Congenital intestinal obstruction in children lecture

Congenital high and low
intestinal obstruction in children
Lecture for 5th year students
of the medical faculty
Urgenic branch of TMA
Department of Pediatric Surgery

The purpose of the lesson:
 To acquaint with the etiology,
pathogenesis, clinic, diagnosis,
principles of treatment of congenital
intestinal obstruction in children.

Lesson objective:
 Deepening the integration of knowledge and skills
gained during previous training in topics related to
congenital intestinal obstruction. To train a general
practitioner in self-diagnosis, to carry out differential
diagnostics of patients with intestinal obstruction in
primary health care with other types of intestinal
obstruction, liver and biliary tract diseases, etc. To
train students in the application of practical skills in
the diagnosis and differential diagnosis of intestinal
obstruction at all stages of the activity of a general
practitioner.

Theoretical part.
The concept - intestinal obstruction or "ileus" is a
violation of the passage of its contents due to
obstruction, compression or dysfunction of the
intestine. According to etiology, congenital and
acquired are distinguished, according to the
mechanism - mechanical (strangulation, obturation
and intussusception) and dynamic (spastic, paralytic).

Congenital intestinal obstruction

Organogenesis begins at 3-4 weeks of intrauterine development.The
"solid" stage passes when the proliferating epithelium completely closes
the intestinal lumen.Then - vacuolization and restoration of the lumen of
the intestinal tube.

Bowel Rotation Process
consists in returning the
"middle" intestine to a
sufficiently grown abdominal
cavity, the intestine
continues to rotate
counterclockwise by
another 90 °.If rotation is
delayed at this stage, the
baby is born with
incomplete bowel rotation.

Stage of physiological umbilical hernia

In this case, the "middle" intestine remains fixed at one point at the origin of the
superior mesenteric artery. The cecum, located in the epigastric region, is fixed
by embryonic strands that squeeze the duodenum and cause its obstruction

The loops of the small
intestine are located in
the right half of the
abdominal cavity, the
blind loops are located in
the epigastric region, and
the large intestine is
located on the left. With
such fixation, there are
conditions for the
development of volvulus
around the mesentery
root and for the
development of acute
strangulated intestinal
obstruction.

Rotation around the mesenteric artery

Congenital intestinal obstruction
Acute (in newborns)
Highlow
Recurrent (Malformations of the
intestines, mesentery and other
abdominal organs)

High congenital bowel
obstruction

Acute congenital bowel obstruction
 malformations of the intestinal tube itself (atresia
and stenosis of the intestine).compression of a
normally formed intestinal tube ("external type" of
obstruction): - incorrectly located mesenteric
vessels (more often the duodenum is compressed by
the superior mesenteric artery); adhesions of the
peritoneum; a tumor or cyst in the abdomen; the
annular pancreas, which encloses the duodenum in
the descending part;impaired rotation of the midgut
in the embryo (isolated volvulus and Ladd
syndrome).obturation of the intestinal lumen with
viscous meconium (meconium ileus - cystic
fibrosis);

Types of intestinal atresia. a, b - two blindly ending sections of the intestinal tube are connected by a fibrous
cord, the latter may have a narrow lumen (b); c - multiple intestinal atresia; d - complete break of the intestinal
tube throughout; e, f - membranous (membranous) form of atresia, the membrane can be solid or have a narrow
opening (f).

Duodenal obstruction caused by compression by an abnormally located
vessel (a) and an annular pancreas (b).

The combination of compression of the
duodenum with volvulus of the "midgut" is
regarded as Ledd's syndrome.

Duodenal atresia below the nipple of Vater

Variants of duodenal atresia below the Vater papilla

Variant of duodenal atresia below the nipple of Vater

Duodenal atresia 12 below the nipple of VaterWebbed
form

Duodenal atresia 12 above the nipple of Vater

Variants of the location of the annular pancreas

Diagram of intestinal rotation disorders

The clinical picture. Vomit.
 manifests itself from the first day of life, and
sometimes in the first hours after birth.The most
persistent and early symptom is vomiting.With
obstruction of the duodenum above the Vater's
nipple, vomiting occurs soon after birth, the amount
of vomit is large, there is no admixture of bile, which
enters the intestines entirely.With obstruction of the
duodenum below the nipple of Vater, the vomit is
colored with bile. After latching the newborn to the
mother's breast, vomiting becomes repeated and
profuse, exceeding the amount of milk swallowed by
the baby.With partially compensated stenoses,
vomiting occurs on the 2-4th day of the child's life
and usually not immediately after feeding, but after
20-40 minutes, sometimes with a "fountain".

