Maria Cecilia T. Leyson, M.D. Health-Process-Evidence-based Clinical Practice Guidelines Acute Abdomen in Newborns Rommel Q. De Leon, M.D. Maria Cecilia T. Leyson, M.D.

Operational concept of acute abdomen in newborn any abdominal condition from various causes involving the intra-abdominal organs that requires immediate/urgent intervention in newborn (1-28 Day of Life)

The two general categories of acute abdomen in newborn Acute Surgical abdomen – requiring immediate operative intervention Acute Non-Surgical Abdomen – requiring immediate non-operative intervention

What are common causes of acute surgical abdomen in newborn? Non-Trauma G.I. Obstruction G.I. bleeding G.I. Perforation Abdominal Wall defects Trauma

What are the more common causes of acute non-surgical abdomen? Non-trauma Ileus Diarrhea

NEONATAL INTESTINAL OBSTRUCTION

Patient with imperforate anus Patient with perforate anus with : What are reliable signs and symptoms (more than 90% certainty) that a newborn patient has intestinal obstruction? Patient with imperforate anus Patient with perforate anus with : Abdominal distention Persistent vomiting Non-passage of meconium within the first 24 hours of life or non-passage of stool within 24 hours

Types of Intestinal Obstruction Mechanical no recent history of systemic illness prior to the presentation of intestinal obstruction Non Mechanical recent history of systemic illness prior to the presentation of intestinal obstruction

Causes of mechanical intestinal obstruction High Obstruction Gastric outlet obstruction 1:1,000,000 live births pyloric atresia Pyloric stenosis Antral web

Duodenal obstruction Jejunal obstruction Duodenal atresia Duodenal stenosis Annular pancreas Preduodenal portal vein Malrotation Jejunal obstruction Atresia Jejunal stenosis

Causes of mechanical intestinal obstruction Low Obstruction Distal small bowel Ileal atresia Meconium ileus Uncomplicated Complicated

Colonic obstruction Dysmotility states Meconium plug 1:500-1,000 live births Small left colon syndrome -- rare Hirschsprung's disease 1:4,000 live births Colonic atresia Anorectal malformations 1:4,00-8,000

Reliable S/Sx of High Obstruction Localized distention Upper abdomen Generalized Distention

Algorithm patient DRE Imperforate anus Perforate anus Generalized/ Abdominal Distention Generalized/ Diffuse Localized High Obstruction Low Obstruction

In a newborn patient with suspected neonatal intestinal obstruction, what is the most cost-effective initial procedure? Ans: High Obstruction Plain abdominal film Upper GI series

Low Obstruction Contrast Barium

What are reliable signs and symptoms (more than 90% certainty) that a newborn patient has intestinal obstruction that needs operation? Signs of peritonitis Clinical deterioration Unequivocal clinical evidence of obstruction Radiographic evidence of obstruction Mattei, P. Neonatal Intestinal Obstruction. Surgical Directives: Pediatric Surgery. 2003;313-316

TREATMENT GOALS Neonatal intestinal obstruction Identification of cause Relieve the obstruction Restore bowel continuity (if stable)

Gastrointestinal Bleeding in Newborn

Causes of Upper GI Bleeding Hemorrhagic disease of the newborn Stress gastritis Systemic illness

Causes of Lower GI Bleeding Hemorrhagic disease of the newborn Necrotizing enterocolitis Presence of systemic illness

In a newborn patient with neonatal gastrointestinal bleeding, what is the most cost-effective initial procedure? Vigilant observation/examination

TREATMENT GOALS Identification of cause Control the bleeding

Treatment of Upper GI Bleeding Hemorrhagic disease of the newborn Self-limiting Give 1mg Vit K Swallowed maternal blood Stress gastritis Nasogastric suctioning Lavage H2-blockers

Treatment of Lower GI Bleeding Anal fissure Stool softners Rectal dilatation Necrotizing enterocolitis Antibiotics Bowel rest TPN Malrotation with volvulus Emergency surgery

Meconium Peritonitis

Perforation Relaible S/Sx Paraclinical Diagnosis No reliable signs of perforation Abdominal distention is a clue for perforation Paraclinical Diagnosis Plain abdominal film

Meconium Peritonitis Is a chemical or foreign-body reaction of the peritoneum to prenatal perforation of the intestinal tract The perforation may sealed off before birth or it may persists

ETIOLOGY Meconium ileus, vascular compromise Atresias or stenosis, intussusception Volvulus, congenital bands etc. intestinal obstruction Intrauterine intestinal perforation

