Monitored for additional 24 hours; had normal stools and resolution of symptoms
Follow up with PMD, GI
Further evaluation including rectal suction biopsy for recurrence of symptoms
F/U CF Genetic studies
Presentation to Pediatric Floor
Initially doing well
BM’s occurred every feed until 1 day PTA
Developed Poor feeding
Watery, mucousy stool
One episode of bilious emesis
SHx/FHx/Allergies/Meds -non contributory
T:36.5 HR140 RR40 BP N.O. Ox Sat 98%
General: Alert, Awake, in NAD
Abdomen: hyperactive bowel sounds, distended but soft, no palpable masses or HSM
Perianal exam-normally placed anus
Rectal: normal; hemoccult negative; no narrowing or explosive stool
Abdominal X-Ray B A Abnormal Colonic Caliber
Normal saline enemas BID
Rectal suction biopsy
Readmitted for full thickness biopsy of sigmoid colon
Scheduled for definitive surgery today
Points for Discussion
Differential Diagnosis of Meconium Plug
Diagnostic Methods for Hirschsprung’s Disease
Choice of biopsy: Rectal Suction vs. Full thickness
Anal rectal Manometry
Meconium Plug Syndrome
Transient disorder of the newborn colon characterized by delayed passage of meconium and intestinal dilatation
Incidence increased in premature infants of diabetic mothers and in infants whose mothers received magnesium sulfate
Immaturity of myenteric plexus nerve cells or their hormonal receptors
Failure to pass significant meconium in the first 24 hours of life
Hirschsprung Disease is eventually diagnosed in 10-30%
Aganglionic megacolon: lack of intramural ganglionic cells
Occurs in 1:5000 births
Associated with Down syndrome
Signs: distended abdomen, palpable loops of bowel, rectal exam without stool in ampulla
Diagnostic Workup/ Dilemmas
Contrast enema- demonstrates the retained meconium as a filling defect or plug.
Must done in an “unprepped patient”
MPS diagnosis of exclusion: enema findings in neonatal Hirschsprung disease can be indistinguishable from meconium plug syndrome
Rectal suction biopsy-risk of perforation, bleeding
Full thickness biopsy
Meconium Plug Obstruction: Retrospective Case Review 21 patients with Large Bowel Obstruction Relieved by Passage of Meconium Plugs Conclusion: Essential for all babies with MP obstruction to have HD excluded. Burge, D. Meconium Plug obstruction. Pediatric Surg Int(2004) 20:108-110 2 8 6 Bilious emesis 4 8 7 Abdominal Distention 3403 3363 3369 Mean BW (gms) 37 39 37 Mean gestation (wks) 4 (19%) 8 (38%) 9 (43%) Number SLCS HD MPS Diagnosis
Diagnosis of Hirschsprung’s Disease: a prospective, comparative accuracy study of common tests 111 Infants suspected of HD Anal Manometry 83% sensitive 93% specific Rectal Suction Biopsy 93% sensitive 100% specific Contrast Enema 76% sensitive 97% specific Conclusion: Rectal Suction Biopsy is the most accurate test for diagnosing HD, with lowest rate of inconclusive results.
De Lorijn, et al. “Diagnosis of Hirschsprung’s disease: a prospective, comparative accuracy study of common tests” J. Pediatrics. 2005, 146 (6): 787-92.
Primary pull-through procedure
Soave (endorectal) procedure
Early colostomy with resection of aganglionic segment & Re-establishment of continuity
Diament, M. Emedicine. “Meconium Plug Syndrome.” 3/05.
Nonspecific film: No air fluid levels Dilated loops of bowel present 4.3 23 .3 141 108 15 150 N 76 L 16 M 7.5 9.5 11.6 35 421
6 month old ex 23 week premature female with bilious emesis, rule out bowel obstruction
NG Tube decompression
Serial abdominal exam
NG tube output replacement
Mom reported change in activity and behavior to staff
Increased abdominal distension becoming more tense
Repeat x-ray was ordered –showed signs of obstruction, with air fluid levels
Transferred to the PICU for presumed obstruction and signs of shock
Intubated and taken to the OR emergently
Hospital Course, cont’d.
closed loop bowel obstruction
large areas of ischemic bowel- no resection
abdominal compartment syndrome
Transferred back to the PICU
PICU course: post op
intubated until POD #7.
Weaned to nasal cannula.
lasix prn for fluid retention.
albuterol & flovent.
Stable; Negative echo
Broad spectrum antibiotics
PRBC, platelet transfusions
TPN x 2 weeks.
NG feeds 1 wk post-op
Advanced to full nipple feeds
sedated for intubation
Post-operative film Multiple air fluid levels Dilated loops of bowel
Hospital course, continued
HD # 26
Transferred back to pediatric floor
Hospital course on B3:
Tolerated full feeds
Intermittent abdominal distension with stable x-rays
Discharged home after 5 days.
Readmitted 1 week after discharge, with fever, r/o SBI
Irritability in an infant with changing clinical exam warrants further investigation.
What are the signs/symptoms of a closed loop bowel obstruction vs. partial bowel obstruction?
Could a different diagnostic test have been performed to detect closed loop obstruction?
Repeat examinations by surgical team is essential.
Follow clinical judgement especially with changing exam/history.
Differential Diagnosis of Small Bowel Obstruction in Infants
Malrotation with midgut volvulus
Types of Obstruction
Simple -blocked in 1 place
Closed-loop-blocked in 2 places
Strangulated -Decreased blood flow
Incarcerated -When obstruction is not relieved and bowel becomes necrotic
Closed Loop Bowel Obstruction 2 sites of bowel obstruction
Pathophysiology of Small Bowel Obstruction Obstruction Accumulation of chyle, salivary,gastric, biliary,pancreatic & intestinal secretions Peristaltic contractions There is also: Impaired perfusion Ischemia/necrosis Perforation
Pathophysiology of Small Bowel Obstruction
Clinical Features of Bowel Obstruction
Colicky abdominal pain
Irritable, fussy or inconsolable
Vomiting (bilious in proximal obstruction, feculent in distal obstruction)
Constipation (complete obstruction)
Fever (with bowel strangulation/necrosis)
Diagnostic Work Up
Plain abdominal film-flat and upright
Upper GI series
Labs: CBC, electrolytes, stool guiac
Closed Loop Obstruction
Diffuse abdominal tenderness
Increased irritablility in an infant
Absence of bowel sounds
Blood in stool
These clinicial features are non-specific and may NOT be present even when ischemia and necrosis is occurring
Diagnosis of Closed Loop Bowel Obstruction with CT
19 cases of closed loop obstruction imaged with CT & x-ray
ABDOMINAL X-RAY CT
Non-specific findings of SBO Signs of closed loop in 8
in 10 pts pts
Finding specific to closed Signs of closed loop &
bowel loop obstruction in 1 pt strangulation in 7 pts
Closed Loop and Strangulating Intestinal Obstruction: CT Signs.Radiology 1992,185:769-775 Conclusion: CT is a promising modality for diagnosis of closed-loop and strangulating small bowel obstruction