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GIT EMERGENCIES

Neonatal Intestinal obstruction


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

Adults
Terminal ileitis
Ureteric coli
Pyelonephritis
Perforated peptic ulcer
Testicular torsion
Acute pancreatitis
Rectus sheath haematoma

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