Approach of Neonatal

Intestinal Obstruction
By Noah Ismail GSRIII
Moderator Dr. Fisseha Temesgen consultant of
General surgery and pediatric surgery
 Outline
• Introduction
• Causes of neonatal intestinal obstruction
• Approach to neonatal intestinal obstruction (NIO)
• Neonatal Intestinal Obstruction
• Duodenal atresia and
• Jejunoileal atresia
• Malrotation and valvulus
• References
 Introduction
• Intestinal obstruction in the first month of life
• Common cause of admission to the surgical neonatal unit (1:2000 LB)
• Most are result of congenital abnormalities
• Usually associated with other system anomalies
• The Out come of neonates has improved
• Successful management of neonatal intestinal obstruction demands
timely diagnosis and appropriate intervention
 Causes of Neonatal Intestinal Obstruction
• Duodenum
Atresia or Stenosis
Congenital • Annular Pancreas
Acquired
• Jejunum/Ileum
Mechanical Functional 

Atresia or Stenosis  Paralytic ileus
Midgut Malrotation with  Sepsis
• ARM • Prematurity Volvulus
• Duodenal atresia • Hypothyroidism  Electrolytic imbalance
Meconium Ileus
• Jejunoileal atresia • Hirschsprung’s disease (hypocalcemia,
NEC
• Colonic atresia • syndrome hypokalemia)
• Intestinal • • Colon
Narcotics, & Rectum
substance  Peritonitis
malrotation abuse Hirshsprung’s disease  NEC
/midgut volvulus Anorectal malformation
• Meconium ileus • Atresia or stenosis
• Meconium plug
• Microcolon
• Incarcerated
inguinal hernia
• Congenital bands
• Intra-abdominal
cyst
Clinical Features of NIO
Cardinal features of neonatal intestinal obstruction are the following
but could be subtle and nonspecific:
History of maternal polyhydramnios
Feeding intolerance •Bilious vomiting
•Projectile vomiting in an infant 3-6 w/k
Vomiting of age
Delayed passage of meconium •Hematemesis
•Hematochezia
Abdominal distention
a neonate presenting with sudden bilious vomiting
should be considered as mid-gut malrotation with
volvulus until proven otherwise.
Physical Examination
• General Condition

• Abdomen
• Inspection
• Abdominal distention
• Abdominal movement with respiration
• Abdominal wall Erythema
• Perineal area
• Palpation
• Tenderness & guarding
• Palpable mass
• Auscultation
• Bowel Sound
Diagnosis
• Prenatal diagnosis
• U/S
• MRI
• Postnatal diagnosis
• Plain abdominal X-ray
• UGI contrast Study
• Contrast Enema
• Abdominal U/S
• Vertebral x-ray
• Echocardiography
Prenatal
• U/S: Polyhydramnios & dilated bowel loops
• MRI
Plain abdominal X-ray
Dilated intestinal loops proximal to the obstruction
The absence of air distal to the obstruction
A double-bubble sign/ a triple-bubble sign
Signs of complications of the intestinal obstruction
• Peritoneal calcifications
• Pneumoperitoneum, intramural air
• UGI contrast Study: Gold standard to dx malrotation
DJ flexure not crossing the midline to lie to the left of the L2 spinous
process
‘bird-beak’ cut-off /spiraling/ corkscrew appearance
Duodenum travel downward
The low position of the pylorus - inferior to the L2 horizontal plane
o Contrast Enema - When there is clinical suspicion of distal bowel obstruction
- Serve as both diagnostic and therapeutic tool
o Abdominal U/s - Urgent evaluation of Malrotation with volvulus
-A reversed configuration of the SMA and SMV
-An abnormal position of the 3rd part of the duodenum b/n SMA and aorta
-Whirlpool sign on color Doppler ultrasound

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 management
General
Initial resuscitation
 Stop feeding
 Bowel decompression

 Open IV line
• Fluid (10-20ml/kg over one hr then monitor Uop)
• Electrolyte
• Nutrition
• Antibiotics

 Secure air way

Specific
Depending on the underlying specific pathology
16
Intestinal Atresia
Duodenal Atresia
• Affecting boys more commonly than girls.
• Associated anomalies have been reported in 45–65% of cases.
• Operative correction is accomplished via laparoscopically or open.
• Survival rates of >90%

Most commonly ½ of pts are trisomy 21.

