Zaporozhia State medical university
Department of Pediatrics’s Surgery
Methodical recommendations for students of VI rate of medical faculty on a
theme:
Acquired Intestinal Obstruction
(Etiology, pathogenic and clinical picture disease, differential diagnostics, methods of
examination, treatment)
Confirm at methodical meeting of faculty the report № ___ from __________ 2014.
Authors: Baruchovich V., Kokorkin A.
The head of the department prof. Spakhi O.V.
Zaporozhia – 2014
The topic: Vomiting in children of acquired intestinal obstruction.
1. Actuality of the topic: student, examining a child, should assess character of
vomiting and others symptoms of acquired intestinal obstruction, what is a way to
correct diagnosis and necessary treatment .
This position especially important in process of examination of the newborns
and young children’s, in whom early diagnosis is a pledge of a survival. Often a
wrong diagnosis in children with vomiting due to ileus leads to development of lifethreatening complications (peritonitis, sepsis, cardio-respiratory disorders, acute
renal insufficiency).
3. Objects of the lesson:
3.1. General objects. Students should know etiology, pathogenic, clinical picture,
differential diagnostics and treatment of acquired intestinal obstruction.
3.2. Educational objects.
As a result of lesson in students must be formed the
responsible regard to examination of children’s with acquired intestinal obstruction.
3.3. Concrete objects.
Students must know:
1. Pathogenesis of different kinds of vomiting.
2. Basic characteristics of vomiting.
3. Diseases with syndrome of vomiting.
4. Methods of examinations of the children with acquired intestinal obstruction.
5. Basic principles of the treatment children’s with acquired intestinal obstruction.
3.4.Students should be able:
1. Compile anamnesis of the disease in children with acquired intestinal obstruction.
2. Examine children of the different age with the complaint on vomiting.
3. Appoint a plan of examination of the child with acquired intestinal obstruction.
4. Assess results of examination.
5. Make a diagnosis on the ground of examination.
4. The contents of a topic:
Background
Small-bowel obstructions in pediatric patients are uncommon but should be
suspected in any child with persistent vomiting, distention, and abdominal pain
because delayed diagnosis and treatment can have devastating consequences.
Infants and young children with intestinal obstruction present with pain, irritability,
vomiting, and abdominal distension. Small-bowel obstructions progress to
decreased or no bowel movements. Undiagnosed or improperly managed
obstructions can lead to vascular compromise, which causes bowel ischemia,
necrosis, perforation, sepsis, and death.
Many different pathologic processes can cause small-bowel obstructions.
These processes can be divided into acute intestinal obstructions and chronic
partial intestinal obstructions. These conditions can be further subdivided into
those that present in the immediate postnatal period and those that occur later in
childhood.
Causes of Acquired Intestinal Obstructions
Intussusceptions
Intussusception is the most common cause of intestinal obstruction in infants
and children aged 3 months to 6 years and is the second most common cause of
acute abdomen in this age group. It occurs when a proximal segment of the
intestine (called intussusceptum) telescopes or invaginates into the lumen of
another immediately adjacent distal segment (called intussuscipiens). The peak age
of presentation is between 5 and 10 months. Intussusception is more common in
males. Less than 1% of intussusceptions are found in neonates; however, cases
have been reported in newborns and premature babies. Early diagnosis and prompt
treatment prevent catastrophic complications in this group of patients. In 95% of
cases, the intussusception is in the ileocecal area. Ileoileal and colocolic
intussusceptions are rare. Occasionally, an ileoileal intussusception of the terminal
ileum may progress through the ileocecal valve, a condition known as ileoileocolic
intussusception.
Incarcerated hernias
Incarcerated hernias occur when the contents of a hernia sac cannot be
reduced back into the abdominal cavity. Incarcerated hernias can be inguinal,
femoral, or umbilical. Inguinal and femoral incarcerated hernias are most common
in both sexes. The vast majority of inguinal hernias in children are indirect hernias.
Most direct hernias in the pediatric population occur following repair of an indirect
hernia. Femoral hernias, which tend to incarcerate, are extremely rare in children
and are the only hernias that occur in girls more often than boys. Incarceration
represents the most common complication associated with inguinal hernias. In
several large series, incarceration was reported in 6-18% of patients. The incidence
could be as high as 30% for infants younger than 2 months. Umbilical hernias are
very common in children, rarely incarcerate, and often close spontaneously by age
5 years.
