Infant Bowel Obstruction

Robert W. Letton, Jr., MD

Associate Professor of Surgery
Pediatric Surgery
Oklahoma University Health Sciences Center
Question 1?

Why do Pediatric Surgeons

always make such a big deal
out of a little yellow or
green emesis?
Answer
Because unlike when Stan
sees Wendy in Southpark©,
it usually means
bowel obstruction or
necrosis in our
patients!
Goals
 Discuss the work-up and management of
the child with potential bowel obstruction
 Recognize the common causes of bowel
obstruction in children
 Discuss surgical management of common
causes of bowel obstruction
History
 Birth History
 Feeding History
 Formula intolerance

 Emesis
 Bilious vs non-bilious

 Bowel Habits
 passage of meconium
History
 Antecedent episodes
 Irritable, lethargic
 History of inguinal hernia
 Family history
 Hirschsprung’s

 Recent immunization or URI

 Intussusception
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
Physical Exam
 Must remove diaper
Physical Exam
 Must perform rectal exam, not just look!
Ancillary Studies
 CBC, Lytes, UA, +/- Blood Cx, +/- ABG
 Acute abdominal series
 left lateral decub, KUB, CXR

 Contrast Study
 From above or below??
Initial Management
 NG or OG to low wall suction (NPO!!)
 Hydrate and replace losses
 10 cc/kg of crystalloid IS NOT AN

ADEQUATE BOLUS!!
 Antibiotics if suspect perforation or necrosis
 Consult surgeon and/or transfer to appropriate
facility
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 it’s
too late
Etiology of Bowel Obstruction
 Atresias
 Hirschsprung’s
 Malrotation
 Volvulus
 Intussusception
 Incarcerated Hernia
 Perforated appendix
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
Atresias
 Esophageal: aspirate feeds immediately, OG
tube won’t pass (non-bilious, but still bad)
 Duodenal: bilious vomiting immediately,
“double bubble” on KUB with absence of
distal gas, Down’s Syndrome
 Jejunal: usually present 1st 24 hours, large
dilated proximal loop or loops
Atresias
 Ileal: may take 24-48 hours before bilious
emesis
 Colonic: rare, may present with bilious
emesis after 2-3 days
 Anal: should be diagnosed at birth, often a
perineal fistula is labeled normal
Obvious Obstruction
Atresias may be multiple
Jejunal Atresia
Apple Peel Deformity (IIIb)
Imperforate Anus: Anal atresia
Hirschsprung’s 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
Hirschsprung’s
 Delayed passage of meconium at birth
 Meconium plug syndrome, small left colon

syndrome, Down’s 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 WBC’s with colitis
Hirschsprung’s
 Rectal exam may seem normal until
withdraw finger
 “Explosive” release of liquid stool almost
diagnostic
 Barium enema while dilated
 Irrigate and dilate until decompressed
 Suction rectal biopsy
Hirschsprung’s Disease
Barium Enema
Treatment

NO WAY!
Hirschsprung’s Disease
Toxic Megacolon
 Severe enterocolitis
 Very rare to get with idiopathic constipation
 Usually only seen with Hirschsprung’s
Disease or Ulcerative Colitis
 NG decompression, IV fluids, IV antibiotics
 Mortality 20-30% in some studies
Toxic Megacolon
Hirschsprung’s in an 8 year old
Malrotation

Normal
Malrotation
 Most often presents during the first few
months 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
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
Malrotation
Malrotation
Volvulus
 Malrotation most common condition
resulting in midgut volvulus
 Can have volvulus with normal rotation
 omphalomesenteric remnant

 internal hernia

 Duplication

 Adhesive small bowel obstruction

Midgut Volvulus
Small Bowel Obstruction
Meckel’s
Duplication/Volvulus
Duplication
Intussusception
 Inversion of the bowel upon itself
secondary to a lead point
 Juvenile intussusception most often
idiopathic
 Also secondary to Meckel’s

 Presents 6 months to 2 years of age

 As early as 1 month
Intussusception
 Acute painful episodes followed by periods
of lethargy
 When incarcerated progress to continuous
lethargy
 May or may not have “currant-jelly” stool
 But often stool is heme positive

 Rule out with a left lateral decubitus film

Left-lateral Decubitus Film
Intussusception
Intussusception
Intussusception
Intussusception
Bad Intussusception
Intussusception
 7% chance of recurrence after ACE
reduction
 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 any
surgery
Incarcerated Hernia
 Inguinal/Scrotal Anatomy

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

Inguinal Hernia

From Atlas of Pediatric Surgery, Ashcraft, 1994

Incarcerated Inguinal Hernia
 Hernia Reduction

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

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
Incarcerated Hernia
 If unable to reduce: urgent operative
exploration (NPO)
 If able to reduce without sedation: urgent
surgical referral with repair soon
 If extremely difficult (sedation, surgical
referral): repair next day
 Watch child for obstructive symptoms
Perforated Appendix
 Children still die from complications of
perforated appendicitis
 Resuscitation is critical
 Response to surgery variable
 Often require multiple procedures,
hyperalimentation, prolonged antibiotic
therapy
 Diagnosis difficult
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 solid
malignancies
 Minimally invasive procedures
 Infants and children with medical conditions that
increase operative risk
Morbidity
Incidence of Perforation
< 1 year old 90-100%

1-2 years old 70-80%

2-5 years old 50%

> 65 years old 50%

Perforated Appendix
 Suspect in children 3-5 years old with
history suggestive of appendicitis
 “Bowel obstruction” in a 3-5 year old
without obvious etiology is perforated
appendix until proven otherwise
 Fever > 101.5, WBC > 20 with bands,
diffuse abdominal pain, guarding, SBO on
AAS
Perforated Appendix
Perforated Appendix
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
Perforated Appendix
Summary
 Atresias
 Hirschsprung’s
 Malrotation
 Volvulus
 Intussusception
 Incarcerated Hernia
 Perforated Appendix
Question 2?
Why are Pediatric Surgeons so
interested in flatus?

Contrary to popular
belief, kids with
obstruction can still
have bowel
movements, but they
won’t pass gas!