2018.Surgery Intestinal Obstruction in Infants and Children

Intestinal Conditions in Infants and Children Surgery II SURGERY II

FACILITATOR: Ma. Celine A. Villegas, M.D.

DATE: September 5, 2016 -

OBJECTIVES 

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Identify the Signs and Symptoms of Intestinal obstruction in neonates and in the older child Identify causes of Intestinal Obstruction Identify Laboratory and radiologic exams needed to diagnose an Intestinal obstruction Describe Emergency Room measures to resuscitate such patients especially in the Emergency room Describe the surgical treatment for the most common cases of intestinal obstruction in the Pediatric Age group

Definition of Intestinal Obstruction -

Interference with the normal passage of intestinal Contents along the bowel lumen

Infants and Children Effects of Intestinal Obstruction in Infants and Children       

Respiratory Distress Aspiration of vomitus Peripheral circulatory collapse o Because of the resulting hypovolemia due to the inability to take in fluids Hypoglycemia---overall metabolic conditions Acidosis Infection o Stasis of GI content—overall proliferation of intestinal bacteria Hypothermia

ants and Children Diagnostic Modalities in Intestinal Obstruction 

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Intestinal Obstruction in a Fetus

Clinical Features of Intestinal Obstruction in Infants and Children 1) Prenatal - Polyhydramnios (in the mother) 2) Postnatal (V-A-N)

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Vomiting especially bilious vomiting Abdominal Distention No passage or disturbance of meconium passage

For Diagnosis o Abdominal x-rays (plain) o Contrast Studies (UGIS, Barium enema)  Very rarely you request for UGIS or Barium swallow Assessment Investigation o Complete Blood Count o Serum Electrolytes o Culture Studies of blood, urine (occasionally)  For very septic patients o Blood Gases (rarely)  For patients who require intubation  Cyanotic Patients  Rarely done because it is painful for the babies

Features of Intestinal Obstruction in In

QUESTION: Why do you have cyanosis in abdominal distension? ANSWER: because the diaphragm is displaced upward due to the abdominal distension, hence, there will be reduced lung capacity and lower oxygen perfusion

General Principles of Management        

Respiratory Care o Make sure that the airway is clear Control of Hypoglycemia Control of Hypothermia Control of Acidosis Maintenance of Blood Volume Correction of Fluids/Electrolytes Antibiotics Parenteral alimentation if needed especially in post-op period

Nasogastric Tube Insertion in a Neonate 

Ke Take measurement (to know how much is needed to insert) o From the nares to the ears then to the xyphoid process o It should be secured on the CHEEK and not on the NOSE because nose will nercrotize o OGT—an NGT can be inserted through the mouth o 2016 transcription: sometimes, an orogastric tube is placed instead of an NGT and it is much easier to insert

OROGASTRIC TUBE

Common Causes of Intestinal Obstruction in Children Neonates ( 28 days but less than 1 year old) and older Children o Intussusception o Incarcerated Inguinal Hernia—MOST COMMON o Post-operative adhesions o Obstruction from Meckel’s Diverticulum o Hirschsprung’s disease o

DUODENAL ATRESIA

Embryology  

Failure of Recanalization during solid stage of Duodenal Development Incidence: 1:20,000 to 40,000 live births

Radiologic- double bubble sign and Duodenal atresia intraoperative findings

Embr Clinical Picture of Duodenal Atresia  

Bilious Vomiting  Bile is secreted at the level of the duodenum Mild Epigastric Distention

Radiologic Picture of Duodenal Atresia  

Double-bubble finding on X-ray No distal gas

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Operative Management of Duodenal Atresia   

Depends on the intraoperative findings; Principle – bypass obstructed segment Duodenoduodenostomy

Operative Management of Intestinal Atresia 

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Resection of proximal bulbous bowel and atrectic segment o The bulbous bowel won’t function anymore because the muscular layer is overly stretched. End-to-end anastomosis--preferably Enterostomy Ileostomy if the patient is septic

*resection

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Duodenoduodenostomynt of

INTESTINAL ATRESIA Embryology  

Vascular accident in Utero o Volvulus or Intussusception Incidence:1:330 to 1:1,500 live births o

