NEONATAL INTESTINAL

OBSTRUCTION
Noha Al-khawaja
Maram Al-zein
Amani Azeez Alrahman
SUPERVISOR:Dr.Aayed Al-Qahtani
 Neonatal intestinal obstruction
• Can be grouped into high & low intestinal
obstructions:
High obstructions:
• Pyloric obstruction
• Duodenal obstruction: complete - partial
• Very proximal Jejunal obstruction
Low obstructions:
• Small bowel obstruction
• Meconium ileus & meconium plug
• Colonic atresia
• Hirshsprung’s disease
• Anorectal malformation
• small colon syndrome
 Pyloric stenosis
• Extremely rare in the neonates
• 3rd – 8th week
• Usually 1st born male child
• History: Present with non bilious projectile vomiting that
becomes progressively worse, weight loss & dehydration
• Examination: Peristaltic waves may be seen, palpable
hard mass in the epigastrium
• Investigations: CBC, urea & electrolytes ,US{ thickness ,
diameter ,& length of pylorus}. If equivocal do barium swallow
• Treatment: NG tube, NPO, correct dehydration.
pyloromyotomy.
 CONGENITAL DUODENAL
:OBSTRUCTION
Types:
• Duodenal atresia
• Duodenal stenosis
• Duodenal web
• Annular pancreas
• Malrotation
Incidence:
• 1 in 10000 to 40000 births
Pathology:
Failure of canalization,vascular accidents,& arrest of normal
pancreatic development.
 :Duodenal atresia
• 1 in 5000 live births
• May be associated with Down’s syndrome( 30%) &
congenital heart disease.
• Due to failure of recanalization after the 6th week of
gestation.
History & examination:
• History of maternal polyhydramnious.
• Bilious vomiting.
• Pass meconium.
• On examination:
- visible gastric peristaltic waves.
-stomach may be palpable.
-diffuse abdominal distention is not characteristic.
:Investigations
• Antenatal diagnosis with
US
• CBC.
• Urea and electrolytes
• Abdominal x-ray shows
double bubble sign
• Echocardiography
• Some recommend a
routine karyotype in
neonates born with
duodenal obstruction
 MANAGEMENT
• NPO
• Nasogastric tube.
• IV fluids, antibiotics (Ampicillin – Gentamicin)
• Goals are:
~restoration of continuity without sacrificing
intestinal length or absorpative area
~avoidance of injury to the pancreas or ampulla of
vater
• Best approach is duodenoduodenostomy
duodenojejunostomy reserved for obstructing lesions in
the distal duodenum
 :Results
• Neonates require a period of several weeks before
entral feeding is tolerated
• Surgical outcome is excellent
• Mortality is confined to neonates with Down’s
syndrome and congenital heart disease
• Duodenal stenosis
• Duodenal web
• Annular pancreas :
~ characterised by
circumferential persistence of
the gland around the
duodenum at the site of the
embryonic ventral pancreatic
diverticulum
~associated with intrinsic
duodenal obstruction and a
patent accessory pancreatic
duct
 Symptoms & Signs
• Same presentation
• However, many produce few symptoms
• Diagnostic delay later in life is relatively
frequent
• Abdominal radiograph shows double
bubble sign with some gas distally.
 Management
• Same preoperative preparation
• Excision of duodenal web
• Duodenoduodenostomy
 Small intestinal atresia
• Occurs secondary to in utero ischemic insult
• Overall distribution is roughly equal between
jejunum & ileum
• 90% of infants with congenital jejunoileal
obstructions have atresia
• More than one atresia is reported in 6% to 20%
of these infants
• Low incidence of significant associated anomalies
< 10%
 Types of Atresia
• Type I  a single
membranous atresia, with
continuity of the bowel
wall and intact mesentry

• Type II single atresia

with discontinuity of the
bowel wall
• Type IIIa  atresia without connection by a fibrous cord ,
with a mesenteric gap
• Type IIIb  apple-peel mesentery or christmas_tree
atresia of a large segment of bowel and mesentery
the proximal part is dilated
the distal segment is collapsed & spiraled about distal
branches of ileocolic artery
• Type IV  multiple atresias
intussusception ,segmental volvolus ,or thromboembolism
could be the causes
 History and Examination
• Maternal history of polyhydramnious ( 25% of ileal )
• Bilious vomiting ,abdominal distention.
• Failure to Pass meconium.
• Signs of dehydration .
• Palpable individual loops of proximal intestine.
 Investigations
• CBC, Urea and electrolytes.
• Plain x-ray:
~marked distention of proximal intestinal loops
with gasless distal small bowel & colon
~in ileal atresia multiple dilated loops of bowel
,with multiple air fluid levels
• Contrast enema: because haustral markings are
not normally apparent in neonatal colon it
cannot be differentiated from small bowel.
 Management
• NPO, IV fluids ,NG Tube, antibiotics
• Via a supraumblical incision simple end to end
anastomosis & short segmental bowel resection
• Multiple atresias may require multiple
anastomoses .
 :Results
• Incidence of anastomotic problems as leak is
nearly 5% to 10%.
• Prolonged dysfunction of the proximal gut for
days or weeks is common.
• Morbidity & mortality are generally limited to
those with heart disease,prematurity,or other
associated problems.