NEONATAL INTESTINAL OBSTRUCTION

Noha Al-khawajaMaram Al-zein

Amani Azeez AlrahmanSUPERVISOR:Dr.Aayed Al-Qahtani

Neonatal intestinal obstructionNeonatal intestinal obstruction

• Can be grouped into high & low intestinal obstructions:

High obstructions:• Pyloric obstruction • Duodenal obstruction: complete - partial• Very proximal Jejunal obstruction

Low obstructions:• Small bowel obstruction• Meconium ileus & meconium plug• Colonic atresia• Hirshsprung’s disease• Anorectal malformation• small colon syndrome

Pyloric stenosisPyloric stenosis• Extremely rare in the neonates• 3rd – 8th week• Usually 1st born male child• History: Present with non bilious projectile vomiting that

becomes progressively worse, weight loss & dehydration• Examination: Peristaltic waves may be seen, palpable

hard mass in the epigastrium• Investigations: CBC, urea & electrolytes ,US{ thickness ,

diameter ,& length of pylorus}. If equivocal do barium swallow

• Treatment: NG tube, NPO, correct dehydration. pyloromyotomy.

CONGENITAL DUODENALCONGENITAL DUODENAL OBSTRUCTIONOBSTRUCTION::

Types:• Duodenal atresia• Duodenal stenosis• Duodenal web• Annular pancreas• MalrotationIncidence:• 1 in 10000 to 40000 birthsPathology:Failure of canalization,vascular accidents,&

arrest of normal pancreatic development.

Duodenal atresia:

• 1 in 5000 live births• May be associated with Down’s

syndrome( 30%) & congenital heart disease.• Due to failure of recanalization after the 6th

week of gestation.History & examination:• History of maternal polyhydramnious.• Bilious vomiting.• Pass meconium.• On examination: - visible gastric peristaltic waves. -stomach may be palpable. -diffuse abdominal distention is not

characteristic.

Investigations:

• Antenatal diagnosis with US

• CBC. • Urea and electrolytes • Abdominal x-ray

shows double bubble sign

• Echocardiography • Some recommend a

routine karyotype in neonates born with duodenal obstruction

MANAGEMENT• NPO• Nasogastric tube.• IV fluids, antibiotics (Ampicillin – Gentamicin) • Goals are: ~restoration of continuity without

sacrificing intestinal length or absorpative area

~avoidance of injury to the pancreas or ampulla of vater

• Best approach is duodenoduodenostomy duodenojejunostomy reserved for obstructing lesions in the distal duodenum

ResultsResults::

• Neonates require a period of several weeks before entral feeding is tolerated

• Surgical outcome is excellent • Mortality is confined to neonates with

Down’s syndrome and congenital heart disease

• Duodenal stenosis • Duodenal web • Annular pancreas : ~ characterised by

circumferential persistence of the gland around the duodenum at the site of the embryonic ventral pancreatic diverticulum

~associated with intrinsic duodenal obstruction and a patent accessory pancreatic duct

Symptoms & Signs

• Same presentation • However, many produce few

symptoms • Diagnostic delay later in life is

relatively frequent

• Abdominal radiograph shows double bubble sign with some gas distally.

Management

• Same preoperative preparation

• Excision of duodenal web

• Duodenoduodenostomy

Small intestinal atresia

• Occurs secondary to in utero ischemic insult

• Overall distribution is roughly equal between jejunum & ileum

• 90% of infants with congenital jejunoileal obstructions have atresia

• More than one atresia is reported in 6% to 20% of these infants

• Low incidence of significant associated anomalies < 10%

Types of Atresia

• Type I a single membranous atresia, with continuity of the bowel wall and intact mesentry

• Type II single atresia with discontinuity of the bowel wall

• Type IIIa atresia without connection by a fibrous cord , with a mesenteric gap

• Type IIIb apple-peel mesentery or christmas_tree atresia of a large segment of bowel and mesentery the proximal part is dilated the distal segment is collapsed & spiraled about distal branches of ileocolic artery

• Type IV multiple atresias intussusception ,segmental volvolus ,or

thromboembolism could be the causes

History and Examination

• Maternal history of polyhydramnious ( 25% of ileal )

• Bilious vomiting ,abdominal distention.• Failure to Pass meconium. • Signs of dehydration .• Palpable individual loops of proximal

intestine.

Investigations

• CBC, Urea and electrolytes. • Plain x-ray: ~marked distention of proximal intestinal

loops with gasless distal small bowel & colon

~in ileal atresia multiple dilated loops of bowel ,with multiple air fluid levels

• Contrast enema: because haustral markings are not normally apparent in neonatal colon it cannot be differentiated from small bowel.

Management

• NPO, IV fluids ,NG Tube, antibiotics• Via a supraumblical incision simple

end to end anastomosis & short segmental bowel resection

• Multiple atresias may require multiple anastomoses .

ResultsResults::

• Incidence of anastomotic problems as leak is nearly 5% to 10%.

• Prolonged dysfunction of the proximal gut for days or weeks is common.

• Morbidity & mortality are generally limited to those with heart disease,prematurity,or other associated problems.