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Khaled H.K Bahaaeldin
Professor of Pediatric & Neonatal Surgery
Cairo, University
www.slideshare.net/kbahaaeldin
4/6/2017 1
www.slideshare.net/kbahaaeldin
4/6/2017 2
 How many (it’s relative…)
 Resuscitation (it works every time!)
 Simple vs Strangulating (countdown to a Deadline)
 D...
 In the 2006 population census we had 2.5 millions
babies born
 Luckily most will be born healthy
 Unfortunately a smal...
 Birth defects are quite uncommon
 Conditions requiring surgery at birth are rare
 But rare loses its meaning here…
 S...
Normal
need help
•Congenital anomalies
requiring surgery are
small percentage of live
births.
•It’s a very small slice,
le...
An intestinal obstruction
occurring during the first
month of life.
4/6/2017 7
 Esophageal:
◦ Atresia (TOF)
 Gastric:
◦ Congenital hypertrophic Pyloric Stenosis
 Duodenal:
◦ Atresia
◦ Stenosis
◦ Dia...
 Jeujunal & ileal obstruction:
◦ Obstructed inguinal hernia
◦ Itussusception
◦ Atresia
◦ Stenosis
◦ Meconium ileus
◦ Peri...
 Large bowl obstruction:
◦ Hirschsprung’s disease
◦ Anorectal anomalies
◦ Meconium plug syndrome
◦ Atresia (rarest)
 Nec...
Any baby presenting with persistent, bile
stained vomiting should be considered to be
surgical until proven otherwise.
Cli...
 Gastric decompression (naso-gastric
tube)
 IV line (for fluid replacement)
 Urinary catheter (to monitor urine output)...
After initial resuscitation, every effort is
directed towards rapid diagnosis and
treatment of the specific cause
Imaging:...
Any neonate presenting with projectile, non bilious
vomiting, associated with hunger and constipation
should be considered...
 Etiology:
◦ Unknown, but appears to be polygenic
(environmental, and genetic)
 Pathology:
◦ Progressive hypertrophy of ...
 Clinical picture:
◦ Symptoms:
 projectile, progressive, non bilious vomiting after
which the baby is hungry and ready t...
4/6/2017 17
4/6/2017 18
 Differential diagnosis:
◦ Gastroenteritis
◦ Gastro-esophageal reflux
◦ Other obstructive lesion of the gut
◦ Increased I...
4/6/2017 20
 Atresia
◦ Types:
 Type I: mucosal diaphragmatic (web) membrane
 Type II: short fibrous cord connects two atretic ends
...
 Stage II (Rotation):
◦ Non-rotation: leaving the major part of the colon on
the left side and the small intestines to th...
4/6/2017 23
4/6/2017 24
4/6/2017 25
 Stage I (Return):
◦ Exomphalos major (umbilical defect
>5cm)
◦ Exomphalos minor (umbilical defect<5cm)
◦ Gastroschisis, ...
4/6/2017 27
 Stage III:
◦ Non fixation may predispose to volvulus of the
gut or caecum
◦ Interference with the blood supply of a segm...
4/6/2017 29
4/6/2017 30
4/6/2017 31
 Obstruction of Ilieum due to thick inspissated
meconium
 Occurs in 10% of patients with cystic fibrosis
 Gives the cha...
4/6/2017 33
It is the commonest cause of intestinal
obstruction in infancy
 Epidemiology:
◦ Affects 1:1000 live births
◦ Male/Female ...
 Pathology:
◦ Failure of caudal migration of neuroblasts
derived form the neural crest
◦ There is absence of ganglions in...
 Clinical picture:
◦ History of delayed passage of meconium and
persistent constipation
◦ On examination there is abdomin...
 Treatment:
◦ Temporary measures include laxatives and
enemas.
◦ Colostomy may be a life saving procedure in
some cases
◦...
4/6/2017 38
4/6/2017 39
Definition:
The main pathology is atresia of the esophagus! Tracheoesophageal fistula is secondary
to that.