The clinical picture. Meconium.
 As a rule, there is a discharge of meconium. If the
obstruction is located above the Vater's nipple, then
the amount and color of meconium is almost normal,
its discharge is observed up to 3-4 days.With a lower
obstruction, the amount of meconium is small, its
consistency is more viscous than that of a healthy
child, and its color is grayish.With atresia and
subtotal stenosis, there is usually a single excretion
of meconium or it is excreted in small portions
several times within 1-2 days, and subsequently
absent.Neonates with multiple intestinal atresia do
not pass meconium. With congenital volvulus,
meconium leaves, but in a meager amount.

The clinical picture. Child behavior.
 on the first day the usual. Sometimes
lethargy attracts attention. At first, he
actively sucks, but as the general
condition worsens, he refuses to
breast. Characterized by progressive
loss of body weight (0.2-0.25 kg /
day). Already from 2 days, the
phenomena of dehydration are clearly
expressed.

The clinical picture. Locally.
 The abdomen is swollen in the upper sections,
especially in the epigastric region, due to the
distended stomach and duodenum. In the early
days, you can see the waves of peristalsis. After
profuse vomiting, the swelling in the epigastric
region decreases, sometimes completely
disappears. There is some retraction of the lower
abdomen.On palpation, the abdomen in all parts
is soft, painless; if the obstruction is caused by a
tumor or cyst, then usually these formations are
quite easily felt through the thin and somewhat
flabby abdominal wall. In some cases, in
children with congenital volvulus, it is possible to
palpate a conglomerate with indistinct outlines in
the abdominal cavity.

Laboratory indicators
 Due to prolonged vomiting, hypochloremia
develops, in which the ratio changes and the
amount of K + and Na + ions decreases.
Against the background of exsicosis, there is
a thickening of the blood: an increase in the
hematocrit number, hemoglobin content, an
increase in the number of erythrocytes and
leukocytes.

X-ray examination (with an upright
position of the child.)
 two gas bubbles with horizontal liquid levels are visible, which
corresponds to a distended stomach and duodenum. The size
of the gas bubbles varies. With a complete interruption of
patency in the lower parts of the intestine, gas is not
detected. Sometimes it is also absent in the stomach, and
then X-ray reveals a "dumb" stomach.For children with this
type of obstruction, it is recommended to carry out
irrigography (40-60 ml of a water-soluble contrast agent) to
clarify the position of the colon: If the colon is partially
filled with a contrast agent, it is located on the left, one
should think about the presence of a midgut volvulus in the
newborn. This clarification of the anatomical cause of the
obstruction is necessary for the correct calculation of the
preoperative preparation time.

Plain X-ray of the abdominal cavityin frontal and lateral projection
(two levels of liquid are visualized)

Passage through the gastrointestinal tract (the delay of the contrast
agent in the stomach for more than 8 hours). The picture is typical for
duodenal stenosis
After 8 hours Also in lateral projection

Differential diagnosis
 Pylorospasm manifests itself in the first days after birth
by vomiting, which is unstable and less abundant in
quantity than with congenital intestinal obstruction. In
addition, there is no admixture of bile in the vomit with
pylorospasm. Plain radiographs usually help clarify the
diagnosis.
 Pyloric stenosis is suspected in children with congenital
subcompensated stenosis, in which there is a partial
intestinal obstruction. However, constant staining of
vomit with bile can completely exclude pyloric stenosis.
The diagnosis is confirmed by X-ray examination: with
pyloric stenosis, there is one large gas bubble
corresponding to an enlarged stomach, in the remaining
parts of the intestine, a uniform distribution of gas is
visible. The study with contrasting according to Yu.R.
Levin helps to clarify the diagnosis.

