Pediatric Intestinal Obstruction
Necrotizing Enterocolitis: Clinical presentation
*Abd distention* *Bilious vomiting* *Emesis or... * *Hematochezia/Melana* *Plus other Non-specific findings:* - Apnea/Dyspnia - Bradycardia and/or Hypotension - Feeding intolerance - Lethargy - Temp instability
Meconium Ileus: Complications
*Intussusception* Intestinal *perforation* Intestinal *atresia* Meconium *peritonitis* *Necrosis* Rectal *prolapse* Segmental *volvulus*
Malrotation: Treatment
*Ladd procedure* - Surgical approach Malrotation with volvulus is *MEDICAL EMERGENCY*
Necrotizing Enterocolitis: Ddx (Hint: *MMAIN*)
*M*alrotation *A*tresia - Duodenal - Intestinal *I*ntussiception *N*ecrotizing enterocolitis Also... Appendicitis Hirschsprung disease/Hernia (Incarcerated inguinal) Meconium plug syndrome Neonatal small left colon syndrome Volvulus
*Duodenal* Atresia: Tx
*Pre-op*: Gastric decompression, fluids *Surgical*: Duodenodenostomy (re-establish patent GI tract) *Post-op*: nasogastric tube decompression (until bowel function returns)
*Duodenal* Atresia: Chief Complaint
1. *Bilious vomiting* within *hours* of birth 2. Feeding intolerance 3. Abd is *NON*-distended (*Scaphoid* abd)
Necrotizing Enterocolitis: Complications
1. *Death* 2. Intestinal *perf*oration 3. Short bowel syndrome (*SBS*) 4. *Sepsis* 5. Intra-abd *abscess* 6. Intestinal *obstruction*
Necrotizing Enterocolitis
1. *GI emergency* of acute intestinal necrosis in neonates 2. Classic necrotizing enterocolitis (NEC) usually occurs in *premature infants* born *</= 35wks* gestation
Necrotizing Enterocolitis: Who is most affected
1. *Premature* infants of very *low birth weight* 2. More common in *males* 3. *MC* cause of GI-related *NICU morbidity and mortality*
Malrotation: Diagnosis
1. *Upper GI* imaging - Necessary to *confirm* malrotation 2. *X-ray* - Rule out *other* obstruction 3. U/S - Used as *screening*, but findings may not be definite
Meconium Ileus: Presentation
1. Abd *distention* at birth 2. *Bilious vomiting* 3. *Failure to pass meconium* rectally 4. Maternal Hx of... - Polyhydramnios - Hyperechoic masses - Dilated bowel - Non visualization of the gallbladder
Necrotizing Enterocolitis: Work-up
1. Abd x-ray to confirm - *Hallmark* findings... - *Pneumatosis* intestinal and *portal venous* gas 2. Blood and urine cultures prior to abx 3. CBC 4. CMP (looking at glucose and lytes) 5. OFB test
*Intestinal* Atresia: Complications
1. Adhesive *obstruction* 2. *Blind-loop syndrome* 3. Prolonged *ileus* 4. Problems with *anastomosis* 1. *Short bowel syndrome*/Vitamin deficiencies 2. Stomal *prolapse*
Malrotation: Complications (Hint: 5 specific)
1. Adhesive *obstruction* (Small Bowel) 2. Incisional *hernia* 3. *Perforated* viscus 4. Short bowel syndrome (*SBS*) 5. *Volvulus*
Necrotizing Enterocolitis: Risk Factors
1. Five-minute *APGAR* score *< 7* 2. Early-onset *neonatal sepsis* 3. Mechanical *Ventilation* 4. Perinatal *asphyxia* 5. *Transfusions*
Meconium Ileus: Tx
1. Gastric *decompression* 2. *Correction* of coagulation disorders 3. *Abx* 4. Surgical *resection* 5. Other - Resuscitative measures - IV hydration
Necrotizing Enterocolitis: Tx
1. Gastric *decompression* with ng tube 2. D/C enteral feeds + *IV fluids* 3. Broad spectrum IV *abx* after cultures
*Intestinal* Atresia: Tx
1. Initial - supportive care immediately after birth: GI decompression, NG tube, IV fluids 2. *Surgery*: re-establish intestinal continuity (emergent with colonic atresia)
Malrotation: Epidemiology
1. More frequently presents in *newborn infants*, but may present at any age 2. *Males* affected slightly more than females
Malrotation: Clinical presentation (Hint: *Diff in Newborns vs. Older*)
1. Newborn Infants - *>80%* of cases - *bilious vomiting* (*first month* of life but often the *first week*) 2. Older infants/children (More general findings) - N (non-bilious)/V/D and Constipation - *Intermittent* acute crampy abd *pain and distension* - Irritability - *Hematochezia* - *GER*
Necrotizing Enterocolitis: Diagnosis?
1. One or more *clinical findings* of... - Abd distention - Bilious vomiting - Emesis or... - Hematochezia/Melana *PLUS* 2. One or more *x-ray* finding of... - Hepatobiliary gas - Pneumatosis intestinal - Pneumoperitoneum
What is pneumatosis intestinalis?
A cardinal finding indicative of Necrotizing Enterocolitis A pneumatosis (a.k.a. a cyst made up of gas) of the Intestine. This is when you have *gas* build up *in the wall* of the intestine as opposed to the lumen.
