infant bowel obstruction 2005

8/2/2019 Infant Bowel Obstruction 2005

1/68

Infant Bowel Obstruction

Robert W. Letton, Jr., MD

Associate Professor of Surgery

Pediatric SurgeryOklahoma University Health Sciences Center


2/68

Question 1?

Why do Pediatric Surgeons

always make such a big dealout of a little yellow orgreen emesis?


3/68

Answer

Because unlike when Stansees Wendy in Southpark,

it usually meansbowel obstruction or

necrosis in ourpatients!


4/68

Goals

Discuss the work-up and management of

the child with potential bowel obstruction

Recognize the common causes of bowelobstruction in children

Discuss surgical management of common

causes of bowel obstruction


5/68

History

Birth History

Feeding History

Formula intolerance

Emesis

Bilious vs non-bilious

Bowel Habits

passage of meconium


6/68

History

Antecedent episodes

Irritable, lethargic

History of inguinal hernia

Family history

Hirschsprungs

Recent immunization or URI

Intussusception


7/68

Physical Exam

General state of hydration

Obvious source of sepsis

meningitis, strep throat, otitis, pneumonia, UTI

Inspect abdomen

scaphoid or distended, discolored

Auscultate Palpate

masses, tenderness, peritonitis


8/68

Physical Exam

Must remove diaper


9/68

Physical Exam

Must perform rectal exam, not just look!


10/68

Ancillary Studies

CBC, Lytes, UA, +/- Blood Cx, +/- ABG

Acute abdominal series

left lateral decub, KUB, CXR

Contrast Study

From above or below??


11/68

Initial Management

NG or OG to low wall suction (NPO!!)

Hydrate and replace losses

10 cc/kg of crystalloidIS NOT AN

ADEQUATE BOLUS!!

Antibiotics if suspect perforation or necrosis

Consult surgeon and/or transfer to

appropriate facility


12/68

Bowel Obstruction

Diagnosis often age specific

Bilious vomiting in the infant and child is a

surgical emergency until proven otherwise

Difficult to tell when volvulus is present

Child may look surprisingly good until its

too late


13/68

Etiology of Bowel Obstruction

Atresias

Hirschsprungs

Malrotation Volvulus

Intussusception

Incarcerated Hernia Perforated appendix


14/68

Atresia

Usually presents the first few days of life

Child may feed well for a day or two with

distal atresia

Duodenal atresia often diagnosed on

antenatal U/S

Atresias can occur anywhere in GI tract

from pharynx to anus


15/68

Atresias

Esophageal: aspirate feeds immediately, OG

tube wont pass (non-bilious, but still bad)

Duodenal: bilious vomiting immediately,double bubble on KUB with absence of

distal gas, Downs Syndrome

Jejunal: usually present 1st 24 hours, largedilated proximal loop or loops


16/68

Atresias

Ileal: may take 24-48 hours before bilious

emesis

Colonic: rare, may present with biliousemesis after 2-3 days

Anal: should be diagnosed at birth, often a

perineal fistula is labeled normal


17/68

Obvious Obstruction


18/68

Atresias may be multiple


19/68

Jejunal Atresia


20/68

Apple Peel Deformity (IIIb)


21/68

Imperforate Anus: Anal atresia


22/68

Hirschsprungs Disease

Congenital colonic aganglionosis

Physiologic obstruction

May present first few days to weeks of life

Short segment disease often tolerated for

months

Starts at anus and extends proximally a

variable distance


23/68

Hirschsprungs

Delayed passage of meconium at birth

Meconium plug syndrome, small left colon

syndrome, Downs syndrome Often present with distension and diarrhea at 2-4

weeks of life

May or may not have emesis

Profoundly distended abdomen with dilated bowel

Fever and WBCs with colitis


24/68

Hirschsprungs

Rectal exam may seem normal until

withdraw finger

Explosive release of liquid stool almostdiagnostic

Barium enema while dilated

Irrigate and dilate until decompressed

Suction rectal biopsy


25/68



26/68

Barium Enema


27/68

Treatment

NO WAY!


