1. CHO NICU Lecture PJ, AD, DD Revised 06/29/11
Neonatal GI Problems 2: The “Surgical Abdomen” Abdominal Wall, NEC, CDH and some cases
CHO NICU Lecture
PJ, AD, DD
Revised 06/29/11

2. Abdominal Wall Defects

3. Abdominal wall defects
Omphalocele Gastroschisis
Covering sac with cord No sac, cord to the side
10-20% premature 50% premature, SGA common
Other major anomalies Occasional minor anomalies
cardiac, CNS, renal intestinal atresias
syndromes, trisomies
malrotation
Liver may be in sac Liver never out
Malabsorption Malabsorption, prolonged ileus

8. Abdominal Wall Defects Management
Cover the defect: sterile non-latex gloves, turkey bag, plastic wrap, sterile saline soaked gauze
Vascular access: IV, arterial line
D5/D10 1/2 NS ml/kg/day
NG/OG drainage
Volume expander, blood pressure support
Respiratory support: lung hypoplasia is common
Blood culture, antibiotics (ampicillin, gentamicin)

9. NEC

13. Necrotizing Enterocolitis Management
NPO, OG/NG to low intermittent suction
Vascular access, IV and arterial
Volume, pressors to support blood pressure
Blood culture, antibiotics: ampicillin, gentamicin, clindamycin
Respiratory compromise and apnea are common
Blood products to correct coagulopathy, anemia, and thrombocytopenia
Serial abdominal x-rays (2 views), CBC, blood gasses

14. CDH

18. Congenital Diaphragmatic Hernia: Pathophysiology
Pulmonary hypoplasia: affects both lungs
Pulmonary vascular hypoplasia
Pulmonary artery hypertension
Associated anomalies: cardiac, limb, and syndromes
Tracheobronchial anomalies

19. Congenital Diaphragmatic Hernia: Delivery Room Management
Place orogastric tube
Limit bag/mask ventilation
Early intubation of infants with respiratory distress
Consider administration of surfactant
Limit peak pressures to < 25 cm H2O
Avoid overventilation and overdistention

20. Congenital Diaphragmatic Hernia: Initial management
Vascular access
Accept pCO2 in the 40’s - 60’s
Cardiovascular support: volume, pressors
Look carefully for other anomalies
Echocardiogram
Head ultrasound

21. Congenital Diaphragmatic Hernia: Respiratory Management
Permissive hypercapnea (PCO2 50s-60s)
Spontaneous respiration vs. paralysis
High frequency oscillation
Avoid overdistention and pneumothorax
Surfactant

22. Congenital Diaphragmatic Hernia: Management of Pulmonary Hypertension
Previous therapies: intentional hyperoxia and hyperventilation, NaHCO3 infusion
Don’t do this!!!!
Maintenance of systemic blood pressure
Nitric oxide
No benefit in a large randomized prospective trial in neonates with diaphragmatic hernia
May have some short term benefits

23. Real Cases…..

24. Case 1 Labor & Delivery 570 g, 23 5/7 wks, born 8/27/09
Uncomplicated prenatal course until ROM 8/23
Betamethasone, antibiotics
Transferred to Doctors Hospital
Vaginal delivery, Apgars 1/5
Intubated, Surfactant in DR
Anna Bergquist
CHO MR

25. Case 1 Early Course HA and trophic feeds started day 1 Extubated day 4
PDA Rx’d with 2 courses Indomethacin
NUS showed bilat GMH
Blood cultures negative
ETT culture positive for Ureaplasma
Anna Bergquist
CHO MR

26. Case 1 Day 12
On day 12 an Xray was done……

29. Case 1 Isolated GI Perforation
Not the same as NEC
Increased incidence with:
Low gestational age
Hydrocortisone
Combined Indomethacin & Hydrocortisone
Isolated Indomethacin not a risk factor (?)
Symptoms secondary to peritonitis
Heals spontaneously
Risk for strictures

30. Case 2 Labor & Delivery 530 g, 23 3/7 wks, born 7/29
Pre-term labor at 21 wks
Betamethasone, antibiotics
Cesarean for breech
Apgars 2/3/10
Intubated in DR
Jose Chavez
CHO MR

31. Case 2 Early Course HA and trophic feeds started day 1
Prophylactic Indomethacin
Failed initial attempt at extubation
Blood cultures negative
Echo on day 12 showed PDA
Started Indomethacin
Hypotension Rx’d with dopamine, hydrocortisone
Indomethacin D/C’d because of hypotension
Pulmonary hemorrhage, HFOV on day 13
Jose Chavez
CHO MR

