NEONATAL NEONATAL ABDOMINAL ABDOMINAL
EMERGENCIESEMERGENCIESCarlos J. Sivit M.D.Carlos J. Sivit M.D.
Low intestinal obstructionLow intestinal obstructionHigh intestinal obstructionHigh intestinal obstruction
INTESTINAL INTESTINAL OBSTRUCTIONOBSTRUCTION
High obstruction High obstruction -- proximal to midproximal to mid--ileumileumFew dilated, air filled bowel loopsFew dilated, air filled bowel loopsComplete obstruction diagnosed by KUBComplete obstruction diagnosed by KUBPartial obstruction diagnosed by UGIPartial obstruction diagnosed by UGI
Low obstruction Low obstruction -- distal ileum & colondistal ileum & colonMany dilated airMany dilated air--filled bowel loopsfilled bowel loopsContrast enema study of choiceContrast enema study of choice
LOW INTESTINAL LOW INTESTINAL OBSTRUCTIONOBSTRUCTION
LOW OBSTRUCTIONLOW OBSTRUCTION
Typically present with failure to pass Typically present with failure to pass meconiummeconium or constipationor constipation90% of normal neonates pass 90% of normal neonates pass meconiummeconium in 1in 1stst 24 hours; 99% in 124 hours; 99% in 1stst 48 hours48 hours
LOW OBSTRUCTIONLOW OBSTRUCTION
Hirschprung’sHirschprung’s diseasediseaseFunctional immaturityFunctional immaturity
MeconiumMeconium plug, small left colon plug, small left colon MeconiumMeconium ileusileusIlealIleal atresiaatresiaColonic Colonic atresiaatresia
CONTRAST ENEMACONTRAST ENEMA
Water soluble contrastWater soluble contrastDilute Dilute gastrograffingastrograffin
Patient immobilizationPatient immobilizationOctagon boardOctagon board
Foley catheterFoley catheter8 8 frenchfrenchDo not inflate balloonDo not inflate balloon
HIRSCHPRUNG’S HIRSCHPRUNG’S DISEASEDISEASE
Arrest in migration of ganglion cellsArrest in migration of ganglion cellsExtends proximally from anus Extends proximally from anus Without skip areasWithout skip areasRare form is total colonic Rare form is total colonic aganglionosisaganglionosisTransition zone most specific findingTransition zone most specific findingMost common site is Most common site is rectosigmoidrectosigmoid (2/3)(2/3)
MECONIUM PLUG MECONIUM PLUG SYNDROMESYNDROME
Failure to pass Failure to pass meconiummeconium in 1st 24 hrsin 1st 24 hrsCharacterized by multiple Characterized by multiple meconiummeconium plugsplugsUsually improves following enemaUsually improves following enema
ClatworthyClatworthy. Surgery 1956;39:131. Surgery 1956;39:131--4141
SMALL LEFT COLON SMALL LEFT COLON SYNDROMESYNDROME
Caliber change near Caliber change near splenicsplenic flexureflexureAssociated w/ maternal diabetesAssociated w/ maternal diabetesDdxDdx -- Hirschprung’sHirschprung’s diseasedisease
Davis. AJR 1974;1974;120:322Davis. AJR 1974;1974;120:322--99
MECONIUM ILEUSMECONIUM ILEUS
InspissatedInspissated meconiummeconium in distal ileum in distal ileum Almost always associated w/ CFAlmost always associated w/ CFPresenting feature in 5Presenting feature in 5--10% w/ CF10% w/ CFComplications include Complications include volvulusvolvulus, , perforation, peritonitis & perforation, peritonitis & microcolonmicrocolon
MECONIUM ILEUSMECONIUM ILEUS
Bubbly appearance in Bubbly appearance in rlqrlqPaucity of air fluid levelsPaucity of air fluid levelsReflux into Reflux into nondilatednondilated distal ileum distal ileum Dilated small bowelDilated small bowel
MECONIUM MECONIUM PERITONITISPERITONITIS
Results from intrauterine perforation Results from intrauterine perforation Primarily from Primarily from meconiummeconium ileusileusCalcification of peritoneal Calcification of peritoneal meconiummeconiumSite of perforation usually not foundSite of perforation usually not found
ILEAL ATRESIAILEAL ATRESIA
Secondary to vascular insultSecondary to vascular insultAtresiasAtresias may be multiplemay be multiple+/+/-- MicrocolonMicrocolon
COLONIC ATRESIACOLONIC ATRESIA
