NEONATAL BILIOUS VOMITING- Part 1

A PROBLEM ORIENTED APPROACH

Dr.B.Selvaraj MS;Mch; FICS;Professor of Surgery

Melaka Manipal Medical CollegeMelaka 75150 Malaysia

OBJECTIVESTo discuss the differential diagnosis of biliary emesis in neonates

To do appropriate workup to confirm the diagnosis

To select the various treatment options

To make you confident in managing a newborn with bilious vomiting

Neonatal Bilious Vomiting-Causes

Meconium Peritonitis

Necrotising Enterocolitis

Hirschsprung’s Disease

Anorectal Malformation

Rarely Mesentric Cyst & Intestinal Duplication

Incarcerated inguinal hernia

Duodenal atresia/stenosis

Annular Pancreas

Malrotation&MGV

Intestinal Atresia: Jejunal&Ileal

Meconium Ileus

Meconium Plug

Neonatal Bilious Vomiting-Causes

• MALROTATION & MGV• MESENTRIC CYST& DUPLICATION CYST• CONGENITAL BANDS LIKE VI DUCT BANDS

• MECONIUM ILEUS• MECONIUM PLUG• MECONIUM PERITONITIS

EXTRINSIC

• DUODENAL ATRESIA/STENOSIS• JEJUNAL/ILEAL ATRESIA• HIRSCHSPRUNG’S DISEASE• NECROTISING ENTEROCOLITIS

CAUSES

MURAL

INTRALUMINAL

DUODENAL ATRESIA/STENOSIS

Failure of vacuolisation & recanalisation of solidcord state of duodenum at 7 to 10 wks of intrauterine life

Proximal Stomach & Duodenum get dilated and hypertrophied

Bilious vomiting in Postampullary type

Failure to pass meconium

Minimal upper abdominal distension

Hydramnios in mother& Down’s syndrome in the child

DUODENAL ATRESIA/STENOSIS- Types

1. Membrane Type

a. Simple

b. Fenestrated

c. Windsock Anomaly2. Complete Mural discontinuity with connecting fibrous cord3. Complete Mural discontinuity without connecting fibrous cord

DUODENAL ATRESIA/STENOSIS- Types

Duodenal Atresia/StenosisWorkup

Antenatal USG Abdomen

Double Bubble appearance

Postnatal AXR

Classical Double Bubble Appearance

Kimura’s Diamond ShapedDUODENODUODENOSTOMY

Duodenal Atresia- Windsock anomaly

Duodenal Atresia- Post op care

Dysmotility due to Megaduodenum may require a period of TPN

Transanastomotic feeding tube may obviate the need for TPN

Graded introduction of enteral feeds as bowel motility recovers

Prophylactic antibiotics for 48 hrs

ANNULAR PANCREAS

A rim of pancreatic tissue encircles 2nd part of duodenum

A defect in rotation and fusion of ventral analgae with the dorsal analgae of pancreas

Clinical picture and radiological findings are akin to Duodenal Atresia

Treatment also same as that of Duodenal Atresia

ANNULAR PANCREAS

PREDUODENAL PORTAL VEIN

MALROTATION- Embryology

Physiological Umbilical Hernia in Fetus

MALROTATION

MALROTATION- Different Degrees

MALROTATION

Any defect/ deviation of normal midgut rotation leads to Malrotation

60% of Malrotation patients present in neonatal period

Most common type of Malrotation is caused by Ladd’s band due to arrest of rotation at 180*

Midgut volvulus is due to narrow duodenocolic isthmus

MALROTATION

Bilious Vomiting

Passing scanty meconium

Upper abdominal distension

In Midgut volvulusBleeding PR,abdominal distension and vomiting

MALROTATION- IMAGING STUDIES

AXR- “ Double Bubble Appearance”

Upper GI Series:In Simple MalrotationAbsence of C loop; DJ flexure & jejunal loops on the right side of abdomenIn MGV “Corkscrew Appearance”

USG with Doppler scan:

Reversed position of SMA & SMV

MALROTATION- IMAGING STUDIES

Double Bubble Appearance Corkscrew Appearance

MALROTATION- IMAGING STUDIES

Absence of C LoopJejunum on Rt side

Reversed position ofSMA & SMV

MALROTATION- Ladd’s Procedure

Division of Ladd’s band

Widening of Duodenocolic isthmus

Malrotation with Midgut Volvulus

Derotation of Volvulus

If bowel is viable leave it

If bowel not viable Resection and EEAIf bowel viability is doubtful Second look laparotomyComplication Short bowel syndrome

JEJUNAL & ILEAL ATRESIA

Due to mesenteric vascular accident during fetal life

Incidence 1 in 3000 livebirthsPresent within 24hrs with bilious vomiting,not passed meconium & abdominal distension Proximal obstruction earlier & more severe is the bilious vomiting Distal obstruction more severe is the abdominal distension

JEJUNAL & ILEAL ATRESIA Types

JEJUNAL & ILEAL ATRESIA Types

JEJUNAL & ILEAL ATRESIA- AXRJejunal Atresia

Triple Bubble Appearance

ILeal atresia Multiple airfluid levels

JEJUNAL & ILEAL ATRESIA

Barium Enema

Unused Microcolon

JEJUNAL ATRESIA- Tapering Jejunoplasty

End to back Anastomosis

Jejunal & Ileal Atresia- Operative Techniques

NECROTISING ENTEROCOLITIS

Disease of paradoxes- unknown etiologyMost likely mechanism vascular compromise to GIT resulting bacterial invasion of portal venous system

Common in premature babies

Occurs during 1st or 2nd wk of life after starting oral feedings in babies weighing < 1.5 kgs

Distal Ileum & Rt colon are commonly involved

NECROTISING ENTEROCOLITIS

NECROTISING ENTEROCOLITIS

Affected bowel Dilated with mucosal necrosis and subserosal collection of gas

Bilious vomiting,abdominal distension,rectal bleeding and/or diarrheaAbdominal wall edema, erythema and fixed persistent loop of bowelAXR Pneumatosis intestinalis, Gas in portal vein and/or Free air in peritoneal cavity

NECROTISING ENTEROCOLITIS- Staging

NECROTISING ENTEROCOLITIS

NECROTISING ENTEROCOLITIS- AXR

Pneumatosis Intestinalis

Portal Venous Gas—Pneumobilia

NECROTISING ENTEROCOLITIS

ManagementStart aggressive medical treatment immediately

Keep NPO,NGT aspiration & TPN

Broadspectrum Antibiotics

Physical, radiographic and ultrasonographic evaluation Q6H for 1st 48 hrs in NICU

NECROTISING ENTEROCOLITIS

Indications for SurgeryPneumoperitoneum & signs of peritonitis

Edematous & Erythematous anterior abdominal wall

Fixed persistent loop of bowel

Portal venous gas- Pneumobilia

Sudden deterioration of baby during medical treatment

NECROTISING ENTEROCOLITIS Surgery

Operative strategy depends on extend of involvement of bowel

If perforation is small Direct suture closure or re section & primary anastomosis is adequate

In extensive bowel necrosis Remove all gross gangrenous bowel& do enterostomy

In doubtful bowel viability Second look laparotomy

In low birth weight infants with poor general condition do just peritoneal drainage

TAKE HOME MESSAGE

“YELLOW COLOR VOMITUS IS THE RED SIGNAL OF INTESTINAL OBSTRUCTION UNLESS PROVED OTHERWISE”