Malrotation of bowel with midgut volvulus
Intestinal malrotation refers to errors of midgut rotation around the superior
mesenteric artery axis and the subsequent fixation of the midgut in the peritoneal
cavity. Nonrotation, incomplete rotation, reversed rotation, and alterations of
fixation including the internal hernias (mesocolic, paraduodenal) and the mobile
cecum are among the many embryonic variants of the anomaly. Malrotation is
always present in patients with abdominal wall defects (gastroschisis,
omphalocele) and patients with congenital diaphragmatic hernia. It is often
associated with other congenital and acquired lesions of the GI tract, such as
Hirschsprung disease, intussusception, and atresia of the jejunum, duodenum, and
esophagus. In children, the most common form of malrotation occurs when the
process of rotation is incomplete and the ligament of Treitz or the cecum is
abnormally located or fixed. The mesenteric attachment of the midgut to the
posterior abdominal wall is narrow and predisposes the midgut to twist around an
axis formed by the superior mesenteric artery (midgut volvulus). Complete
volvulus of the bowel for more than 1-2 hours can totally obstruct blood supply to
the bowel, leading to complete necrosis of the involved segment.
Postoperative adhesions
Adhesive small-bowel obstruction is an annoying surgical complication. It is
incidence seems to be lower after laparoscopic procedures than after laparotomy.
Postoperative adhesions are responsible for about 7% of the intestinal obstructions
in infants and children. A single adhesion causes most obstructions, regardless of
the nature of the previous illness or type of abdominal surgery. Onset of
obstructive symptoms can range from 2 days to 10 years postsurgery, although
most adhesions (>50%) occur within the first 3-6 postoperative months, and few
occur after 2 years.
Mesocolic hernia
Mesocolic hernia is a malrotation abnormality. Nonfixed colonic and
duodenal mesenteries lead to formation of potential hernia pouches, which
transiently and recurrently entrap the bowel and cause partial obstructions. Their
exact incidence is still unknown, but, fortunately, they are rather rare. The internal
hernias may be right- or left-sided and can sometimes incarcerate and strangulate.
The mesocolic hernia is not a malrotation anomaly per se but occurs in the
presence of a rotational anomaly. Mesocolic hernias can also occur as a
consequence of retroperitoneal surgery in cases in which a mesenteric defect is not
properly closed during the procedure.
Cecal volvulus
Cecal volvulus is a rare disorder of nonfixation (ie, a mobile cecum), rather
than a pure malrotation. Cecal volvulus most commonly occurs as axial twisting of
the cecum, ascending colon, and terminal ileum. It has also been described in
patients who have undergone a Malone antegrade continence enema (MACE)
procedure, in which the cecal appendix is used as a tubular conduit between the
abdominal wall and the cecum, creating a stoma through which the patient can get
an antegrade enema to achieve "social continence."
Duplication cysts
Duplications of the alimentary tract comprise a group of rare malformations
that vary greatly in appearance, size, location, and symptoms. Foley et al reported
on 12 cases of enteric duplications during an 11-year period. Duplication cysts are
either cystic or tubular in shape. They have been reported to occur anywhere along
the GI tract from the tongue to the anus, although most are located in the terminal
ileum near the ileocecal valve. Duplications are seen in 1 of every 4500 autopsies;
85% of cases are detected by age 2 years. The 3 characteristics of alimentary tract
duplications proposed by Ladd and Gross include (1) contiguity with and strong
adherence to some part of the alimentary tract, (2) a smooth muscle coat (usually in
2 layers), and (3) a mucosal lining that consists of one or more types of cells
normally observed in the alimentary tract. Most duplications are truly enteric cysts;
only a select group actually represent attempts to double the alimentary tract. The
intestinal epithelium may or may not correspond to the epithelium of the adjacent
intestinal structure. Gastric mucosa is the most common ectopic tissue found.
Intestinal obstruction, bleeding, infection, and carcinomatous degeneration have
been observed with these anomalies, and early correct diagnosis is vital. Most
symptoms are caused by the mass effect, and the duplication causes either a partial
or complete small-bowel obstruction.
Mortality/Morbidity
Mortality and morbidity depend on the type of lesion that causes the smallbowel obstruction, whether it is a closed-loop or strangulated obstruction, and the
time elapsed before diagnosis and definitive adequate treatment is established.
Mortality is low with early diagnosis and treatment. If left untreated, strangulated
obstructions are always lethal. Mortality rates may reach 65% if more than 75% of
the small bowel is necrotic at the time of laparotomy. Strictures and adhesions are
only 2 of the late complications of treated obstructions. Too much bowel damage
can cause malnutrition due to short bowel syndrome. Long-term survival in
patients with duodenal atresia or stenosis is approximately 86%. Most of the
morbidity and mortality is related to cardiac anomalies. This includes patients with
annular pancreas. Although intussusception-associated infant deaths in the United
States have declined substantially over the past 2 decades, some of these deaths
may have been preventable because they were apparently related to delayed or
reduced access to health care. The survival rate at 1 year is approximately 92% in
patients with uncomplicated MI and 89% in those with complicated disease.
