this ppt consist four congenital anomalies of intestine duodenal atresia Meckel's diverticulum jejunal atresia midgut malrotation may be helpful for nursing students

1. NOOR HASMEE
MSC (N)2ND YEAR
CON,ILBS
1
CONGENITAL ANOMALIES OF INTESTINE

2. ANATOMY AND PHYSIOLOGY
2

3. SMALL INTESTINE
• Longest Part Of The Digestive System.
• Extends From The Stomach (Pylorus) To The Large Intestine (Cecum)
• Consists Of Three Parts: Duodenum, Jejunum And Ileum.
• Six Meters In Length.
• All Three Parts Are Covered With The Greater Omentum Anteriorly.
• The Duodenum Has Both Intraperitoneal And Retroperitoneal Parts, While
The Jejunum And Ileum Are Entirely Intraperitoneal Organs.
3

4. 4

5. Table 1. Cells of the Small Intestinal Mucosa
Cell type Location in the mucosa Function
Absorptive Epithelium/intestinal glands
Digestion and absorption of nutrients
in chyme
Goblet Epithelium/intestinal glands Secretion of mucus
Paneth Intestinal glands
Secretion of the bactericidal enzyme
lysozyme; phagocytosis
G cells Intestinal glands of duodenum
Secretion of the hormone intestinal
gastrin
I cells Intestinal glands of duodenum
secretion of the hormone
cholecystokinin, which stimulates
release of pancreatic juices and bile
5

6. Table 1. Cells of the Small Intestinal Mucosa
K cells Intestinal glands
Secretion of the hormone glucose-
dependent insulinotropic peptide,
which stimulates the release of insulin
M cells
Intestinal glands of
duodenum and jejunum
Secretion of the hormone motilin,
which accelerates gastric emptying,
stimulates intestinal peristalsis, and
stimulates the production of pepsin
S cells Intestinal glands Secretion of the hormone secretin
6

7. CASE REPORT- NON-CLASSIFIED TYPE DUODENAL
ATRESIA
• A baby boy weighing 2930 g delivered via cesarean section at 36th gestational
week to a G2P2 mother was admitted to our intensive care unit with initial
diagnosis of duodenal atresia.
• His prenatal ultrasound obtained at 29th gestational week revealed suspect
polyhydramnios and duodenal atresia.
• The first evaluation of his postnatal radiogram which demonstrated a double-
bubble image could not disclose any additional pathology (Figure 1). Nasogastric
drainage was devoid of any evidence of bile. On postnatal 3rd day he was
operated. During laparotomy dilated stomach and first part of the duodenum
were seen.
7

8. DOUBLE-BUBBLE APPEARANCE ON ABDOMINAL
RADIOGRAM
8

9. CONTD..
• Between the proximal and distal parts of the duodenum luminal integrity was not found
(Figure 2).
• Exploration of the proximal part of the duodenum could not detect any secretion of bile.
Distal part was tried to be catheterized with 10 F Foley catheter and a 5 F Fogarthy balloon
catheter so as to detect a second atresic segment and a distal duodenal web 1.5 cm away from
atresic part was disclosed.
• Following excision of the web, Foley catheter could be hardly advanced up to the distal part.
Air and isotonic serum delivered from duodenum up to the distal part of the bowel passed
freely up to the most distal part of the duodenum. Then bilious secretion was seen to flow
from the distal duodenum.
• Choleduct was retrogradely catheterized with 3 F ureteral stent (Figure 3).
9

10. FIGURE 2
PROXIMAL AND DISTAL PARTS OF THE
DUODENUM.
10
Figure 3 Choleduct was catheterized retrogradely using a 3 F
ureteral stent

11. CONTD…
• Proximal duodenum was catheterized using Foley catheter and any additional
pathology could not be detected. Diamond shaped duodenoduodenostomy was
performed. Postoperative 5th day, oral nutrition was started, he could receive full
dose nutrition. On postoperative 7th day, he was discharged from the hospital with
cure. He is currently at his postoperative 7th month without any medical problem.
11