 Congenital diaphragmatic hernia is sometimes
accompanied by vomiting, which gives rise to
differential diagnosis with high congenital obstruction.
Unlike obstruction in congenital diaphragmatic hernia
in a newborn, dysfunctions of the respiratory and
cardiovascular systems come to the fore. X-ray
examination reveals the displacement of the intestine
into the chest cavity.
 Birth trauma to the brain is often accompanied by
vomiting with an admixture of bile. However, the
passage of meconium is normal. With a brain injury,
symptoms of damage to the central nervous system
are revealed. The diagnosis is clarified by X-ray
examination.

Low congenital intestinal
obstruction

The clinical picture of congenital low
intestinal obstruction
 lack of meconium.
 Vomiting appears relatively late, by the end
of the 2nd - on the 3rd day of life, and is
usually not associated with food intake.very
soon motor restlessness appears, twisting
with legs, refuses to breast or sucks very
sluggishly, does not sleep.
 The general condition is rapidly deteriorating,
intoxication phenomena are increasing, the
child becomes lethargic, adynamic, the skin
is gray-earthy, there may be an elevated
body temperature (37.5-38 ° C).

The clinical picture of low congenital
intestinal obstruction
 Already on the first day, uniform bloating is detected,
which progresses rapidly. The size of the abdomen after
vomiting does not decrease.Intestinal loops stretched
by meconium and gas are contoured through the
anterior abdominal wall. Often, their peristalsis is
visible, which is not traced in later periods, since
intestinal paresis occurs.
 Percussion is determined by tympanitis in all parts of
the abdomen. Auscultation reveals rare deaf sounds of
intestinal peristalsis. Palpation of the abdomen is
painful, accompanied by anxiety and a cry of the child.

X-ray examination
 swollen bowel loops with multiple irregular
horizontal levels (obstruction of the distal
ileum and colon) or several large gas bubbles
with wide levels (obstruction of the jejunum
or ileum, meconium obstruction) are
determined.
 Perforation of the dilated bowel above the
site of the obstruction is usually
radiographically detected by the presence of
free gas in the abdominal cavity.

Congenital low intestinal obstruction (X-ray examination).
Multiple horizontal levels in bowel loops

Small bowel obstruction: wide, numerous, centrally located
Kloyber bowls, even levels, Kerkring folds, arcades (swollen
intestinal loops)

Paralytic obstruction occurs relatively gradually against
the background of a severe general illness (peritonitis,
pneumonia, sepsis, enterocolitis, etc.), usually 5-10 days
after the birth of the child. The phenomena of obstruction
in intestinal paresis are not expressed clearly enough,
less constantly. From the anamnesis it turns out that the
child's meconium departs normally, and on examination,
there is usually a chair (after a gas tube or
enema).Hirschsprung's disease (acute form) can be
relatively easily achieved by conservative methods
(abdominal massage, introduction of a gas tube, enema).
The decisive factor in the diagnosis is X-ray examination
with contrast, in which the enlargement of the lumen of
the colon with the presence of a narrowed zone of
agangliosis, characteristic of Hirschsprung's disease, is
revealed.

Treatment
 The prognosis of the disease depends mainly
on timely diagnosis, correct surgical
correction of the defect, rational preoperative
preparation and postoperative management.
 Preoperative preparation is carried out
strictly individually. In newborns with high
intestinal obstruction, the duration and
quality of preoperative preparation depend
on the severity of the condition, the time of
admission to the hospital and the presence
of complications.

