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NEONATAL INTESTINAL OBSTRUCTIONNoha Al-khawajaMaram Al-zeinAmani Azeez AlrahmanSUPERVISOR:Dr.Aayed Al-Qahtani

Neonatal intestinal obstructionCan be grouped into high & low intestinal obstructions:High obstructions:Pyloric obstruction Duodenal obstruction: complete - partialVery proximal Jejunal obstruction Low obstructions: Small bowel obstructionMeconium ileus & meconium plugColonic atresiaHirshsprungs diseaseAnorectal malformationsmall colon syndrome:

Pyloric stenosisExtremely rare in the neonates3rd 8th weekUsually 1st born male childHistory: Present with non bilious projectile vomiting that becomes progressively worse, weight loss & dehydrationExamination: Peristaltic waves may be seen, palpable hard mass in the epigastriumInvestigations: CBC, urea & electrolytes ,US{ thickness , diameter ,& length of pylorus}. If equivocal do barium swallowTreatment: NG tube, NPO, correct dehydration. pyloromyotomy.

CONGENITAL DUODENAL OBSTRUCTION:Types:Duodenal atresiaDuodenal stenosisDuodenal webAnnular pancreasMalrotationIncidence:1 in 10000 to 40000 birthsPathology:Failure of canalization,vascular accidents,& arrest of normal pancreatic development.

Duodenal atresia:1 in 5000 live birthsMay be associated with Downs 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 USCBC. Urea and electrolytes Abdominal x-ray shows double bubble sign Echocardiography Some recommend a routine karyotype in neonates born with duodenal obstruction

MANAGEMENTNPONasogastric 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 vaterBest approach is duodenoduodenostomy duodenojejunostomy reserved for obstructing lesions in the distal duodenum

Results:Neonates require a period of several weeks before entral feeding is tolerated Surgical outcome is excellent Mortality is confined to neonates with Downs 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.

ManagementSame preoperative preparation Excision of duodenal web Duodenoduodenostomy

Small intestinal atresiaOccurs 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 gapType 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 ExaminationMaternal history of polyhydramnious ( 25% of ileal )Bilious vomiting ,abdominal distention.Failure to Pass meconium. Signs of dehydration .Palpable individual loops of proximal intestine.

InvestigationsCBC, 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, antibioticsVia a supraumblical incision simple end to end anastomosis & short segmental bowel resectionMultiple atresias may require multiple anastomoses .

Results: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.