12. DISCUSSION
• Duodenal atresia can be diagnosed beginning from the early stages of pregnancy in line with
developments in diagnostic methods .
• Gastroduodenal dilation seen in ultrasound during prenatal period is diagnostic for duodenal
atresia or stenosis.
• Upright plain abdominal radiograms of the new-born's which demonstrate double air levels
• Also in our case, ultrasonographic examination performed at prenatal 29th week revealed dilated
stomach and duodenum in the upper abdominal quadrant.
• Upright abdominal radiogram obtained with suspect duodenal atresia disclosed a “double-
bubble” image.
12

13. DISCUSSION
• In cases with duodenal atresia surgery is the treatment modality and in technically suitable
cases most frequently diamond shaped duodenoduodenostomy is preferred.
• Ruangtrakool et al. reported that in cases with duodenal web, web excision and duodenoplasty
were performed with outcomes comparable to duodenoduodenostomy .
• Duodenal atresia is a well known pathology by pediatric surgeons, though rarely one can
encounter non-classified cases. Therefore, before proceeding with duodenotomy, possibilities
of concomitant second atresia or web should be kept in mind and during the procedure,
presence of any atresic distal and/or proximal segment should be investigated.
13

14. DUODENAL ATRESIA
14

15. INTRODUCTION
Duodenal atresia is a congenital intestinal obstruction that can cause bilious or non bilious
vomiting within the first 24 to 38 hours of neonatal life, typically following the first oral
feeding.
It is associated with in-utero polyhydramnios and is one of the most common causes of fetal
bowel obstruction.
15

16. ASSOCIATIONS
• 1. Prematurity (45%)
• 2. Growth retardation (33%)
• 3. Annular pancreas
• 4. Down’s syndrome (30%)
• 5. Miller-Dieker syndrome
• 6. More than 50% patients have associated congenital anomalies –
Congenital heart disease (30%) Incomplete rotation of gut (20%) Anorectal
malformations (10%)
16

17. EPIDEMIOLOGY
• Duodenal atresia occurs in 1 in 5000 to 10,000 live births. It is often associated with other
anomalies, including trisomy 21/Down syndrome and cardiac malformations.
• Approximately 30% to 40% of children with duodenal atresia have Down syndrome.
• There is no difference in prevalence between the genders. There is an association with annular
pancreas, and other bowel atresias, including jejunal atresia, ileal atresia, and rectal atresia
17

18. ETIOLOGY
• During the eighth to the tenth week of embryological development, errors of duodenal re-
canalization are the main cause of duodenal atresia.
• A duodenal web is a more rare cause of duodenal obstruction, which tends to cause a windsock
deformity of the duodenal lumen.
18
https://youtu.be/2g7LqCOqq7M

19. 19

20. A- mucosal web/ diaphragm between proximal and distal ends
B- fibrous cord between both ends
C- complete separation of both ends with absent mesentry in between
Fig. 7: Diagrammatic representation - Duodenal atresia
References: Skandalakis' surgical anatomy
20
Anatomical classification

21. 21

22. 22
The windsock sign is a typical appearance of
a duodenal web (intraluminal duodenal
diverticulum) on upper gastrointestinal contrast
series which consists of an intraduodenal barium
contrast-filled sac that is surrounded by a narrow
lucent line (web or intraluminal mucosal
diaphragm) which is well demonstrated as the
barium in the duodenum passes distal to the
diverticulum.

23. 23

24. •recurrent episodes of bilious emesis
•abdominal distension maybe seen in the epigastric region
•Jaundice
• Features of gastric outlet obstruction
• Dehydration and electrolytes changes
• Abdominal distension and tenderness
• Absence of flatus
• No passage of stool
Clinical features
24

25. HISTORY AND PHYSICAL
• Duodenal atresia presents early in life as vomiting, usually occurring within the first 24 to 38 hours
of life after the first feeding, and progressively worsens if not treated.
• Sometimes the vomiting may be projectile, which, like pylorospasm and gastroesophageal reflux,
may simulate hypertrophic pyloric stenosis.
• There are cases of atresia proximal to the ampulla of Vater that present without bilious vomiting.
The ampulla of Vater is located in the second or descending portion of the duodenum. Excessive
bilious vomiting can cause metabolic alkalosis. Patients have symptoms of abdominal distension and
absent bowel movements.
25

