1. Intestinal Obstruction In The Neonate
Dr Osama Bawazir
Assistant Professor , Consultant Pediatric surgeon
FRCSI, FRCS(Ed), FRCS (glas), FRCSC,
FAAP,FACS.

2. Incidence
intestinal obstruction is the most common surgical emergency of the newborn.
1 case per every live births.
50% of these neonates will have intestinal atresia or stenosis

3. Presentation Cardinal signs of intestinal obstruction in neonate
Antenatal polyhydramnios
Bilious vomiting
Delayed passage of meconium (> 24 hrs)
Gastric residual > 30 cc
Abdominal distention
bloody diarrhea indicating bowel ischemia or necrosis.

4. Imaging Study
New born has air within the proximal small bowel within 30 minutes. Air can be identified in the rectum by 6-8 hours.
Multiple dilated loops of bowel with “stepladder” air fluid levels on the upright film is the pattern most often seen with distal intestinal obstruction.
peritoneal and/or scrotal calcifications which may signify an intrauterine perforation with meconium peritonitis.

5. contrast enema may be useful to distinguish between causes of distal bowel obstruction
Upper gastrointestinal barium studies (not useful) only for bowel rotation.
small unused colon

7. Causes of neonatal intestinal obstruction
Common:
Malrotation (duodenal obstruction, volvulus, internal hernia)
Duodenal atresia, stenosis or annular pancreas
Jejunal atresia or stenosis
Ileal atresia or stenosis
Simple meconium ileus
Meconium ileus with perforation
Meconium plug syndrome
Hirschsprung’s disease
Drug-induced ileus
Hypertrophic pyloric stenosis
Uncommon:
Pyloric atresia or web
Tumors
Intussusception
Segmental intestinal dilatation
Small left colon syndrome
Milk bolus obstruction
Colonic atresia
Functional Intestinal obstruction
Intestinal Psuedo-Obstruction
Neuronal Intestinal Dysplasia
Megalocystis-Microcolon-Intestinal Hypoperistalsis Syndrome
Inguinal hernia

8. Pathophysiology
Proximal intestinal obstruction  loss of H+ ,K+ & Cl‾  Hypochloremic alkalosis
Distal intestinal obstruction  fluid loss from emesis & from fluid sequestered into the lumen of dilated bowel loops
Fluid shifts and volume depletion  dehydration, oliguria, metabolic acidosis, and inadequate peripheral perfusion.
impair diaphragmatic function
bowel ischemia and necrosis.

9. Perioperative Management (1)
Fundamental rule: previous losses /maintenance/ongoing needs
Urine output best measure of adequate resuscitation
?Need for central monitoring if problematic
Recall distribution of various IV solution
Bolus: as per PALS (20 cc/kg)
Titrate to heart rate, urine output BP
↑ Maintained 25% for each quadrant of abdomen involved

10. Perioperative Management(2)
Antibiotics if any viscus opened, cardiac issues, immunosuppresed (newborn)
Steroids: if on previously/deficiency (stress dose physiology)
Nasogastric tube (Decompression)
Keep patient warm
surgery should not be delayed once volume resuscitation is adequate

11. Two weeks old full term female with bilious vomiting.

12. Be Aware of Child with Bilious (Green) Vomiting

13. Malrotation
10th Week of Development rapid growth of intestine which returns to abdominal cavity with rotation
0.5–1% of the population
only 1 in 6000 live births will present with clinical symptoms.
Problems can occur at any of the 3 stages
Duodenal rotation
Elongation and fixation of the mesentery
Rotation of the colon

15. spiral or corkscrew
cut-off to passage of barium described
as a “bird’s beak”

16. In simple malrotation, the upper gastrointestinal series shows the incomplete rotation of the duodeno-jejunal loop
cut-off to passage of barium described as a “bird’s beak”
spiral or corkscrew
Ultrasound  superior mesenteric vein is normally to the right of the artery

17. Treatment Midgut volvulus is a surgical emergency.
Malrotation without volvulus is a relatively nonemergent condition
The operative management (Ladd procedure)
Recurrent volvulus 10% after Ladd procedure.
5-6% bowel obstruction secondary to adhesions.

18. Full term female who was 6 hours old
Full term female who was 6 hours old. The pregnancy history was remarkable for polyhydramnios on prenatal ultrasound. Immediately after birth the patient developed bilious emesis.

19. Duodenal Atresia/ Annular Pancreas
Primary problem is one of recanalization of solid duodenum.
Obstruction typically at level of common bile duct and pancreas
Duodenal obstruction occurs distal to the ampulla of Vater in 80% of cases.
Duodenal obstruction can be secondary to intrinsic or extrinsic lesions.

20. Associated anomalies common: almost 50%
Down syndrome 29%
malrotation 19%
congenital heart disease 17%
TEF 7%
Others (renal, respiratory, imperforate anus - roughly 10%)
surgical treatment of choice is a ‘double diamond’ duodenoduodenostomy

21. Newborn 36 week premature female with bilious vomiting.
polyhydramnios on prenatal ultrasound.

22. Jejunal & Ileal Atresia
Pathology related to late second trimester vascular accident (Barnard)
most common gastrointestinal atresia
one per 2,000 live births.
Associated anomalies rare
Classification system

23. 2 month old boy with bilious vomiting and a palpable right lower quadrant mass

24. Inguinal hernia Indirect 99% 1% to 3% of all children
3% to 5% in preterm baby
R 60% L 30% Bilateral 10-15%
Males to females ratio is 6:1
Present as bulge in the groin, scrotum, or labia.
A reliable history is sufficient to make the diagnosis, even if the hernia cannot identify.
An incarcerated inguinal hernia presents as a mass in the labia or scrotum that does not reduce spontaneously.

25. What embryological events account for this abnormality?
Failure of the processus vaginalis to close (it remains patent).
What are your recommendations to the parents?
The hernia should be repaired electively; the parents should be warned about possible incarceration in the meantime.
If at the time of your examination the child were irritable and the mass irreducible, what would be your approach?
Attempt manual reduction (use sedation if necessary); emergency surgery if unsuccessful.