Surgical treatment.
-Operational access is paramedian.
-- Revision of the abdominal cavity.
-- elimination of obstruction:duodenojejunostomy with carrying
out the jejunum behind the transverse colon (in rare cases, it is
possible to impose a duodenoduodenostomy).
-enterotomy and membrane excisionlongitudinal dissection of
the area of stenosis followed by oblique transverse suturing of
the woundDissection of adhesions
-Operation Ladd"Unloading" Y-shaped anastomosisdirect end-
to-side anastomosis.ileocolostomy ("end to side").
-Mikulich's operation.
-Removal of a compressed cyst or tumor

Multiple atresia of the small intestine

Meconium ileus (cystic fibrosis)

The imposition of an anastomosis between the duodenum and the jejunum, and -
the transverse colon is retracted upward, the mesentery is bluntly stratified; the
initial part of the jejunum is enlarged according to the Wangensteen method; b -
the jejunum is sewn to the duodenum, the lumen is opened, the second row of
sutures is applied to the back

Excision of the membrane from the duodenum. a - cut line of the
intestine; b - excision of the membrane; c - stitching up the
wound of the intestine.

Operation Ladd. a - congenital volvulus of the "midgut"; b - elimination of bloat; c -
the intersection of the strands of the peritoneum, fixing the cecum; d - the cecum
is transferred to the left half of the abdominal cavity.

"Unloading" Y-shaped anastomosis

Double ileostomy according to Mikulich

Postoperative treatment of AIO includes the
following mandatory areas:
 Reimbursement of BCC, correction of the electrolyte
and protein composition of the blood;
 Treatment of endotoxicosis, including mandatory
antibiotic therapy;
 Restoration of the motor, secretory and absorption
functions of the intestine, that is, the treatment of
enteral insufficiency.

Postoperative complications
 peritonitis resulting from insufficient
anastomotic sutures.
 Aspiration pneumonia
 Adhesive obstruction.
 Divergence of the edges of the
postoperative wound and intestinal
eventration

Recurrent intestinal
obstruction

Recurrent Congenital Intestinal
Obstruction
 Most often it occurs in connection with congenital
circular stenosis of the ileum and colon, disruption of
the normal rotation of the midgut in the embryo,
entrapment of an intraperitoneal hernia and
compression of the intestinal lumen by cystic formation.
 All types of this disease are characterized by
inconsistent symptoms, but the common thing is the
intermittent nature of the obstruction. It is not always
possible to establish the cause of congenital recurrent
obstruction before the operation.
 The first signs of the disease usually appear months or
years after birth due to a weakening of the
compensatory capabilities of the body and a change in
the nature of the child's diet.

Internal abdominal hernia, a - a true hernia; b - false
hernia.

Clinical picture
 The child has periodic bouts of anxiety, bloating,
vomiting. The chair is rare, but independent, gases go
away. The attacks are short-lived, occur several times a
day, sometimes much less frequently. The child does
not take the breast well, the body weight increases a
little.
 Gradually, the attacks of pain become more intense,
stool retention appears, the general condition
worsens.When examining the patient, attention is
drawn to bloating and some asymmetry of the
abdomen. Visible peristalsis is usually determined.
Intestinal noises are heard, percussion - tympanitis.
The abdomen is slightly painful, muscle tension is not
detected.
 There is no stool, gases do not go away. After a
hypertensive enema, a temporary improvement may
occur, gases may pass away.

X-ray examination
 Plain radiographs show many horizontal
levels in the upper abdomen and gas-
distended loops of the small intestine.
 Study with contrasting is possible only in the
"light" interval. A liquid suspension of barium
sulfate given through the mouth during mass
production of radiographs (every 2 hours)
can be detected due to a long retention of
the mass above the narrowing point. In
acute cases, such a study is unacceptable.

Treatment
 In the period of recurrence of
obstruction, an emergency operation is
indicated.
 Midline laparotomy, revision and
elimination of the cause of obstruction.

Congenital pyloric stenosis in
children

Congenital pyloric stenosis
severe malformation, has an autosomal recessive
inheritance.
The disease is based on a congenital disorder of
the morphological structures of the pyloric gastric
pulp as a result of the proliferation of the circular
muscle layer and interstitial tissue, leading to
pyloric stenosis and impaired patency in this
section of the gastrointestinal tract.
Morphologically, pyloric stenosis is manifested by a
thickening of the pyloric canal wall up to 3-7 mm
(norm 1-2 mm).

In the structure of malformations, congenital pyloric
stenosis occurs quite often, second only to
malformations of the musculoskeletal system and
the cardiovascular system. The population
frequency is 4: 1000. The male to female sex ratio is
5: 1.

