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

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

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

4. 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

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

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

7. 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

8. Physical Exam
Must remove diaper

9. Physical Exam
Must perform rectal exam, not just look!

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

11. 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

12. 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

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

14. 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

15. 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

16. 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

17. Obvious Obstruction

18. Atresias may be multiple

19. Jejunal Atresia

20. Apple Peel Deformity (IIIb)

21. Imperforate Anus: Anal atresia

22. 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

23. 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

24. 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

25. Hirschsprung’s Disease

26. Barium Enema

27. Treatment
NO WAY!

28. Hirschsprung’s Disease

29. 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

30. Toxic Megacolon

31. Hirschsprung’s in an 8 year old

32. Malrotation
Normal

33. 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

34. 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

35. Malrotation

36. Malrotation

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

38. Midgut Volvulus

39. Small Bowel Obstruction

40. Meckel’s

41. Duplication/Volvulus

42. Duplication

43. 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

44. 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

45. Left-lateral Decubitus Film

46. Intussusception

47. Intussusception

48. Intussusception

49. Intussusception

50. Bad Intussusception

51. 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

52. Incarcerated Hernia

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

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

55. Incarcerated Inguinal Hernia

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

57. 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

58. 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

59. 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

60. 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

61. Morbidity Incidence of Perforation

62. 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

63. Perforated Appendix

64. Perforated Appendix

65. 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

66. Perforated Appendix

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

68. 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!