Infant Bowel Obstruction

Robert W. Letton, Jr., MDRobert W. Letton, Jr., MDAssociate Professor of SurgeryAssociate Professor of Surgery

Pediatric SurgeryPediatric Surgery

Oklahoma University Health Sciences CenterOklahoma University Health Sciences Center

Question 1?

Why do Pediatric Surgeons always make such a big deal out of a

little yellow or green emesis?

Answer

Because unlike when Stan sees Wendy in Southpark©, it usually means bowel obstruction or necrosis in our patients!

Goals

Discuss the work-up and management of Discuss the work-up and management of the child with potential bowel obstructionthe child with potential bowel obstruction

Recognize the common causes of bowel Recognize the common causes of bowel obstruction in childrenobstruction in children

Discuss surgical management of common Discuss surgical management of common causes of bowel obstructioncauses of bowel obstruction

History

Birth HistoryBirth History Feeding HistoryFeeding History

Formula intoleranceFormula intolerance EmesisEmesis

Bilious vs non-biliousBilious vs non-bilious Bowel HabitsBowel Habits

passage of meconiumpassage of meconium

History

Antecedent episodesAntecedent episodes Irritable, lethargicIrritable, lethargic History of inguinal herniaHistory of inguinal hernia Family historyFamily history

Hirschsprung’sHirschsprung’s Recent immunization or URIRecent immunization or URI

IntussusceptionIntussusception

Physical Exam General state of hydrationGeneral state of hydration Obvious source of sepsisObvious source of sepsis

meningitis, strep throat, otitis, pneumonia, UTImeningitis, strep throat, otitis, pneumonia, UTI Inspect abdomenInspect abdomen

scaphoid or distended, discoloredscaphoid or distended, discolored AuscultateAuscultate PalpatePalpate

masses, tenderness, peritonitismasses, tenderness, peritonitis

Physical Exam

Must remove diaperMust remove diaper

Physical Exam

Must perform rectal exam, not just look!Must perform rectal exam, not just look!

Ancillary Studies

CBC, Lytes, UA, +/- Blood Cx, +/- ABGCBC, Lytes, UA, +/- Blood Cx, +/- ABG Acute abdominal seriesAcute abdominal series

left lateral decub, KUB, CXRleft lateral decub, KUB, CXR Contrast StudyContrast Study

From above or below??From above or below??

Initial Management

NG or OG to low wall suction (NPO!!)NG or OG to low wall suction (NPO!!) Hydrate and replace lossesHydrate and replace losses

10 cc/kg of crystalloid10 cc/kg of crystalloid IS NOT AN IS NOT AN ADEQUATE BOLUS!!ADEQUATE BOLUS!!

Antibiotics if suspect perforation or necrosisAntibiotics if suspect perforation or necrosis Consult surgeon and/or transfer to Consult surgeon and/or transfer to

appropriate facilityappropriate facility

Bowel Obstruction

Diagnosis often age specificDiagnosis often age specific Bilious vomiting in the infant and child is a Bilious vomiting in the infant and child is a

surgical emergency until proven otherwisesurgical emergency until proven otherwise Difficult to tell when volvulus is presentDifficult to tell when volvulus is present Child may look surprisingly good until it’s Child may look surprisingly good until it’s

too latetoo late

Etiology of Bowel Obstruction

AtresiasAtresias Hirschsprung’sHirschsprung’s MalrotationMalrotation VolvulusVolvulus IntussusceptionIntussusception Incarcerated HerniaIncarcerated Hernia Perforated appendixPerforated appendix

Atresia

Usually presents the first few days of lifeUsually presents the first few days of life Child may feed well for a day or two with Child may feed well for a day or two with

distal atresiadistal atresia Duodenal atresia often diagnosed on Duodenal atresia often diagnosed on

antenatal U/Santenatal U/S Atresias can occur anywhere in GI tract Atresias can occur anywhere in GI tract

from pharynx to anusfrom pharynx to anus

Atresias

Esophageal: aspirate feeds immediately, Esophageal: aspirate feeds immediately, OG tube won’t pass (non-bilious, but still OG tube won’t pass (non-bilious, but still bad)bad)

Duodenal: bilious vomiting immediately, Duodenal: bilious vomiting immediately, “double bubble” on KUB with absence of “double bubble” on KUB with absence of distal gas, Down’s Syndromedistal gas, Down’s Syndrome

Jejunal: usually present 1Jejunal: usually present 1stst 24 hours, large 24 hours, large dilated proximal loop or loopsdilated proximal loop or loops

