APPROACH TO BOWEL

OBSTRUCTION, INFANT
AND OLDER CHILD

DR JAISHREE NAIDOO
 OBJECTIVES
• CAUSES OF OBSTRUCTION-
INFANT AND OLDER CHILD

• AXR – APPROACH

• IMPORTANT TIPS ON APPROPRIATE

RADIOLOGICAL INVESTIGATIONS
BOWEL OBSTRUCTION IN THE
INFANT
NORMAL NEONATAL GAS PATTERN
• Neonatal abdomen is very gassy
• Swallowed gas is present in the stomach and
proximal bowel in a few seconds.
• Gas reaches the caecum by the 5th to 11th
hour.
• Cannot tell the difference between small and
large bowel
• Jumbled mosaic pattern, cubes
 AXR APPROACH

• GASSES

• MASSES

• STONES

• BONES
CAUSES OF OBSTRUCTION

PROXIMAL DISTAL
OESPHAGEAL ATRESIA HIRSHPRUNGS DISEASE

HYPERTROPHIC PYLORIC ILEAL ATRESIA

STENOSIS
DUODENAL ATRESIA, STENOSIS MECONIUM ILEUS

MALROTATION, MIDGUT MECONIUM PLUG

VOLVULUS
JEJUNAL ATRESIA ANAL ATRESIA / ARM
 BOWEL OBSTRUCTION
• Presentations of both PROXIMAL AND DISTAL
obstruction may be identical.
• Proximal –defined as proximal to ileum
• Distal – distal to ileum
• Clinical presentation : inability to pass a NG
tube, vomiting (bilious, non bilious,
projectile), slow or no passage of meconium
OESOPHAGEAL ATRESIA

SOURCE: Merck Manual

OESPHAGEAL ATRESIA
HYPERTROPHIC PYLORIC STENOSIS
• Typically infant with progressive projectile
vomiting
• Usually 2-8 weeks of life, although it can
occur as early as a few days and as late as 3
month
• Hypertrophy of the circular musculature of
the pylorus
• May be able to palpate an ‘olive’
• Best diagnosed on ultrasound
Normal channel length = <15mm
Normal wall thickness = <3mm
 DUODENAL OBSTRUCTION
• Most common site of intestinal atresia.
• May be partial (stenosis), complete (atresia)
or associated with a membrane (web) or
annular pancreas. All part of a spectrum of
similar abnormalities.
• Usually in the region of the ampulla of Vater.
• 30% assoc with Down Syndrome.
• Other associations: VACTER, CHD, biliary
abnormalities.
• X-ray gives a ‘double bubble’ appearance
DUODENAL ATRESIA
 MALROTATION/VOLVULUS
• TRUE EMERGENCY!!
• Usually presents with abdominal distention
• Bile stained vomiting
• Caused by abnormal fixation of small bowel
mesentery resulting in a short mesenteric base
that predisposes to twisting
• Symptoms –any age but most in the first month
• Possible Volvulus is an EMERGENCY
• Delay can result in bowel ischaemia
NORMAL DJ FLEXURE
MALROTATION
VOLVULUS
 JEJUNAL ATRESIA
• Common cause of congenital intestinal
atresia, and neonatal intestinal obstruction
• Pathogenesis: late intra-uterine mesenteric
vascular accident
• 4 types
• Proximal jejunal atresia:Dilated stomach +
duodenum + 1-2 loops of jejunum.
JEJUNAL ATRESIA
JEJUNAL ATRESIA
 DISTAL BOWEL OBSTRUCTION IN
NEONATE
• HIRSCHPRUNGS DISEASE
• ILEAL ATRESIA
• MECONIUM PLUG
• MECONIUM ILEUS
• IMPERFORATE ANUS/ARM

• AXR:MULTIPLE DILATED LOOPS

 HIRSCHSPRUNG DISEASE
• Functional obstruction of the colon
secondary to lack of ganglion cells.
• Denervated colon spasms and is narrow.
• The innervated colon proximal to it dilates.
• Can be a short or long segment of colon.
• Enema looks for ‘transition’zone, and
estimates length of involved colon.
CONTRAST ENEMA
 ILEAL ATRESIA

• Distal ileal atresia

• AXR: multiple dilated bowel loops
• Enema shows micro colon, secondary to
disuse
 MECONIUM ILEUS
• Secondary to obstruction of the distal ileum
due to accumulation of thick meconium.
• Occurs almost exclusively in CF.
• Is the presenting finding of CF in 10%.
• May be complicated by perforation and
peritonitis.
• Classic finding is ‘bubbly’ gas pattern in RLQ
 MECONIUM ILEUS
• Enema with dilute non-ionic contrast to
diagnose, may Rx
• Typically get a small caliber micro colon
second to non use, with multiple filling
defects in the TI.
• Serial enemas success rate 50-60%.
 MECONIUM PLUG
• Small left colon
• Transient functional obstruction of the
newborn colon
• Predisposing factors : infants of diabetic
mothers /mothers treated with magnesium
sulfate for preeclampsia
• Most frequent encountered diagnosis in
neonates who fail to pass meconium
• Often resolves after diagnostic water soluble
contrast enema
MECONIUM PLUG
 ANORECTAL MALFORMATION
• Usually a clinical diagnosis – no anus evident
.
• 1:5000 – commoner in boys.
• HIGH- rectal pouch terminates above levator
sling which is poorly developed. Get
colostomy. Also 40% have GU problems.
• LOW – rectal pouch passes through levator
sling. Sling well developed, get anoplasty or
pull through soon after birth.
FISTULOGRAM
 SMALL BOWEL OBSTRUCTION IN
THE OLDER CHILD

• Different spectrum of disease compared to

the neonate
• A- appendicitis
adhesions
• I- intussusception
incarcerated hernia
• M-malrotation
meckel diverticulum
 APPENDICITIS
• Most common presentation of abdominal pain
• Obstruction of the appendiceal lumen:
infection, ischaemia and eventually
perforation
• Imaging :diagnosis, decrease perforation rate,
identify alternative diagnosis
APPENDICITIS
 INTUSSUSEPTION
• Peristalsis: invagination of the more proximal
bowel (intussusceptum) into the lumen of the
more distal bowel (intussuscipiens)
• Most common site terminal ileum /ileocecal
valve
• 90% ileocolic
• Typical age is between 3 months and 1 year
• Older than 3 years: consider a pathological
lead point
INTUSSUSEPTION
 AIR REDUCTION ENEMA

• SASPI PROTOCOL ON RSSA WEBSITE

www.rssa.co.za
 INCARCERATED HERNIA
• LOOK FOR GASES IN FUNNY PLACES
 MALROTATION /VOLVULUS
• CAN PRESENT LATER IN AN OLDER CHILD
 CONCLUSION
• AGE OF PATIENT
• AXR : GAS PATTERN
GAS IN FUNNY PLACES
FREE AIR
CALCIFICATIONS
MASSES
BONES
THANK YOU
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