Intestinal resections have been reported in about 1.4-1.8% of patients with
incarcerated inguinal hernias. The incidence of testicular infarction and atrophy
ranges from 4-12%; young infants seem to be at higher risk.
Sex
The male-to-female ratio for incarcerated hernias is 8:1. Hernias occur on the
right in about 60% of males, on the left in 25%, and bilaterally in 15%. Females
more often have bilateral inguinal hernias. Malrotation of the bowel with midgut
volvulus can affect either sex. Neither duplication cysts nor jejunoileal atresia and
stenosis exhibit a sexual predilection.
Age
Intussusception can occur at any time in life, yet the idiopathic form is
primarily a childhood disease, developing especially during infancy. Peak
occurrence is in infants aged 5-10 months; average age is about 7-8 months. Most
patients with inguinal hernias present during the first year of life. Approximately
one third are younger than 6 months at the time of surgery. Most patients with
symptomatic malrotation of the bowel with midgut volvulus present in early
infancy. Approximately 50% of patients present in the first month of life, and 80%
present in the first year. Midgut volvulus has reportedly occurred in utero. Fewer
patients (ie, 6-20%) present at ages older than 1 year; these patients tend to have a
longer course of vague symptoms (eg, intermittent bilious vomiting, chronic
abdominal pain). Most patients with duplication cysts present in early childhood
or infancy, although some may not develop symptoms until much later. Many
duplication cysts are diagnosed within the first week of life, 60% are identified
during the first 6 months of life, and 85% are identified by age 1 year.
History
Obtain as much history as possible from the child. Younger children, for
example, are likely to recall recent events, while adults remember more remote
events. Physicians should seek an accurate chronology of the disorder. Asking
when the child was last completely healthy may provide a more accurate
assessment of the child's pathophysiology. Bilious vomiting in the neonate should
be considered secondary to a mechanical obstruction until proven otherwise, and
every newborn with this symptom warrants an emergent surgical evaluation.
Focus on the following issues:
Abdominal pain
Pain is common. Caregivers may describe an infant or small child with
abdominal pain as irritable or inconsolable. Pain from a small-bowel obstruction is
usually colicky. It is described as cramplike and episodic, persisting a few minutes
at a time. A child with obstructive pain may be unable to remain immobile on the
examining table. Constant pain occurs later in the disease course, with
strangulation and perforation.
Nausea and vomiting
Vomiting is a classic symptom of mechanical obstruction. Emesis caused by a
proximal obstruction is usually of gastric content or bilious if the obstruction is
distal to the ampulla of Vater; in distal ileal obstructions, vomit is feculent.
Anorexia: Anorexia is an early and frequent sign.
Diarrhea: Diarrhea may occur early in the course of the obstruction.
Obstipation: This is a late sign of complete obstruction.
Fever: Fever can occur late in the disease process and is associated with bowel
strangulation and necrosis.
General historical points: Obtain a complete medical history, specifically
including information on prior malignancies, radiation therapies, and abdominal or
pelvic surgeries. A history of repetitive abdominal pain with vomiting indicates a
chronic partial small-bowel obstruction. In addition to the general guidelines
above, the following evidence may suggest the specific cause of a small-bowel
obstruction:Intussusception usually causes a sudden onset of severe colicky
abdominal pain that often causes a child to draw up both legs. Children appear
healthy between paroxysms of pain. As the intussusception progresses, the child
becomes progressively more irritable and lethargic until shock develops. Vomiting
occurs in the early phase of the illness and is bilious in 30% of cases. Early in the
course of the disease, stools are normal but rapidly become bloody and mucoid
within the first 12 hours.
The classic triad described for intussusception, which consists of colicky
abdominal pain, a sausage-shaped palpable abdominal mass, and currant-jelly
stools, is actually found in only 20% of cases. Postoperative intussusception occurs
within 2-3 weeks after an extensive retroperitoneal dissection (Wilms tumor or
neuroblastoma). It is usually an ileoileal intussusception, and affected patients lack
the palpable mass and rectal bleeding.
An incarcerated hernia is usually associated with signs and symptoms of
intestinal obstruction (eg, bilious vomiting, abdominal distention, constipation,
obstipation). A tender, edematous, slightly discolored–to–pale mass in the inguinal
area may extend down into the scrotum. A swollen erythematous mass that
becomes erythematous to violaceous and is exquisitely tender usually indicates a
strangulated hernia. Fever and toxicity suggest frank necrosis of the incarcerated
organ and impending or completed perforation.