Atresias

Ileal: may take 24-48 hours before bilious Ileal: may take 24-48 hours before bilious emesisemesis

Colonic: rare, may present with bilious Colonic: rare, may present with bilious emesis after 2-3 daysemesis after 2-3 days

Anal: should be diagnosed at birth, often a Anal: should be diagnosed at birth, often a perineal fistula is labeled normalperineal fistula is labeled normal

Obvious Obstruction

Atresias may be multiple

Jejunal Atresia

Apple Peel Deformity (IIIb)

Imperforate Anus: Anal atresia

Hirschsprung’s Disease

Congenital colonic aganglionosisCongenital colonic aganglionosis Physiologic obstruction Physiologic obstruction

May present first few days to weeks of lifeMay present first few days to weeks of life Short segment disease often tolerated for Short segment disease often tolerated for

monthsmonths Starts at anus and extends proximally a Starts at anus and extends proximally a

variable distancevariable distance

Hirschsprung’s

Delayed passage of meconium at birthDelayed passage of meconium at birth Meconium plug syndrome, small left colon Meconium plug syndrome, small left colon

syndrome, Down’s syndromesyndrome, Down’s syndrome Often present with distension and diarrhea at 2-4 Often present with distension and diarrhea at 2-4

weeks of lifeweeks of life May or may not have emesisMay or may not have emesis Profoundly distended abdomen with dilated bowelProfoundly distended abdomen with dilated bowel Fever and Fever and WBC’s with colitisWBC’s with colitis

Hirschsprung’s

Rectal exam may seem normal until Rectal exam may seem normal until withdraw fingerwithdraw finger

““Explosive” release of liquid stool almost Explosive” release of liquid stool almost diagnosticdiagnostic

Barium enema while dilatedBarium enema while dilated Irrigate and dilate until decompressedIrrigate and dilate until decompressed Suction rectal biopsySuction rectal biopsy

Hirschsprung’s Disease

Barium Enema

Treatment

NO WAY!

Hirschsprung’s Disease

Toxic Megacolon

Severe enterocolitisSevere enterocolitis Very rare to get with idiopathic constipationVery rare to get with idiopathic constipation Usually only seen with Hirschsprung’s Usually only seen with Hirschsprung’s

Disease or Ulcerative ColitisDisease or Ulcerative Colitis NG decompression, IV fluids, IV antibioticsNG decompression, IV fluids, IV antibiotics Mortality 20-30% in some studiesMortality 20-30% in some studies

Toxic Megacolon

Hirschsprung’s in an 8 year old

Malrotation

Normal

Malrotation

Most often presents during the first few Most often presents during the first few months of lifemonths of life

Infant with acute onset of bilious emesisInfant with acute onset of bilious emesis May be diagnosed on UGI for other reasonsMay be diagnosed on UGI for other reasons Malrotation is a surgical urgency due to the Malrotation is a surgical urgency due to the

possibility of volvuluspossibility of volvulus VOLVULUS IS A SURGICAL VOLVULUS IS A SURGICAL

EMERGENCYEMERGENCY

Malrotation

Abdomen usually Abdomen usually NOTNOT distended distended AAS usually normalAAS usually normal

May show bowel obstruction, double-May show bowel obstruction, double-bubble, or gaslessbubble, or gasless

UGI is definitive diagnostic studyUGI is definitive diagnostic study Infant in extremisInfant in extremis

resuscitate and operateresuscitate and operate

Malrotation

Malrotation

Volvulus

Malrotation most common condition Malrotation most common condition resulting in midgut volvulusresulting in midgut volvulus

Can have volvulus with normal rotationCan have volvulus with normal rotation omphalomesenteric remnantomphalomesenteric remnant internal herniainternal hernia DuplicationDuplication Adhesive small bowel obstructionAdhesive small bowel obstruction

Midgut Volvulus

Small Bowel Obstruction

Meckel’s

Duplication/Volvulus

Duplication

Intussusception

Inversion of the bowel upon itself Inversion of the bowel upon itself secondary to a lead pointsecondary to a lead point

Juvenile intussusception most often Juvenile intussusception most often idiopathicidiopathic Also secondary to Meckel’sAlso secondary to Meckel’s

Presents 6 months to 2 years of agePresents 6 months to 2 years of age As early as 1 monthAs early as 1 month

Intussusception

Acute painful episodes followed by periods Acute painful episodes followed by periods of lethargyof lethargy

When incarcerated progress to continuous When incarcerated progress to continuous lethargylethargy