32. Case 2 Early Course Trophic feeds re-started d 14
Stopped on d 17 for abdominal distension
Prominent bowel loops, no pneumatosis
NPO for 7 days
Feeds re-started around d 21
NPO again on 8/29 (d 30) for abdominal distension
Jose Chavez
CHO MR

33. Case 2 Transfer Transferred on 8/30 (1 month) for PDA ligation
800 g, systolic murmur, abdomen distended but soft
NPO on HA
PC/PS 17, PEEP 8, Rate 50
Multiple meds:
Albuterol
Pulmicort
Caffeine
Lasix
Fluconazole
Vancomycin
Phenobarbitol
Ativan
Jose Chavez
CHO MR

35. Case 2 Radiology Evaluation
Upper GI
Flow through normal duodenum, duodenal-jejunal junction, jejunum
Contrast enema
Microcolon
Distended RUQ loops do not fill during enema
Small bowel follow-through
Opacification of distended loops
Jose Chavez
CHO MR

37. Case 2 Radiology Diagnosis
Microcolon
Dilated ileum secondary to obstruction
Differential diagnosis:
Stricture
Adhesions
Meconium Ileus
Jose Chavez
CHO MR

38. Case 2 Surgery Exploratory laparotomy Extensive lysis of adhesions
Resection of 11 cm of distal ileum secondary to a concealed perforation
Creation of a double-barrel ileostomy
Jose Chavez
CHO MR

39. Case 2 Findings at Surgery
“Most of the small bowel in the proximal part of the jejunum all the way to the distal jejunum was quite small, and so was the ascending, descending colon. The distal small bowel appeared very distended and there was a lot of adhesions in the right lower quadrant involving several loops of distal ileum. It was apparent that there was a concealed perforation involving a segment of the distal ileum causing a significant amount of inflammatory changes and adhesions, which is causing the bowel obstruction.”
Jose Chavez
CHO MR

40. Case 2 What Caused the Adhesions?
Isolated perforation?
NEC leading to intestinal perforation?
Obstruction leading to perforation?
Atresia
Stenosis
Web
Volvulus
Hirschprungs?
Meconium ileus?
Microcolon?
In-utero perforation?
Jose Chavez
CHO MR

42. Vomiting Surgical vs Medical
Pyloric stenosis
Bowel atresia
Malrotation with volvulus
NEC
Hirschsprungs disease
Meconium ileus/plug
Intussuception
Incarcerated inguinal hernia
Imperforate anus
Stricture
Inborn errors of metabolism
Gastroesophageal reflux
Gastroenteritis
Pyelonephritis
Sepsis/meningitis
Intracranial pathology

43. Final Thoughts Normal abdominal Xray is: Bilious emesis is bad:
Multiple, irregular, overlapping polygons
Bilious emesis is bad:
Malrotation can occur with normal XR
Volvulus is an emergency
Unexplained distension requires contrast studies:
Pediatric radiologist
Pediatric surgeon

44. Case 1 Oh, oh….. On day 12…. Rx…. Free air noted on abdominal XR
No clinical abdominal symptoms
Rx….
Intubated for transport
NPO
Antibiotic coverage expanded
Transported to Oakland
Anna Bergquist
CHO MR

45. Case 1 Admission to Children’s
Weight 560 g
HR 157, BP 49/24 (mean 34)
Grade 1/6 murmur, good pulses and perfusion
Lungs unremarkable
Abdomen “…full but not tense and does not appear tender.”
Comfortable, vigorous, responsive
Anna Bergquist
CHO MR

46. Case 1 “Mini Laparotomy”
“… a right lower quadrant incision was made. The peritoneum was entered. Purulent fluid presented, which was cultured. A small feeding tube was placed gently in the abdomen and the abdomen was irrigated with warm saline in all 4 quadrants. A little more purulent fluid came from the pelvis. An 1/8-inch Penrose drain was then positioned through the opening down toward the pelvis and secured to the skin using a 5-0 PDS suture. A stoma bag was placed over the drain.”
Anna Bergquist
CHO MR

47. Case 2 Post-op Course EEG for “jerking” normal
NUS showed GMH, subsequently resolved
PDA ligation 9/25 (2 months)
Feeds started 9/29
Distal re-feeding of ostomy output
Advanced to full feeds by 10/18
Extubated 10/10
Room Air 11/5
Ostomy takedown 11/19 (4 months)
“Extensive lysis of adhesions”
Feeds re-started 11/29
Adavanced to full feeds by 12/4
Jose Chavez
CHO MR

48. Case 2 Discharge Home Dec 24 (5 months) Weight 2.96 kg
Ad lib Enfacare 24
Multivitamins
Room Air
Stage 3 ROP
Jose Chavez
CHO MR