Pediatric Surgery—Neonatal Bowel Obstruction
Concept
Bilious vomiting is always a surgical emergency in the newborn. Multiple possible etiologies:
Annular pancreas Duodenal web Malrotation Jejunoileal atresia Meconium ileus Hirschprung’s Infection/NEC Cl⫺
Metabolic abnormalities (K+, Mg++)
Always look for associated anomalies such as cystic fibrosis (meconium ileus) and Trisomy 21 (duodenal atre- sia, malrotation).
Way Question May be Asked?
“Called to NICU to evaluate a baby that has had bilious vomiting since birth. What do you want to do?” Always look for congenital anomalies, Down’s stigmata, and remember that this is a surgical emergency.
How to Answer?
History
Maternal polyhydramnios
Onset of bilious emesis (w/every feeding) Delayed meconium passage
Prematurity Family history
Physical Exam
Evidence dehydration (sunken fontanelle, skin turgor) Abdominal distension or scaphoid abdomen
Any congenital anomalies (perforate anus?)
Diagnostic Tests
“Babygram”—look for pattern of the gas
“double bubble”—duodenal atresia or malrotation with volvulus
dilated SB loops—jejunoileal atresia
UGI if suspect proximal obstruction or malrotation BE if suspect distal obstruction
Surgical Treatment
(1) NPO/IVF/NGT/Correct electrolytes
(2) determine if obstruction is proximal or distal (3) OR for any evidence peritonitis
(4) Duodenal Atresia→OR once resuscitated
(a) duodenojejunostomy through transverse RUQ incision
(b) obstruction usually immediately post- ampullary
(c) G-tube
(5) Malrotation (often associated with diaphragmatic hernia, abdominal wall defects, and jejunoileal atresia)
(a) counterclockwise detorsion if volvulus present
(b) second look for questionable viability (c) Ladd’s procedure
dividing peritoneal bands crossing duodenum (extend from ligament of Trietz)
positioning duodenum and jejunum to right of midline
positioning colon to left of midline incidental appendectomy
(d) treat other anomalies if present (e) cecopexy/duodenopexy not necessary (6) Jejunoileal atresia
(the more distal the obstruction, the more abdomi- nal distension child will have)
(a) BE to document normal colon (b) resect atretic portion
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(c) inject saline to make sure no distal obstruction (web/atresia)
(d) end to end anastomosis (7) Duodenal web
(a) longitudinal duodenotomy (b) partial membrane excision
(8) Meconium ileus—failure to pass meconium < 24 h with bilious emesis, abdominal distension, perforate anus
(produces obstruction from inspissated meconium secondary to pancreatic exocrine insufficiency) (a) evaluate for Cystic Fibrosis
(b) ground glass appearance on AXR instead of A/F levels
(c) gastrografin enema, pancreatic enzymes by NGT, and mucomyst for uncomplicated presentation
(d) complicated meconium ileus→OR resect nonviable bowel
repair perforations drain any abscesses
enterotomy + injection mucomyst
Common Curveballs
Double bubble on x-ray will be malrotation and not duodenal obstruction
Scenario will change from proximal to distal obstruc- tion
Pt will have multiple atretic areas in jejunum/ileum Pt will have appearance of total small bowel infarction Pt will have associated anomalies (only cardiac affects
your decision to operate)
Strikeouts
Not identifying malrotation
Not knowing Ladd’s bands or details of Ladd’s procedure Not knowing what “double bubble” means on “baby-
gram”
Not looking for associated anomalies
Not treating bilious vomiting as surgical emergency
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