NEONATAL BOWEL. Humberto Lugo-Vicente MD FACS FAAP Professor Pediatric Surgery UPR School of Medicine

Transcription

1 NEONATAL BOWEL OBSTRUCTION Humberto Lugo-Vicente MD FACS FAAP Professor Pediatric Surgery UPR School of Medicine

2 NEONATE FAILURE TO PASS MECONIUM BILIOUS VOMITING ABDOMINAL DISTENSION SIMPLE ABDOMINAL FILMS PYLORIC, DUODENAL or JEJUNAL atresia/stenosis NEC dilated bowel loops CONTRAST ENEMA dilated bowel loops with calcifications, gasless abdomen with eggshell calcification microcolon NO microcolon MECONIUM PERITONITIS GIANT CYSTIC MECONIUM PERITONITIS Air-fluid levels NO air-fluid levels ground-glass appearance Transitional zone barium retention past 24 hours INTESTINAL ATRESIA HYPOPERISTALSIS SYNDROME MECONIUM ILEUS MECONIUM PLUG SYNDROME Rectal biopsy HIRSCHSPRUNG S LEFT HYPOPLASTIC COLON

3 Congenital bowel obstruction Triad Bilious vomiting Retained meconium Abdominal distension Pathologic types Intraluminal Extraluminal Functional Aids in early dx Mother history, miscarriage, siblings Polyhydramnious Investigation Plain X-ray (KUB or babygram) Contrast studies (enema or UGIS)

4 Gastro-pyloric anomalies Pyloric atresia Epidermolysis bullosa Management gastroduodenostomy Pyloric stenosis

5 Pyloric stenosis Concentric muscle hypertrophy Males:female 4:1 Post-prandialnon-bilious vomiting Metabolic hypochloremic alkalosis Dehydration Palpable pyloric muscle Diagnosis US UGIS Management hydration Pyloromyotomy Periumbilical approach

6 Duodenal lesions Bilious vomiting Types Atresia Stenosis Annular pancreas Ladd s bands Diagnosis KUB Colon contrast study Associated anomalies Cardiac Down s syndrome

7 Duodenal atresia KUB Double bubble Down syndrome 30% Management Duodenoduodenostomy

8 Case 1 5 days-old-male with intermittent bilious vomiting and no abdominal distension. Meconium passed at birth.

9 Duodenal stenosis KUB Double-bubble Scanty air distally Causes Pure stenosis Annular pancreas Ladd s bands Management Depends on cause

10 Case 2 10 days well-baby develops abdominal distension, bilious vomiting and metabolic acidosis

11 Malrotation and Volvulus Embryology Clockwise rotation midgut Obstruction 3 rd portion duodenum Ischemia midgut Symptoms Bilious vomiting Abdominal distension Metabolic acidosis Diagnosis KUB UGIS contrast enema Management Ladd s procedure Laparoscopic

12 Malrotation: Embryology

13 Volvulus: Dx Diagnosis UGIS Contrast enema

14 Volvulus: Tx Ladd s procedure Counter-clockwise derotation bowel Lysis Ladd s bands Incidental appendectomy

15 Case 3 2 days-old baby-girl with bilious vomiting, obstipation and no abdominal distension

16 Intestinal atresias Intrauterine vascular accident Types Diagnosis Bilious vomiting Abdominal distension KUB Dilated bowel loops Contrast enema Microcolon Management anastomosis

17 Meconium Diseases Meconium peritonitis Meconium ileus Meconium plug syndrome

18 Meconium Peritonitis Intrauterine bowel perforation Types Simple observe Complicated Resection/anastomosisor enterostomy KUB Calcifications Associated Cystic fibrosis

19 Case 4 2 days-old-female with bilious vomiting, abdominal distension, no passage of meconium. Colon contrast: microcolon with intraluminal meconium pellets

20 Meconium Ileus Intraluminal obstruction Cystic fibrosis Types Simple Complicated KUB Multiple dilated bowel loops water-soap appearance Management Medical Gastrograffin enema Pancreatic enzyme replacement Surgical Enterostomy evacuation

21 Meconium plug syndrome Grey impacted meconium Distal obstruction Remove manually R/O aganglionosis

22 Case 5 2 days-old full-term male with abdominal distension and no passage of meconium or

23 Hirschsprung s Disease Congenital absence ganglion cells Absent cranio-caudal migration neuroblast Symptoms Absent meconium 1 st 48 hrs of life Painless abdominal distension TAGA male Diagnosis First enema: barium enema Suction rectal biopsy Management Laparoscopic Pull-through Neonatal > 5 kg weight Colostomy Perforated HAEC Premature No compliance

24 Imperforate Anus Physical exam Males vs female defect Associated anomalies Cardiac Renal Management anoplasty Initial colostomy PSARP

25 Bowel Duplications Rare Distal ileum Cystic or tubular Management Resection anastomosis

26 NEC: Bells Classification Stage 1: Suspect Perinatal asphyxia, abd distension, blood in stools, gastric residue, ileus in KUB Stage 2: Definitive Cellulitis, edema, pneumatosis Thrombocytopenia, metabolic acidosis Portal vein air Stage 3: Advance Pneumoperitoneum Intractable metabolic acidosis

27 NEC: Initial Tx Volume replacement Respiratory support Correct electrolytes/abg Antibiotherapy Stop feedings Monitor CBC, SMA-6 KUB (cross-table)

28 NEC: Surgical principles Drain, patch & wait Resect gangrenous bowel Avoid massive resections Exteriorize bowel