Dr. Mahdi Aziz – Sess 12 – Lec 2
Neonatal Intestinal Obstruction
• Most common surgical emergency in neonate
• Management depends on timely diagnosis
• Needs radiological assessment
• Outcome is excellent
Presentation
• Refusal to take feed
• Vomiting
• Abdominal distension
• Delayed/failure to pass meconium
Causes
• High Intestinal Obstruction:
• Proximal to ileum i.e., gastric, duodenal & jejunal
• Low Intestinal Obstruction:
• Distal ileum & colon
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High Intestinal Obstruction
1. Gastric Atresia
• Rare
• Usually, distal
• AXR-gas filled stomach without distal intestinal air (single bubble sign)
• Can be diagnosed antenatally by US
2. Duodenal atresia
• Congenital failure of recanalization
• Association with VATER/VACTREL & trisomy 21
• Post. Ampullary – bilious vomiting
• On AXR: (double bubble sign)
➢ gas filled distended stomach & duodenal cap
➢ Absent distal bowel gas
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3. Duodenal stenosis
• Gastro duodenal distension but distal gases present
• On contrast-slow transit of contrast distally
4. Duodenal web
• Small congenital obstructive membrane with central aperture
5. Malrotation & Mid gut volvulus
• Failure of normal physiological herniation in embryo
• Leads to narrow mesenteric attachment
• Predispose to rotation around superior mesenteric vessels
• If untreated leads to bowel ischemia & infarction
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6. Jejunal Atresia
• Intestinal ischemia during intra uterine life.
•
Present with bilous vomitting & abdominal distention.
• TRIPLE BUBBLE SIGN
Distention of stomach, duodenum & jejunum.
Low Intestinal Obstruction
1. Ileal Atresia
• Due to intra uterine ischemic insult.
• Bilous vomiting & distention. Numerous dilated bowel
loops.
2. Meconium Ileus
• Meconium plugs obstruct colon & distal small bowel.
• Associated with cystic fibrosis.
• AXR- multiple distended gut loops.
• Contrast study-meconium plugs & micro colon.
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3. Functional Immaturity of Colon
• Meconium plug /small left colon syndrome.
• Benign & self-limiting condition.
• Due to immaturity of colonic ganglion cells.
• To infants of diabetic mothers & those who took MgSO4 for pre-eclampsia.
Contrast studies- dilated ascending & transverse colon small descending colon rectum
normal
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4. Hirschsprung Disease
•
Arrest of neuron migration to distal bowel before
12 week.
➢ Rectosigmoid- 75%
➢ Splenic flexure- 20%
➢ Whole colon- 5%
CLINICAL PRESENTATION
➢ Neonatal Intestinal Obstruction (NIO)
➢ Chronic Constipation (CC)
➢ Enterocolitis (EC)
• Affected segment narrowed
• Proximal dilatation
Contrast Enema showing Aganglionic
segment with the transition zone
5. Colonic Atresia
• Rarely an uncommon condition
• Intrauterine vascular insult
• Proximal to splenic flexure
6. Anorectal Malformation
• Association with VATER
• High/Low depending levator ani muscle
• Incidence: 1 in 5000 live births.
• Most common in females is a rectovestibular fistula
• 50% of all patients with anorectal malformations have an associated urogenital
anomaly
• The relationship of the distal rectum to the puborectalis muscle divides the imperforate
anus malformations into high (supralevator) and low (infralevator) malformations
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Early treatment for neonates born with an anorectal anomaly is crucial.
During the first 24-48 hours of life, answer the following 2 questions:
1. Are any associated anomalies present that threaten the baby's life and need to be
addressed immediately?
2. Should the infant undergo a primary procedure with no protective colostomy or a
protective colostomy with a definitive repair at a later date?
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