GASTROINTESTINAL OBSTRUCTION MARIA NAVAL C. RIVAS, M.D. DEPARTMENT OF PEDIATRICS THE MEDICAL CITY

Anatomy Stomach Small intestines Duodenum Jejenum Ileum Esophagus Stomach Small intestines Duodenum Jejenum Ileum Large Intestines Cecum Ascending, Transverse and Descending colon Sigmoid colon Rectum

Definition Blockage of the esophagus, stomach, small or large intestines Prevents food and fluids from passing through

Pathophysiology accumulation of food, gas and gastric/intestinal secretions gastric / bowel distention decreased intestinal absorption and increased secretion of fluid and electrolytes fluid and electrolyte imbalance

Symptoms / Signs abdominal pain abdominal distention nausea vomiting : bilious vs. non-bilious symptoms of malabsorption

MECHANICAL OBSTRUCTION Esophageal Atresia most common congenital anomaly 1: 4,000 neonates 90% assoc with tracheoesophageal fistula 50% assoc with VATER/VACTERL s/sx : frothing/bubbling of mouth and nose coughing respiratory distress

MECHANICAL OBSTRUCTION Diagnosis : inability to pass nasogastric or orogastric tube early signs of respiratory distress absence of gas in the stomach Treatment: managing airway preventing aspiration surgical intervention

MECHANICAL OBSTRUCTION Gastric Obstruction Hypertrophic Pyloric Stenosis Congenital Gastric Outlet Obstruction Gastric Duplication Gastric Volvulus

MECHANICAL OBSTRUCTION Intestinal Obstruction Duodenal Obstruction Jejunal and Ileal Atresia Obstruction Malrotation Intestinal Duplication Meckel’s Diverticulum Adhesions Intussusception

HYPERTROPHIC PYLORIC STENOSIS Incidence : 3 / 1000 infants whites > blacks > Asians male 4x > females associated with other congenital defects e.g. tracheo-esophageal fistula etiology : unknown

HYPERTROPHIC PYLORIC STENOSIS abdominal pain abdominal distention nausea vomiting bilious non-bilious others: jaundice sx of malabsorption occ peristaltic waves

HYPERTROPHIC PYLORIC STENOSIS Diagnosis palpable pyloric mass firm, movable, approx 2 cm length. olive-shaped located above and to the right of the umbilicus (midepigastrium) Ultrasonography Treatment Ramstedt pyloromyotomy Correction of fluid imbalance

MECHANICAL OBSTRUCTION Gastric Obstruction Hypertrophic Pyloric Stenosis Congenital Gastric Outlet Obstruction Gastric Duplication Gastric Volvulus

MECHANICAL OBSTRUCTION Intestinal Obstruction Duodenal Obstruction Jejunal and Ileal Atresia / Obstruction Malrotation Intestinal Duplication Adhesions Intussusception

DUODENAL OBSTRUCTION abdominal pain abdominal distention nausea vomiting bilious non-bilious others: jaundice sx of malabsorption

DUODENAL OBSTRUCTION Causes congenital duodenal atresia annular pancreas Ladd’s bands of malrotation

CONGENITAL DUODENAL ATRESIA Etiology : failure to recanalize the duodenal lumen after the solid phase of intestinal development during 4th to 5th week of gestation Incidence : 1 in 10,000 births 25-40% of all intestinal atresias 50% are premature

Other associated congenital anomalies Down’s syndrome 20-30% Malrotation 20% Esophageal atresia 10-20% congenital heart disease 10-15% anorectal and renal anomalies 5%

Diagnosis : “double – bubble sign” on plain abdominal radiographs : readily detected by fetal ultasonography : echocardiogram : radiography of chest and spine Treatment : nasogastric / orogastric decompression intravenous fluids surgery - duodenoduodenostomy

ANNULAR PANCREAS rare condition 2nd part of duodenum is surrounded by a ring of pancreatic tissue complete / incomplete obstruction Diagnosis: abdominal ultrasound & radiograph Treatment: duodenoduodenostomy

JEJUNAL AND ILEAL OBSTRUCTION abdominal pain abdominal distention nausea vomiting bilious non-bilious others: jaundice sx of malaborption

JEJUNAL AND ILEAL OBSTRUCTION Causes congenital jejuno-ileal atresias meconium ileus Hirschsprung disease

CONGENITAL JEJUNOILEAL ATRESIA attributed to intrauterine vascular accidents leading to ischemic necrosis of the bowel and resorption of the affected segments associated with prematurity, polyhydramnios, monozygotic twins, failure to pass meconium

CONGENITAL JEJUNOILEAL ATRESIA Diagnosis: prenatal sonograms air-fluid levels on plain radiographs contrast studies ultrasound Treatment: resection of dilated proximal portion of bowel followed by end to end anastomosis