26. DIAGNOSTIC EVALUATION
• Antenatal imaging will show a double bubble
• The use of prenatal ultrasound has allowed for an earlier diagnosis of duodenal atresia.
26

27. PLAIN ABDOMINAL X-RAY.
• The initial postnatal radiographic evaluation for diagnosing duodenal atresia is a plain
abdominal x-ray.
• A plain abdominal x-ray may reveal the double-bubble sign, which is seen postnatally as
a large radiolucent (air-filled) stomach usually in the normal position to the left of the
midline, and a smaller, more distal bubble to the right of the midline, which represents a
dilated duodenum.
• A double-bubble sign on an abdominal x-ray is a reliable indicator of duodenal atresia.
27

28. BARIUM FLUOROSCOPY
• can be used to assess the gastrointestinal tract. If necessary further evaluation with
ultrasound or upper gastrointestinal series (UGI) may be performed.
28

29. PEDIATRIC CT
• plays a very limited if any, role in the diagnosis and evaluation
of duodenal atresia.
• However, a CT reconstruction may allow for further
evaluation of bowel layout in confusing cases.
29

30. TREATMENT / MANAGEMENT
• Treatment involves nasogastric suction to decompress the stomach and surgery to correct the obstructing
lesion.
• Duodenoduodenostomy is the typical surgery performed.
• Doudenodoudenostomy can be performed as an open or laparoscopic procedure.
• Doudenodoudenostomy is a type of bypass procedure ,A diamond-shaped anastomosis is constructed
with a proximal transverse to the distal longitudinal duodenal anastomosis.
• Before surgery, the stomach and proximal duodenum are decompressed with an orogastric tube, and
intravenous fluid resuscitation is performed.
• Possible complications of duodenoduodenostomy include gastroesophageal reflux and impaired
duodenal motility.
30

31. 31
During surgery to repair duodenum atresia, the surgeon opens up the blocked ends of the duodenum
(A) and then sutures them together (B)

32. LAPROSCOPIC DUODENOSTOMY
32

33. STENT PLACEMENT
33

34. DUODENODUODENOSTOMY
34
Surgical bypass for the duodenal obstruction is done by
Side-to-side Duodenoduodenostomy.

35. KIMURA’S DIAMOND SHAPED ANASTOMOSIS:
35
Kimura’s diamond shaped anastomosis: Done between transversly
opened proximal pouch and longitudinally opened distal pouch.
https://youtu.be/kJNx-
gYYoXI

36. TAPERING DUODENOPLASTY:
36

37. HEINEKE-MICULICZ DUODENOPLASTY:
37
Partial web resection is done transduodenally in Duodenal mucosal web.With a
laparoscopic approach, a longitudinal incision is performed completely through the
pylorus, with extension to the duodenum and gastric antrum. This incision is then closed
transversely in a classical Heineke–Mikulicz fashion to increase the diameter at pylorus
and maintain greater patency
https://youtu.be/FoLcHM-
EkOI

38. 38
CASE REPORT

39. DELAYED PRESENTATION OF DUODENAL
ATRESIA IN A MALE WITH TRISOMY 21
• A two-year-old male was admitted for concerns of duodenal atresia on the upper GI scan due to repeated
bouts of emesis and a history of trisomy 21. His mother stated that the patient has always had “reflux” and
would vomit after feeds. The patient also suffered from oropharyngeal dysphagia. The patient was referred to
the gastroenterology service, and an upper GI study was done, which showed abnormality findings
suspicious of duodenal atresia. It was not previously detected on other imaging studies, including prenatal
ultrasounds and postnatal plain films.
• The patient was prenatally diagnosed with trisomy 21 via chorionic villus sampling. He had a history of
tetralogy of Fallot, bladder diverticulum, and hypothyroidism. He had surgical repairs of his tetralogy of
Fallot and bladder diverticulum at another hospital from 2019 to 2020. He also had tympanostomy tubes
placed, and his adenoids were removed in 2020. His mother expressed no ongoing concerns with those
procedures or conditions. He also presented with stage 2 chronic kidney disease and was being followed by
the nephrology service. He was taking cyproheptadine and levothyroxine daily.
39