congenital heart disease 30%.
malrotation in 30% of cases.
can be part of the VACTERL association (vertebral, anal
atresia, cardiac, tracheoesophageal fistula, renal, limb).
annular pancreas.
 CLASSIFICATION SYSTEM
Ladd Classification (Duodenal obstruction)
Intrinsic (Common):-
 Failure of Recanalization of fetal duodenum
Atresia, Stenosis, Web (perforate or imperforate)
Extrinsic :-
 Adjacent organ Maldevelopment
• Annular Pancreas, Preduodenal portal vein,
Malrotation and Ladd’s bands
Diagnosis
• Prenatal
• Maternal Polyhydramnios (50%) of duodenal atresia
• Double-bubble sign

• Postnatal
• Vomiting
• Bilious Emesis 85% with in the 1st hr of Birth
• Complete obstruction, Early
• Partial obstruction, Late
• Aspiration via a nasogastric (NG) tube of >20 mL of gastric contents

• Abdominal distention
• Absent (Scaphoid)
Radiography
• Plain film
 ‘’double bubble” sign with no distal
bowel gas

• Contrast study
 To exclude Malrotation & volvulus
The presence of distal gas does not
necessarily exclude the diagnosis of
atresia.
 Management
•General : Appropriate resuscitation
•Specific
The various techniques either open or laparoscopic are:
I. side-to-side duodenoduodenostomy,
II. diamond shaped duodenoduodenostomy,
III. partial web resection with Heineke–Mikulicz-type
duodenoplasty,
IV. tapering duodenoplasty, and
V. Gastrojejunostomy
• Preferred technique for Laparoscopic or open duodenoduodenostomy
• a proximal transverse to distal longitudinal, or ( Diamond shaped
anastomosis ).

Surgery is not emergency

Jejunoileal Atresia
• It occurs equally in males and females
• 1 in 3 infants is premature.
• Although the majority of cases are thought to occur sporadically,
familial cases of intestinal atresia have been described.
• It is generally accepted that jejunoileal atresia occurs as a result of an
intrauterine ischemic insult to the midgut.
Grosfeld Classification system of jejunoileal
atresia
Type I: (23%) Mucosal atresia with intact
bowel and mesenetery

TypeII: (10%) Blind ends separated by a

fibrous cord

Type III(a): (16%) Blind ends separated

by a V-shape mesenteric defect

Type III(b): (19%) Apple-peel atresia

(christmas tree)

Type IV: (20%) Multiple atresias (string

of sausages)
Diagnosis
• Prenatal
• Maternal Polyhydramnios.
• Dilated small bowel
• Postnatal
• Clinical presentation
• Bilious Vomiting
• jaundice
• Failure to pass meconium
• Plan x-ray
• Dilated loops of bowel with air fluid levels
• Absent air at rectum
• If perforation has occurred: free air and/or peritoneal calcifications
• Barium enema: small unused colon and often shows reflux of contrast into a collapsed
terminal ileum.
Management
• General 1950s the surgical mortality for newborns with intestinal
• Fluid and electrolyte atresia was 80–90%. This high mortality rate was mostly
related to late presentation and dysmotility of the proximal
• Specific dilated bowel, which led to complications related to chronic
• Surgical mgt is based on:- obstruction.
 Location of the lesion
 Types of the lesion
 Length of the remaining intestine

• Different surgical strategy indicated for each

type of lesion.

• In general
 Resection of the dilated and hypertrophic proximal
bowel with primary end to end anastomosis with or
with out tapering of the proximal bowel.
Approach can be:-
Supra umbilical transverse incision or
Umbilical
1. Identify the type and site of the atresia
2. Confirm the patency of distal bowel
with saline injection.
3. Resection of the proximal bulbous
atretic segment
4. Limited distal bowel resection
6 Accurate measurement of residual
bowel length proximal and distal to the
anastomosis.
7 Single or double layer end-to-end or end-
to-back anastomosis.
In the presence of established peritonitis
The fashioning of proximal or distal
stomas are indicated.
Bowel conservation technique
Tapering jejunoplasty
Reduce disparity in anastomotic
diameter size
Improve peristalsis
Plication and Folding
 Less risk of leakage
 Conserves mucosal surface area
 Fast return of peristalsis
 Disadvantages
Unraveling
Antimesenteric Seromuscular Stripping
and Inversion Plication:
 Prevent unraveling
 preserves maximal mucosal surface for
absorption
Malrotation
 Malrotation
• Epidemiology
1/6000 live birth
Most present in <1 month
No sex/race predilection
Individuals can live their entire life with
malrotation with out symptom
Presentation
• Range from acute midgut volvulus to chronic abd pain
• Neonates and infant