May or may not have “currant-jelly” stoolMay or may not have “currant-jelly” stool But often stool is heme positiveBut often stool is heme positive

Rule out with a left lateral decubitus filmRule out with a left lateral decubitus film

Left-lateral Decubitus Film

Intussusception

Intussusception

Intussusception

Intussusception

Bad Intussusception

Intussusception

7% chance of recurrence after ACE 7% chance of recurrence after ACE reductionreduction Usually recur in 48 hoursUsually recur in 48 hours

Operative exploration warranted on second Operative exploration warranted on second recurrence to R/O pathologic lead pointrecurrence to R/O pathologic lead point

Recurrence after surgery rare but possibleRecurrence after surgery rare but possible Post-op intussusception can occur after any Post-op intussusception can occur after any

surgerysurgery

Incarcerated Hernia

Inguinal/Scrotal Anatomy

From Surgery of Infants and Children, Oldham, et. al., 1997

Inguinal Hernia

From Atlas of Pediatric Surgery, Ashcraft, 1994

Incarcerated Inguinal Hernia

Hernia Reduction

From Surgery of Infants and Children, Oldham, et. al., 1997

Incarcerated Hernia

Most can be reduced in clinic or EDMost can be reduced in clinic or ED Bowel usually OK if able to reduceBowel usually OK if able to reduce Surgical consultation if reduction difficultSurgical consultation if reduction difficult Repair with 1-2 days of incarcerationRepair with 1-2 days of incarceration Beware the “inguinal node’ in femalesBeware the “inguinal node’ in females

incarcerated ovaryincarcerated ovary

Incarcerated Hernia

If unable to reduce: urgent operative If unable to reduce: urgent operative exploration (NPO)exploration (NPO)

If able to reduce without sedation: urgent If able to reduce without sedation: urgent surgical referral with repair soonsurgical referral with repair soon

If extremely difficult (sedation, surgical If extremely difficult (sedation, surgical referral): repair next dayreferral): repair next day

Watch child for obstructive symptomsWatch child for obstructive symptoms

Perforated Appendix

Children still die from complications of Children still die from complications of perforated appendicitisperforated appendicitis

Resuscitation is criticalResuscitation is critical Response to surgery variableResponse to surgery variable Often require multiple procedures, Often require multiple procedures,

hyperalimentation, prolonged antibiotic hyperalimentation, prolonged antibiotic therapytherapy

Diagnosis difficultDiagnosis difficult

AAP Guidelines for Pediatric Surgical Referral Patients 5 years or younger who may need surgical Patients 5 years or younger who may need surgical

carecare Infants and children with perforated appendicitisInfants and children with perforated appendicitis Seriously injured infants and children Seriously injured infants and children Infants, children, and adolescents with solid Infants, children, and adolescents with solid

malignancies malignancies Minimally invasive procedures Minimally invasive procedures Infants and children with medical conditions that Infants and children with medical conditions that

increase operative risk increase operative risk

MorbidityIncidence of Perforation

< 1 year old 90-100%

1-2 years old 70-80%

2-5 years old 50%

> 65 years old 50%

Perforated Appendix

Suspect in children 3-5 years old with Suspect in children 3-5 years old with history suggestive of appendicitishistory suggestive of appendicitis

““Bowel obstruction” in a 3-5 year old Bowel obstruction” in a 3-5 year old without obvious etiology is perforated without obvious etiology is perforated appendix until proven otherwiseappendix until proven otherwise

Fever > 101.5, WBC > 20 with bands, Fever > 101.5, WBC > 20 with bands, diffuse abdominal pain, guarding, SBO on diffuse abdominal pain, guarding, SBO on AASAAS

Perforated Appendix

Perforated Appendix

Resuscitation

NG tube, NPONG tube, NPO 20 cc/kg boluses until UOP > 1 cc/kg/hr 20 cc/kg boluses until UOP > 1 cc/kg/hr

and VS stableand VS stable 1.5-2 times maintenance fluids1.5-2 times maintenance fluids Broad Spectrum AntibioticsBroad Spectrum Antibiotics

Perforated Appendix

Summary

AtresiasAtresias Hirschsprung’sHirschsprung’s MalrotationMalrotation VolvulusVolvulus IntussusceptionIntussusception Incarcerated HerniaIncarcerated Hernia Perforated AppendixPerforated Appendix

Question 2?Why are Pediatric Surgeons so interested in flatus?

Contrary to popular belief,

kids with obstruction can still have bowel movements, but they won’t pass

gas!