The hallmark of acute midgut volvulus is the sudden onset of bilious
vomiting, which may be projectile vomiting and, on occasion, have a coffeeground appearance or contain frank blood. History may reveal feeding problems,
with transient episodes of bilious vomiting or failure to thrive. An abdominal
distention or a palpable mass may not be evident because the obstruction occurs so
high in the GI tract. Older children typically describe colicky abdominal pain.
Stools are usually absent but those that do occur yield positive results on guaiac
tests. Bright-red blood passed through the rectum implies intestinal ischemia.
Postoperative adhesive small-bowel obstructions usually cause a sudden
cramplike abdominal pain, followed by anorexia, nausea, and vomiting. Bowel
movements typically cease shortly after symptom onset.
Presentation of duplication cysts primarily depends on the type of mucosal
lining and cyst location. At least 16% of small-bowel duplications contain gastric
mucosa and may manifest with peptic ulceration and GI hemorrhage. Spheric
cystic duplications may enlarge sufficiently to cause obstruction. Always consider
duplication cysts in the differential diagnosis of a vomiting infant or child with a
palpable solid abdominal mass and abdominal distention. These cysts may also act
as the lead point for an intussusception or form the apex of a volvulus.
Abdominal gastric and duodenal duplications may be confused with pyloric
stenosis because of their similar presentations. Older patients may present with
chronic intermittent vomiting caused by recurring partial obstruction or with an
unexplained GI hemorrhage. Because 20% of patients with rectal duplications have
fistulae, drainage of mucous or pus through the anus or a perianal fistula is not
uncommon.
Patients with mesocolic hernias typically have repeated episodes of colicky
abdominal pain and vomiting. These symptoms spontaneously subside when the
hernia spontaneously reduces. Patients with incarcerated hernias have continuous
pain, abdominal distention, nausea, and vomiting. The presenting symptoms of
cecal volvulus include pain, distention, constipation or obstipation, and vomiting.
Physical
Patients do not develop fever unless the blood supply to the obstructed bowel
becomes compromised, which may allow bacterial proliferation and subsequent
sepsis. In children who present late in the course of their illness, poor capillary
refill, hypotension, and even shock may occur as a result of increasing loss of fluid
into the bowel lumen. Abdominal tenderness may be minimal and diffuse or
localized and severe. Patients who develop peritonitis obviously have severe pain
and rebound tenderness. In affected patients, the abdomen may be tympanic to
percussion.
Mechanical obstructions produce active, high-pitched, hyperactive bowel
sounds with occasional rushes. Peristalsis may be increased in the upper abdomen
(above the obstruction; termed "fighting peristalsis") and decreased in the lower
abdomen. With time, peristaltic waves and bowel sounds may diminish. During
abdominal examinations, look for hernias of the groin, femoral triangle, and
obturator foramina. Perform a pelvic examination to exclude a genitourinary
pathology as the cause of an obstruction.
Rectal examination includes the following: Check for gross or occult bleeding
that suggests strangulation. The absence of stool in the vault may help confirm a
diagnosis of bowel obstruction, although its presence does not eliminate a more
proximal obstruction. In proximal obstructions, patients may be able to evacuate
preexisting rectal contents. Massive diarrhea after rectal examination of an empty
rectal vault is suggestive of colonic aganglionosis (ie, Hirschsprung disease). In
intussusception, physical examination of the abdomen occasionally reveals a
tender, sausage-shaped mass that is variable in size and firmness, with spasms of
pain. Because most intussusceptions are ileocolic, patients may present with Dance
sign (empty right lower quadrant). Careful physical examination is most useful in
the diagnosis of an incarcerated hernia. In patients with a postoperative adhesive
small-bowel obstruction, physical examination may reveal abdominal distention
and hyperactive high-pitched bowel sounds. Patients usually have a diffuse and
poorly localized tenderness that improves with proximal decompression by suction
tube.
Intussusception
Although the cause of intussusception is unknown in 90-95% of children, a
viral etiology is suspected because of its seasonal predisposition for spring and
autumn. Gastroenteritis, rotavirus infection, or allergic stimuli are believed to
cause intestinal lymphoid tissue to swell and become a lead point to pull the mass
into adjacent proximal intestine. In patients younger than 1 month and older than 3
years, pathologic lesions serve as the lead points that produce the condition.
Intussusception is a well-described complication of patients with Meckel
diverticulum, Waugh syndrome, cocaine abuse, laxative use, and even antibiotic
use, presumably due to motility derangements caused by some of these agents. In
Henoch-Schönlein purpura, mucosal hematomas are thought to act as lead points.
Peutz-Jeghers syndrome is a rare cause of intussusception in older children; in
this condition, hamartomatous polyps act as the lead point. Similarly, familial
polyposis coli and juvenile polyposis can also cause intussusceptions, and a
vermiform appendix may occasionally cause an intussusception. Suspect intestinal
lymphomas in all children older than 6 years with intussusception. As mentioned
above, extensive retroperitoneal dissections are known to predispose children to
postoperative intussusception. Blunt abdominal trauma has also been known to
cause intussusception.
