Bowel obstruction and associated mesenteric vascular compromise may occur, leading to bowel ischemia and, eventually, infarction if untreated. Intussusception is telescoping of a proximal bowel loop the intussusceptum into itself distally the intussuscipiens. Clinical presentation of a neonate with intussusception differs from that of older infants, who typically have intermittent abdominal pain, a palpable mass, and bloody stools. In neonates being evaluated for bowel obstruction or necrotizing enterocolitis, an abdominal radiograph is obtained and dilated loops of small bowel are seen.
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It has been suggested for further evaluation of neonates in whom intussusception is a diagnostic consideration. In neonates with a complete bowel obstruction due to intussusception, surgical exploration is curative and not usually delayed. Jejunal, ileal, and colonic atresias most often occur due to vascular insult with ischemia to the affected bowel, and may coexist.
Jejunal and ileal atresia occur in 1—3 out of 5, births. Ileal atresia may present with vomiting and failure to pass meconium. The initial radiograph shows at least four dilated bowel loops, suggesting that the obstruction is distal. Contrast enema often reveals a small and unused microcolon and may or may not demonstrate additional foci of atresia Figure 6A. Figure 6 Intestinal atresias in newborns with distal intestinal obstruction.
A Image during contrast enema shows blind ending terminal ileum arrowhead in ileal atresia. Treatment for jejunal and ileal atresia will include nasogastric tube decompression, fluid resuscitation, and prophylactic antibiotics before surgical repair.
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Colonic atresia is rare by comparison, occurring in approximately 1 in 20, live births. The initial abdominal radiograph shows multiple dilated loops of bowel, with some air—fluid levels compatible with a distal obstruction. The loops of bowel just proximal to the obstruction are often massively dilated. Treatment for colonic atresia includes nasogastric tube decompression, fluid resuscitation, and prophylactic antibiotics before surgical repair. Surgical repair should be urgent due to increased risk of perforation or volvulus compared to other atresias, with initial management consisting of decompression of the intestine by an ostomy procedure.
Meconium ileus is an intestinal obstruction at the level of the terminal ileum that occurs when inspissated meconium obstructs the intestinal lumen. Patients typically present with abdominal distention and failure to pass meconium. Air—fluid levels may not be present due to the thick consistency of meconium. A water-soluble contrast enema should be undertaken for further evaluation of lower intestinal obstruction and is diagnostic, showing filling defects in an extreme microcolon and the distal ileum, with proximal small bowel dilatation Figure 7A.
Figure 7 Meconium plugs in neonates with meconium ileus and functional immaturity of the colon. A Image during contrast enema shows innumerable meconium filling defects arrowheads in an extreme microcolon and the terminal ileum, with dilated air-filled bowel proximally, in meconium ileus. B Image during contrast enema shows meconium filling defect arrowhead in a small left colon arrows in functional immaturity of the colon. Functional immaturity of the colon is also known as meconium plug syndrome or small left colon syndrome, and is a benign, usually self-limiting, transient, functional colonic obstruction due to immature neuronal ganglion cells in the myenteric plexus.
Newborns typically present with abdominal distention and failure to pass meconium in the first 48 hours of life. Water-soluble contrast enema is usually curative. Hirschsprung disease occurs when there is absence of normal neuronal ganglion cells in the submucosal and myenteric plexus of the large bowel.
Rarely, the distal small bowel could also be affected. Hirschsprung disease occurs in 1 in 4, live births with a male to female ratio. Abnormal neuronal cells in the large bowel result in the inability of the affected bowel to relax normally, which creates a functional bowel obstruction with proximal bowel dilation and problems with defecation. While the diagnosis of Hirschsprung disease requires tissue sampling and histologic confirmation of abnormal neuronal cells, radiologic workup may suggest or confirm the diagnosis.
