1. NEONATAL INTESTINAL OBSTRUCTION Noha Al-khawaja Maram Al-zein Amani Azeez Alrahman SUPERVISOR:Dr.Aayed Al-Qahtani

2. Neonatal intestinal obstruction Can be grouped into high & low intestinal obstructions: High obstructions: Pyloric obstruction Duodenal obstruction: complete - partial Very proximal Jejunal obstruction Low obstructions: Small bowel obstruction Meconium ileus & meconium plug Colonic atresia Hirshsprung’s disease Anorectal malformation small colon syndrome :

3. Pyloric stenosis Extremely rare in the neonates 3 rd – 8 th week Usually 1 st born male child History: Present with non bilious projectile vomiting that becomes progressively worse, weight loss & dehydration Examination: Peristaltic waves may be seen, palpable hard mass in the epigastrium Investigations: CBC, urea & electrolytes,US { thickness, diameter,& length of pylorus}. If equivocal do barium swallow Treatment: NG tube, NPO, correct dehydration. pyloromyotomy.

5. CONGENITAL DUODENAL OBSTRUCTION: Types: Duodenal atresia Duodenal stenosis Duodenal web Annular pancreas Malrotation Incidence: 1 in 10000 to 40000 births Pathology: Failure of canalization,vascular accidents,& arrest of normal pancreatic development.

6. Duodenal atresia: 1 in 5000 live births May be associated with Down’s syndrome( 30%) & congenital heart disease. Due to failure of recanalization after the 6 th week of gestation. History & examination: History of maternal polyhydramnious. Bilious vomiting. Pass meconium. On examination: - visible gastric peristaltic waves. -stomach may be palpable. -diffuse abdominal distention is not characteristic.

7. Investigations: Antenatal diagnosis with US CBC. Urea and electrolytes Abdominal x-ray shows double bubble sign Echocardiography Some recommend a routine karyotype in neonates born with duodenal obstruction

8. MANAGEMENT NPO Nasogastric tube. IV fluids, antibiotics ( Ampicillin – Gentamicin) Goals are: ~restoration of continuity without sacrificing intestinal length or absorpative area ~avoidance of injury to the pancreas or ampulla of vater Best approach is duodenoduodenostomy duodenojejunostomy reserved for obstructing lesions in the distal duodenum

9. Results: Neonates require a period of several weeks before entral feeding is tolerated Surgical outcome is excellent Mortality is confined to neonates with Down’s syndrome and congenital heart disease

10. Duodenal stenosis Duodenal web Annular pancreas : ~ characterised by circumferential persistence of the gland around the duodenum at the site of the embryonic ventral pancreatic diverticulum ~associated with intrinsic duodenal obstruction and a patent accessory pancreatic duct

11. Symptoms & Signs Same presentation However, many produce few symptoms Diagnostic delay later in life is relatively frequent Abdominal radiograph shows double bubble sign with some gas distally.

12. Management Same preoperative preparation Excision of duodenal web Duodenoduodenostomy

13. Small intestinal atresia Occurs secondary to in utero ischemic insult Overall distribution is roughly equal between jejunum & ileum 90% of infants with congenital jejunoileal obstructions have atresia More than one atresia is reported in 6% to 20% of these infants Low incidence of significant associated anomalies < 10%

14. Types of Atresia Type I  a single membranous atresia, with continuity of the bowel wall and intact mesentry Type II  single atresia with discontinuity of the bowel wall

15. Type IIIa  atresia without connection by a fibrous cord, with a mesenteric gap Type IIIb  apple-peel mesentery or christmas_tree atresia of a large segment of bowel and mesentery the proximal part is dilated the distal segment is collapsed & spiraled about distal branches of ileocolic artery Type IV  multiple atresias intussusception,segmental volvolus,or thromboembolism could be the causes

17. History and Examination Maternal history of polyhydramnious ( 25% of ileal ) Bilious vomiting,abdominal distention. Failure to Pass meconium. Signs of dehydration. Palpable individual loops of proximal intestine.

18. Investigations CBC, Urea and electrolytes. Plain x-ray: ~marked distention of proximal intestinal loops with gasless distal small bowel & colon ~in ileal atresia multiple dilated loops of bowel,with multiple air fluid levels Contrast enema: because haustral markings are not normally apparent in neonatal colon it cannot be differentiated from small bowel.

20. Management NPO, IV fluids,NG Tube, antibiotics Via a supraumblical incision  simple end to end anastomosis & short segmental bowel resection Multiple atresias may require multiple anastomoses.

21. Results: Incidence of anastomotic problems as leak is nearly 5% to 10%. Prolonged dysfunction of the proximal gut for days or weeks is common. Morbidity & mortality are generally limited to those with heart disease,prematurity,or other associated problems.