Secondary to vascular insultSecondary to vascular insultType I Type I –– Complete obstruction by Complete obstruction by diaphragmdiaphragmType II Type II –– Obstruction by Obstruction by atreticatretic cordcordType III Type III –– Complete separation of Complete separation of proximal & distal colonproximal & distal colon
CONTRAST ENEMA DDXCONTRAST ENEMA DDX
MicrocolonMicrocolonMeconiumMeconium ileusileusIlealIleal atresiaatresiaTotal colonic Total colonic aganglionosisaganglionosisColonic Colonic atresiaatresia
CONTRAST ENEMA DDXCONTRAST ENEMA DDX
Transition zoneTransition zoneHirschprung’sHirschprung’sSmall left colon Small left colon syndromesyndrome
CONTRAST ENEMA DDXCONTRAST ENEMA DDX
NormalNormalHirschprung’sHirschprung’sIlealIleal atresiaatresia
HIGH INTESTINAL HIGH INTESTINAL OBSTRUCTIONOBSTRUCTION
HIGH OBSTRUCTIONHIGH OBSTRUCTION
MidgutMidgut malrotationmalrotationDuodenal Duodenal atresiaatresia/stenosis/web/stenosis/webJejunalJejunal atresiaatresia/stenosis/stenosis
MIDGUT MALROTATIONMIDGUT MALROTATION
Most important UGI obstruction in newbornMost important UGI obstruction in newbornArrest in normal rotation of Arrest in normal rotation of midgutmidgutResults in abnormal mesenteric fixationResults in abnormal mesenteric fixationObstruction 2Obstruction 2oo twisting around SMA twisting around SMA ((volvulusvolvulus)) oror abnlabnl peritoneal attachments peritoneal attachments ((LaddsLadds bandsbands))
ASSOCIATED CONDITIONSASSOCIATED CONDITIONSAlways presentAlways present
OmphaloceleOmphaloceleGastroschisisGastroschisisCongenital diaphragmatic herniaCongenital diaphragmatic hernia
Increased incidenceIncreased incidenceDuodenal/Duodenal/jejunaljejunal atresiaatresia/stenosis/stenosisHirschprungHirschprung diseasediseaseHeterotaxyHeterotaxy syndromesyndrome
MIDGUT MALROTATIONMIDGUT MALROTATION
RADIOGRAPHIC FINDINGSRADIOGRAPHIC FINDINGSNormalNormalPartial / complete obstructionPartial / complete obstructionProximal / mid small bowelProximal / mid small bowel
MIDGUT MALROTATIONMIDGUT MALROTATION
UGI FINDINGSUGI FINDINGSAbnormal duodenalAbnormal duodenal--jejunaljejunal junctionjunction
Normal = left of left vertebral pedicle Normal = left of left vertebral pedicle at level of bulbat level of bulb
Duodenal obstructionDuodenal obstructionCorkscrew appearance of small bowelCorkscrew appearance of small bowel
PitfallsPitfalls
False positive diagnosisFalse positive diagnosisLow DJJ due to bowel dilatationLow DJJ due to bowel dilatationDuodenal redundancyDuodenal redundancy
False negative diagnosisFalse negative diagnosisAbnormal DJJ Abnormal DJJ rarelyrarely to left of to left of spine and at level of bulbspine and at level of bulb
Ladd’s bands•Condensations of mesentery•Cross & compress duodenum
Midgut volvulus • Spiraling of bowelaround SMA
• Beaked deformitydistal bowel
MIDGUT MALROTATIONMIDGUT MALROTATION
US/CTUS/CT FINDINGSFINDINGSReversal of mesenteric vesselsReversal of mesenteric vessels
SMV to left of SMASMV to left of SMA“Whirlpool” appearance of vessels“Whirlpool” appearance of vesselsNot accurate enough for 1Not accurate enough for 1oo dxdx
DUODENAL OBSTRUCTIONDUODENAL OBSTRUCTION
Most common cause of high obstruction Most common cause of high obstruction AtresiaAtresia > stenosis > web> stenosis > web3/4 distal to papilla & associated with 3/4 distal to papilla & associated with bilious vomitingbilious vomiting1/3 associated w/ Down’s syndrome1/3 associated w/ Down’s syndromeMay be part of VACTERL associationMay be part of VACTERL association
JEJUNAL ATRESIAJEJUNAL ATRESIA
Due to vascular insultDue to vascular insultAtresiaAtresia > Stenosis> StenosisAtresiasAtresias may be multiplemay be multipleNormal caliber colonNormal caliber colon
NEONATAL ABDOMINAL NEONATAL ABDOMINAL EMERGENCIESEMERGENCIES
Low intestinal obstructionLow intestinal obstructionHigh intestinal obstructionHigh intestinal obstruction