1. Neonatal intestinal obstruction
HASHEM AL-MOMANI
SENIOR CONSULTANT PEDIATRIC SURGEON
JORDAN UNIVERSITY HOSPITAL

2. Introduction
Neonatal intestinal obstruction is one of the common pediatric emergencies.
Neonatal intestinal obstruction has an incidence of in 2000 live births.
A wide range of congenital anomalies may result in neonatal bowel obstruction.

3. Causes of intestinal obstruction in the neonatal period
Congenital atresia and stenosis constitute the majority of cases.
Other causes include
Malrotation
Volvulus
Meconium ileus
Hirschsprung disease
Anorectal malformations

4. Causes of intestinal obstruction in the neonatal period
Gastric
Early pyloric stenosis
Pyloric web or atresia
Epidermolysis bullosa pyloric atresia syndrome
Duodenum
Stenosis
Atresia
Malrotation
Annular pancreas
Jejunum-Ileum
Meconium ileus
Vitello-intestinal duct remnant
Intussusception
Milk curd obstruction
Colonic
Stenosis
Atresia
Imperforate anus
Poorly developed colon e.g.
megacystis microcolon intestinal
hypoperistalsis syndrome
Global
Duplication anomalies
Internal hernia or inguinal hernia
Volvulus with or without (e.g. about a
Meckel’s band) malrotation
Neoplasm

5. Etiology 113 etiologies in 106 patients

6. Presentation
“A neonate with bilious vomiting or aspirate is considered to have intestinal obstruction until proved otherwise.”
The presenting symptoms could be any combination of the following:
Bilious vomiting
Abdominal distension
Delayed passage of meconium
Sepsis

7. Prenatal sonography
Echogenic bowel
Dilated bowel
Polyhydramnios

8. Bilious vomiting
Bilious vomiting is synonymous with intestinal obstruction, be it functional or mechanical.

9. Examination dehydration abdominal distension
Visible and palpable bowel loops
Erythema and tenderness of abdominal wall
The presence of a normal anus
Associated anomaly

10. A newborn with marked abdominal distension
suggesting
distal obstruction
necrotizing enterocolitis
sepsis
The more marked the abdominal distension, the more distal is the obstruction

11. Perineal Examination
Absent anus
Rectal stimulation

12. Vomiting
Vomit produced by a neonate should be classified carefully into one of two groups:
Non-bilious vomit: Colorless or milky if a feed has been taken.
Bilious vomit: Dark green . Freshly produced bile of golden color has been acted upon by stomach acid to produce the green color.
Neonatal bilious vomiting should be considered to be a surgical emergency until proved otherwise.

13. Constipation
A term neonate should pass meconium within 24 h of life.

14. Passage of meconium
is absent in complete duodenal and small intestinal obstruction
meconium passage may be present in anomalies of rotation and fixation
delayed in Hirschsprung’s disease
Occurs by an abnormal route (by a fistula or micturition) or not at all in anorectal malformations

15. Abdominal Radiology
The simplest and most informative radiological procedure is the plain abdominal X-ray.
confirmation of bowel obstruction with some information about the level of the obstruction.

16. Imaging Studies Plain x-ray abdomen: supine film lateral decubitus
Invertogram or a prone cross-table lateral film for anorectal malformations

17. Plain abdominal X-ray The extent and position of bowel gas
Presence or absence of gas in the rectum
Degree and level of distended loops
Air fluid levels
Evidence of free gas would confirm perforation.
“Football sign”,
The rigler sign, also known as the  double wall sign

18. Intestinal air progression

19. Abdominal x-ray showing dilatation of bowel loops with air–fluid level

20. single air bubble

21. Plain abdominal x-ray
Dilated stomach with air distally suggesting partial duodenal obstruction

22. Complete duodenal obstruction

23. Triple bubbles

24. Pneumo-peritoneum
Free air due to perforation from any cause is suspected on supine film when
“football sign” : a large pocket of air overlying liver and the ligamentum teres
Rigler sign: the bowel wall is sharply delineated (pencil lining).

25. Football sign

26. Rigler sign

27. Lateral decubitus
Lateral decubitus film with the right side uppermost should be used to see air above the liver.

28. Free air above the liver

31. Ileal atresia with volvulus

32. Calcification
Calcification of meconium implies long-standing stasis and may be identifiable outside of the bowel loops, which would suggest previous perforation.

33. Diffuse calcifications

34. Contrast Studies
The first enema a neonate receives should be a contrast enema.
The contrast enema acts not just a diagnostic tool but works as a therapeutic measure in cases of:
meconium plug
meconium ileus
Hirschsprung’s disease

35. Lower contrast study showing small left colon syndrome

36. Lower contrast study showing Hirschsprung’s disease

37. Lower contrast study showing meconium plug syndrome

38. A lower contrast study: small unused colon suggesting small bowel obstruction or total colonic hirschprung’s disease.

39. Contrast upper gastrointestinal (GI) studies
If malrotation is suspected
Sometimes to characterize the duodenal obstruction

40. Malrotation

41. Malrotation

42. Volvulus neonatorum- spiral twist of the bowel

43. Upper contrast study showing congenital duodenal obstruction.

44. Remember While Doing the Contrast Study
Use water soluble contrast
Make sure the baby is well hydrated
Make sure the radiology suit temperature is warm enough for the baby.
Avoid using Foley catheter with the baloon inflated.
Perform the study using image intensifier.

45. Ultrasound To look for other associated anomalies
Helps to diagnose free or loculated intra-abdominal fluid collection denoting perforation or a meconium cyst.
In malrotation if the arrangement of the superior mesentric vessels is reversed, then malrotation should be suspected - operator-dependent and is not widely used.

46. Transverse ultrasound scan through the upper abdomen

47. “whirlpool” configuration of the superior mesenteric vessels

48. Treatment
The success of treatment of neonates with intestinal obstruction depends on several factors:
Early diagnosis
Proper preoperative stabilization
The right choice of surgical procedure
Good postoperative care

49. Principles of Treatment
This is individualized according to the diagnosis but certain principals remain common.
The baby is cared for in the NICU with regulation of temperature and adequate monitoring.
The baby should receive broad spectrum antibiotic cover
The baby should be transported in an incubator to and from the operating room (OR).
The OR temperature should be kept high and measures should be taken to keep the baby warm during surgery.
Warm saline is used during the procedure and all the fluids given to the baby are warmed appropriately.

50. Preoperative care:
Once the diagnosis of neonatal intestinal obstruction is made, the patient should be fully resuscitated.
Fluid resuscitation.
Gastric decompression via an orogastric or a nasogastric tube.
The use of umbilical lines should be avoided because of the increased risk of infection and because they interfere with the incision for laparotomy.
Vitamin K is given intramuscularly.
Broad-spectrum antibiotics are given intravenously.
Control of temperature to avoid hypothermia.

51. Postoperative management:
The patient is admitted to the neonatal intensive care unit.
Nothing by mouth (NPO).
The baby should be kept warm.
An orogastric tube should be placed for gastric decompression.
TPN should be started shortly after surgery and continued until enteral feeds are tolerated.

52. Outcome and Prognosis
the overall survival rates of newborns with intestinal obstruction is 90 %
The most common cause of death is infection related to pneumonia, peritonitis, or sepsis.
The most important surgical complications are anastomotic leaks and functional intestinal obstruction at the level of the anastomosis

53. Outcome in 106 patients at JUH

54. THANK YOU