Incarcerated hernia
During the third month of gestation, the abdominal peritoneum protrudes at
the internal inguinal ring and extends to the scrotum to form a diverticulum known
as the processus vaginalis. In females, this diverticulum is called the canal of Nuck
and extends through the internal inguinal ring to the labia majora.
At birth, the processus vaginalis is open and in communication with the
peritoneal cavity in about 80% of babies. Closure takes place progressively during
the first 2 years of life, with an estimated 20-30% incidence of patency at age 2
years and then little further decline. This patent processus vaginalis becomes a
hernia only when it contains abdominal viscera.
Incarcerated or nonreducible hernias may contain small bowel, appendix,
omentum, colon, or, rarely, Meckel diverticulum (Littre hernia). In girls, the ovary,
fallopian tube, or both are usually incarcerated. Umbilical hernias are the result of
an incompletely closed umbilical ring. Most spontaneously resolve by age 5 years.
Malrotation of the bowel with midgut volvulus
The primitive gut, which forms during the fourth week of embryonal life, is
divided into the foregut, midgut, and hindgut. The largest of these, the midgut, is
the only portion that undergoes rotation by herniating extraembryonically into the
umbilical cord and rotating 270° in a counterclockwise direction around the
superior mesenteric artery on its journey back to the abdominal cavity. This
produces the normal C-shaped configuration of the duodenum and results in the
cecum coming to rest in the right lower quadrant of the abdomen.
For unknown reasons, midgut rotation can arrest at any point, most commonly
rotating 180° and leaving the cecocolic loop in the right upper quadrant. Dense
peritoneal bands (ie, Ladd bands) cross from the malpositioned right colon across
the duodenum to the right lateral abdominal wall. This configuration leaves a
narrow mesenteric root and creates a predisposition to clockwise torsion of the
midgut, while the Ladd bands themselves can obstruct the duodenum.
Theories of malrotation are based on anatomical and pathologic findings, but
the actual rotation movements have not been seen in human embryos. Recent
evidence suggests that, at least in rats, the midgut never rotates around the superior
mesenteric artery and the final normal position and fixation of the midgut is
probably due to differential growth of specific intestinal segments, rather than to
rotation movements.
Postoperative adhesive small-bowel obstruction
Duplication cysts: The embryogenesis of rectal duplications has been
attributed to the pinching off of diverticula that are present in the 8- to 9-week-old
embryo. The reported association of spinal abnormalities makes the split notochord
mechanism another probable origin of rectal duplications. Annular pancreas:
Annular pancreas occurs when the ventral pancreatic bud fails to rotate behind the
duodenum, leaving pancreatic tissue fully encircling the second portion of the
duodenum. This results in a nondistensible ring of pancreatic parenchyma and a
functional stenosis.
The 3 basic morphologic features of duodenal atresias are as follows:
Type I atresias are characterized by luminal webs or membranes.
Type II is characterized by a complete atresia connected by a fibrous cord.
Type III is characterized by complete atresia with a gap between the segments.
Imaging Studies
Plain abdominal radiography should be the initial radiologic study in
suspected cases of small-bowel obstruction. Obtain flat and upright radiographs of
the abdomen. Study radiographs for signs of dilated small-bowel loops and of airfluid levels produced by the layering of air and intestinal content. Absent colonic
or rectal gas also indicates a small-bowel obstruction. The pattern of bowel gas on
plain radiography can help differentiate between proximal and distal bowel
obstructions. When intestinal perforation is suspected and the child cannot be
placed in an upright position, a left lateral decubitus film with horizontal beam is
helpful in diagnosing free intraperitoneal air. Contrast studies such as upper GI
series and contrast enemas can help determine obstruction location. Contrast
studies also reveal whether the obstruction is intrinsic or extrinsic to the bowel.
Abdominal CT scanning should not be obtained when the diagnosis is evident
on radiography because this would only delay treatment and subject the child to
unnecessary radiation. CT scanning helps identify causes of chronic partial
obstructions, as well as abscesses, tumors, and many other causes of acute
abdominal
pain.
Ultrasonographic
examinations
reveal
many
intestinal
abnormalities, including tumors, mesenteric cysts, and intussusceptions.
Intussusception imaging includes the following:
In approximately 60% of intussusception cases, plain abdominal radiography
reveals the head of the intussusceptum projecting into the air-filled colon.
