Infant Bowel Obstruction Robert W. Letton, Jr., MD Associate Professor of Surgery Pediatric Surgery Oklahoma University Health Sciences Center

Question 1? Why do Pediatric Surgeons always make such a big deal out of a little yellow or green emesis?

Answer Because unlike when Stan sees Wendy in Southpark©, it usually means bowel obstruction or necrosis in our patients!

Goals Discuss the work-up and management of the child with potential bowel obstruction Recognize the common causes of bowel obstruction in children Discuss surgical management of common causes of bowel obstruction

History Birth History Feeding History Formula intolerance Emesis Bilious vs non-bilious Bowel Habits passage of meconium

History Antecedent episodes Irritable, lethargic History of inguinal hernia Family history Hirschsprung’s Recent immunization or URI Intussusception

Physical Exam General state of hydration Obvious source of sepsis meningitis, strep throat, otitis, pneumonia, UTI Inspect abdomen scaphoid or distended, discolored Auscultate Palpate masses, tenderness, peritonitis

Physical Exam Must remove diaper

Physical Exam Must perform rectal exam, not just look!

Ancillary Studies CBC, Lytes, UA, +/- Blood Cx, +/- ABG Acute abdominal series left lateral decub, KUB, CXR Contrast Study From above or below??

Initial Management NG or OG to low wall suction (NPO!!) Hydrate and replace losses 10 cc/kg of crystalloid IS NOT AN ADEQUATE BOLUS!! Antibiotics if suspect perforation or necrosis Consult surgeon and/or transfer to appropriate facility

Bowel Obstruction Diagnosis often age specific Bilious vomiting in the infant and child is a surgical emergency until proven otherwise Difficult to tell when volvulus is present Child may look surprisingly good until it’s too late

Etiology of Bowel Obstruction Atresias Hirschsprung’s Malrotation Volvulus Intussusception Incarcerated Hernia Perforated appendix

Atresia Usually presents the first few days of life Child may feed well for a day or two with distal atresia Duodenal atresia often diagnosed on antenatal U/S Atresias can occur anywhere in GI tract from pharynx to anus

Atresias Esophageal: aspirate feeds immediately, OG tube won’t pass (non-bilious, but still bad) Duodenal: bilious vomiting immediately, “double bubble” on KUB with absence of distal gas, Down’s Syndrome Jejunal: usually present 1st 24 hours, large dilated proximal loop or loops

Atresias Ileal: may take 24-48 hours before bilious emesis Colonic: rare, may present with bilious emesis after 2-3 days Anal: should be diagnosed at birth, often a perineal fistula is labeled normal

Obvious Obstruction

Atresias may be multiple

Jejunal Atresia

Apple Peel Deformity (IIIb)

Imperforate Anus: Anal atresia

Hirschsprung’s Disease Congenital colonic aganglionosis Physiologic obstruction May present first few days to weeks of life Short segment disease often tolerated for months Starts at anus and extends proximally a variable distance

Hirschsprung’s Delayed passage of meconium at birth Meconium plug syndrome, small left colon syndrome, Down’s syndrome Often present with distension and diarrhea at 2-4 weeks of life May or may not have emesis Profoundly distended abdomen with dilated bowel Fever and WBC’s with colitis

Hirschsprung’s Rectal exam may seem normal until withdraw finger “Explosive” release of liquid stool almost diagnostic Barium enema while dilated Irrigate and dilate until decompressed Suction rectal biopsy

Hirschsprung’s Disease

Barium Enema

Treatment NO WAY!

Hirschsprung’s Disease

Toxic Megacolon Severe enterocolitis Very rare to get with idiopathic constipation Usually only seen with Hirschsprung’s Disease or Ulcerative Colitis NG decompression, IV fluids, IV antibiotics Mortality 20-30% in some studies

Toxic Megacolon

Hirschsprung’s in an 8 year old

Malrotation Normal

Malrotation Most often presents during the first few months of life Infant with acute onset of bilious emesis May be diagnosed on UGI for other reasons Malrotation is a surgical urgency due to the possibility of volvulus VOLVULUS IS A SURGICAL EMERGENCY

Malrotation Abdomen usually NOT distended AAS usually normal May show bowel obstruction, double-bubble, or gasless UGI is definitive diagnostic study Infant in extremis resuscitate and operate

Malrotation

Malrotation

Volvulus Malrotation most common condition resulting in midgut volvulus Can have volvulus with normal rotation omphalomesenteric remnant internal hernia Duplication Adhesive small bowel obstruction

Midgut Volvulus

Small Bowel Obstruction

Meckel’s

Duplication/Volvulus

Duplication

Intussusception Inversion of the bowel upon itself secondary to a lead point Juvenile intussusception most often idiopathic Also secondary to Meckel’s Presents 6 months to 2 years of age As early as 1 month

Intussusception Acute painful episodes followed by periods of lethargy When incarcerated progress to continuous lethargy May or may not have “currant-jelly” stool But often stool is heme positive Rule out with a left lateral decubitus film

Left-lateral Decubitus Film

Intussusception

Intussusception

Intussusception

Intussusception

Bad Intussusception

Intussusception 7% chance of recurrence after ACE reduction Usually recur in 48 hours Operative exploration warranted on second recurrence to R/O pathologic lead point Recurrence after surgery rare but possible Post-op intussusception can occur after any surgery

Incarcerated Hernia

Inguinal/Scrotal Anatomy From Surgery of Infants and Children, Oldham, et. al., 1997

From Atlas of Pediatric Surgery, Ashcraft, 1994 Inguinal Hernia From Atlas of Pediatric Surgery, Ashcraft, 1994

Incarcerated Inguinal Hernia

Hernia Reduction From Surgery of Infants and Children, Oldham, et. al., 1997

Incarcerated Hernia Most can be reduced in clinic or ED Bowel usually OK if able to reduce Surgical consultation if reduction difficult Repair with 1-2 days of incarceration Beware the “inguinal node’ in females incarcerated ovary

Incarcerated Hernia If unable to reduce: urgent operative exploration (NPO) If able to reduce without sedation: urgent surgical referral with repair soon If extremely difficult (sedation, surgical referral): repair next day Watch child for obstructive symptoms

Perforated Appendix Children still die from complications of perforated appendicitis Resuscitation is critical Response to surgery variable Often require multiple procedures, hyperalimentation, prolonged antibiotic therapy Diagnosis difficult

AAP Guidelines for Pediatric Surgical Referral Patients 5 years or younger who may need surgical care Infants and children with perforated appendicitis Seriously injured infants and children Infants, children, and adolescents with solid malignancies Minimally invasive procedures Infants and children with medical conditions that increase operative risk

Morbidity Incidence of Perforation

Perforated Appendix Suspect in children 3-5 years old with history suggestive of appendicitis “Bowel obstruction” in a 3-5 year old without obvious etiology is perforated appendix until proven otherwise Fever > 101.5, WBC > 20 with bands, diffuse abdominal pain, guarding, SBO on AAS

Perforated Appendix

Perforated Appendix

Resuscitation NG tube, NPO 20 cc/kg boluses until UOP > 1 cc/kg/hr and VS stable 1.5-2 times maintenance fluids Broad Spectrum Antibiotics

Perforated Appendix

? Summary Atresias Hirschsprung’s Malrotation Volvulus Intussusception Incarcerated Hernia Perforated Appendix

Question 2? Why are Pediatric Surgeons so interested in flatus? Contrary to popular belief, kids with obstruction can still have bowel movements, but they won’t pass gas!