NEONATAL NEONATAL ABDOMINAL ABDOMINAL

EMERGENCIESEMERGENCIESCarlos J. Sivit M.D.Carlos J. Sivit M.D.

Low intestinal obstructionLow intestinal obstructionHigh intestinal obstructionHigh intestinal obstruction

INTESTINAL INTESTINAL OBSTRUCTIONOBSTRUCTION

High obstruction High obstruction -- proximal to midproximal to mid--ileumileumFew dilated, air filled bowel loopsFew dilated, air filled bowel loopsComplete obstruction diagnosed by KUBComplete obstruction diagnosed by KUBPartial obstruction diagnosed by UGIPartial obstruction diagnosed by UGI

Low obstruction Low obstruction -- distal ileum & colondistal ileum & colonMany dilated airMany dilated air--filled bowel loopsfilled bowel loopsContrast enema study of choiceContrast enema study of choice

LOW INTESTINAL LOW INTESTINAL OBSTRUCTIONOBSTRUCTION

LOW OBSTRUCTIONLOW OBSTRUCTION

Typically present with failure to pass Typically present with failure to pass meconiummeconium or constipationor constipation90% of normal neonates pass 90% of normal neonates pass meconiummeconium in 1in 1stst 24 hours; 99% in 124 hours; 99% in 1stst 48 hours48 hours

LOW OBSTRUCTIONLOW OBSTRUCTION

Hirschprung’sHirschprung’s diseasediseaseFunctional immaturityFunctional immaturity

MeconiumMeconium plug, small left colon plug, small left colon MeconiumMeconium ileusileusIlealIleal atresiaatresiaColonic Colonic atresiaatresia

CONTRAST ENEMACONTRAST ENEMA

Water soluble contrastWater soluble contrastDilute Dilute gastrograffingastrograffin

Patient immobilizationPatient immobilizationOctagon boardOctagon board

Foley catheterFoley catheter8 8 frenchfrenchDo not inflate balloonDo not inflate balloon

HIRSCHPRUNG’S HIRSCHPRUNG’S DISEASEDISEASE

Arrest in migration of ganglion cellsArrest in migration of ganglion cellsExtends proximally from anus Extends proximally from anus Without skip areasWithout skip areasRare form is total colonic Rare form is total colonic aganglionosisaganglionosisTransition zone most specific findingTransition zone most specific findingMost common site is Most common site is rectosigmoidrectosigmoid (2/3)(2/3)

MECONIUM PLUG MECONIUM PLUG SYNDROMESYNDROME

Failure to pass Failure to pass meconiummeconium in 1st 24 hrsin 1st 24 hrsCharacterized by multiple Characterized by multiple meconiummeconium plugsplugsUsually improves following enemaUsually improves following enema

ClatworthyClatworthy. Surgery 1956;39:131. Surgery 1956;39:131--4141

SMALL LEFT COLON SMALL LEFT COLON SYNDROMESYNDROME

Caliber change near Caliber change near splenicsplenic flexureflexureAssociated w/ maternal diabetesAssociated w/ maternal diabetesDdxDdx -- Hirschprung’sHirschprung’s diseasedisease

Davis. AJR 1974;1974;120:322Davis. AJR 1974;1974;120:322--99

MECONIUM ILEUSMECONIUM ILEUS

InspissatedInspissated meconiummeconium in distal ileum in distal ileum Almost always associated w/ CFAlmost always associated w/ CFPresenting feature in 5Presenting feature in 5--10% w/ CF10% w/ CFComplications include Complications include volvulusvolvulus, , perforation, peritonitis & perforation, peritonitis & microcolonmicrocolon

MECONIUM ILEUSMECONIUM ILEUS

Bubbly appearance in Bubbly appearance in rlqrlqPaucity of air fluid levelsPaucity of air fluid levelsReflux into Reflux into nondilatednondilated distal ileum distal ileum Dilated small bowelDilated small bowel

MECONIUM MECONIUM PERITONITISPERITONITIS

Results from intrauterine perforation Results from intrauterine perforation Primarily from Primarily from meconiummeconium ileusileusCalcification of peritoneal Calcification of peritoneal meconiummeconiumSite of perforation usually not foundSite of perforation usually not found

ILEAL ATRESIAILEAL ATRESIA

Secondary to vascular insultSecondary to vascular insultAtresiasAtresias may be multiplemay be multiple+/+/-- MicrocolonMicrocolon

COLONIC ATRESIACOLONIC ATRESIA

Secondary to vascular insultSecondary to vascular insultType I Type I –– Complete obstruction by Complete obstruction by diaphragmdiaphragmType II Type II –– Obstruction by Obstruction by atreticatretic cordcordType III Type III –– Complete separation of Complete separation of proximal & distal colonproximal & distal colon