Abdominal radiography may also reveal scattered air-fluid levels that suggest an
ileus or partial obstruction. Contrast radiography using a barium enema can be
therapeutic as well as diagnostic. A classic sign is a coil spring appearance caused
by the tracking of barium around the lumen of the edematous intestine. Air and
water enemas have been used to reduce intussusception with extremely good
results.Ultrasonography is useful in some cases and may have sensitivity in as
many as 75% of patients. The characteristic finding is a target or bull's eye
configuration, consisting of 2 rings of low echogenicity that are separated by an
intermediate hyperechoic ring visible on a cross-sectional image of intussuscepted
bowel.
Incarcerated hernia imaging includes the following:
In complete bowel obstruction, air-fluid levels are visible on plain
radiography. The bowel may be visible within the inguinal canal and scrotum.
Ultrasonography may reveal the incarcerated viscera in the inguinal canal or the
umbilical ring and can be useful in difficult cases. A careful physical examination
is more helpful than imaging studies for the diagnosis of incarcerated inguinal or
umbilical hernias. Incarcerated hernias are diagnosed clinically, and no imaging
studies are required. Determining the level of the obstruction is not that important
because the treatment does depend on this finding. Imaging for malrotation of the
bowel with midgut volvulus includes the following: Plain abdominal radiography
sometimes reveals a double-bubble sign that depicts air-fluid levels in both the
stomach and in the distended duodenum. The abdomen often appears gasless on
abdominal plain radiography. Distended loops of small bowel are only
occasionally visible because the point of obstruction is proximal, in the third
portion of the duodenum. Definitive diagnosis of midgut volvulus requires contrast
studies. Barium enema findings may provide indirect evidence by revealing an
ectopically placed right colon and cecum, but a high or mobile cecum is common
in many asymptomatic infants. In fact, 10-15% of patients with malrotation have
barium enema findings that appear normal. An upper GI series is a quicker and
more direct approach with high sensitivity and accuracy, making it the study of
choice for malrotation with or without volvulus. The duodenum usually has a "C"
shape, and the duodenojejunal junction is localized to the left of the midline. In
malrotation, the duodenum lacks its normal shape and does not cross the midline.
Duodenal obstructions due to volvulus, Ladd bands, or angulation are evident. The
classic patterns of volvulus are the "bird beak" in cases involving complete
duodenal obstruction or the "corkscrew in cases involving incomplete obstruction.
Imaging for postoperative adhesive small-bowel obstruction includes the
following:
Supine and upright abdominal radiography reveals dilated gas-filled loops of
small intestine with multiple air-fluid levels scattered throughout the abdomen
above the obstruction site. Air in the colon usually indicates a partial obstruction,
although determining whether a gas-filled loop is the colon or small bowel is
difficult in infants. Demonstrating gas in the rectum is the only way to be certain of
gas in the colon. An upper GI contrast study helps confirm the diagnosis in
questionable cases.
Imaging for duplication cysts is as follows:
Plain radiography usually reveals a soft-tissue mass within the abdomen that
displaces the adjacent bowel and causes the obstruction. An upper GI contrast
series may reveal stenosis or extrinsic compression by a mass.
For most abdominal duplications, ultrasonography is more expedient and
provides greater detail than conventional contrast radiography. Ultrasonography
reveals either a sonolucent mass that has good through transmission because of its
clear fluid content or an echogenic mass secondary to hemorrhage that has
inspissated material within the duplication. Intraabdominal enteric duplication
cysts are increasingly likely to be prenatally detected.
Mesocolic hernia imaging is as follows:
An upper GI study with small bowel follow-through during a hernia episode
can support the diagnosis. This study usually reveals the intestines bunched
together as if enveloped by a sac. Abdominal CT scanning may reveal a mesocolic
hernia during nonherniating periods.
Cecal volvulus imaging is as follows:
Plain abdominal radiography may reveal a large air-filled loop of colon that
occupies the right lower quadrant, in addition to depicting a typical small-bowel
obstruction. The characteristic barium enema finding is a bird-beak–shaped
deformity, coupled with nonvisualization of the cecum.
Medical Care
General principles
Stabilize the patient and monitor airway, breathing, and circulation (ABC).
Replace fluids with diligent intravenous resuscitation, using isotonic sodium
chloride solution or lactated Ringer solution. Earlier bowel decompression with an
NG tube decreases the chance of bowel necrosis and perforation. Administer
broad-spectrum antibiotics when necrosis or perforation is suspected.
Intussusception
Stabilize the patient's ABCs and replace large fluid losses. Administer nothing
by mouth (NPO) to the child and place an NG tube in an attempt to decompress the
obstruction from above. The use of antibiotics is appropriate for management of
bacterial translocation. Barium, water, or air reduction is appropriate after surgical
consultation if symptom duration is less than 24 hours and the patient has no signs
of
peritonitis.