Figure 8 Hirschsprung disease in neonates with distal intestinal obstruction. A Supine abdominal radiograph shows more than three dilated air-filled loops of bowel and absence of air in the rectum. B Image during contrast enema in a different patient shows abnormal rectosigmoid ratio and transition point arrow. Treatment of Hirschsprung disease includes stabilization of the patient and decompression of the bowel initially, and fluid resuscitation to replace lost fluids.
Fluid resuscitation should be done to replace lost fluids. The spectrum of anorectal malformations includes imperforate anus and ranges from isolated perineal fistula to complex cloacal malformations where there is a common channel between the genitourinary system and rectum. Neonates with anorectal malformation present with abdominal distention, failure to pass meconium, and absence of a normal anal opening on physical examination. A perineal fistula may also be visible. Physical examination shows the absence of a normal anal opening. Figure 9 Anorectal malformation in neonate with sacral agenesis.
A Supine abdominal radiograph shows absence of sacrum and air in the rectum. B Lateral abdominal radiograph shows absence of sacrum and blind ending air-filled rectum arrow. As associated congenital anomalies may be present, assessment for possible life-threatening anomalies should be undertaken prior to corrective surgery. High lesions are treated with colostomy as a temporizing measure, with later definitive surgical repair after better delineation of anatomy. Neonatal bowel obstruction is common and may involve the upper or lower gastrointestinal tract.
Acute Abdomen in Neonates
Workup usually involves abdominal radiography, which may direct further evaluation with fluoroscopic examination such as an UGI contrast study or contrast enema. Depending on the etiology and the level of obstruction, surgery may be indicated for treatment. If intestinal malrotation is a differential consideration, prompt surgical exploration or evaluation with UGI contrast study is paramount to decrease morbidity and mortality. Juang D, Snyder CL. Neonatal bowel obstruction. Surg Clin North Am. Clark DC. Esophageal atresia and tracheoesophageal fistula. Am Fam Physician. Philadelphia : Saunders; Alimentary tract duplications in newborns and children: diagnostic aspects and the role of laparoscopic treatment.
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[Full text] Managing neonatal bowel obstruction: clinical perspectives | RRN
Comparative effectiveness of imaging modalities for the diagnosis of intestinal obstruction in neonates and infants: a critically appraised topic. Acad Radiol.
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Neonatal malrotation with midgut volvulus mimicking duodenal atresia. Am J Roentgenol. Intestinal malrotation in children: a problem-solving approach to the upper gastrointestinal series. Reid JR. Practical imaging approach to bowel obstruction in neonates: a review and update. Semin Roentgenol. Diagnostic performance of the upper gastrointestinal series in the evaluation of children with clinically suspected malrotation. Marine MB, Karmazyn B.
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Barium Enema: Ileocecocolic intussusception containing viableloop treated by milking and appendictomy Neglected ileocecal intussusception with gangrenousperforated intestines treated by resection and primaryanastmosis Barium EnemaBarium Enemashowing 3 differentshowing 3 differentzoneszones Spastic lower zone-Spastic lower zone-funnel shaped middle-funnel shaped middlezonezone-markedly dilated proximal-markedly dilated proximal normal colon normal colon Laparoscopic Assissted transanal pullthrough : the affectedsegment has been withdrawn through the anus after beingdissected free from its mesentry and blood vessels usinglaparoscopy V fluids-Broad spectrum antibiotics and metronidazole-Frequent colonic irrigation.
Operative photo of a 4 years old child presented with intestinalobstruction. PC line: pubococcygeal lineI line: ischial line A flat perineumA flat perineum Perineal fistulaPerineal fistula Imperforate anus with rectovesical fistula Imperforate anus with rectourethral fistula Definitive repairDefinitive repair1-Anoplasty :— Rectoperineal fistula— Covered anus— Bucket-handle malformation TreatmentTreatmentPrinciples:-Asymptomatic malrotationmost recommend surgical treatmentsome believe operation only necessary in young children-High intestinal obstructionoperated on promptly, but not necessarily emergently-Volulus with sign of bowel necrosis: immediate operation You just clipped your first slide!
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