A PRESENTATION ON

NEONATAL INTESTINAL
OBSTRUCTION (NIO)
Presenters:
1. Mba John ( Midgut Anatomy)
2. Abdallah Jabir Mariam ( Jejunoileal atresia and stenosis)
3. Abdul Rahim Umar Farouk ( meconium plug syndrome)
 OBJECTIVES
1. Midgut anatomy
 Blood vessels, nerves and lymphatics
2. Jejunoileal atresia and stenosis
 Concept, incidence, etiology, classification, clinical
features, radiographic findings other tests and
management.
3. Meconium plug syndrome
 Concept, incidence, etiology, classification, clinical
features, radiographic findings other tests and
management.
Anatomy of the Midgut
Overwiew

THE MIDGUT CONSIST OF THE ;

 THE DISTAL DUODENUM(3RD AND 4TH PART)
 JEJUNUM
 ILEUM
 PROXIMAL LARGE INTESTINE
 THE CAECUM & APPENDIX
 ASCENDING COLON
 TRANSVERSE COLON(PROXIMAL 2/3rd)
 DISTAL DUODENUM

The proximal duodenum is largely retroperitoneal

but the distal is intraperitoneal;has four main parts
the duodenum ends in association with the jejunum
at the duodenanojejunal flexure,which is
supported by the suspensory ligament of the
duodenum(ligament of treitz)
 JEJUNUM &ILEUM

 the jejunum is the second part of the small

intestine(midgut)
 also known as the midsection of the small intestines.
 It has the most highly developed circular folds lining the
lumen known as plicae ciercularis as well as villi.
 it is about 2.5m long
ILEUM

 the ileum is the 3rd and final part of the midgut

 it contains large lymphatic aggregates known as the
payer's patches
 in contrast to the jejunum the ileum has fewer circular
folds lining the lumen and more vascular arcades
 the terminal ileum has a thickened smooth muscle layer
known as the ileocecal sphincter(Valve).
CAECUM & APPENDIX

 the caecum is a pouch within the peritoneum that is

considered to be the begining of the the large intestine.
 it located in the lower right quadrant of the abdominal
cavity
 superiorly it forms the ascending colon
 inferiorly it tappers to form the vermiform
appendix,which is a considered a vestigial organ.
ASCENDING AND COLON

 the ascending colon lies in the right upper quadrant of the

trunk
 it extends from the cecum,upward to the inferior surface
of the right lobe of the liver.At this point it turns left to
form the right colic flexure and become continous with
the transverse colon.
 the peritoneum covers the front and the sides of the
ascending colon and blinds it to the posterior abdominal
wall
TRANSVERSE COLON

 the transverse colon has its own mesentery which is

known as the mesocolon.
 extends from the the right colic flexure to the left colic
flexure.
 the transverse colon passes from the right hypochondrisc
into the left hypochondriac region
 BLOOD SUPPLY

 The blood supply of the midgut is mainly the superior

mesenteric artery(SMA).A single branch of the aorta
 branches;
 SMA anastomose with the superior pancreaticoduodenal
artery(derived from the celiac trunk);supplies the
pancrease and duodenum
 ther SMA artery gives rise to numerous branches that
supply the jejunum and the ileum
 the middle and right colic arteries supply the transverse
and ascending colons respectively
 ileocolic supplies the caecum and the appendix
VENOUS DRAINAGE

 inferior mesenteric vein drain the colon

 superior mesenteric;
 post inferior pancreaticoduodenal veins drain the pancreas
and duodenum
 jejunal vein drains the jejunum
 ileal vein drains the ileum
 ileocolic vein drains the ileum colon and caecum
 right colic ;the ascending colon
 middle colic drains the transverse colon
NERVE SUPPLY

 the duodenum gets its innervation from the vagus nerve

via the celiac and mesenteric plexi(parasympathetic) and
intestinal plexi around arterial vessels(sympathetic)
 innervation of the jejunum and ileum is from the vagus
nerve via mysenteric and submucosal
plexi(parasympathetic)and greater and lesser splanchnic
(sympathetic)
 the superior mesenteric plexus provides sympathetic
innervation to the caecum ,appendix, ascending and
transverse colon;paraympatetic innervation is mainly by
the vagus nerve
INTRODUCTION TO NEONATAL
INTESTINAL OBSTRUCTION
 JEJUNAL AND ILEAL
ATRESIAS
Jejunoileal atresias are classified under intrinsic
abdomalities in the anatomic development causing mid to
distal small bowel obstruction. They occur in 1/3000 per
lives births and 1/1500 per lives births together with all
forms of intestinal obstructions.
ETIOLOGY 1