INTESTINAL PERFORATION MECONIUM LEAKS INTO PERITONIUM PERITONIUM WILL EXHIBIT RAPID FIBROBLAST PROLIFERATION FIBROBLASTIC ADHESION ENVELOPS THE LESION PSEUDOCYSTS INCREASE VASCULARITY & FORMATION OF MATURE COLLAGEN FOREIGN BODY GRANULOMAS & CALCIFICATIONDEVELOPS

Four Pathologic Types TYPE I Meconium Pseudocysts Perforation not sealed in utero Fibrous cysts wall formed from the surrounding bowel loops Gangrenous segment of the intestine is a major part of the cysts Rest of the intraperitoneal cavity devoid of adhesions Calcifications may lined the walls

Four Pathologic Types TYPE II Plastic Generalized Meconium Peritonitis Wide spread spillage of meconium throughout the peritoneum Scattered peritoneal calcifications Dense fibrous adhesions Intestinal obstruction occurs due to adhesions

Four Pathologic Types TYPE III Meconium Ascites Perforation occurs shortly before birth Meconium-stained ascitic fluids Fine stripped calcification may be present

Four Pathologic Types TYPE IV Infected Meconium Peritonitis Perforation that did not sealed off before birth There is colonization of neonatal gut allows bacterial peritonitis Air and meconium present in the peritoneal cavity The most serious type of meconium peritonitis

Clinical Presentation: 1 in 35,000 live births Intestinal obstruction is the most common presentation Vomiting may be present on the first or 2nd day of life Plain abdominal x-rays shows intestinal obstruction and intraabdominal calcifications

INDICATIONS FOR OPERATION INTESTINAL OBSTRUCTION PERSITENT INTESTINAL LEAKS Specific indications X-ray evidence of intestinal obstruction and intraperitoneal air Abdominal mass encysted meconium Localized or generalized cellulitis of the abdominal wall sepsis

GOAL OF MANAGEMENT Remove all devitalized tissue Preservation of adequate length of bowel Reestablish bowel continuity

Abdominal wall defects in newborn

GASTROSCHISIS Congenital defect of the abdominal wall right of the umbilicus no sac or membrane covering the midgut OMPHALOCOELE Congenital defect in which the abdominal viscera remain herniated covered with sac

Etiology - failure of the lateral portion of the abdominal wall to join its upper and lower component - failure in the muscular migrating from the dorsal myotomes invade the splanchnopleura of the embryomic abdominal wall

Goals of treatment - close defect - prevent dehydration and electrolyte imbalance - return of bowel function

Treatment primary abdominal closure prevention of dehydration and electrolyte imbalanve

Omphalocele congenital defect in which the abdominal viscera remain herniated covered with sac

Paraclinical X Ray AP/L Lateral – presence of presacral gas

Paraclinical for GI Bleeding Hemorrhagic dse Necrotizing Enterocolitis Xray Clinical with a background of a septic px

Paraclinical for Perforation Xray Plain abdomen upright

Etiology -incomplete fetal growth and fusion of the cephalic, lateral and caudal tissue - usually present with congenitak gear dye.

- prevent dehydration and electrolyte imbalance Treatment goals -close defect - prevent dehydration and electrolyte imbalance return of bowel function

Treatment primary closure of the defect

Abdominal Trauma in Newborn

25% of total trauma victims are children Blunt abdominal trauma—most common

Abdominal Trauma What are reliable signs and symptoms (more than 90% certainty) that a patient with abdominal trauma needs urgent operation? Ans: -hemodynamic instability -definite (persistent, progressive) direct tenderness with at least guarding -abdominal rigidity

Abdominal Trauma Most common causes Birth canal trauma Vehicular accident

Abdominal Trauma In a newborn patient with suspected blunt abdominal trauma, what is the most cost-effective initial procedure? Ultrasound

Clinical Questions 9. What are reliable symptoms and signs (more than 90% certainty) that a patient has perforated abdominal viscus that needs urgent operation? Ans: -definite (persistent, progressive) direct tenderness with at least guarding -abdominal rigidity

References Baucke VL; Failure to Pass Meconium: Diagnosing Neonatal Intestinal Obstruction, American Family Physician, vol 60, 1999 Irish MJ, Pearl; Pediatric Surgery for the Primary Care of Pediatrician, The Approach to Common Abdominal Diagnoses In Infants and Children; Pediatric Clinics of North America, vol 45, 1990 Jona J; Advances in Neonatal Surgery, Neonatology Update, Pediatric Clinics of North America, vol 95, 1998 Kimura K; Bilious Vomiting in the Newborn, Rapid Decision of Intestinal Obstruction; American Family Physician vol 61, 2001 Schulman MH; Imaging of Neonatal Gartrointestinal Obstruction, Radiologic Clinic of North America, vol 37, 1999