Barium
reduction
successfully
reduces
80-95%
of
all
intussusceptions and has even better success in short-duration intussusceptions.
Children whose symptoms persist longer than 24 hours or who have signs of
peritonitis should not be considered candidates for enema reduction. Stabilize these
children and immediately transport them to the operating room because untreated
intussusception is almost always fatal. The recurrence rate is higher after enema
reduction than after surgical reduction. Surgery is also indicated for patients whose
intussusception cannot be reduced after 2 enema attempts.
Adhesive small-bowel obstruction
Only about 6-7% of children with adhesive small-bowel obstruction require
immediate laparotomy. Approximately one half of these patients respond to
medical treatment, which includes NPO, intravenous fluids, NG decompression,
and antibiotics. Children younger than 1 year tend to respond poorly to
conservative management. No single agent or treatment has proven effective in
preventing adhesion formation after a laparotomy. The use of water-soluble
contrast via NG tube may decrease the need for surgery in some patients. Watersoluble contrast media (Urografin) cause redistribution of intravascular and
extracellular fluid into the intestinal lumen because of their hyperosmolarity. As a
result, these media decrease intestinal wall edema and act as a direct stimulant to
intestinal peristalsis
Incarcerated hernia
The patient's ABCs and focus on replacing the large fluid losses.
Nonoperative reduction of a nonstrangulated hernia is possible in approximately
95-98% of cases. Facilitate the reduction by sedating the patient and placing the
patient in a mild Trendelenburg position. Gentle traction on the hernia and the
contents of the sac usually suffices to reduce the volume and rapidly retract the
contents of the sac into the abdominal cavity. The only contraindication to
nonoperative reduction is a long-standing incarceration with evidence of peritoneal
irritation. Antibiotic therapy is usually unwarranted, but critically ill infants with
perforation and peritonitis require coverage for aerobic gram-negative organisms
and anaerobic infections.
Surgical Care
Intussusception: Intussusception can be reduced by radiographic means in 8095% of patients. Surgical reduction is indicated when symptoms have been present
for more than 24 hours, in the presence of shock that cannot be corrected, when a
lead point has been identified, when necrosis or perforation are present, or if the
intussusception is irreducible by radiographic means.
Incarcerated hernia: After reducing the hernia, elective repair is possible 2448 hours after the edema subsides. For patients whose hernias cannot be reduced
and for patients with strangulation, immediate surgery is mandatory to prevent the
incarceration from progressing to perforation and frank peritonitis.
Malrotation of the bowel with midgut volvulus preserving intestinal viability
requires rapid diagnosis and surgery for malrotation with midgut volvulus. Initiate
NG suction and intravenous hydration when entertaining the possibility of midgut
volvulus. If abdominal plain radiographic findings confirm the diagnosis, defer
contrast studies and take the child directly to the operating room.
A Ladd procedure is the preferred treatment. It includes evisceration and
inspection of the mesenteric root, derotation of the volvulus (which has always
been reported to occur in a clockwise direction), lysis of Ladd bands with
kocherization of the duodenum along the right abdominal gutter, opening of the
visceral peritoneum that covers the mesentery, and replacing the small bowel into
the right side of the abdomen and the large bowel into the left side (in a position of
nonrotation). It also includes
an
appendectomy (usually an inversion
appendectomy) because the cecum and appendix are located in an unusual place.
Any frankly necrotic bowel should be resected and end-to-end anastomosis
performed unless the peritoneal cavity is grossly contaminated or the condition of
the patient does not allow it; in such cases, stomas should be created.
Postoperative adhesive small-bowel obstruction: A possible diagnosis of
adhesive small-bowel obstruction requires prompt surgical consultation because
delay can lead to intestinal necrosis. Patients usually present with a single-point
obstruction. Adhesiolysis is the treatment of choice. This can be achieved
laparoscopically or with laparotomy. Some patients require bowel resection
because of perforation or necrosis.
Duplication cysts
The treatment for duplications is surgical excision, even in an asymptomatic
patient who is incidentally diagnosed. The prevalence of gastric mucosa suggests
that the duplications should not be left indefinitely. The procedure may depend on
the location of the cyst. In esophageal duplications, the cyst is excised, and a
mucosectomy is performed if the muscular layer shared with the esophagus is left
behind. The entire muscular wall can be excised with the cyst, taking care not to
penetrate the esophageal mucosa. Duplications of the small intestine usually
require resection and anastomosis. In rectal duplications, only the mucosal lining
usually needs to be excised because the duplication and normal rectum share the
muscularis layer. If malignant degeneration is suspected, total excision including
the normal rectum may be necessary. Infected duplications may require initial
drainage, followed by a staged resection. Laparoscopically assisted resection of
ileocecal duplications is safe and effective.
