NEONATAL BILIOUS VOMITING- Part 2

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

HIRSCHSPRUNG’S DISEASE

Craniocaudal migration of ganglion cells of the bowel begins at 12th wk of gestationArrest of this migration produces an aganglionic segment of bowel-absence of Aurbach’s & Meissener’s plexusThis aganglionic segment of bowel unable to relax & peristaltic wave stops proximally- functional obstruction

Incidence 1 in 5000

Male:Female 4:1

HIRSCHSPRUNG’S DISEASE

Mutations in RET proto-oncogene are commonly associated with Hirschsprung’s disease

Not passed/ delayed passage of meconium

Abdominal distension

Bilious vomiting

Fever & diarrhea suggest Toxic megacolon

HIRSCHSPRUNG’S DISEASE Classification

HIRSCHSPRUNG’S DISEASE

Workup

AXR: Dilated Bowel Loops

Barium Enema: Swan Neck

Appearance

HIRSCHSPRUNG’S DISEASE

Workup

Absence of ganglion cells in myenteric

plexus

Suction rectal bx

Noblet Rectal Mucosal Suction Biopsy Gun

HIRSCHSPRUNG’S DISEASE Management

Empty bowel with saline enema (30 to 50 ml) daily

If can successfully decompress the bowel- continue rectal washouts for 45 days

If unable to decompress the bowel- do Rt transverse colostomy or Levelling colostomy

HIRSCHSPRUNG’S DISEASE

Colostomy

HIRSCHSPRUNG’S DISEASE

Swenson’s Rectosigmoidectomy

Soave’s Transabdominal

Endorectal Pullthrough

HIRSCHSPRUNG’S DISEASE

HIRSCHSPRUNG’S DISEASE

Duhamel’s Retrorectal Pullthrough

HIRSCHSPRUNG’S DISEASEDe La Torre’s TransanalEndorectal Pullthrough

MECONIUM ILEUS

Uncomplicated cases show impacted meconium in terminal ileum- inspissated tar like meconiumAccounts for 9 to 10% of all neonatal intestinal obstructions

Present in 8 to 10% of cystic fibrosis patients at birth

Complicated cases include volvulus,perforation and peritonitis with sepsis

MECONIUM ILEUS

Signs depend on degree of obstruction and complications

Significant abdominal distension may develop during neonatal periodGeneral status progressively deteriorates with incipient sepsis in cases of perforation In perforation, the scrotum or labia may have greenish discoloration due to patent processus vaginalis

MECONIUM ILEUS

MECONIUM ILEUS- Imaging Studies

Disparate sized bowel loops

Soap bubble appearance-Neuhauser’s sign

MECONIUM ILEUS- Management

60 to 70% of simple Meconium ileus can be successfully treated with Gastrograffin enema

Other 30% need operative management

Goal of surgery is to remove the abnormal meconium from GIT & maintain adequate length of bowel

Surgery consists of resection& anastomosis of involved segment and/or roux-en-y ileostomy

MECONIUM ILEUS- Management

MECONIUM ILEUS- Management

Paul MikuliczDouble Barrel

Ileostomy

Bishop-Koop’sDistal

chimneyIleostomy

Santulli’sProximal chimney

Ileostomy

MECONIUM PLUG

A long plug of mucus and sticky meconium in rectum & distal colon results low intestinal obstructionDue to immaturity of colonic & rectal expulsive mechanism

Often associated with neonatal Hirschsprung’s disease

Rectal exam/rectal wash results in expulsion of the plug and relief of intestinal obstruction

MECONIUM PLUG

MECONIUM PERITONITIS

Intrauterine perforation of intestineleakage of meconium into peritoneal cavity reaction of peritoneum to this leaked meconium

Due to intrauterine vascular compromise of intestine ischemia&perforation as early as 4th month of intrauterine life

Different pathological typesMeconium pseudocyst, generalised adhesive peritonitis,meconium ascites & infected meconium peritonitis

MECONIUM PERITONITIS

Often associated with cystic fibrosis & Prognosis is poor

Bilious vomiting, failure to pass meconium and abdominal distension

Abdominal wall edema, erythema and free fluid in peritoneal cavity

AXR multiple air fluid levels and peritoneal calcificationsSurgical treatment releasing of adhesions, removal of devitalised tissues, closure of perforation, intestinal resection& anastomosis

MECONIUM PERITONITIS

Meconium AscitesCentral bowel loops

Amorphous calcification

Multiple focal calcificationsDilated bowel loops

Neonatal Bilious Vomiting - Algorithm

Neonatal Bilious VomitingSl No

History Physical Plain XRay

Contraststudies

Diagnosis Treatment

1

Bilious vomitingNot passed meconiumMaternalhydramnios

Upper abdominal distensionVGPDown’s syndrome

DoubleBubbleappearance

Barium meal :Duodenalobstruction

Duodenal Atresia Or Annular Pancreas

Kimura’sDiamond ShapedDuodenoduodenostomy

2

BiliousVomiting

Infrequent passage of small amount of meconium

Upper abdominal distension

DoubleBubbleAppearance

Paucity of gas in distal bowel

Barium meal:Absence of C loop DuodenumCork screw appearance

Malrotation

Midgut volvulus

Ladd’sProcedure

DerotationResectionAnastomosis

Neonatal Bilious VomitingSl No

History Physical Plain XRay

Contraststudies

Diagnosis Treatment

3

Bilious vomiting

Not passed meconium

Abdominal distension

Empty rectum

Triple bubble appearanceMultiple air fluid levels

Barium enema :Micro colon

Jejunalatresia Or Ileal atresia

Resection& End to back anastomosis

4

BiliousVomiting

Passing meconium

Prematurity&Birth asphyxia

Bleeding PR

Sick child

Septicemia

Abdominal distension

Signs of Peritonitis

Pneumatosis intestinalis

Portal venous gasFree peritoneal gas

------------

Necrotising enterocolitis

Aggressive medical treatment

If it faillsSurgical intervention

Neonatal Bilious VomitingSl No

History Physical Plain XRay

Contraststudies

Diagnosis Treatment

5

Delayed passage of meconium

Vomiting

Gross abdominal distensionP/R:Explosive passage of meconium & flatus

Distended bowel loops

Barium enema:Swan neck appearance

Hirschsprung’s disease

Pullthrough operation with or without colostomy

6

BiliousVomiting

Failure to pass meconium

Moderate to severe abdominal distension

Disparate sized bowel loopsSoap bubble appearance

Barium Enema:Microcolon

Meconium ileus

Gastrograffin enemaResection anastomosisBishop-koop & Santulli Ileostomy

Neonatal Bilious VomitingSl No

History Physical Plain XRay

Contraststudies

Diagnosis Treatment

7

Bilious vomiting

Failure to pass meconium

Moderate to severe abdominal distensionP/R: Child passes plug

Distended bowel loops --------------

Meconium plug syndrome

Rectal washouts

8

BiliousVomiting

Failure to pass meconium

Severe abdominal distension

Abdominal wall edema & erythema

Multiple air fluid levelsPeritoneal calcificationFree peritoneal gas

Barium Enema:Microcolon

Meconium peritonitis

Release pf adhesionsClosure of perforation

Resection & Anastomosis

TAKE HOME MESSAGE

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