Bowel Obstruction: Infants and Bowel Obstruction: Infants and ChildrenChildren

• Age specific:• Adhesions, Malrotation, intusception,

meckel’s, appendicitis (“febrile obstruction”)

• Hx + Physical much closer to adults

PresentationPresentation

Four cardinal signs of intestinal obstruction in neonate1. Antenatal polyhydramnios2. Bilious vomiting3. Delayed passage of

meconium (> 24 hrs)4. Gastric residual > 30 cc

Cardinal sing in adult1. Vomiting2. Abdominal pain3. Abdominal distension4. Obstipation/ constipation

Perioperative ManagementPerioperative Management

• Fundamental rule: previous losses /maintenance/ongoing needs

• Urine output best measure of adequate resuscitation• ?Need for central monitoring if problematic• Recall distribution of various IV solution• Bolus: as per PALS (20 cc/kg)• Titrate to heart rate, urine output BP• ↑ Maintained 25% for each quadrant of abdomen involved• Antibiotics if any viscus opened, cardiac issues,

immunosuppresed (newborn)• Steroids: if on previously/deficiency (stress dose physiology)• Nasogastric tube (Decompression)• Keep patient warm

Be Aware of Child with Be Aware of Child with Bilious (Green) VomitingBilious (Green) Vomiting

MalrotationMalrotation

• 10th Week of Development rapid growth of intestine which returns to abdominal cavity with rotation

• Problems can occur at any of the 3 stages– Duodenal rotation– Elongation and fixation of the

mesentery– Rotation of the colon

Tracheo-esophageal fistulaTracheo-esophageal fistulaPresentationPresentationMaternal polyhydramnios on U/S Maternal polyhydramnios on U/S Drooling, choking, coughing, cyanosis with Drooling, choking, coughing, cyanosis with feeding feeding tracheomalacia tracheomalaciaNo passage of NG tube No passage of NG tube

VACTERL(Vertebral, anal, cardiac, tracheal, (Vertebral, anal, cardiac, tracheal, esophageal, renal, limb)esophageal, renal, limb)

Work-upComplete physical examComplete physical examCXR, AXR – vertebral / rib anomaliesCXR, AXR – vertebral / rib anomaliesEchocardiogram – aortic arch L vs. R to plan Echocardiogram – aortic arch L vs. R to plan incisionincisionRenal U/SRenal U/SCT head in selected patientsCT head in selected patients

Pneumonitis prevention and treatmentPneumonitis prevention and treatmentParenteral antibiotics – gentamicin, ampicillinParenteral antibiotics – gentamicin, ampicillinSump suction catheter (Replogle)Sump suction catheter (Replogle)

Treatment surgical repair

Meckel’s Diverticulum'sMeckel’s Diverticulum's• True diverticulum's• Result from persistence vitelline

duct and the omphalomesenteric duct.

• Incidence 2%, Most of these people remain asymptomatic throughout life.

• Role of 2.• Complication: hemorrhage, acute

diverticulitis, perforation, and small bowel obstruction or intussusception

IntussusceptionIntussusception

Duodenal Atresia/ Annular Duodenal Atresia/ Annular PancreasPancreas

• Primary problem is one of recanalization of solid duodenum.

• Obstruction typically at level of common bile duct and pancreas

• Associated anomalies common: almost 50%– Down syndrome 29%– malrotation 19%– congenital heart disease 17%– TEF 7%– Others (renal, respiratory, imperforate

anus - roughly 10%)

Jejunal & Ileal AtresiaJejunal & Ileal Atresia• Pathology related to late

second trimester vascular accident (Barnard)

• Associated anomalies rare • Classification system

Imperforated AnusImperforated Anus

Hirschsprung’sHirschsprung’s

Meconium IleusMeconium Ileus

NECNEC

Abdominal Wall DefectAbdominal Wall Defect

Omphalocele

Gastroschisis

Wilms tumor

asymptomatic abdominal massWell babyrapid abdominal enlargement ( pain, fever, and gross hematuria). 2 to hemorrhage Treatment is surgical resection

Neuroblastoma cells are derived from the primitive neural crestIt was found that patients with an increased number of copies of the N-myc gene had a much worse prognosisSite: adrenal, retroperitoneum, mediastinum & neck.Treatment: surgery +/-chemotherapy

Neuroblastoma

Duplication Cyst

Question?