment
 10% acetylcystiene po
 oral feeding
 pancreatic enzyme
replacement
 prophylactic pul.therapy
e. MPS
* contrast enema
f. HSD
* colostomy
* pull through procedure
 one stage
 two stage
 Swenson, Duhamel, Soave procedures
g.Imperforate anus
* low lesions---perineal anoplasty
* Intermediate and high lesions---
colostomy and PSARP
 POST-OP CARE
 Immediate post op period the following
complications are expected:

 fluid imbalance
 glucose metabolism derrangement
 respiratory problem.

 Maintainance fluid -----1.5 of the normal

 NPO
 NGT
 TPN
 predigested or lactose free formula
 antibiotics
 wound care

LONG TERM OUT COME

 Survival depends on
 comodities
 presence of peritonities
 bowel compromise
 amount of bowel remaining after resection
 TPN
 Example: DA---> 90% survival rate
JIA---> 80-90% Survival rate
 Complications
 anastomotic leak---15%
 post op adhesion
 poor motility
 short bowel syndrome
* Estimated minimum jejunoileal
length for sufficient bowel function
is 75 cm.
* Normal length of small bowel in
neonates is 250 cm.
* Resection of greater than 60% of
small bowel predisposes for
malabsorption.