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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.