Incidence:
•1-...
Embryology:
4/6/2017 41
Types:
4/6/2017 42
DDiagnosis
Antenatal:
Maternal ultrasound
Postnatal:
Tracheoesophageal fistula present within the first few hours of life ...
4/6/2017 44
The treatment is ultimately surgical but management strategy
include also preoperative, operative and postoperative
measur...
 Definition:
Strictly the term should be agenesis or atresia but the term is
widely used.
 Incidence:
Affects 1:4500 liv...
4/6/2017 47
4/6/2017 48
Management
As there are frequent association with other anomalies these should be also
looked for, diagnosed or excluded
•...
4/6/2017 50
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Neonatal intestinal obstruction

Neonatal Intestinal Obstruction Presentation
Pediatric Surgery undergraduates

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Neonatal intestinal obstruction

  1. 1. Khaled H.K Bahaaeldin Professor of Pediatric & Neonatal Surgery Cairo, University www.slideshare.net/kbahaaeldin 4/6/2017 1
  2. 2. www.slideshare.net/kbahaaeldin 4/6/2017 2
  3. 3.  How many (it’s relative…)  Resuscitation (it works every time!)  Simple vs Strangulating (countdown to a Deadline)  Development of the Midgut (What goes wrong)  Specific diagnosis 4/6/2017 3
  4. 4.  In the 2006 population census we had 2.5 millions babies born  Luckily most will be born healthy  Unfortunately a small percentage will be born with lesser chances at surviving.  All they need is some TIMELY help to put them back on the road to life. 4/6/2017 4
  5. 5.  Birth defects are quite uncommon  Conditions requiring surgery at birth are rare  But rare loses its meaning here…  Something that happens once every 12000 babies occurs >200 times a year  Cases of conjoined twins happen once every half a million births  We get at least 2 or 3 every year 4/6/2017 5
  6. 6. Normal need help •Congenital anomalies requiring surgery are small percentage of live births. •It’s a very small slice, less than 0.5%. •But it’s one huge pie! •This small slice represents around 100000 babies 4/6/2017 6
  7. 7. An intestinal obstruction occurring during the first month of life. 4/6/2017 7
  8. 8.  Esophageal: ◦ Atresia (TOF)  Gastric: ◦ Congenital hypertrophic Pyloric Stenosis  Duodenal: ◦ Atresia ◦ Stenosis ◦ Diaphragm ◦ Malrotation with bands or volvulus ◦ Annular pancreas 4/6/2017 8
  9. 9.  Jeujunal & ileal obstruction: ◦ Obstructed inguinal hernia ◦ Itussusception ◦ Atresia ◦ Stenosis ◦ Meconium ileus ◦ Peritoneal bands or herniae ◦ Duplication cysts 4/6/2017 9
  10. 10.  Large bowl obstruction: ◦ Hirschsprung’s disease ◦ Anorectal anomalies ◦ Meconium plug syndrome ◦ Atresia (rarest)  Necrotizing enterocolitis  Complicated Inguinal Hernias 4/6/2017 10
  11. 11. Any baby presenting with persistent, bile stained vomiting should be considered to be surgical until proven otherwise. Clinical picture: The cardinal signs are 2C, 2V, 2D Colics, Constipation Vomiting, Visible peristalsis Distention, Dehydration 4/6/2017 11
  12. 12.  Gastric decompression (naso-gastric tube)  IV line (for fluid replacement)  Urinary catheter (to monitor urine output)  Fluids: ◦ 10-20ml/kg over an hour, to be repeated according to response  Drugs: ◦ To cover anaerobes as well as Gram stained bacteria 4/6/2017 12 Resuscitation
  13. 13. After initial resuscitation, every effort is directed towards rapid diagnosis and treatment of the specific cause Imaging: ◦ Plain X ray ◦ Contrast studies etc 12345 4/6/2017 13
  14. 14. Any neonate presenting with projectile, non bilious vomiting, associated with hunger and constipation should be considered CHPS  Incidence: ◦ 8:1000 ◦ M/F ratio=4:1 ◦ More in first born babies ◦ More in infants born to a mother who had suffered from CHPS ◦ More during spring and Autumn! 4/6/2017 14