40. DISCUSSION
• The Upper GI contrast study showed a
collection of contrast material in a dilated
cone-shaped duodenum, suggesting duodenal
web or stenosis. The abdominal plain film
showed gaseous distension with gas and stool
in the distal bowel, suggesting a lack of
complete obstruction (Figure 1). It is
important to note that this patient did not
have the classic sign of a “double bubble” on
the abdominal plain film.
40
Single-view abdominal plain film showing normal caliber gas and stool in the proximal and distal bowel, with no evidence of obstruction. There is mild-to-moderate gaseous
distention, without the classic double "bubble sign" of one gastric air bubble and one proximal duodenal air bubble, that would suggest duodenal atresia.

41. CONTD…
• During surgery, the patient was noted to have numerous Ladd’s bands, which were
removed. He had a portion of the duodenum that was significantly stenosed and
much smaller in diameter than the proximal portion.
• He remained nothing by mouth (NPO) for seven days, with intravenous (IV) fluids
and nasogastric (NG) suction. He began NJ tube feeds after three days, and he began
taking oral feeds after seven days following a repeat upper GI follow-through study
showing patency of the anastomosis without leaks.
41

42. MECKEL'S DIVERTICULUM
42

43. MECKEL'S DIVERTICULUM
• Meckel's diverticulum is the congenital
anomaly of the gastrointestinal tract. It
results from incomplete obliteration of the
vitelline duct leading to the formation of a
true diverticulum of the small intestine .
Meckel's diverticula are uncommon and
often clinically silent, particularly in the
adult.
43

44. CONTD…
• The omphalomesenteric duct normally involutes between the fifth and sixth weeks of
human gestation as the bowel settles into its permanent position within the abdominal
cavity.
• The persistence of the omphalomesenteric duct beyond fetal development may result in a
variety of anatomic patterns (figure 1), including omphalomesenteric cysts,
omphalomesenteric fistulas that drain through the umbilicus, and fibrous bands from the
diverticulum to the umbilicus (picture 1) that predispose to bowel obstruction.
• The most common form is a diverticulum without additional attachment, commonly
referred to as Meckel's diverticulum .
• The rich blood supply to the diverticulum is provided by the vitelline artery, which is a
branch of the superior mesenteric artery (figure 2).
44
https://youtu.be/nQ8rZFhy_QA

45. A) Umbilical polyp. B) Meckel's diverticulum. C) Fibrous band. D) Omphalomesenteric duct cyst. E) Patent omphalomesenteric duct.
F) Patent omphalomesenteric duct with prolapse.
45

46. EPIDEMIOLOGY
46
• Meckel's diverticulum is the most common congenital malformation of the
gastrointestinal tract .
• There is probably no familial predisposition for Meckel's diverticulum, although a few
cases of occurrence within the same family have been reported .
• The prevalence of Meckel's diverticulum is increased in children born with major
malformation of the umbilicus, alimentary tract, nervous system, or cardiovascular
system, in descending order .
• In a study of 7927 patients (all ages) who underwent appendectomy, Meckel's
diverticulum was present in 3 percent of patients . In the general population, the
prevalence of Meckel's diverticulum has been estimated to be approximately 2 percent.

47. CONTD…
47
The "rule of twos" is the classic description of the essential features of Meckel's diverticulum .
It states that Meckel's diverticulum
• occurs in approximately 2 percent of the population with a male-to-female ratio of 2:1,
• is located within two feet from the ileocecal valve,
• and can be two inches in length Approximately 2 to 4 percent of patients develop a
complication over the course of their lives, often before the age of two.

