Clinical features Bilious vomiting Develops early in more proximal obstruction (e.g.. duodenal / jejunal) o Is a relatively late feature, developing after abdominal distension in distal obstruction (e.g.. ileal, colonic) Abdominal distension o Is less pronounced in more proximal obstruction (e.g.. duodenal) o Is more pronounced in distal obstruction (e.g.. ileal, colonic) Absence of meconeum o 90% of newborns pass meconeum within the 1 st 24 hours of life 24 hours delay in passing meconeum should be treated with suspicion o Neonates with an incomplete intestinal obstruction (e.g.. stenosis) may pass meconeum o A neonate with bilious vomiting should be considered to have intestinal obstruction until proven otherwise
Causes of neonatal intestinal obstruction Atresia / stenosis o Duodenal o Jejunal / ileal o Colonic Malrotation of gut Meconeum ileus Meconeum plug syndrome Hirschsprungs diseass Anorectal anomalies
Further evaluation Assess state of hydration Are there signs of sepsis Are there signs of devitalised bowel / perforation
Investigations To confirm diagnosis o Plane X rays of the abdomen: AP supine, AP erect or left lateral decubitus o Contrast studies o USS of the abdomen Assess general state o FBC, U&E, blood gasses, RBS, LFT, (blood cultures), (group and cross match blood) Screen for associated anomalies o Eg. Down syndrome in duodenal atresia
Principles of Management Stop feeds NG tube for decompression (free drainage & intermittent aspiration) Intravenous fluids o Maintenance o Deficit correction o Replace ongoing losses Antibiotics to cover Streptococci, gram ve rods, anaerobes Temperature regulation Vitamin K Transfer to a centre with paediatric surgical facilities
Definitive treatment Resect & establish bowel continuity o Bowel atresias o Necrotic bowel Bypass obstruction o Duodeno-duodenostomy in duodenal atresia / stenosis Divide peritoneal bands causing obstruction o Eg. Ladds procedure in malrotation Creation of a stoma o Hirschsprungs disease o Meconeum ileus o High anorectal anomalies Primary anoplasty o Low anorectal anomalies Colonic washouts o Meconeum plug syndrome o Meconeum ileus
Oesophageal atresia & Tracheo-oesophageal fistula Clinical features Maternal polyhydramnios Preterm babies Drooling saliva Respiratory distress Coughing / choking / cyanotic spell after a feed Resistance to the passage of a firm NG tube
Confirming the diagnosis..; Plain X-ray of chest & abdomen, AP with NG tube o NG tube coiled in the upper oesophageal pouch o Presence of gas in the bowel indicates TOF o Absent gas in the bowel indicates pure OA
Investigations Assess general state FBC, U&E, Blood gasses, RBS, (grouping & cross matching) Screen for associated anomalies VACTERL Vertebral Anorectal Cardiac Tracheoesophageal Renal Limb
Pre-operative management Stop feeds IV fluids Wide bore NG / Replogle tube in upper oesophageal pouch for continuous / frequent suction & oropharyngeal suction Antibiotics, e.g.. penicillin & gentamicin Nurse with head end elevated to prevent gastric reflux into lungs via TOF Temperature regulation O2 therapy depending on need Vitamin K Transfer to paediatric surgical unit
Surgical Treatment Closure of TOF and restoration of oesophageal continuity (oesophageo- oesophagostomy), via a right thoracotomy
Gastoschisis Bowel herniation through a small defect on the right of the normally formed umbilical cord No membrane / sac Bowel wall & mesentery thickened & foreshortened Few associated anomalies other than malrotation & bowel atresias More common in babies of young mothers (<20 years) Associated with maternal substance abuse
Omphalocele / exomphalos Central abdominal wall defect with herniation of abdominal viscera into umbilical cord Viscera covered by a membrane from which umbilical cord emerges Liver commonly herniates with bowel Commonly associated with malrotation & other anomalies (e.g.. Trisomy 13,14,15,18,21, Beckwith-Weidemann syndrome, Pentalogy of Cantrell
Pre-operative management Ideally all infants with abdominal wall defects should be delivered at a centre with neonatal & paediatric surgical expertise Nasogastric tube for decompression Aggressive fluid resuscitation Avoid hypothermia (temp controlled environment) Avoid twisting / kinking of bowel in gastroschisis Bowel wrapped in warm saline soaked gauze, supported on anterior abdo wall, covered in waterproof dressing (e.g.. Cellophane, polythene) Antibiotics (penicillin, gentamicin, metronidazole) Vitamin K Screen for associated anomalies (especially in omphalocele)
Surgical treatment options Primary closure of defect Delayed primary closure (using a silo for gradual reduction) Allowing large omphalocele to granulate & epithelialise & repair the ventral hernia later