  15. 15.  Etiology: ◦ Unknown, but appears to be polygenic (environmental, and genetic)  Pathology: ◦ Progressive hypertrophy of circular pyloric muscles ◦ Persistent vomiting leads to development of hypochloremic hyponatremic alkalosis and dehydration 4/6/2017 15
  16. 16.  Clinical picture: ◦ Symptoms:  projectile, progressive, non bilious vomiting after which the baby is hungry and ready to suckle again. Classically the symptoms start 2-3 weeks after birth ◦ Signs:  Signs of dehydration which may be severe an life threatening.  Visible peristalsis in the upper abdomen can usually be seen after the baby is given a test feed followed by projectile vomiting. 4/6/2017 16
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  19. 19.  Differential diagnosis: ◦ Gastroenteritis ◦ Gastro-esophageal reflux ◦ Other obstructive lesion of the gut ◦ Increased Intracranial tension  Investigations: ◦ Imaging: sonography and contrast X ray ◦ Laboratory: to detect and correct electrolyte and metabolic disturbances  Treatment: ◦ First aid treatment to correct dehydration and metabolic disturbances ◦ Definitive surgery, the Ramstedt’s pyloromyotomy 4/6/2017 19
  20. 20. 4/6/2017 20
  21. 21.  Atresia ◦ Types:  Type I: mucosal diaphragmatic (web) membrane  Type II: short fibrous cord connects two atretic ends  Type III: complete separation of two atretic ends ◦ Commomly associated with Down’s syndrome 30% ◦ Vomiting is bilious in around 85% of cases ◦ Shows characteristic double bubble sign in X ray ◦ Treatment is by duodeno-duodenostomy with high success rate  Annular pancreas ◦ Incidence is around 1:7000 ◦ Failure of normal fusion of the two ◦ pancreatic buds which may obstruct ◦ the duodenum from without  It might be Malrotation! 4/6/2017 21
  22. 22.  Stage II (Rotation): ◦ Non-rotation: leaving the major part of the colon on the left side and the small intestines to the right of the midline ◦ Incomplete rotation: the coecum is situated in the sub-hepatic region ◦ Reversed rotation: the final 180o rotation occurs in a clockwise manner so that the colon is lying posterior to the duodenum and the superior mesenteric artery ◦ Hyper-rotation: the rotation continues to 360o or 450o so that the coecum rests in the region of the splenic flexure. 4/6/2017 22
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  26. 26.  Stage I (Return): ◦ Exomphalos major (umbilical defect >5cm) ◦ Exomphalos minor (umbilical defect<5cm) ◦ Gastroschisis, refers to extrusion of intestines through a defect to the right of a normally formed umbilicus 4/6/2017 26
  27. 27. 4/6/2017 27
  28. 28.  Stage III: ◦ Non fixation may predispose to volvulus of the gut or caecum ◦ Interference with the blood supply of a segment of gut during rotation may result in an atresia of a segment or segments of intestines ◦ The Yolk sac which was attached to the midgut by the vitello-intestinal duct normally disappear completely. The common remnant of this system is the Meckel’s diverticulum 4/6/2017 28
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  32. 32.  Obstruction of Ilieum due to thick inspissated meconium  Occurs in 10% of patients with cystic fibrosis  Gives the characteristic “Ground glass” appearance in plain X ray  Gastrografin enema is both diagnostic and has potential therapeutic effect  Operative intervention may be needed in non responsive cases 4/6/2017 32
  33. 33. 4/6/2017 33
  34. 34. It is the commonest cause of intestinal obstruction in infancy  Epidemiology: ◦ Affects 1:1000 live births ◦ Male/Female ratio = 4:1 ◦ Most cases are sporadic ◦ Long segment and total colonic aganlionosis have strong familial association (15% &25%) 4/6/2017 34
