Neonatal Acute Abdomen

Dr P. Shinondo
By the end of this session, students shall be
able to:
 Classify causes of neonatal acute abdomen
 Identify neonatal acute abdomen
 Explain the management of neonatal acute

abdomen
 Briefly explain common surgical causes of

neonatal acute abdomen

Outline
 Etiology
 Causes: surgical and non-surgical
 Signs and symptoms
 Classification
 Investigations
 Management
 NEC
 Intussusception
Etiology
 Embryological insults
 Intrinsic developmental defects
 Insults acquired in utero, after the formation

of normal bowel
 Abnormalities of peristalsis and/or abnormal

intestinal contents.
Embryology – dev of embryonal ileal
loops
Mesenteric insertion in
retroperitoneum
Causes - surgical
 One of surgical emergencies in neonates
 May include
 Intestinal obstruction
 Necrotising Enterocolitis
 GI perforation in a newborn
 Incarcerated inguinal hernia
 Congenital lesion internal hernia/volvulus
 Malrotation/volvulus
Non-surgical causes
 Sepsis & ileus – bilious vomiting & abdominal
distension (most important non-surgical
cause)
 Intracranial lesions – Hydrocephalus &

subdural hemorrhage
 Renal Dx with uremia - renal agenesis,

polycystic Dx.
Signs & Symptoms of IO
 Bilious vomiting – always abnormal. NB! Until
proven otherwise it’s a malrotation and/or
volvulus
 Abdominal distension (scaphoid possible)
 Failure to pass meconium (delayed/scanty)
 Antenatal: Polyhydramnios in mother
 Family history (HSD, DM mother, jejunal

atresia)
Clinical scenarios in acute abdomen
 Occlusive
- Intestinal Atresia
- Anorectal Atresia
- Meconium Ileus (both occlusive and
peritonitic)
 Peritonitic
 Hemorrhagic

- Malrotation Volvulus (all three )

Classification of neonatal IO
 High Obstruction
• Gastric outlet
• Duodenal

• Jejunal
 Low obstruction

• Distal small bowel

• Colonic
 Congenital (bowel atresias & stenoses; HSD;

Meconium Ileus)
 Acquired (pyloric stenosis, malrotation &

midgut volvulus, hernias)

Investigations
1. Plain abdominal X-Rays.
 Complete high obstruction – no gas in distal

small bowel
 Low obstruction – many gas filled loops

(24hrs)
 May be non specific – malrotation
Double bubble – duodenal atresia
Jejunal atresia
Ileal atresia
Types of Intestinal atresias
Anorectal Atresia
Investigations
2. Contrast enema – differentiates types of low
IO. (meconium plug, HSD)

3. Upper GI series – procedure of choice to

diagnose malrotation

4. Rectal biopsy – HSD (suction biopsy & full

thickness)
Management
 Diagnose early to prevent clinical
deterioration, aspiration pneumonia, sepsis &
biochem & hematological derangements.
 Surgery …… once preliminaries done
 Resuscitation
 NGT
 Baseline labs
 Discuss with parents & consent for OT.
Necrotising Enterocolitis (NEC)
Necrotising Enterocolitis (NEC)
 1:1000 live births
 Risk factors

– prematurity and low birth weight. 750-1000g

have highest incidence.
 Infant related (perinatal asphyxia, congenital

heart disease. Etc)

 Maternal related (pre-eclampsia, prolonged

PROM, drugs)
Pathophysiology of NEC
 Inappropriate inflammatory response to an
insult -> injury & disruption of epithelial
barrier -> bacterial translocation ->
activation of host immune system -> release
of cytokines -> global & detrimental immune
response
Pathology
 NEC may be
- Focal (isolated) disease : single area of
the bowel is necrotic or perforated
-Multifocal disease : multisegmental
disease with > 50% viable
- NEC totalis : necrosis of at least 75% of
the gut
Pathology
 NEC - mucosal disease
that extends well into the
normal intestine
 Terminal ileum,