Hypertrophic pyloric stenosis Hypertrophy of the circular muscle of the pylorus, causing pyloric channel narrowing
Clinical features Boys : girls, 4:1 Age of onset 3-6 weeks Vomiting, initially regurgitation of feeds, later projectile, after every feed, never bilious, may contain fresh or altered blood Hungry Poor weight gain or weight loss Dehydration Infrequent stools Test feed o Visible peristalsis o Palpable tumour
Investigations Blood gases o Hypochloraemic metabolic alkalosis U&E USS of abdomen
Pre-operative management Stop feeds NG tube for decompression Correction of fluid & electrolyte deficits (Na+, K+, Cl-), & acid-base anomaly o 0.45% NaCl in 5% dextrose with added KCl Transfer to a paediatric surgical unit
Operative treatment- Pyloromyotomy
Intussusception May occur at any stage, the peak presentation 3 months- 2 years Aetiological types o Idiopathic (common) o Associated with lead point (e.g. Meckels diverticulum, polyp, Henoch-Schonlein purpura) Classification according to site o Ileo-colic (common) o Colo-colic o Ileo-ileal
Clinical features Peak incidence at 3-9 months of age May have preceding gastroenteritis or respiratory tract infection Sudden onset of screaming attacks o Lasting few minutes o Every 15 minutes or so & becoming progressively severe o Draws legs up o Listless between attacks May vomit Stools o Initially normal o Later blood & mucus (red current jelly) Abdomen o Lump palpable (sausage shaped) Rectal examination o Blood stained mucus on finger o Apex may be felt
Investigations X-ray abdomen AP, supine o Absent caecal gas o May have bowel obstruction pattern USS abdomen o Typical mass seen o Diagnostic Ba enema o Rarely needed To assess general state o FBC o U&E
Treatment Stop feeds NG tube for decompression IV fluids Antibiotics: e.g. penicillin, gentamicin, metronidazole Analgesics Transfer to a paediatric surgical unit Non operative o Pneumatic reduction (air enema) o Hydrostatic reduction (saline enema, Ba enema) Operative o Reduction o Resection (failed reduction, non viable bowel)
Inguinal hernia Inguinal hernias in children are indirect Incarceration / irreducibility occurs when the contents of the sac are blocked at its neck This can lead to obstruction Strangulation occurs when there is vascular compromise of the incarcerated contents due to constriction at the neck of the sac Incarcerated inguinal hernia May rapidly progress to strangulation Incidence of incarceration in neonates and young infants is high (24- 40%). It is higher in premature infants compared with full term infants Significant risk of testicular / ovarian infarction & atrophy Clinical features Irritability Vomiting Tense, tender groin lump with ill defined upper margin Previously noted intermittent groin lump Moderately distended abdomen (?obstruction) Occasionally bleeding PR Treatment Infant / child is placed on a bed with the foot end elevated Adequate sedation If not reduced within 1 hour, attempt gentle taxis. Vast majority are reduced by these methods Keep in hospital for observation after reduction Elective herniotomy in 24-48 hours
Swallowed foreign body Clinical features History of swallowing objects Choking Vomiting Respiratory distress Dysphagia Drooling Tracheal deviation
Investigations X-ray of abdomen AP view X-ray of neck and chest AP, if FB is not seen on abdominal view Management In general, if the FB reaches the stomach, it will be expelled in the faeces. Therefore watchful waiting is the best option Long, rigid, pointed objects (e.g. hairpins) may perforate the bowel at points of angulation or fixation (e.g. duodenum, DJ flexure). If such an object stays in one place (on X-ray) for 3-5 days, it should be surgically or endoscopically removed FBs lodged in the oesophagus are removed endoscopically Button batteries reaching the stomach do no harm if they keep moving along the GIT. Removal should be considered if they remain in the same place for > 24 hours
Appendicitis Rare in infants but the most common cause of an Acute abdomen in childhood and early adulthood
Aetiology/Pathology Obstructive in 50%-80% Cause of obstruction ; faecolith (rare; fibrotic stricture, tumour, ball of worms) Early acute appendicitis > Acute suppurative appendicitis > Acute gangrenous appendicitis Sequelae ; resolution, perforation with peritonitis, mass, abcess
Clinical features Periumbilical pain ; colic/vague > shifts to RIF (aggravated by movements, coughing) Anorexia Nausea/vomiting Fever ; typically low grade ( <38.5 0 C) Look unwell Coated toungue Tender RIF Guarding Rebound/ Percussion tenderness Rovsing sign Psoas sign Obturator sign Diarrhea/ urinary symptoms (pelvic appendix) Pelvic tenderness in DRE (pelvic appendix)
