infant bowel obstruction robert w. letton, jr., md associate professor of surgery pediatric surgery...
TRANSCRIPT
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Infant Bowel Obstruction
Robert W. Letton, Jr., MDRobert W. Letton, Jr., MDAssociate Professor of SurgeryAssociate Professor of Surgery
Pediatric SurgeryPediatric Surgery
Oklahoma University Health Sciences CenterOklahoma University Health Sciences Center
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Question 1?
Why do Pediatric Surgeons always make such a big deal out of a
little yellow or green emesis?
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Answer
Because unlike when Stan sees Wendy in Southpark©, it usually means bowel obstruction or necrosis in our patients!
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Goals
Discuss the work-up and management of Discuss the work-up and management of the child with potential bowel obstructionthe child with potential bowel obstruction
Recognize the common causes of bowel Recognize the common causes of bowel obstruction in childrenobstruction in children
Discuss surgical management of common Discuss surgical management of common causes of bowel obstructioncauses of bowel obstruction
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History
Birth HistoryBirth History Feeding HistoryFeeding History
Formula intoleranceFormula intolerance EmesisEmesis
Bilious vs non-biliousBilious vs non-bilious Bowel HabitsBowel Habits
passage of meconiumpassage of meconium
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History
Antecedent episodesAntecedent episodes Irritable, lethargicIrritable, lethargic History of inguinal herniaHistory of inguinal hernia Family historyFamily history
Hirschsprung’sHirschsprung’s Recent immunization or URIRecent immunization or URI
IntussusceptionIntussusception
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Physical Exam General state of hydrationGeneral state of hydration Obvious source of sepsisObvious source of sepsis
meningitis, strep throat, otitis, pneumonia, UTImeningitis, strep throat, otitis, pneumonia, UTI Inspect abdomenInspect abdomen
scaphoid or distended, discoloredscaphoid or distended, discolored AuscultateAuscultate PalpatePalpate
masses, tenderness, peritonitismasses, tenderness, peritonitis
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Physical Exam
Must remove diaperMust remove diaper
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Physical Exam
Must perform rectal exam, not just look!Must perform rectal exam, not just look!
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Ancillary Studies
CBC, Lytes, UA, +/- Blood Cx, +/- ABGCBC, Lytes, UA, +/- Blood Cx, +/- ABG Acute abdominal seriesAcute abdominal series
left lateral decub, KUB, CXRleft lateral decub, KUB, CXR Contrast StudyContrast Study
From above or below??From above or below??
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Initial Management
NG or OG to low wall suction (NPO!!)NG or OG to low wall suction (NPO!!) Hydrate and replace lossesHydrate and replace losses
10 cc/kg of crystalloid10 cc/kg of crystalloid IS NOT AN IS NOT AN ADEQUATE BOLUS!!ADEQUATE BOLUS!!
Antibiotics if suspect perforation or necrosisAntibiotics if suspect perforation or necrosis Consult surgeon and/or transfer to Consult surgeon and/or transfer to
appropriate facilityappropriate facility
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Bowel Obstruction
Diagnosis often age specificDiagnosis often age specific Bilious vomiting in the infant and child is a Bilious vomiting in the infant and child is a
surgical emergency until proven otherwisesurgical emergency until proven otherwise Difficult to tell when volvulus is presentDifficult to tell when volvulus is present Child may look surprisingly good until it’s Child may look surprisingly good until it’s
too latetoo late
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Etiology of Bowel Obstruction
AtresiasAtresias Hirschsprung’sHirschsprung’s MalrotationMalrotation VolvulusVolvulus IntussusceptionIntussusception Incarcerated HerniaIncarcerated Hernia Perforated appendixPerforated appendix
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Atresia
Usually presents the first few days of lifeUsually presents the first few days of life Child may feed well for a day or two with Child may feed well for a day or two with
distal atresiadistal atresia Duodenal atresia often diagnosed on Duodenal atresia often diagnosed on
antenatal U/Santenatal U/S Atresias can occur anywhere in GI tract Atresias can occur anywhere in GI tract
from pharynx to anusfrom pharynx to anus
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Atresias
Esophageal: aspirate feeds immediately, Esophageal: aspirate feeds immediately, OG tube won’t pass (non-bilious, but still OG tube won’t pass (non-bilious, but still bad)bad)
Duodenal: bilious vomiting immediately, Duodenal: bilious vomiting immediately, “double bubble” on KUB with absence of “double bubble” on KUB with absence of distal gas, Down’s Syndromedistal gas, Down’s Syndrome
Jejunal: usually present 1Jejunal: usually present 1stst 24 hours, large 24 hours, large dilated proximal loop or loopsdilated proximal loop or loops
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Atresias
Ileal: may take 24-48 hours before bilious Ileal: may take 24-48 hours before bilious emesisemesis
Colonic: rare, may present with bilious Colonic: rare, may present with bilious emesis after 2-3 daysemesis after 2-3 days
Anal: should be diagnosed at birth, often a Anal: should be diagnosed at birth, often a perineal fistula is labeled normalperineal fistula is labeled normal