*end-to-end anastomosis

f Duodenal Atresia Clinical Picture of Intestinal Atresia   

Vomiting Abdominal Distention Non-passage of Meconium

Operative Management of Duodenal Atresia Diagnosis of Intestinal Atresia   

Plain Abdominal X-rays Dilated loops of Bowel with differential airfluid levels Barium Enema – Microcolonof

Plain, UGIS, Barium A

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MALROTATION *this is the most dangerous

Embryology 

Normal Intestinal Rotation o Usually at the 4th week of life o Return of GIT in the abdomen o From powerpoint: At 4th week AOG, normal occurrence of return of fetal GIT from extraembryonic coelom back into the abdomen. Bowel undergoes rotation and fixation at certain parts of posterior abdominal wall o If the process is incomplete or deviated from normal, MALROTATION results.

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Cecum remains in the RUQ Ladd’s Bands (top-left) o Between the duodenum and Cecum o Fix Cecum at RUQ Extrinsic Duodenal Obstruction—caused by Ladd’s bands o Duodenum is a straight tube instead of a C-loop

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UGIS (small bowel confined at the right)

Narrow Vascular pedicle can cause bowel to twist on itself > volvulus o If there is midgut Volvulus and the patient did not underwent surgery, there will be necrosis of the bowel (whole midgut) From 2016 transcription: you may want to visit this site for further discussion of the normal intestinal rotation: http://www.youtube.com/rs44cXvjbMA

Operative Management of Intestinal Atresia Clinical Picture of Malrotation  

Bilious Vomiting Once Volvulus is present: o Abdominal Distention o Bloody Stools- If volvulus if Present o Decreased or Absent Stools o Shock if bowels strangulated

Malrotation of the intestines showing the duodenaljejunal junction is in the right of the spine and most of the small bowel is on the right side of the abdomen

Diagnosis of Malrotation 

Barium Enema (cecum at right upper )

Red arrow pointing to the Ladd’s band between the duodenum and cecum

Operative Management of Malrotation 

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Ladd’s Procedure o Untwisting the bowel

o o o

Dividing the Ladd’s bands compressing the duodenum Appendectomy Bowel resection if ischemia or necrosis is present

Clinical Presentation Of Intussusception    

Older infants : 8 months – 1 year A healthy chubby child Male predominance History of Upper Respiratory Tract Infection (Diarrhea can also be an early sign of Intussusception)

Dreaded Complication of Malrotation : VOLVULUS

Signs and Symptoms of Intussusception      

*midgut volvulus in malrotation

INTUSSUSCEPTION  

Telescoping of a bowel to itself due to persitatltic activity (invaination of the Intestine on itself) Proximal portion of the bowel is drawn into the distal bowel by peristaltic activity

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Abdominal Colic Vomiting “Currant Jelly” stool---(Kids, itaga po to sa long term memory. Say it with me “Intu Currant Jelly” Repeat 10x) Abdominal Distention – Late Hypovolomic Shock – Very Late Period of quiscence when peristalsis stops for a time o Recurs (peristalsis as the GIT tries to propel the bowel content resulting into currant jelly stools

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 Ultrasound Examination o 100% Specific and Sensitive o Pseudo Kidney sign Superimposed hypoecohic and hLayers indicative of edematous walls of intussuscpetion o Target Sign 2 rings of low echogenicity separated by a hyperechoic ring

Diagnosis 

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Physical Exam o Palpable tubular mass—at right hemiabdomen o Rectal Exam : No stool in the rectum, only bloody mucus o Irritable, Lethargic baby o Marked abdominal distention—LATE Diagnostic Studies  Plain Abdominal X-ray o Dilated Bowel Loops o Airless Right Lower Quadrant o Indicative of Intestinal Obstruction o Lateral View:Differential air fluid levels

 Contrast Enema o Coiled Spring Sign o Diagnostic and Therapeutic o Contrast material will push the intussusception and straighten out the GIT

Contrast Enema

Nonsurgical Treatment Of Intussusception 

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*plain lateral decubitus x-ray of a patient with intussusception

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Reduction of Intestines o Air (Pneumatic Reduction)—90% reduction rate; most successful o Saline (Hydrostatic Reduction) o Barium Instillation per Rectum can Straighten out Intestine Reduction Success Rate o 42-80% Saline/Barium Reduction o 90% Penumatic Reduction