 Jejunoileal atresia are generally attributed to intrauterine

vascular accidents which results in segmental infarction
and resorption of the fetal intestine.
 Underlying events that potentiates vascular compromise
include;
1. Intestinal volvulus
2. Intussuception
3. Meconeum ileus
4. Strangulating herniation(gastroschisis and omphalocele
Etiology 2

 Maternal behaviours that promote vasoconstriction such as

cigarette smoking and cocaine use might also have a role
 Only a few cases of familial inheritance have been
reported(multiple intestinal atresias –autosomal recessive
pattern)
 They have also been linked with multiple births, low birth
weight and prematurity. And they are relatively not
commonly associated with extraintestinal anomalies.
CLASSIFICATION 1
Five(5) types of Jejunoileal atresias are encountered:
1. TYPE I: In this type a mucosal web occludes the lumen but
continuity is maintain between the proximal and distal
bowel.(20%)
2. TYPE II: This involves a small-diameter solid cord that
connects the proximal and distal bowel.(30-35%)
3. TYPE IIIa: Occurs when both ends of the bowel end in
blind loops, accompanied by a small mesenteric
defect(30-35%)
Classification 2

1. TYPE IIIb: Similar but associated with an extensive

mesenteric defect and a loss of the normal blood supply to
the distal bowel. The distal ileum coils around the
ileocolic artery( apple-peel appearance)—prematurity, an
unusually short distal ileum and significant foreshortening
of the bowel
2. TYPE IV: Invoves multiple atresias( + type IIIb =(10-20%)
DIFFERENTIAL DIAGNOSIS

 Meconium ileus
 Long segment Hirschprung disease
 Duodenal atresia
POSITIVE DIAGNOSIS
 Clinical features
1. Polyhydramnios(20-35%)- first sign of intestinal
obstruction.
2. Abdominal distension(rarely present at birth:12-24hrs).
3. Vomiting(often bilious)
4. Failure to pass meconium in first 24h(approximately 80%)
5. Jaundice associated with unconjugated
hyperbilirubinemia(20-30%)
Radiographic study and other tests

 Plain radiographs
1. Multiple air-fluid level in the upright or lateral
decubitus proximal to the obstruction.
2. Patchy calcifications(meconium peritonitis)
3. Pneumoperitonium (intestinal perforation)
 Contrast studies and CT
 Water soluble enemas(gastrografin and hypaque)

Abdominal Ultrasound(adjunctive study)

Management

 Stabilize, adequate fluid and electrolyte balance unless

volvulus is suspected.
 Appropriate antibiotics-documented infections
 Surgery
1. Prophylactic antibiotics
2. End to end anastomosis
3. Jejunoplasty or ileoplasty
Meconium Plug
Syndrome(MPS)
CONCEPT

 MPS is a transient distal colonic obstruction as a result of

dehydrated and inspissated meconium.
 MPS is also known as functional immaturity of the colon.
 It is the most common form of functional bowel
obstruction in newborns.
 The colon of newborns with MPS is usually small.
 Presents within the first 24 to 36 hours of age.
Etiology

 The exact cause is unkown.

 However, MPS is attributed to functional immaturity of
the colon in newborns.
 MPS is associated with other conditions
 Cystic fibrosis 30-40%
 Hirschprung’s disease 10-30%
 Other risk factors( hypotonia, hypermagnesemia,
prematurity, respiratory distress, sepsis, hypothyroidism
and maternal DM)
Incidence

 The most common form of functional bowel obstruction in

newborns.
 The incidence is 1 in 1,000 births.
 Exist as isolated disease in up to 80% of cases.
Clinical features

 Premature newborns who are otherwise normal.

 Impacted meconium
 Delayed passage of meconium (>24-48h)
 Failure to pass meconium
 Abdominal distension
 Vomiting (bilious)
Investigations 1

 Plain film radiography

 both supine and left lateral.
 shows multiple dilated bowel loops with absence of
rectal gas.
 There may be calibre change around the splenic
flexure.
Investigations 2

 Fluoroscopy with contrast enema

 there is dilatation of ascending and transverse colon.
 there is a sudden change in calibre from the splenic
flexure with narrow descending and rectosigmoid colon
with multiple filling defect due to retained meconium.
 NB: in Hirschprung disease the aganglionic colon is
usually of normal calibre.
MPS 1
MPS 2
Differential dx

1. Hirschprung’s disease
2. Meconium ileus(right colon usually not dilated
3. Small left colon syndrome
4. Megacystis-microcolon-hypoperistalsis syndrome
5. Visceral neuropathies
6. Neural intestinal dysplasia
Management

 A gentle rectal washout with temperate normal saline

might alleviate the obstruction immediately.
 A rectal suction biopsy and or a contrast
enema should rule out HD.
END OF PRESENTATIION

THANK YOU
 REFERENCES

 Paediatric surgery: comprehensive text for Africa

 Baja