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Obvious Obstruction
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Atresias may be multiple
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Jejunal Atresia
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Apple Peel Deformity (IIIb)
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Imperforate Anus: Anal atresia
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Hirschsprung’s Disease
Congenital colonic aganglionosisCongenital colonic aganglionosis Physiologic obstruction Physiologic obstruction
May present first few days to weeks of lifeMay present first few days to weeks of life Short segment disease often tolerated for Short segment disease often tolerated for
monthsmonths Starts at anus and extends proximally a Starts at anus and extends proximally a
variable distancevariable distance
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Hirschsprung’s
Delayed passage of meconium at birthDelayed passage of meconium at birth Meconium plug syndrome, small left colon Meconium plug syndrome, small left colon
syndrome, Down’s syndromesyndrome, Down’s syndrome Often present with distension and diarrhea at 2-4 Often present with distension and diarrhea at 2-4
weeks of lifeweeks of life May or may not have emesisMay or may not have emesis Profoundly distended abdomen with dilated bowelProfoundly distended abdomen with dilated bowel Fever and Fever and WBC’s with colitisWBC’s with colitis
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Hirschsprung’s
Rectal exam may seem normal until Rectal exam may seem normal until withdraw fingerwithdraw finger
““Explosive” release of liquid stool almost Explosive” release of liquid stool almost diagnosticdiagnostic
Barium enema while dilatedBarium enema while dilated Irrigate and dilate until decompressedIrrigate and dilate until decompressed Suction rectal biopsySuction rectal biopsy
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Hirschsprung’s Disease
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Barium Enema
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Treatment
NO WAY!
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Hirschsprung’s Disease
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Toxic Megacolon
Severe enterocolitisSevere enterocolitis Very rare to get with idiopathic constipationVery rare to get with idiopathic constipation Usually only seen with Hirschsprung’s Usually only seen with Hirschsprung’s
Disease or Ulcerative ColitisDisease or Ulcerative Colitis NG decompression, IV fluids, IV antibioticsNG decompression, IV fluids, IV antibiotics Mortality 20-30% in some studiesMortality 20-30% in some studies
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Toxic Megacolon
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Hirschsprung’s in an 8 year old
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Malrotation
Normal
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Malrotation
Most often presents during the first few Most often presents during the first few months of lifemonths of life
Infant with acute onset of bilious emesisInfant with acute onset of bilious emesis May be diagnosed on UGI for other reasonsMay be diagnosed on UGI for other reasons Malrotation is a surgical urgency due to the Malrotation is a surgical urgency due to the
possibility of volvuluspossibility of volvulus VOLVULUS IS A SURGICAL VOLVULUS IS A SURGICAL
EMERGENCYEMERGENCY
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Malrotation
Abdomen usually Abdomen usually NOTNOT distended distended AAS usually normalAAS usually normal
May show bowel obstruction, double-May show bowel obstruction, double-bubble, or gaslessbubble, or gasless
UGI is definitive diagnostic studyUGI is definitive diagnostic study Infant in extremisInfant in extremis
resuscitate and operateresuscitate and operate
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Malrotation
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Malrotation
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Volvulus
Malrotation most common condition Malrotation most common condition resulting in midgut volvulusresulting in midgut volvulus
Can have volvulus with normal rotationCan have volvulus with normal rotation omphalomesenteric remnantomphalomesenteric remnant internal herniainternal hernia DuplicationDuplication Adhesive small bowel obstructionAdhesive small bowel obstruction
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Midgut Volvulus
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Small Bowel Obstruction
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Meckel’s
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Duplication/Volvulus
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Duplication
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Intussusception
Inversion of the bowel upon itself Inversion of the bowel upon itself secondary to a lead pointsecondary to a lead point
Juvenile intussusception most often Juvenile intussusception most often idiopathicidiopathic Also secondary to Meckel’sAlso secondary to Meckel’s
Presents 6 months to 2 years of agePresents 6 months to 2 years of age As early as 1 monthAs early as 1 month
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Intussusception
Acute painful episodes followed by periods Acute painful episodes followed by periods of lethargyof lethargy
When incarcerated progress to continuous When incarcerated progress to continuous lethargylethargy
