neonatal abdominal emergenciesh24-files.s3.amazonaws.com/110213/287283-7dx34.pdflow obstructionlow...

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NEONATAL NEONATAL ABDOMINAL ABDOMINAL

EMERGENCIESEMERGENCIES

LOW OBSTRUCTIONLOW OBSTRUCTION

HIGH OBSTRUCTIONHIGH OBSTRUCTION

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INTESTINAL INTESTINAL OBSTRUCTIONOBSTRUCTION

High obstruction High obstruction -- proximal to midproximal to mid--ileumileumFew dilated, air filled bowel loopsFew dilated, air filled bowel loopsComplete obstruction diagnosed by KUBComplete obstruction diagnosed by KUBPartial obstruction diagnosed by UGIPartial obstruction diagnosed by UGI

Low obstructionLow obstruction distal ileum & colondistal ileum & colonLow obstruction Low obstruction -- distal ileum & colondistal ileum & colonMany dilated airMany dilated air--filled bowel loopsfilled bowel loopsContrast enema study of choiceContrast enema study of choice

LOW INTESTINALLOW INTESTINALLOW INTESTINAL LOW INTESTINAL OBSTRUCTIONOBSTRUCTION

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Typically present with failure toTypically present with failure toTypically present with failure to Typically present with failure to pass meconium or constipationpass meconium or constipation90% of normal neonates pass 90% of normal neonates pass meconium in 1meconium in 1stst 24 hours; 99% 24 hours; 99% in 1in 1stst 48 hours48 hours


Hirschprung’s diseaseHirschprung’s diseaseFunctional immaturityFunctional immaturity

Meconium plug, small left colon Meconium plug, small left colon Meconium ileusMeconium ileusIleal atresiaIleal atresiaColonic atresiaColonic atresia

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CONTRAST ENEMACONTRAST ENEMA

Water soluble contrastWater soluble contrastWater soluble contrastWater soluble contrastDilute gastrograffin (4:1)Dilute gastrograffin (4:1)

Patient immobilizationPatient immobilizationOctagon boardOctagon board

Foley catheterFoley catheterFoley catheterFoley catheterDo not inflate balloonDo not inflate balloon

Initial imaging in lateral Initial imaging in lateral projectionprojection

HIRSCHPRUNG’S HIRSCHPRUNG’S DISEASEDISEASE

Arrest in migration of ganglion cellsArrest in migration of ganglion cellsExtends proximally from anus Extends proximally from anus Without skip areasWithout skip areasRare form is total colonic aganglionosisRare form is total colonic aganglionosisTransition zone most specific findingTransition zone most specific findingTransition zone most specific findingTransition zone most specific finding

Rectosigmoid 75%Rectosigmoid 75%Descending colon 15%Descending colon 15%

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RectosigmoidRectosigmoidIndexIndex S

RNormal rectum Normal rectum wider than sigmoidwider than sigmoidOpposite noted in Opposite noted in Hirschprung’sHirschprung’s

RMeconium plug

R/S >1

SHirschprung sHirschprung sR/S R/S >> 1.0 normal1.0 normal

Hirschprung’sR/S <1

R

S

HIRSCHPRUNG’S HIRSCHPRUNG’S DISEASEDISEASE

Enema has poor diagnosticEnema has poor diagnosticEnema has poor diagnostic Enema has poor diagnostic accuracy accuracy

False negative: 20False negative: 20--25%25%Should not be relied for diagnosisShould not be relied for diagnosisIf diagnosis suspected should If diagnosis suspected should undergo rectal biopsyundergo rectal biopsyundergo rectal biopsyundergo rectal biopsy

O’Donovan. AJR 1996;167:520O’Donovan. AJR 1996;167:520Smith. Pediatr Surg Int 1991;6:318Smith. Pediatr Surg Int 1991;6:318Taxman. Am J Dis Child 1986;140:881Taxman. Am J Dis Child 1986;140:881

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EnterocolitisEnterocolitis

Major ca se of morbidit & mortalitMajor ca se of morbidit & mortalitMajor cause of morbidity & mortalityMajor cause of morbidity & mortalityIncidence increases with delayed Incidence increases with delayed diagnosisdiagnosisDiarrhea, fever, abdominal distension, Diarrhea, fever, abdominal distension, abdominal pain & hematocheziaabdominal pain & hematocheziaabdominal pain & hematocheziaabdominal pain & hematocheziaFecal stasis & bowel dilatation with Fecal stasis & bowel dilatation with secondary infectionsecondary infection