48. RISK FACTORS FOR DEVELOPING SYMPTOMS
48
Meckel's diverticulum can cause symptoms or can remain clinically silent.
Asymptomatic Meckel's diverticulum is occasionally identified incidentally on imaging but is more
commonly diagnosed during abdominal exploration for an unrelated pathology.
Clinical features associated with an increased risk of developing symptoms from a Meckel's
diverticulum
a) Severe haemorrhage
b) intussusception
c) Meckel’s diverticulitis
d) Chronic peptic ulceration
e) Intestinal obstruction

49. CONTD…
49
Meckel's diverticulum should be suspected in:
●Children with painless lower gastrointestinal bleeding
●Children with intussusception, particularly recurrent or atypical intussusception
●Patients with features of acute appendicitis, particularly when the appendix has already been
removed
●Adults with gastrointestinal bleeding but no source identified with upper endoscopy or
colonoscopy

50. DIAGNOSIS
50
●Adult patients, particularly in young adults <40 years of age, with gastrointestinal bleeding but no
source identified with standard endoscopic and possibly radiographic evaluation (eg, colonoscopy,
CT angiography, small bowel studies, or radionuclide scanning).

51. CONTD..
51
Arteriography — Conventional contrast mesenteric arteriography may be appropriate if a source of
gastrointestinal bleeding is brisk enough to require transfusion and the source has not been
identified using other imaging modalities

52. CONTD…
52
Meckel's scan — In hemodynamically stable patients
with less severe or intermittent gastrointestinal
bleeding and for whom suspicion for Meckel's
diverticulum is high, a Meckel's scan should be
performed.
A Meckel's scan is a nuclear medicine study in which
99m technetium pertechnetate, which has an affinity for
gastric mucosa, is first administered intravenously and
subsequently scintigraphy is performed to identify
areas of ectopic gastric mucosa .

53. CONTD…
53
Wireless capsule endoscopy — In a study that identified Meckel's
diverticulum as the source of bleeding in 13 patients, wireless capsule
endoscopy had a positive predictive value of 84.6 percent for the
diagnosis of Meckel's diverticulum associated with gastrointestinal
bleeding of uncertain origin.

54. CONTD…
54
Double-balloon enteroscopy — Double-balloon enteroscopy (DBE) has also been reported in small case
series in patients undergoing evaluation for gastrointestinal bleeding or abdominal pain . used to
confirm the diagnosis of Meckel's diverticulum based upon a suspicion from other imaging studies (eg,
CT, Meckel's scan), or to evaluate the distal small bowel directly in patients with negative radiographic
studies but in whom a high suspicion of a Meckel’s diverticulum remains.

55. DIAGNOSTIC APPROACH
55

56. MANAGEMENT
56
Initial management — Initial medical management of symptomatic Meckel's
diverticulum is :
●Intravenous lines should be placed and fluid and electrolyte therapy
administered, as needed.
●Patients with symptoms and signs of bowel obstruction may require
nasogastric decompression
●Patients with gastrointestinal bleeding should be initiated on proton-pump
inhibitor therapy. The use of proton-pump inhibitors does not alter the
sensitivity or specificity of a Meckel's scan.

57. TREATMENT ALGORITHM
57

58. RESEARCH
58

59. DUODENAL ATRESIA AND STENOSIS: LONG-TERM
FOLLOW-UP OVER 30 YEARS
59
Background
Duodenal atresia and stenosis is a frequent cause of congenital, intestinal obstruction. Current operative
techniques and contemporary neonatal critical care result in a 5% morbidity and mortality rate, with late
complications not uncommon, but unknown to short-term follow-up.
Methods
A retrospective review of patients with duodenal anomalies was performed from 1972 to 2001 at a tertiary,
children’s hospital to identify late morbidity and mortality.
Results
Duodenal atresia or stenosis was identified in 169 patients. Twenty children required additional abdominal
operations after their initial repair with average follow-up of 6 years (range, 1 month to 18 years) including
fundoplication (13), operation for complicated peptic ulcer disease (4), and adhesiolysis (4). Sixteen children
underwent revision of their initial repair: tapering duodenoplasty (7), conversion of duodenojejunostomy to