Mesocolic hernia: Surgically reduce the hernia and repair the potential hernia
pouch, either electively (for reducible hernias) or emergently (for incarcerated
hernias.)
Cecal volvulus: Surgical reduction of the cecal volvulus is usually required, in
addition to fluid resuscitation, bowel decompression, and ABC monitoring.
Drug Name Metronidazole (Flagyl)
Description Imidazole ring-based antibiotic active against various anaerobic
bacteria and protozoa. Used in combination with other antimicrobial agents (used
alone in Clostridium difficile enterocolitis).
Pediatric Dose Neonates:
<1200 grams: 7.5 mg/kg IV q48h
<7 days and >1200 grams: 7.5-15 mg/kg IV daily or divided q12h
>7 days and >1200 grams: 15-30 mg/kg IV daily or divided q12h
Infants and children: 30 mg/kg IV daily or divided q6h; not to exceed 4 g/d
Contraindications Documented hypersensitivity
Interactions May increase toxicity of anticoagulants, lithium, and phenytoin;
cimetidine may increase toxicity; disulfiram reaction may occur with orally
ingested ethanol. Precautions Do not use in first trimester of pregnancy; adjust
dose in hepatic disease; monitor for seizures and development of peripheral
neuropathy.
Drug Name Aztreonam (Azactam)
Description Monobactam that inhibits cell wall synthesis during bacterial growth.
Active against gram-negative bacilli. Effective against aerobic gram-negative
organisms.
Pediatric Dose 30 mg/kg IV q6-8h
Contraindications Documented hypersensitivity
Interactions Tetracyclines may reduce effects
Precautions Adjust dose in renal insufficiency
Drug Name Imipenem and cilastatin (Primaxin)
Description Effective against aerobic and anaerobic gram-negative organisms.
Adult Dose 500 mg IV q6h
Pediatric Dose <1 week and >1500 grams: 25 mg/kg IV q12h1-4 weeks and >1500
grams: 25 mg/kg IV q8h4 weeks to 3 months and >1500 grams: 25 mg/kg IV
q6h>3 months: 15-25 mg/kg/IV q6h
Contraindications Documented hypersensitivity
Interactions Coadministration with cyclosporine may increase adverse CNS effects
of both agents; coadministration with ganciclovir may result in generalized
seizures.
Further Inpatient Care
Patients with partial small-bowel obstructions can be nonoperatively treated
with adequate fluid resuscitation and nasoenteric suctioning. Patients who do not
respond to nonoperative treatment within 48 hours require surgical treatment. After
nonoperative hernia reduction, elective repair may be accomplished 24-48 hours
after the edema subsides. Admit any child with an intussusception that is
successfully reduced with a barium enema for observation because this condition
has a high reoccurrence rate, especially in the first 24 hours.
Further Outpatient Care
Close follow-up observation is mandatory for patients whose partial smallbowel obstructions are nonoperatively treated and who are stable for discharge.
Instruct parents that they must take their child immediately to an ED if the child's
symptoms (eg, vomiting, pain) recur.
Complications:
1.
2.
3.
4.
5.
6.
7.
8.
Bowel necrosis
Bowel perforation
Sepsis
Shock
Abscess
Short bowel syndrome with malabsorption and malnutrition
Death
Testicular infarction and atrophy, lesion to the testicular vessels or vas
deferens, hernia recurrence (complications of incarcerated hernias)
Prognosis
The prognosis of small-bowel obstruction depends on the location and source
of obstruction and on the extent of bowel necrosis. With early diagnosis and
treatment, the prognosis is good; however, mortality rates may reach 65% if more
than 75% of the small bowel is necrotic at the time of laparotomy.
Literature:
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2. Ashkraft K.W., Cholder T.M. Pediatric surgery , V. II / S-Pb. - 1997. –P.358 .
3. Ashkraft K.W., Cholder T.M. Pediatric surgery , V. III / S-Pb. - 2000. –
P.306.
4. Fonkalsrud E.W., Folgia R.P. Operative treatment for the gastroesophageal
reflux syndrome in children./ J. Pediatr. Surg. –1989. - V.24.- P. 525-529.
5. Grosfeld J.L. Common problems in pediatric surgery / Mosby YB . – St. Louis
. – 1991 . – P. 310.
6. Isakov Y.F. Surgical diseases in children, V.I / Moscow . – Medicine . - 1990.
– P. 426.
7. Isakov Y.F. Surgical diseases in children , V.II / Moscow . – Medicine . 1990. – P. 410
8. Isakov Y.F., Stepanov E.A., Krasovskaja T.V. Abdominal surgery in children /
Moscow .- Medicine . – 1988. - P.294.
9. Rickam P.P., Lister J. Neonetal surgery / London. – 1988 . – P.621.