MECONIUM PLUG MECONIUM PLUG SYNDROMESYNDROME

Failure to pass meconium in 1st 24 hrsFailure to pass meconium in 1st 24 hrsCharacterized by multiple meconium plugsCharacterized by multiple meconium plugsUsually improves following enemaUsually improves following enema

Clatworthy. Surgery 1956;39:131Clatworthy. Surgery 1956;39:131--4141

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SMALL LEFT COLON SMALL LEFT COLON SYNDROMESYNDROME

Caliber change near splenic flexureCaliber change near splenic flexureAssociated w/ maternal diabetesAssociated w/ maternal diabetesDdx Ddx -- Hirschprung’s diseaseHirschprung’s disease

Davis. AJR 1974;1974;120:322Davis. AJR 1974;1974;120:322--99

PitfallPitfall

Hirschprung’s Hirschprung’s transition zone transition zone can be at splenic can be at splenic flexureflexureBiopsy if Biopsy if symptoms persistsymptoms persist

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MECONIUM ILEUSMECONIUM ILEUS

I i d i i di l ilI i d i i di l ilInspissated meconium in distal ileum Inspissated meconium in distal ileum Almost always associated w/ CFAlmost always associated w/ CFPresenting feature in 5Presenting feature in 5--10% w/ CF10% w/ CFComplications include Complications include volvulus, volvulus,

f ti it iti & i lf ti it iti & i lperforation, peritonitis & microcolonperforation, peritonitis & microcolon

MECONIUM ILEUSMECONIUM ILEUS

Bubbly appearance in rlqBubbly appearance in rlqPaucity of air fluid levelsPaucity of air fluid levelsReflux into nondilated distal ileum Reflux into nondilated distal ileum Dilated small bowelDilated small bowel

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MECONIUM MECONIUM PERITONITISPERITONITIS

Results from intrauterine perforation Results from intrauterine perforation Primarily from meconium ileusPrimarily from meconium ileusCalcification of peritoneal meconiumCalcification of peritoneal meconiumSite of perforation usually not foundSite of perforation usually not foundSite of perforation usually not foundSite of perforation usually not found

ILEAL ATRESIAILEAL ATRESIA

Secondary to vascular insultSecondary to vascular insultAtresias may be multipleAtresias may be multiple+/+/-- MicrocolonMicrocolon

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COLONIC ATRESIACOLONIC ATRESIA

Secondary to vascular insultSecondary to vascular insultSecondary to vascular insultSecondary to vascular insultType I Type I –– Complete obstruction by Complete obstruction by diaphragmdiaphragmType II Type II –– Obstruction by atretic cordObstruction by atretic cordType IIIType III –– Complete separation ofComplete separation ofType III Type III Complete separation of Complete separation of proximal & distal colonproximal & distal colon

CONTRAST ENEMA DDXCONTRAST ENEMA DDX

MicrocolonMicrocolonMicrocolonMicrocolonMeconium ileusMeconium ileusIleal atresiaIleal atresiaTotal colonic Total colonic aganglionosisaganglionosisaganglionosisaganglionosisColonic atresiaColonic atresia

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Transition zoneTransition zoneTransition zoneTransition zoneHirschprung’s Hirschprung’s Small left colon Small left colon syndromesyndrome


NormalNormalHirschprung’s Hirschprung’s Ileal atresiaIleal atresia

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HIGH INTESTINALHIGH INTESTINALHIGH INTESTINAL HIGH INTESTINAL OBSTRUCTIONOBSTRUCTION

HIGH OBSTRUCTIONHIGH OBSTRUCTION

Mid t l t tiMid t l t tiMidgut malrotationMidgut malrotationDuodenal atresia/stenosis/webDuodenal atresia/stenosis/webJejunal atresia/stenosisJejunal atresia/stenosis

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MIDGUT MALROTATIONMIDGUT MALROTATION

Most important UGI obstruction in newbornMost important UGI obstruction in newbornMost important UGI obstruction in newbornMost important UGI obstruction in newbornArrest in normal rotation of midgutArrest in normal rotation of midgutResults in abnormal mesenteric fixationResults in abnormal mesenteric fixationObstruction 2Obstruction 2oo twisting around SMA twisting around SMA (volvulus)(volvulus) oror abnl peritoneal attachmentsabnl peritoneal attachments(volvulus)(volvulus) oror abnl peritoneal attachments abnl peritoneal attachments ((Ladds bandsLadds bands))