60. CONT…
60
duodenoduodenostomy (3), redo duodenojejunostomy (3), redo duodenoduodenostomy (2), and
conversion of gastrojejunostomy to duodenoduodenostomy (1). There were 10 late deaths (range, 3
months to 14 years) attributable to complex cardiac malformations (5), central nervous system
bleeding (1), pneumonia (1), anastomotic leak (1), and multisystem organ failure (2).
Conclusions
Late complications occur in 12% of patients with congenital duodenal anomalies, and the associated
late mortality rate is 6%, which is low but not negligible. Follow-up of these patients into adulthood is
recommended to identify and address these late occurrences.

61. 61
Malrotation and
Midgut volvulus

62. MALROTATION AND MIDGUT VOLVULUS
62
Midgut malrotation is a defect in the normal embryonic rotation of the gut, which causes an abdominal
obstruction that presents acutely or with chronic intermittent gastrointestinal symptoms.
During embryonic development, the small bowel usually rotates in a counterclockwise direction around the
superior mesenteric artery (SMA) axis between the fourth to eight weeks of gestation. During this period in
embryonic development, the bowel protrudes through the yolk stalk (which will become the future umbilicus).
During this process, the digestive tract elongates and undergoes counterclockwise 90 degrees rotation, followed
by retraction of the bowel into the abdominal cavity where another 180-degrees counterclockwise rotation occurs.
There are different types of Midgut Malrotation:
•Non-rotation
•Incomplete rotation
•Reverse rotation

63. CONTD..
• repeated vomiting ( bile stained in most cases)
• abdominal distension
• Plain radiograph: upper GI obstruction Fig. 11
• UGI contrast study: "Right"sided DJ; corkscrew jejunum Fig. 12
• USG: Fig. 13
• 1. altered SMA & SMV relationship with SMA on the right;
• 2. whirlpool sign on color doppler;
• 3. mesentric vein twisting around the artery
63

64. Fig. 11: Plain radiograph: Upper GI obstruction in a newborn
with intestinal malrotation
References: Department of Radiology, L.H.M.C. Delhi/IN
Fig. 12: Malrotation with midgut volvulus: Right
sided DJ junction with cork-screw jejunum
References: Department of Radiology, L.H.M.C.
Delhi/IN
64

65. 65

66. SURGICAL MANAGEMENT
• Ladd's procedure is the standard corrective measure for intestinal malrotation in children
and consists of division of peritoneal bands (Ladd's bands) traversing the posterior
abdomen, reduction of volvulus, appendectomy, and functional postioning of the intestine
with or without fixation.
• The procedure involves counterclockwise detorsion of the bowel, surgical division of
Ladd's bands, widening of the small intestine's mesentery, performing
an appendectomy, and reorientation of the small bowel on the right and the cecum
and colon on the left (the appendectomy is performed so as not to be confused by
atypical presentation of appendicitis at a later date). Most Ladd surgical repairs take
place in infancy or childhood.
66
https://youtu.be/_k_CQ9VZ_Hw

67. LADD,S PROCEDURE
67
https://youtu.be/E5t6MBrXdGY

68. CONTD..
68

69. PRENATAL DIAGNOSIS OF FETAL JEJUNAL ATRESIA:
A CASE REPORT
• A 35-year-old pregnant woman (G2P1), at 33 weeks of gestation, presented to the emergency
department of our hospital reporting fluid leakage from the vagina. Her pregnancy so far was low
risk. She was not on any regular medications, did not have any known allergies, and was a
nonsmoker. Vaginal speculum examination revealed amniotic fluid leakage from the cervical os, and a
diagnosis of preterm rupture of membranes was made.
• A transabdominal ultrasound examination revealed a normally grown fetus. Polyhydramnios was
noted, with the deepest vertical pool measuring 10 cm. In addition, we noted small bowel dilatation,
with a maximum diameter of 25 mm (Figure ​(Figure1).1). These findings were compatible with fetal
jejunal atresia. Detailed ultrasound examination demonstrated no other fetal malformations. A
nuchal translucency scan at 12 weeks had shown a low risk for chromosomal abnormalities, and the
anomaly scan at 22 weeks was normal.
69

70. 70
Distended bowel loops of the small intestine.