May or may not have “currant-jelly” stoolMay or may not have “currant-jelly” stool But often stool is heme positiveBut often stool is heme positive
Rule out with a left lateral decubitus filmRule out with a left lateral decubitus film
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Left-lateral Decubitus Film
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Intussusception
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Intussusception
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Intussusception
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Intussusception
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Bad Intussusception
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Intussusception
7% chance of recurrence after ACE 7% chance of recurrence after ACE reductionreduction Usually recur in 48 hoursUsually recur in 48 hours
Operative exploration warranted on second Operative exploration warranted on second recurrence to R/O pathologic lead pointrecurrence to R/O pathologic lead point
Recurrence after surgery rare but possibleRecurrence after surgery rare but possible Post-op intussusception can occur after any Post-op intussusception can occur after any
surgerysurgery
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Incarcerated Hernia
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Inguinal/Scrotal Anatomy
From Surgery of Infants and Children, Oldham, et. al., 1997
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Inguinal Hernia
From Atlas of Pediatric Surgery, Ashcraft, 1994
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Incarcerated Inguinal Hernia
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Hernia Reduction
From Surgery of Infants and Children, Oldham, et. al., 1997
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Incarcerated Hernia
Most can be reduced in clinic or EDMost can be reduced in clinic or ED Bowel usually OK if able to reduceBowel usually OK if able to reduce Surgical consultation if reduction difficultSurgical consultation if reduction difficult Repair with 1-2 days of incarcerationRepair with 1-2 days of incarceration Beware the “inguinal node’ in femalesBeware the “inguinal node’ in females
incarcerated ovaryincarcerated ovary
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Incarcerated Hernia
If unable to reduce: urgent operative If unable to reduce: urgent operative exploration (NPO)exploration (NPO)
If able to reduce without sedation: urgent If able to reduce without sedation: urgent surgical referral with repair soonsurgical referral with repair soon
If extremely difficult (sedation, surgical If extremely difficult (sedation, surgical referral): repair next dayreferral): repair next day
Watch child for obstructive symptomsWatch child for obstructive symptoms
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Perforated Appendix
Children still die from complications of Children still die from complications of perforated appendicitisperforated appendicitis
Resuscitation is criticalResuscitation is critical Response to surgery variableResponse to surgery variable Often require multiple procedures, Often require multiple procedures,
hyperalimentation, prolonged antibiotic hyperalimentation, prolonged antibiotic therapytherapy
Diagnosis difficultDiagnosis difficult
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AAP Guidelines for Pediatric Surgical Referral Patients 5 years or younger who may need surgical Patients 5 years or younger who may need surgical
carecare Infants and children with perforated appendicitisInfants and children with perforated appendicitis Seriously injured infants and children Seriously injured infants and children Infants, children, and adolescents with solid Infants, children, and adolescents with solid
malignancies malignancies Minimally invasive procedures Minimally invasive procedures Infants and children with medical conditions that Infants and children with medical conditions that
increase operative risk increase operative risk
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MorbidityIncidence of Perforation
< 1 year old 90-100%
1-2 years old 70-80%
2-5 years old 50%
> 65 years old 50%
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Perforated Appendix
Suspect in children 3-5 years old with Suspect in children 3-5 years old with history suggestive of appendicitishistory suggestive of appendicitis
““Bowel obstruction” in a 3-5 year old Bowel obstruction” in a 3-5 year old without obvious etiology is perforated without obvious etiology is perforated appendix until proven otherwiseappendix until proven otherwise
Fever > 101.5, WBC > 20 with bands, Fever > 101.5, WBC > 20 with bands, diffuse abdominal pain, guarding, SBO on diffuse abdominal pain, guarding, SBO on AASAAS
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Perforated Appendix
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Perforated Appendix
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Resuscitation
NG tube, NPONG tube, NPO 20 cc/kg boluses until UOP > 1 cc/kg/hr 20 cc/kg boluses until UOP > 1 cc/kg/hr
and VS stableand VS stable 1.5-2 times maintenance fluids1.5-2 times maintenance fluids Broad Spectrum AntibioticsBroad Spectrum Antibiotics
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Perforated Appendix
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Summary
AtresiasAtresias Hirschsprung’sHirschsprung’s MalrotationMalrotation VolvulusVolvulus IntussusceptionIntussusception Incarcerated HerniaIncarcerated Hernia Perforated AppendixPerforated Appendix
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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!