• Classic malrotation with Midgut volvulus

• Discovered in a previously healthy term neonate.
• Up to 75% of patients present during the first month of life.
• Another 15% will present within the first year

• Older child or even Adults

• Intermittent duodenal obstruction due to kinking of the duodenum by Ladd’s band.
• Non specific abdominal pain
• Intermittent colicky abdominal pain and bilious vomiting
Diagnosis
• Prenatal
• Prenatal U/S
• Dilated bowel loops
• Abnormal SMA and SMV relation ship
• Postnatal
• Vomiting
• Bilious Emesis:- CARDINAL SIGN
• Hematemesis
• Abdominal distention
• Slight abdominal distention
• Abd wall erythema, Edema
• Tenderness – guarding
• Passage of Meconium
• Melena
• Septic shock
• Bowel perforation
• Unstable Hemodynamics
Diagnosis
• Plain radiograph (non specific)
• Vary from Normal to signs of SBO
• Gasless abdomen
Atypical Atypical
• Pneumoperitoneum
• Distended bowel gas suggesting distal obstruction

• Upper GI contrast studies,

 Examination of choice
• Misplaced DJ in right side
• Duodenal obstruction
• Birds beak, Corkscrew
Diagnosis
 U/S and CT

• Clockwise Whirlpool sign

• Abnormal position of SMVs-

 Inverted SMA/SMV R/n SHIP.

• Large bowels predominantly on Rt

side & Small bowel predominantly
on left side.
Ladd’s procedure

The goal of ladd’s procedure is the place the bowel into

position of non rotation: the small bowel on the Right
and the colon on the left of abdomen.
• Intra-operative
• If there is bowel Ischemia
• Resection and primary anastomosis if localized
• Stomas creation in questionable remaing segment
• Second look laparatomy if questionable long segment
• If gangrenous mid gut
• Resection and putting on TPN
• Closing abdomen palliative care
• Small bowel transplantation
PROGNOSIS
• The incidence of recurrent volvulus is low.
• Postoperative intussusception :- noted in 3.1%
• Adhesive SBO, up to 10%
Reference
• Holcomb and Ashcraft’s Pediatric Surgery-Elsevier (2019)
• Newborn Surgery, Prem Puri, CRC Press, 4th Edition 2018
• Operative General Surgery in Neonates 1st E, 2016.
• Surgical care of major newborn malformations, 2012.
• Rickham's Neonatal Surgery 1st E
• Uptodate 2021
• Prenatal diagnosis and outcome of fetal gastrointestinal obstruction☆
Patricio E. Lau, Stephanie Cruz , Christopher I. Cassady c, Amy R. Mehollin-Ray c, Rodrigo Ruano ,
Sundeep , Timothy C. Lee , Oluyinka O. Olutoye , Darrell L. Cass .
http://dx.doi.org/10.1016/j.jpedsurg.2017.01.028 © 2017 Elsevier Inc. All rights reserved.
• East African Medical Journal Vol. 77 No. 9 September 2000
NEONATAL INTESTINAL OBSTRUCTION IN ZARIA, NIGERIA
E. A. Ameh, MBBS, FWACS, Lecturer and Consultant and L. B. Chirdan, MBBS, Dip. Paed. Surg, FWACS,
Lecturer and Consultant, Paediatric Surgery Unit, Department of Surgery, Ahmadu Bello University Teaching
Hospital, Zaria, Nigeria.
Request for reprints to: Dr. E. A. Ameh, Paediatric Surgery Unit, Department of Surgery, A.B.U. Teaching
Hospital, Zaria, Nigeria.
• Motor and cognitive outcome at school age of children with surgically treated
intestinal obstructions in the neonatal period
Rachel M. Elsinga a,⁎, Elise Roze a, Koenraad N.J.A. Van Braeckel a, Jan B.F. Hulscher b, Arend F. Bos a
a Division of Neonatology, Beatrix Children's Hospital, University Medical Center Groningen, University of
Groningen, Groningen, The Netherlands
b Department of Surgery, Division of Pediatric Surgery, University Medical Center Groningen, University of
Groningen, Groningen, The Netherlands
Thank you so much