71. CONTD…
• At 34+5 weeks of gestation, she delivered a female neonate (2,680 g) by cesarean section
because of initiation of labor with a history of a previous cesarean section. After birth, the
neonate was examined by an expert neonatologist who found a mild abdominal
distention with palpable distended loops of bowel. Appropriate medical treatment and
parenteral nutrition were started the same day. The newborn underwent X-ray imaging
according to the instructions of the neonatal team, and the following surgical
management confirmed the diagnosis of jejunal atresia
(Figure ​(Figure2). Multiple2). Multiple atresias were found in approximately 70 cm of the
jejunal. Following the confirmation of diagnosis, the entire section of the small bowel was
resected and end-to-end anastomosis was performed. The condition of the infant after the
operation was excellent and she was discharged after three weeks.
71

72. 72
X-ray image post-delivery confirming the dilated loops.

73. DISCUSSION
• Bowel atresia may occur at any site of the small bowel or the colon. The most
common type is duodenal atresia, which accounts for approximately 60% of the
cases and is associated with cardiac renal and defects in 10-20% of the cases. In
approximately 30% of the cases, a chromosomal abnormality is noted, mainly
trisomy 21.
73

74. JEJUNAL ATRESIA
• Neonate presents with emesis and abdominal distension
• Radiograph: characterisic "triple bubble" sign with dilated stomach, duodenum and
proximal jejunum
• UGI contrast study: dilated duodenum and proximal jejunum both filled with contrast
• Management: duodeno-ileal anastomosis
74

75. 75

76. 76

77. MANAGEMENT OF JEJUNOILEAL ATRESIA'S: AN
EXPERIENCE AT EASTERN NEPAL
• Background
• Intestinal atresia is a common cause of neonatal intestinal obstruction, and management of this
disease in limited setup of a developing country is very difficult.
• Methods
• This study is a retrospective study of patients with jejunoileal atresias and their postoperative outcome
in a teaching hospital in eastern Nepal over a 5-year period.
• Results
• There were 28 children (19 boys and 9 girls). 11 children (39.28%) had jejunal atresia and 17 (60.71%)
had ileal atresia. Eight (28.5%) patients died, 6 were jejunal atresia (54.5%) and 2 were ileal atresia
(11.7%). The most common cause of death was sepsis which occurred in 7 out of 8 cases (87.5%). The
risk factors for
77

78. CONT..
• mortality identified were leucopenia, neutropenia, delay in surgery, location of atresia and type
of atresia. Jejunal atresia tended to have a higher mortality than ileal atresia, and severe types of
atresia (type IIIb and IV) were more often associated with mortality than other types of atresia.
The significant differences between jejunal and ileal atresia were the increased duration
between presentation and surgery, longer postoperative and total hospital stay, presence of
more severe atresias and an increased risk of mortality in case of jejunal atresias.
• Conclusion
• The prognosis for this disease have definitely changed in the last few decades in developed
countries but in our environment, problems like late presentation and diagnosis, lack of
availability of good neonatal intensive care units and parenteral nutritional support still prevail.
78

79. 79
Nursing Management

80. CONTD…
• Nursing Diagnosis
• Deficient Fluid Volume related to
• Excessive losses through normal routes
• Possibly evidenced by
• Vomiting
• Decreased urine output
• Inadequate fluid intake
• Signs and symptoms of dehydration or electrolyte imbalance
80

81. INTERVENTIONS
• 1. Assess for signs and symptoms of dehydration such as poor skin turgor, dry mucous
membranes, irritability, and delayed capillary refill.
Repeated vomiting and insufficient fluid intake may lead to dehydration.
• 2. Assess fluid intake and output.
Measurement of fluid intake and output is an important indicator of a child’s fluid status.
• 3. Monitor vital signs as frequently as possible.
Vital sign changes such as hypotension, tachycardia, and increased temperature reveal
hypovolemia.
• 4. Monitor characteristics of stool (consistency and color).
Initially, a child with intussusception may pass a normal stool, but later on, a mucus, blood-filled
or jelly-like stool is observed.
81