28/68



29/68

Toxic Megacolon

Severe enterocolitis

Very rare to get with idiopathic constipation

Usually only seen with Hirschsprungs

Disease or Ulcerative Colitis

NG decompression, IV fluids, IV antibiotics

Mortality 20-30% in some studies


30/68

Toxic Megacolon


31/68

Hirschsprungs in an 8 year old


32/68

Malrotation

Normal


33/68

Malrotation

Most often presents during the first fewmonths of life

Infant with acute onset of bilious emesis May be diagnosed on UGI for other reasons

Malrotation is a surgical urgency due to the

possibility of volvulus VOLVULUS IS A SURGICAL

EMERGENCY


34/68

Malrotation

Abdomen usually NOT distended

AAS usually normal

May show bowel obstruction, double-

bubble, or gasless

UGI is definitive diagnostic study

Infant in extremis

resuscitate and operate


35/68

Malrotation


36/68

Malrotation


37/68

Volvulus

Malrotation most common condition

resulting in midgut volvulus

Can have volvulus with normal rotation

omphalomesenteric remnant

internal hernia

Duplication

Adhesive small bowel obstruction


38/68

Midgut Volvulus


39/68

Small Bowel Obstruction


40/68

Meckels


41/68

Duplication/Volvulus


42/68

Duplication


43/68

Intussusception

Inversion of the bowel upon itself

secondary to a lead point

Juvenile intussusception most oftenidiopathic

Also secondary to Meckels

Presents 6 months to 2 years of age

As early as 1 month


44/68

Intussusception

Acute painful episodes followed by periods

of lethargy

When incarcerated progress to continuouslethargy

May or may not have currant-jelly stool

But often stool is heme positive

Rule out with a left lateral decubitus film


45/68

Left-lateral Decubitus Film


46/68

Intussusception


47/68

Intussusception


48/68

Intussusception


49/68

Intussusception


50/68

Bad Intussusception


51/68

Intussusception

7% chance of recurrence after ACEreduction

Usually recur in 48 hours Operative exploration warranted on second

recurrence to R/O pathologic lead point

Recurrence after surgery rare but possible

Post-op intussusception can occur after anysurgery


52/68

Incarcerated Hernia


53/68

Inguinal/Scrotal Anatomy

From Surgery of Infants and Children, Oldham, et. al., 1997


54/68

Inguinal Hernia

From Atlas of Pediatric Surgery, Ashcraft, 1994


55/68

Incarcerated Inguinal Hernia


56/68

Hernia Reduction

From Surgery of Infants and Children, Oldham, et. al., 1997


57/68

Incarcerated Hernia

Most can be reduced in clinic or ED

Bowel usually OK if able to reduce

Surgical consultation if reduction difficult

Repair with 1-2 days of incarceration

Beware the inguinal node in females

incarcerated ovary


58/68

Incarcerated Hernia

If unable to reduce: urgent operative

exploration (NPO)

If able to reduce without sedation: urgentsurgical referral with repair soon

If extremely difficult (sedation, surgical

referral): repair next day Watch child for obstructive symptoms


59/68

Perforated Appendix

Children still die from complications ofperforated appendicitis

Resuscitation is critical Response to surgery variable

Often require multiple procedures,hyperalimentation, prolonged antibiotictherapy

Diagnosis difficult


60/68

AAP Guidelines for Pediatric

Surgical Referral Patients 5 years or younger who may need surgical

care

Infants and children with perforated appendicitis

Seriously injured infants and children

Infants, children, and adolescents with solidmalignancies

Minimally invasive procedures Infants and children with medical conditions that

increase operative risk


61/68

Morbidity

Incidence of Perforation< 1 year old 90-100%

1-2 years old 70-80%

2-5 years old 50%

> 65 years old 50%


62/68

Perforated Appendix

Suspect in children 3-5 years old withhistory suggestive of appendicitis

Bowel obstruction in a 3-5 year oldwithout obvious etiology is perforatedappendix until proven otherwise

Fever > 101.5, WBC > 20 with bands,

diffuse abdominal pain, guarding, SBO onAAS


63/68

Perforated Appendix


64/68

Perforated Appendix


65/68

Resuscitation

NG tube, NPO

20 cc/kg boluses until UOP > 1 cc/kg/hr and

VS stable 1.5-2 times maintenance fluids

Broad Spectrum Antibiotics


66/68

Perforated Appendix


67/68

Summary

Atresias

Hirschsprungs

Malrotation Volvulus

Intussusception

Incarcerated Hernia Perforated Appendix


68/68

Question 2?

Why are Pediatric Surgeons sointerested in flatus?

Contrary to popularbelief, kids with

obstruction can still

have bowelmovements, but theywont pass gas!

infant bowel obstruction 2005

Documents