  35. 35.  Pathology: ◦ Failure of caudal migration of neuroblasts derived form the neural crest ◦ There is absence of ganglions in the submucous and the myenteric plexuses ◦ There is failure of propulsive peristalsis manifesting by obstruction ◦ Grossly there is a spastic distal segment with a funnel connecting it to a dialated segment ◦ In about 75% of cases the affected region is the recto sigmoid junction 4/6/2017 35
  36. 36.  Clinical picture: ◦ History of delayed passage of meconium and persistent constipation ◦ On examination there is abdominal distention ◦ Rectal examination reveals a tight spastic rectum  Investigations: ◦ Imaging: Ba enema (Without preparation!!) ◦ Anal manometry ◦ Rectal biopsy is the gold standard 4/6/2017 36
  37. 37.  Treatment: ◦ Temporary measures include laxatives and enemas. ◦ Colostomy may be a life saving procedure in some cases ◦ Definitive treatment is surgical excision of the spastic segment an re-anastomosis to the anal canal. Various procedures can be done e.g Swenson’s, Duhamel’s and Soave’s procedures 4/6/2017 37
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  40. 40. Definition: The main pathology is atresia of the esophagus! Tracheoesophageal fistula is secondary to that. Incidence: •1-2500 to 1-10000 •males slightly more affected than females •the second sibling of an affected child has 0.2-0.5% chance of being also affected Associations: Other congenital anomalies occur in 50-70% of infants affected with esophageal atresia. These are most common with esophageal atresia and distal fistula. Anomalies include cardiovascular (the majority), genitourinary, gastrointestinal and skeletal. VACTERL association consists of Vertebral, Anorectal, Cradiac, Tracheo-Esophageal, and radial Limb deformities. It is not correlated with a known genetic abnormality or syndrome. 4/6/2017 40
  41. 41. Embryology: 4/6/2017 41
  42. 42. Types: 4/6/2017 42
  43. 43. DDiagnosis Antenatal: Maternal ultrasound Postnatal: Tracheoesophageal fistula present within the first few hours of life by: - excessive salivation - respiratory distress - cyanosis - inability to pass a nasogastric tube. - Attempts at feeding cause choking, coughing, cyanosis, regurgitation. Radiography: •Plain X-ray •Contrast study(pouchogram) 4/6/2017 43
  44. 44. 4/6/2017 44
  45. 45. The treatment is ultimately surgical but management strategy include also preoperative, operative and postoperative measures Surgical treatment: Division and closure of the fisula and primary anastomosis of the two esophageal segments. If the “Gap” between the two segments is too long, the infant is managed temporarily with an esophagostomy and gastrostomy. Later in life an procedure to replace the esophagus is considered e.g. colon interposition bypass. 4/6/2017 45
  46. 46.  Definition: Strictly the term should be agenesis or atresia but the term is widely used.  Incidence: Affects 1:4500 live births  Classification: Can be broadly classified into High anomaliesLow anomalies: -Anorectal agenesis-Covered anus -Rectal atresia-Ectopic anus -Cloaca-Stenosed anus -Membranous stenosis 4/6/2017 46
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  49. 49. Management As there are frequent association with other anomalies these should be also looked for, diagnosed or excluded •Clinical examination: Usually the clinical diagnosis is made a birth either by inspection or by failing to pass a thermometer easily into the anus •Radiography: Invertogram, done after six hours of birth Contrast studies (distal loopogram): in a clolostomized child to diagnose the site of any fistulous connection to the genito-urinary system •Treatment: -Colostomy: early in the neonatal period for high anomalies -Local procedure: for low anomalies -Full correction of high anomalies is done later in life starting from the 6th month after which the colostomy maybe closed 4/6/2017 49
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