The severity and time of onset
of symptoms of pyloric stenosis
are determined by the degree of
narrowing of the pylorus and the
compensatory capabilities of the
child's body.

All manifestations of the disease
intensify over time. Usually, until the
3-4th week of a child's life, parents do
not consult a doctor, since the
symptoms of the disease are
indistinct. Previously, the diagnosis
was made at a later date, when the
symptoms of the disease became most
pronounced, so the clinical
characteristics are fairly well described
in older children.

The leading symptom of the disease is vomiting, which
appears most often on the 13-21st day of a child's life and
has a persistent character. However, in the early days,
regurgitation and infrequent vomiting are noted. Vomit in
the early stages can sometimes contain an admixture of
bile, but over time, the degree of narrowing of the
gatekeeper increases, and there is no bile in the vomit, then
vomiting appears in a fountain. The volume of vomit
exceeds the volume of the last feeding.

Dystrophy with a typical clinical picture
appears and steadily progresses. There is a
deficiency of trace elements (iron, calcium,
phosphorus) and multivitamins, the child also
loses chlorine and hydrochloric acid. Anemia
develops, there is a violation of water-
electrolyte metabolism, which is manifested by
blood thickening. Alkalosis is characteristic of
this disease.

Particular attention in pyloric stenosis is paid to
the examination of the abdomen, while it is
possible to detect an increase in the epigastric
region in comparison with the sunken lower
parts, to reveal the characteristic symptom of an
"hourglass" caused by the visible peristalsis of
a distended stomach. Sometimes in children
with severe malnutrition, it is possible to
palpate the gatekeeper

The stool is scanty, dark green in color due to the low milk
content and the predominance of bile and secretions of the
intestinal glands. The amount of urine excreted and the
frequency of urination are reduced. Concentrated urine,
intensively stains the diapers.

EFGDS - endoscopic imaging pyloric
Diagnostics

Endoscopic imaging with pyloric
stenosis
Fine

Plain X-ray of the abdominal cavity

Contrast examination of the stomach

The enlarged stomach is contrasted

Contrast study after 2 hours - evacuationabsent
through the stomach

After 4 hours, gastric emptying 20%

After 24 hours, the presence of contrast in the stomach

Treatment - operation pyloromyotomy according to
Frede-Ramshdett

Operation Frede-Ramschdett (incision site)
lateral projection Direct projection

Hirschsprung's disease
 Hirschsprung's disease is a malformation of the distal
colon, congenital agangliosis. According to the latest
data, the incidence rate is 1: 5000 newborns.
 Hereditary pathology, the main clinical manifestations of
which are constipation and bloating. The reason is
underdevelopment (hypogangliosis) or complete absence
(agangliosis) of ganglionic cells of the intermuscular
(Auerbach) and submucosal (Meissner) plexus.
 The aganglionic zone is most often (80-90% of cases)
localized in the rectum (in adults), on a larger or smaller
section of the sigmoid colon, or in another section of the
colon (in children).

 The part of the intestine, devoid of ganglia, is in a
state of spastic contraction, as a result of which the
higher parts of the intestine are hypertrophied.
 Constipation is persistent and appears from the
moment a child is born or in early childhood.
 The duration of constipation is from several days to
several months. The bloating of the intestines that
accompanies constipation and complements the
clinical symptoms does not disappear even after a
cleansing enema, which patients usually resort to
independently and often.

Anatomical forms of Hirschsprung's
disease
%

Hirschsprung's disease - total form,
acute course

Clinical stages of the course
 Compensated stage
 Subcompensated stage
 Decompensated stage

The clinical stage and severity of the
course of Hirschsprung's disease are in
direct proportion to its anatomical
shape, the length of the aganglionic
zone, the degree of suprastenotic
expansion of the intestine and the age
of the child.