ASSOCIATED CONDITIONSASSOCIATED CONDITIONSAlways presentAlways present

OmphaloceleOmphaloceleGastroschisisGastroschisisCongenital diaphragmatic herniaCongenital diaphragmatic hernia

Increased incidenceIncreased incidenceDuodenal/jejunal atresia/stenosisDuodenal/jejunal atresia/stenosisDuodenal/jejunal atresia/stenosisDuodenal/jejunal atresia/stenosisHirschprung diseaseHirschprung diseaseHeterotaxy syndromeHeterotaxy syndrome

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RADIOGRAPHIC FINDINGSRADIOGRAPHIC FINDINGSRADIOGRAPHIC FINDINGSRADIOGRAPHIC FINDINGSNormalNormalPartial / complete obstructionPartial / complete obstructionProximal / mid small bowelProximal / mid small bowel

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UGIUGIPatient immobilization Patient immobilization

O t b dO t b dOctagon boardOctagon boardDo not overdistend stomachDo not overdistend stomachObserve initial passage of Observe initial passage of barium through duodenum barium through duodenum directly with fluoroscopydirectly with fluoroscopydirectly with fluoroscopydirectly with fluoroscopyImage in frontal & lateral Image in frontal & lateral projectionsprojections


UGI FINDINGSUGI FINDINGSUG GSUG GSAbnormal duodenalAbnormal duodenal--jejunal junctionjejunal junction

Normal = left of left vertebral pedicle Normal = left of left vertebral pedicle at level of duodenal bulbat level of duodenal bulb

Duodenal obstructionDuodenal obstructionCorkscrew appearance of small bowelCorkscrew appearance of small bowel

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Midgut volvulusMidgut volvulus

Spiraling of bowelSpiraling of bowelSpiraling of bowel Spiraling of bowel around SMAaround SMABeaked deformity Beaked deformity of bowelof bowelClosed loop Closed loop ppobstructionobstruction

Ladd’s bandsLadd’s bands

C d i fC d i fCondensations of Condensations of mesentery mesentery Cross & compress Cross & compress duodenumduodenumSimple obstructionSimple obstructionSimple obstructionSimple obstruction

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PitfallsPitfalls

False positive diagnosisFalse positive diagnosisLow DJJ due to bowel dilatationLow DJJ due to bowel dilatationLow DJJ due to splenomegalyLow DJJ due to splenomegalyLow DJJ due to renal agenesisLow DJJ due to renal agenesisDuodenal redundancyDuodenal redundancy

False negative diagnosisFalse negative diagnosisFalse negative diagnosisFalse negative diagnosisAbnormal DJJ Abnormal DJJ rarelyrarely to left of to left of spine and at level of bulbspine and at level of bulb


If UGI findings equivocal If UGI findings equivocal identify position of cecumidentify position of cecum80% of children with 80% of children with malrotation have malrotation have abnormal cecal positionabnormal cecal positionabnormal cecal positionabnormal cecal position

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US/CTUS/CT FINDINGSFINDINGSUS/CTUS/CT FINDINGSFINDINGSReversal of mesenteric vesselsReversal of mesenteric vessels

SMV to left of SMASMV to left of SMA“Whirlpool” appearance of vessels“Whirlpool” appearance of vesselsNot accurate enough for 1Not accurate enough for 1oo dxdxNot accurate enough for 1Not accurate enough for 1 dxdx

“Whirlpool” appearance of midgut volvulus

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DUODENAL OBSTRUCTIONDUODENAL OBSTRUCTION

Most common cause of high obstructionMost common cause of high obstructionMost common cause of high obstruction Most common cause of high obstruction Atresia > stenosis > webAtresia > stenosis > web3/4 distal to papilla & associated with 3/4 distal to papilla & associated with bilious vomitingbilious vomiting1/3 associated w/ Down’s syndrome1/3 associated w/ Down’s syndrome1/3 associated w/ Down s syndrome1/3 associated w/ Down s syndromeMay be part of VACTERL associationMay be part of VACTERL association

JEJUNAL ATRESIAJEJUNAL ATRESIA

Due to vascular insultDue to vascular insultAtresia > StenosisAtresia > StenosisAtresias may be multipleAtresias may be multipleNormal caliber colonNormal caliber colon

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NEONATAL NEONATAL ABDOMINAL ABDOMINAL

EMERGENCIESEMERGENCIES

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