ascending & transverse

colon commonly affected
 The disease can occur

anywhere from stomach

to rectum
Clinical presentation
 Onset may be sudden or insidious in nature
 The clinical course can vary from a slow, indolent
process to one that progresses rapidly to death in a
few hours
 Nonspecific findings:
◦ lethargy,
◦ temperature instability,
◦ recurrent apnea,
◦ bradycardia,
◦ hypoglycemia, and
◦ shock
Clinical presentation
 More specific GI symptoms:
◦ abdominal distention (70% to 98%),
◦ blood per rectum (79% to 86%),
◦ vomiting (>70%), and
◦ Diarrhoea (4% to 26%).
◦ Gross blood in the stool is present in 25%
◦ occult blood in 22% to 59%.
 Rectal bleeding is seldom massive
Radiology
 Bowel distension
 Pneumatosis intestinalis – intramural gas
 Portal vein gas
 Pneumoperitoneum
 Pneumatosis
intestinalis with air
over the liver shadow
dispersed within the
radicles of the portal
venous system
 Portal venous gas and
pneumatosis
Bell Staging Criteria
STAGE CLINICAL X-RAY TREATMENT
I. SUSPECT -Mild -Mild ileus -Medical
NEC abdominal workup for
distention sepsis
-Poor feeding
-Emesis
II. DEFINITE -The above plus -Significant ileus Medical
NEC -Marked -Pneumatosis
abdominal intestinalis
distention -PVG
-GI bleeding
III. ADVANCED -The above plus Pneumoperitoneum Surgical
NEC -Unstable vital
signs
-Septic shock
Management
 Nonoperative Therapy is the initial
management
 Commence immediately upon suspicion of

the diagnosis of NEC

 The goals of medical management

include restoration of tissue perfusion,

control of infection or sepsis
careful observation for evidence of
intestinal gangrene or perforation.
Management - Nonoperative

 NEC without necrosis or perforation –

Treatment is supportive
 Keep NPO – Discontinue feeding
 Gastric tube - decompression
 Commence IVF resuscitation
 Commence Antibiotics
 Consider Empirical antifungal if clinical

course is prolonged
Management - Operative
Absolute indication
1. Pneumoperitoneum

Relative indication
2. Clinical deterioration despite adequate therapy

a. Erythema and oedema of abdominal wall

b. Abdominal mass

c. Signs of peritonitis

d. Increasing acidosis

e. Persistent and progressive thrombocytopenia

Intussusception – telescoping of
proximal into distal part of bowel
Types
 Idiopathic :
 10days after URTI or GE
 Change from breast to bottle feeds
 Increase in lymphoid tissue mass (Peyers
Patches) – most likely cause
 Seasonal variation, higher in spring &
summer
 Viruses may play a role (rotavirus; associated
with vaccination)
 Lead Point
 Seen in older children.
 E.g Meckels diverticulum, enlarged LN,

polyps.
 Lead points initiate intussusception on a

mechanical basis
 Postoperative

- 2-5days postop, painless, observation, NG

aspiration is done. May self limit.
Clinical picture
 Well nourished/ fat children 3-18months.
 Sudden onset ‘colicky’ abdominal pain,

associated vomiting.
 ‘Red currant jelly’ stool
 Dehydration/shock
 Palpable mass ‘sausage like’ (may palpate in

rectum – DRE)
 Intussusceptum may prolapse out of rectum
Diagnosis
1. Abdominal Xray :
 Signs of obstruction
 May see a mass
2. Contrast enema:
 Barium or gas may be used.
3. U/S scan.
Donut-like. “Target lesion”
Invagination seen. “
“pseudo kidney”
Management
 Resuscitation !!! Massive third space loss
 NGT
 Antibiotics (Penicillin, Aminoglycoside,

metronidazole)
 Resuscitate before contrast enema, and prior

to reduction
 Sedation/analgesia. pethidine
Management
 Reduction
 Enema reduction
 Pneumatic/ Hydrostatic reduction

Contra-indications:
Shock, septicemia, peritonitis, perforation,
Intestinal infarction, chronic obstruction.
 Surgical management
 When reduction unsuccessful
 Peritonitis
 Perforation
Surgical management
Meconium Ileus
Ileostomies in Meconium Ileus
Malrotation and Volvulus
Torsion of the mesentery
 THANKYOU FOR YOUR ATTENTION!
 QUESTIONS?