Clinic and diagnostics
 The earliest and main symptom of
Hirschsprung's disease is the absence of
independent stool (chronic constipation).
 In most cases, this symptom is observed from
the neonatal period or appears somewhat later.
In the first days and weeks of life, stool
retention is observed in 90–95% of patients, at
the age of 1 to 6 months - in 3–5%, from 6
months to 1 year - in approximately 1%, and
after a year - in less than 0, 5% of patients.
 With a short aganglionic segment, the retention
of meconium and then feces in newborns is
limited to one or two days and is easily resolved
with a cleansing enema.

Clinic and diagnostics
 With a long lesion zone, the picture of intestinal
obstruction is growing, which requires more
vigorous measures.
 A constant symptom of Hirschsprung's disease is
flatulence, which, like constipation, is observed
from the first days and weeks of a patient's life.
Chronic retention of feces and gases leads to the
expansion of the sigmoid colon, and sometimes
the superior colon.
 The older the child or the worse the care for
him, the more pronounced are the secondary
changes arising from chronic fecal intoxication.
So, many children are diagnosed with anemia
and hypotrophy.

With the duration of the disease 3-4
years or more, deep changes in the
intestinal wall lead to sclerosis and
become irreversible, the degree of
structural changes in the intestinal wall
is in direct proportion to the duration
and clinical stage of the disease.

Diagnostics
 1. Detailed history taking
 2. General analysis of blood, urine, scatology
 3. Irrigography
 4. Colonoscopy
 5. Profilometry of intraintestinal pressure
 6. Sphincterometry
 7. Tissue biopsy according to Svenson and
determination of AChE activity
 8. Additional research methods: ultrasound, ECG,
immunological status

General view of a child
sufferingHirschsprung's disease

View of a patient with Hirschsprung's disease

Hirschsprung's disease. Irrigography

The main diagnostic method is contrast
irrigography:

Possible ultrasound diagnosis of Hirschsprung's
disease
Echogram normalstraight
and
sigmoidintestines
after filling
Echograms for
Echogram of the rectum
and sigmoid colon in
Echogram of the sigmoid colon in
Echogram of the rectum and sigmoid
colon in Hirschsprung's disease

Colonoscopic picture
 Catarrhal colitis Erosive colitis

Tactics and optimal terms of treatment
 In the acute form of Hirschsprung's disease and in young
children (up to 3 years), it is recommended to impose a
terminal left-sided colostomy with the removal of the
transition zone on the skin.
 At the age of over 3 years, the decompensated stage of the
course of the disease and if it is impossible to carry out an
effective debridement of the colon, a right-sided colostomy
according to Girdaladze is preferable.
 One-stage radical correction of Hirschsprung's disease in
children should be carried out in a clinically compensated and
subcompensated stage of the course of the disease with
effective sanitation and reduction of the suprastenotically
enlarged sections of the colon to 1-2 degrees; in the
decompensated stage, preliminary colostomy is advisable.
 The optimal age for radical surgery in children with
Hirschsprung's disease is 1-3 years.

The main tasks of preoperative
preparation
 - elimination of chronic
coprostasis and
endotoxemia,
 - elimination or reduction of
megacolon syndrome.

Preoperative preparation program
1-siphon and healing enemas - traditional treatment,
2-percutaneous pulse magnetotherapy using
electroactivated saline solutions - optimized local
treatment,
3-detoxification, infusion, substitution and
immunomodulating therapy.

Svenson-Hiat-Isakov operation scheme

Operation on Soave-Lenyushkin (diagram)

The nature of early postoperative
complications
Соаве
%

Clinical evaluation of long-term results of surgical
treatment of Hirschsprung's disease
 - good - regular independent stool,
no signs of colitis and dysbiosis;
 - satisfactory - recurrent
constipation, kalomazaniya,
flatulence, catarrhal colitis, dysbiosis;
 - unsatisfactory - persistent
constipation, stool only after an
enema, fecal incontinence, erosive
and ulcerative colitis, phase III
dysbiosis.

Reasons for unsatisfactory results of radical
correction of Hirschsprung's disease
1. Coccyx agenesis
2. Injury to the internal sphincter
3. Annular cicatricial narrowing .
4. Incomplete excision of aganglionic
zones
5. Resistance of the mucous membrane
reduced intestines

Congenital intestinal obstruction in children lecture

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