82. NURSING DIAGNOSIS
• Risk for Injury related to
• Bowel dysfunction
82

83. INTERVENTIONS
• 1. Assess the presence of acute abdominal pain accompanied by loud crying
and drawing knees up to the chest which may be episodic, vomiting, the
passage of a brown stool followed by red, currant jelly-like stool, pallor,
irritability.
Provides information that intussusception is present which may result in obstruction
and if left untreated, will lead to peritonitis.
• 2. Monitor older children for the presence of diarrhea, constipation, and
vomiting episodes.
This reveals the presence of intussusception and a further assessment is needed.
• 3. Observe bowel elimination and characteristics of stool and the ability to
eliminate barium following the procedure.
This signifies that the procedure in reducing the affected bowel is successful as the
condition may recur within 36 hours.
83

84. NURSING DIAGNOSIS
• Deficient Knowledge related to
• Lack of information about the condition
84

85. NURSING INTERVENTIONS
• 1. Offer parents clear and brief information; May utilize teaching aids and encourage questions.
Ensures understanding of the care needs to be based on the ability to learn.
• 2. Teach parents about signs and symptoms of infection in the incision area and demonstrate and allow
for return demonstration of dressing change.
Raises awareness of signs and symptoms of wound infection to facilitate immediate intervention.
• 3. Instruct parents to monitor any blood in stool, change in stool characteristics or diarrhea or
constipation, or absence of stools.
Reveals gastrointestinal bleeding and possible recurrence or chronicity of the condition.
• 4. Instruct parents about preparation procedures for reduction by barium enema
or surgery and antibiotic and postoperative care given to the child.
Provides information regarding care to expect during hospitalization.
• 5. Teach parents that a nothing-per-orem (NPO) status will be ordered initially and will be offered clear
fluids and slowly progress to the usual diet once advised.
Prevents vomiting or abdominal distention until the condition is resolved.
85

86. NURSING DIAGNOSIS
• Imbalanced Nutrition related to:
• Restricted intake as ordered to rest the bowel
• Altered absorption of nutrients
• Vomiting or diarrhea
• As evidenced by:
• Hyperactive bowel sounds
• Loss or lack of appetite
• Weight loss
• Abnormal electrolyte panel
• Decreased energy
86

87. INTERVENTIONS
• 1. Maintain NPO status as ordered.
Patients will generally be NPO at first to rest the bowel. This reduces hyperactivity in the bowel and decreases vomiting which will limit the loss
of fluids and nutrients, therefore decreasing further malnutrition.
• 2. Weigh daily.
Daily weight can help evaluate the patient for malnutrition. It also provides information on how effective the ongoing treatment is while the
patient is in the hospital.
• 3. Resume diet as tolerated.
Once the patient is no longer NPO and is cleared to eat, encourage the patient to advance their diet slowly. Starting with a clear liquid diet and
then moving on to smaller meals gives the small intestine a chance to readjust and absorb what is being introduced.
• 4. Encourage patient involvement.
The patient may be hesitant about eating, fearing that food may cause more symptoms. Encouraging them to make a list of foods they enjoy
and would be willing to try may help them feel in control. Also having a chance to eat the foods they most enjoy will help increase their appetite
and willingness to eat.
87

88. NURSING DIAGNOSIS
• Acute pain related to biological agents (infection) as evidenced by expressive
behavior (restlessness, irritability, crying)
88

89. INTERVENTIONS:
• • Perform a comprehensive assessment of pain including location, onset,
duration, frequency and intensity, as well as factors that relieve and aggravate
pain.
• • Control environmental factors that may influence the neonate's response to
discomfort.
• • Encourage adequate sleep periods to facilitate pain relief.
• • Perform pain assessment before and after painful clinical procedures.
89

90. SUMMARY
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91. 91