CONTRAST ENEMA DDXCONTRAST ENEMA DDX

MicrocolonMicrocolonMeconiumMeconium ileusileusIlealIleal atresiaatresiaTotal colonic Total colonic aganglionosisaganglionosisColonic Colonic atresiaatresia

CONTRAST ENEMA DDXCONTRAST ENEMA DDX

Transition zoneTransition zoneHirschprung’sHirschprung’sSmall left colon Small left colon syndromesyndrome

CONTRAST ENEMA DDXCONTRAST ENEMA DDX

NormalNormalHirschprung’sHirschprung’sIlealIleal atresiaatresia

HIGH INTESTINAL HIGH INTESTINAL OBSTRUCTIONOBSTRUCTION

HIGH OBSTRUCTIONHIGH OBSTRUCTION

MidgutMidgut malrotationmalrotationDuodenal Duodenal atresiaatresia/stenosis/web/stenosis/webJejunalJejunal atresiaatresia/stenosis/stenosis

MIDGUT MALROTATIONMIDGUT MALROTATION

Most important UGI obstruction in newbornMost important UGI obstruction in newbornArrest in normal rotation of Arrest in normal rotation of midgutmidgutResults in abnormal mesenteric fixationResults in abnormal mesenteric fixationObstruction 2Obstruction 2oo twisting around SMA twisting around SMA ((volvulusvolvulus)) oror abnlabnl peritoneal attachments peritoneal attachments ((LaddsLadds bandsbands))

ASSOCIATED CONDITIONSASSOCIATED CONDITIONSAlways presentAlways present

OmphaloceleOmphaloceleGastroschisisGastroschisisCongenital diaphragmatic herniaCongenital diaphragmatic hernia

Increased incidenceIncreased incidenceDuodenal/Duodenal/jejunaljejunal atresiaatresia/stenosis/stenosisHirschprungHirschprung diseasediseaseHeterotaxyHeterotaxy syndromesyndrome

MIDGUT MALROTATIONMIDGUT MALROTATION

RADIOGRAPHIC FINDINGSRADIOGRAPHIC FINDINGSNormalNormalPartial / complete obstructionPartial / complete obstructionProximal / mid small bowelProximal / mid small bowel

MIDGUT MALROTATIONMIDGUT MALROTATION

UGI FINDINGSUGI FINDINGSAbnormal duodenalAbnormal duodenal--jejunaljejunal junctionjunction

Normal = left of left vertebral pedicle Normal = left of left vertebral pedicle at level of bulbat level of bulb

Duodenal obstructionDuodenal obstructionCorkscrew appearance of small bowelCorkscrew appearance of small bowel

PitfallsPitfalls

False positive diagnosisFalse positive diagnosisLow DJJ due to bowel dilatationLow DJJ due to bowel dilatationDuodenal redundancyDuodenal redundancy

False negative diagnosisFalse negative diagnosisAbnormal DJJ Abnormal DJJ rarelyrarely to left of to left of spine and at level of bulbspine and at level of bulb

Ladd’s bands•Condensations of mesentery•Cross & compress duodenum

Midgut volvulus • Spiraling of bowelaround SMA

• Beaked deformitydistal bowel

MIDGUT MALROTATIONMIDGUT MALROTATION

US/CTUS/CT FINDINGSFINDINGSReversal of mesenteric vesselsReversal of mesenteric vessels

SMV to left of SMASMV to left of SMA“Whirlpool” appearance of vessels“Whirlpool” appearance of vesselsNot accurate enough for 1Not accurate enough for 1oo dxdx

DUODENAL OBSTRUCTIONDUODENAL OBSTRUCTION

Most common cause of high obstruction Most common cause of high obstruction AtresiaAtresia > stenosis > web> stenosis > web3/4 distal to papilla & associated with 3/4 distal to papilla & associated with bilious vomitingbilious vomiting1/3 associated w/ Down’s syndrome1/3 associated w/ Down’s syndromeMay be part of VACTERL associationMay be part of VACTERL association

JEJUNAL ATRESIAJEJUNAL ATRESIA

Due to vascular insultDue to vascular insultAtresiaAtresia > Stenosis> StenosisAtresiasAtresias may be multiplemay be multipleNormal caliber colonNormal caliber colon

NEONATAL ABDOMINAL NEONATAL ABDOMINAL EMERGENCIESEMERGENCIES

Low intestinal obstructionLow intestinal obstructionHigh intestinal obstructionHigh intestinal obstruction