HIRSCHSPRUNG DISEASE  

Indications for Nonsurgical Hydrostatic Reduction in Intussusception   

Less than 24 hours old symptoms (early cases) No signs of peritonitis No marked obstruction

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*hydrostatic reduction in intussusception

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Surgical Treatment of Intussuscpetion   

Congenital absence of parasymphathetic innervation of the intestines- INTESTINAL MOTILITY DISORDER –common in Filipinos One way for me to describe this to parents is when a patient has a stroke, the right or left side of the body won’t work because there is absence of connection to the brain. The same thing happens for patients with Hirschsprung. There is no connection between a certain segment of the intestines to the brain that’s why it doesn’t function properly. –parang ako walang connection sa iyo kaya di ako nagfufunction (hanudaw) 1:5,000 livebirths 4:1 male:female ratio Certain amount of heredity Clinical Presentation Delayed passage of meconium (more than 24 hours after birth)—94% would pass meconium, if not, they are suspected to have Hirschsprungs May progress to massive distention Chronic constipation Diarrhea from enterocolitis can sometimes result to distention and dehydration Intermittent obstruction relieved by suppositories or insertion of thermometer to stimulate the intestines--the child will actually poop Diagnostic Studies Barium Enema o Coning or transition zone

“Milking” Action on bowel Not a pulling action (if pulled can lead to avulsion) Appendectomy is done after the bowels have straighten out

*Transition zone/cloning on barium enema (area that is narrowed)

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Anorectal manometry—not widely used in the Phils. Rectal Biopsy—gold standard o Absent ganglion cells Acetylcholinesterase determination

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Operative Management Staged operation o Severe disease o Preliminary colostomy then pullthrough (removal of aganglionic portion) procedure later Single stage operation o Transanal pullthrough procedure

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Clinical Manifestations Intestinal obstruction no anal opening or abnormal location fistula may be open on the perineal skin in some males, meconium present in urine or through the urethra

Types of Imperforate Anus  High – Rectal pouch above levator ani  Low- Rectal pouch below levator ani

High (left), Low (right)

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IMPERFORATE ANUS A perineum without an anal opening---very common Most anorectal malformations communicate by a fistulous tract to the urinary or genital systems or alternatively open to the skin of the perineum--sometimes parents would note that stool comes out of the vagina 1:5,000 live births males>females rectal/high lesions – more in males anal/low lesions – more in females

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Diagnosis In males, where is meconium coming from? o Male, low type—meconium on the perineal skin

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Male, high type—meconium comes from the urethra

Imperforate anus-male-low type

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In females, count number of orifices—if the px has 2 orifices, probably she has high imperforate anus. 1 orifice, urine-stool comes out of a single orifice— high. If 3, displaced lang yung where the stool is coming out, that is a low imperforate anus.

Male, high type

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Ultrasound or MRI o Location of distal rectal pouch Accurate determination of level of lesion of imperforate anus will have bearing in management Operative Management

  Imperforate anus-female-low type

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X-ray o Determine the type of imperforate anus and to identify any congenital anomalies that are present---patients with imperforate anus occasionally has VACTRL anomaly V- Vertebra A- Anus C- Cardiac T- Tracheoesophageal fistula E-Esophageal R-Renal and Radial L- Limb o Invertogram/rice-wangsteen prone cross table lateral

Low Type o Definitive treatment in neonatal period o Anoplasty High Type o Definitive treatment at later date 1. Initial colostomy 2. PSARP (Posterior Sagittal Anorectoplasty) 3. Closure colostomy

Transverse loop colostomy for imperforate anus

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PSARP (Posterior Sagittal Anorectoplasty)- definitive correction of imperforate anus

Pagtatapos References: 2016 transcription | recordings and notes | *use at your own risk #ageofOBE #OBEgames #MEDbeforeyou #pustahanlalabasangintussusception #currantjellypamore #hashtagngmaramiparapangfill #districtsurgery #hellomarkcalimbahin “Please don’t forget to evaluate your facilitators!”— mamimiss niyo to (Lapena, 2016) Happy birthday Raiko Cecogo and Kristen Campos!

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