CONGENITAL JEJUNOILEAL ATRESIA Types I – mucosal obstruction caused by an intraluminal membrane with intact bowel wall and mesentery II – small diameter solid cord connects the proximal and distal bowel IIIA – both ends of bowel end in blind loops IIIB – extensive mesenteric defect that causes distal ileum to coil around the ileocolic artery IV – multiple segments of bowel atresia

MECONIUM ILEUS last 20-30cm of ileum is collapsed and filled with pale-colored stool, above which is a dilated bowel of varying length obstructed by meconium with thick syrup consitency 80-90% has cystic fibrosis

MECONIUM ILEUS Diagnosis: plain radiograph shows hazy appearance on the R lower quadrant Treatment: Gastrografin enema resection of ischemic bowel

HIRSCHSPRUNG DISEASE Congenital Aganglionic Megacolon absence of ganglion cells in the bowel wall beginning in the internal anal sphincter extending variably to proximal intestines 5% involves terminal ileum 1 : 5,000 live births male : female (4:1)

HIRSCHSPRUNG DISEASE Clinical Manifestation delayed passage of meconium chronic constipation palpable fecal mass in LLQ empty rectal vault

HIRSCHSPRUNG DISEASE Diagnosis Treatment : surgical rectal manometry and rectal biopsy Radiograph : transition zone (funnel-shaped area) between normal dilated proximal colon and a smaller-caliber obstructed distal colon Treatment : surgical

MALROTATION incomplete rotation of the intestines during fetal development duodenum fixed to the posterior abdominal wall right & left colon and mesenteric artery root fixed to the posterior abdomen most common type: failure of cecum to move to R lower quadrant malposition of ligament of Treitz, superior mesenteric vein located to the left of the artery

MALROTATION abdominal pain abdominal distention nausea vomiting bilious non-bilious others: jaundice sx of malabsorption

MALROTATION complication: VOLVULUS twisting of the small or large bowel around itself acute presentation of bowel obstruction Diagnosis: ultrasound and contrastradiographic studies duodenal obstruction thickened bowel loops to the R of spine free peritoneal fluid

MALROTATION Treatment Malrotation : surgical intervention Volvolus : reduce twisted bowel free duodenum and upper jejenum of any bands / position in R abdominal cavity colon is freed from adhesions and placed in R abdomen with cecum in the L lower quadrant

INTUSSUSCEPTION portion of alimentary tract is telescoped into an adjacent segment most commonly involving ileocolic and ileoileocolic incidence 1-4 in 1,000 live births ( 3mos-6yrs) rare in neonates 60% younger than 12 months 80% of cases occur before 24th month male:female is 4:1

INTUSSUSCEPTION Etiology most cases unknown some associated with adenovirus complicates URTI, AGE, otitis media, Henoch-Schonlein Purpura theory on swollen Peyer’s patches lead points in 2-8% cases meckel’s diverticulum intestinal polyp neurofibroma hemangioma lymphoma

INTUSSUSCEPTION Pathology intussusceptum invaginates into intussuscipiens dragging mesentery constriction of mesentery obstruction of venous return engorgement of intussusceptum edema and bleeding from mucosa bloody stools with mucus (currant-jelly stools)

INTUSSUSCEPTION Early Phase sudden onset of paroxysmal, colicky pain accompanied by straining with legs/knees flexed and loud cries frequent vomiting child may play in between paroxysms of pain Late Phase bile-stained vomitus little / no flatus child is progresively weaker and lethargic fever with shock-like state

INTUSSUSCEPTION Physical Examination Diagnosis slightly tender sausage-shaped mass bloody mucous on rectal exam abdominal distention Diagnosis plain radiograph : density in the area of intussusception barium enema : coiled-spring sign abdominal ultrasound : doughnut or target appearance

INTUSSUSCEPTION Treatment : Prognosis emergency reduction except if with signs of shock, peritoneal irritation, intestinal perforation or pneumatosis intestinalis radiologic reduction under fluoroscopic or ultrasonic guidance Prognosis fatal if untreated spontaneous reduction during pre-operative preparation most recover if reduced within 24 hours Increase mortality after 2nd day

INTESTINAL DUPLICATION well-formed tubular structures firmly attached to the intestine with a common blood supply lining of duplications resembles GI tract very rare cause unknown but attributed to defect in recanalization during embryological development signs of obstruction

ADHESIONS fibrous bands of tissue that are a common cause of post-operative bowel obstruction 2-3% of patients after abdominal surgery majority are single adhesions symptoms of obstruction manifest anytime after 2nd postoperative week Diagnosis: plain and contrast radiographs Treatment: nasogastric decompression IV fluid rescucitation broad-spectrum antibiotic