1. 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.

2. 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)

3. 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

4. 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

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

6. NEONATAL INTESTINAL OBSTRUCTION

7. 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

8. 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

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

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

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

12. 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

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

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

15. 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

16. Low Obstruction
Contrast Barium

17. 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;

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

19. Gastrointestinal Bleeding in Newborn

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

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

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

23. TREATMENT GOALS
Identification of cause
Control the bleeding

24. 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

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

26. Meconium Peritonitis

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

28. 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

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

30. 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

31. 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

32. 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

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

34. 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

35. 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

36. 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

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

38. Abdominal wall defects in newborn

39. 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

40. 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

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

42. Treatment
primary abdominal closure
prevention of dehydration and electrolyte imbalanve

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

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

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

46. Paraclinical for Perforation
Xray
Plain abdomen upright

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

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

49. Treatment
primary closure of the defect

50. Abdominal Trauma in Newborn

51. 25% of total trauma victims are children
Blunt abdominal trauma—most common

52. 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

53. Abdominal Trauma Most common causes Birth canal trauma
Vehicular accident

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

55. 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

56. 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