What is an APGAR score? (Hint: *APGAR*)
A numerical expression of a newborns physical condition. *A*ppearance (Color) *P*ulse (Heart Rate) *G*rimace (Reflex irritability) *A*ctivity (Muscle tone) *R*espirations Numerical values are scaled anywhere between 0-2
*Intestinal* Atresia: *Post*-natal Diagnosis
Abd *x-ray* shows... 1. *dilated loops* of bowel 2. *air-fluid* levels 3. paucity of *gas distally* to obstruction *Contrast enema* - may be necessary for diagnosis
What is Pneumoperitoneum?
Abnormal presence of air or other gas in the peritoneal cavity
What is Situs inversus?
An uncommon condition in which the heart and other organs of the body are transposed through the sagittal plane to lie on the opposite (left or right) side from the usual.
Meconium Ileus
Complete intestinal obstruction in neonates caused by thickened or *congealed meconium* in the bowel lumen *Often the earliest clinical manifestation of CF*
Meconium Ileus: Diagnosis
Confirmed at birth with abd x-ray or contrast enema
Malrotation: Risk factors
Congenital defects 1. Cardiovascular defects 2. Congenital diaphragmatic hernia 3. Gastroschisis 4. Hirschsprung disease 5. Intestinal atresia 6. Omphalocele 7. Situs inversus
*Duodenal* Atresia
Congenital duodenal obstruction (neonatal)
Necrotizing Enterocolitis: Causes
Idiopathic
*Intestinal* Atresia: Causes
In utero *vascular accident* - Probably during *rotation* and *reentry* of bowel into abd
What is Ileus?
Inability of intestine (bowel) to contract normally and move waste out of the body (a.k.a. a painful intestinal obstruction)
Necrotizing Enterocolitis: When is surgery indicated
Indicated in *20-40%* of neonates with NEC 1. Bowel *perforation* is absolute indication 2. Clinical *deterioration* 3. Presence of *portal vein gas* 4. Palpation of tender *abd mass* 5. Erythema and/or *abd wall edema* 6. *Persistent* fixed bowel loops on abd x-ray
What is gastroschisis?
Intestines stick outside of the baby's body, through a hole beside the belly button.
Malrotation: Ddx (Hint: *MMAIN*)
MC causes for Pediatric bowel obstruction (*M*M*AIN*) *M*econium ileus *A*tresia - Duodenal - Intestinal *I*ntussusception *N*ecrotizing entrocolitis Also... Appendicitis Hirschsprung disease/Hernia (Incarcerated inguinal) Meconium plug syndrome Neonatal small left colon syndrome Volvulus
*Intestinal* Atresia: Ddx in pediatrics (Hint: *MMAIN*)
MC causes for Pediatric bowel obstruction (*MMAIN*) *M*alrotation *M*econium ileus *A*tresia - Duodenal *I*tussiception *N*ecrotizing Enterocolitis Also... Appendicitis Hirschsprung disease/Hernia (Incarcerated inguinal) Meconium plug syndrome Neonatal small left colon syndrome Volvulus
Meconium Ileus: Ddx (Hint: *MMAIN*)
MC causes for Pediatric bowel obstruction - (*M*M*AIN*) *M*alrotation *A*tresia - Duodenal - Intestinal *I*ntussiception *N*ecrotizing enterocolitis Also... Appendicitis Hirschsprung disease/Hernia (Incarcerated inguinal) Meconium plug syndrome Neonatal small left colon syndrome Volvulus
*Duodenal* Atresia: Most affected?
Newborns Infants with Down Syndrome (trisomy 21)
Meconium Ileus: Epidemiology
Occurs in up to 20% of patients with CF
What is an omphalocele?
Outpouching of GI organs in a sac structure secondary to defect in abdominal wall muscles
*Duodenal* Atresia: Ddx (Hint: *MMAIN*)
Pediatric Bowel Obstruction DDx (*MMAIN*) *M*econium ileus *M*alrotation *A*tresia - Intestinal *I*ntussiception *N*ecrotizing enterocolitis also... Appendicitis Hirschsprung disease/Hernia (Incarcerated inguinal) Meconium plug syndrome Neonatal small left colon syndrome Volvulus
*Duodenal* Atresia: *Post*-natal Diagnosis
Postnatal diagnosis: Clinical signs - Plain x-rays show "*double-bubble*" sign - Upper GI or barium enema to rule out malrotation
*Duodenal* Atresia: *Pre*-natal Diagnosis
Prenatal diagnosis: - *Amniocentesis* (bile stained amniotic fluid), - U/S - "*double-bubble*"
*Intestinal* Atresia: *Pre*-natal Diagnosis
U/S - *obstruction* and *polyhydramnios*
*Intestinal* Atresia: Clinical presentation (Hint: two types)
Varies according to anatomic location of obstruction *Proximal obstruction* presents: - *Early* bilious vomiting - Early *scaphoid* abd with *progressive distension* *Distal obstruction*: - *Late* bilious vomiting (*>24hrs*) - Early abd *distension* - Failure to pass meconium (Think *D*istal/Far = *D*istended/Late and *P*roximal/Close = sca*P*hoid/Early)
Intestinal Atresia: Testing
x-ray Test for CF