Infants; often presents with generalized peritonitis Elders; RIF signs may be less obvious. May simulate subacute intestinal obstruction. Therefore often more complicated Obese; RIF signs are less obvious Pregnancy; pain and abdominal signs may be in right upper quadrant/flank
Differential diagnosis Children Mesenteric adenitis Acute gastroenteritis Meckels diverticulitis Henoch schonelein purpura Right basal pneumonia
Adult female Ectopic pregnancy Ovarian cyst;torsion/haemorrhage Acute salpingitis Mittelschmerz; midcycle rupture of a follicular cyst
Elderly Sigmoid diverticulitis Intestinal obstruction Carcinoma of the caecum
Investigations Mainly clinical diagnosis FBC; increased WBC, N CRP Urianalysis ; pus cells may mislead Pregnancy test in adult female Imaging; USS (CT scan) Abdominal X ray (supine AP) U&E if dehydrated, elderly
Treatment Nil by mouth IV fluid therapy; correct deficit, ongoing losses, maintenance IV antibiotics; gram-negative bacilli-gentamycin, anaraerobes- metranidazole. Prophylactic/therapeutic Analgesics Appendicectomy; open/laparoscopy
More notes on intestinal obstruction
Causes of intestinal obstruction Dynamic Intraluminal o Impaction o Foreign bodies o Bezoars o Gallstones Intramural o Stricture o Malignancy Extramural o Bands/adhesions o Hernia o Volvulus o Intussusception Adynamic Paralytic ileus Mesenteric vascular occlusion Pseudo-obstruct
Mechanisms of obstruction Volvulus Incarceration Obstruction Intussusception
Volvulus May involve the small intestine, caecum or sigmoid colon; neonatal midgut volvulus secondary to midgut malrotation is life-threatening The commonest spontaneous type in adults is sigmoid Sigmoid volvulus can be relieved by decompression per anum Surgery is required to prevent or relieve ischaemia
Features of obstruction In high small bowel obstruction, vomiting occurs early and is profuse with rapid dehydration. Distension is minimal with little evidence of fluid levels on abdominal radiography In low small bowel obstruction, pain is predominant with central distension. Vomiting is delayed. Multiple central fluid levels are seen on radiography In large bowel obstruction, distension is early and pronounced. Pain is mild and vomiting and dehydration are late. The proximal colon and caecum are distended on abdominal radiography
Cardinal clinical features of acute obstruction Abdominal pain Distension Vomiting Absolute constipation
Intussusception Most common in children Primary or secondary to intestinal pathology, e.g. polyp, Meckels diverticulum Ileocolic is the commonest variety Can lead to an ischaemic segment Radiological reduction is indicated in most cases The remainder require surgery
Radiological features of obstruction The obstructed small bowel is characterised by straight segments that are generally central and lie transversely. No gas is seen in the colon The jejunum is characterised by its valvulae conniventes, which completely pass across the width of the bowel and are regularly spaced, giving a concertina or ladder effect Ileum the distal ileum has been piquantly described by Wangensteen as featureless Caecum a distended caecum is shown by a rounded gas shadow in the right iliac fossa Large bowel, except for the caecum, shows haustral folds, which, unlike valvulae conniventes, are spaced irregularly, do not cross the whole diameter of the bowel and do not have indentations placed opposite one another
Treatment of acute intestinal obstruction Gastrointestinal drainage via a NG tube Fluid and electrolyte replacement Relief of obstruction Surgical treatment is necessary for most cases of intestinal obstruction but should be delayed until resuscitation is complete, provided there is no sign of strangulation or evidence of closed-loop obstruction
Principles of surgical intervention for obstruction Management of: The segment at the site of obstruction The distended proximal bowel The underlying cause of obstruction
Indications for early surgical intervention Obstructed or strangulated external hernia Internal intestinal strangulation Acute obstruction
Treatment of adhesive obstruction Initially treat conservatively provided there are no signs of strangulation; should rarely continue conservative treatment for longer than 72 hours At operation, divide only the causative adhesion(s) and limit dissection Cover serosal tears; invaginate (or resect) areas of doubtful viability Laparoscopic adhesiolysis may have a role in chronic cases