This document presents a case report of a 6 day old female infant referred to the hospital with vomiting since the 5th day of life. On examination, the infant was found to have bilious vomiting but no other symptoms of obstruction. Initial investigations and a barium meal were unremarkable. However, over the course of her hospital stay her symptoms persisted and she was eventually found to have a duodenal web, which was surgically corrected. This case highlights some of the challenges in diagnosing intestinal obstruction in newborns, including the need for high clinical suspicion and the potential limitations of initial radiological investigations.

1. Case Presentation

2. • B/O Shivamma
• 6 days /Female
• Holalkere,Chitradurga
• Was referred to our hospital from Basaveshwara
Medical college,Chitradurga with provisional
diagnosis of Malnourishment with Intestinal
obstruction.

3. • Chief complaints:Vomiting from D5 of life
• Baby had 8-10 episodes of vomiting which was
not associated with feeding,non projectile,bilious
in nature.
• No h/o constipation,delayed passage of
meconium or abdominal distension.
• No h/o poor feeding ,lethargy,convulsion,hurried
breathing,dcereased urine output.

4. Birth history:
• G2P2L1.
• Married life-4 ½ years,NCM,Elder sibling 3 yr
old male ,apparently healthy.
• Concieved spontaneously.Had regular ANC in
C’durga Govt hospital.Taken iron and folic acid
suuplements.Immunised with 2 doses of TT.
• Antenatal USG- was not reviewed at
admission
• No h/o maternal GDM,PE or Hypothyroidism.

5. • Baby born via naturalis at 6:15 am on
03/08/16 in C’durga govt hospital.
• B. wt-2.85kg.
• Cried immediately after birth,was breast fed
within one hour of birth.
• Baby passed meconium and urine within 24
hours .
• Baby has passed stool around 2-3 times/day.
• No episode of vomiting noted upto D5 of life.

6. On Examination:
• PR-148/min Good volume and regular,
RR-52/min , CRT<3 sec .Temp- 99 F.
• Icterus upto Zone 3.
• No pallor, cyanosis or edema.
• Cry reflex and activity-Good.
• Anthropometry:Wt-2.7kg, Length-49cm,OFC-
34cm.
• Head to toe examination-No dysphormic
features.

7. Systemic examination:
Per Abdomen Examination:
• RTA-3ml of bilious aspirate.
• Soft ,mildly distended ,non tender.
• Skin over abdomen-Normal.
• No dilated vein over abdomen.
• No organomegaly,no palpable mass.
• Anal opening patent.
• Bowel sounds-heard.2-3/min

8. CVS:
• S1 S2 heard.
• Systolic murmur best heard Lt lower sternal
border @ 4th ICS.
R/S:
• No retractions ,B/L air entry adequate.
• No crepitations.
CNS:
• AF-2*2 cm open at level
• Cry refelex and activity –Good.
• Moro reflex-Complete and symetrical

9. S/L/T/AGA/F WITH ACUTE INTESTINAL
OBSTRUCTION-SMALL INTESTINAL
?MALROTATION ?DUODENAL
ATRESIA/STENOSIS
WITHOUT PERFORATION OR PERITONITIS,
WITH CAHD –SMALL VSD ,LT TO RT
SHUNT,IN SINUS RHYTHM WITHOUT CCF.
PROVISONAL DIAGNOSIS:

10. Course in hospital and Investigations:
• Baby was kept NPO and ryle tube was inserted
• Baby was started on first line antibiotics.
• Surgical reference was taken and as per advice
2hrly RTA aspirate was done and barium meal
follow through was planned for next day.

11. CBC:
• Hb-13.6 gm/dl,TLC-1580/mm3,
PMN-53%,Platelet count-3.45 lakh/mm3
• Serum sodium-142.9mEq/L,Pottasium-3.8mEq/L
• CRP-20.6mg/L
• RFT-WNL.
• Chest X ray-R UL opacity.
• Echo-Small ASD with Small PDA,normal
biventricular function.
• In view of positive septic screen and upper lobe
opacity baby was changed to second line
antibiotics.

13. • Barium meal done on D2 of admission
showed no e/o malrotation or intestinal
obstruction.
• Baby had no further episodes of vomiting but
continued to have bilious RTA of 60 ml/24hr
on D2 of admission.
• Baby continued to pass 3-4 stools/day.

14. With these findings:Normal Barium meal and
positive septic screen.Diagnosis was revised
to:
TERM/AGA/LATE ONSET SEPSIS WITH
Rt UPPER LOBE CONSOLIDATION ?
Aspiration WITH SEPTIC PARALYTIC
ILEUS with ASD and Small PDA

15. • Baby was contiued on 2nd line antibiotics.
• At D6 of admission RTA aspirate was bilious
8ml/24 hrs and abdomen was soft and non
distended.
• Stomach wash was given and baby started on
small feeds 5ml through spoon along with cover
of motility agent domperidone.
• Baby had abdominal distension after 20ml feeds
,2 feeds were skipped and then again restarted.
• Feeds gradually increased and baby was directly
BF at D9 of admission.

16. • On D10 of admission baby had multiple
episodes of bilious vomiting.
• Baby was kept NPO and USG abdomen was
planned .

18. With report of USG repeat contrast meal
follow through was planned
.

19. TERM/AGA/SMALL INTESTINAL PARTIAL
OBSTRUCTION?STENOSIS-WEB WITH
ASPIRATION PNEUMONIA OF RT UL
WITH CAHD –ASD WITH SMALL PDA
WITHOUT CCF

20. • Baby was operated on D12 of admission.
• On table findings-proximal duodenal dilation
found.Dodenal web was found near DJ
junction.
• Procedure:Explorative laprotomy+web
excision+duodenoplasty

21. Post op course
• Baby had RTA about 30-40 ml/day which
gradually decreased on POD5.
• Baby was started on spoon feeds on POD6.
• Baby was discharged on 30/08/16 at POD 10 .
• Duration of hospital stay-22 days.
• Admission wt-2.7kg
• Discharg wt-2.63kg(@ D27 of life)

22. Follow up:
• Baby is admiited 3 days(28 DOL) back with c/o
of bilious vomiting.
• Admissiion weight-2.5kg
• Antenatal scan were reveiwed at this
admission.

24. “HINDSIGHT IS ALWAYS BETTER
THAN FORESIGHT”
“Before ,you are wise;after, you
are wise .In between you are
otherwise”-

25. Looking back was everything done
perfectly???
• Delivery at tertiary care center.
• Missed antenatal USG scan.
• First barium meal was reported as normal???
• Delayed diagnosis –prolonged stay.

26. Intestinal obstruction in newborn
• Congenital intestinal obstruction occurs
approximately 1 :2000 live births.
• Accounts upto 1/3 of admissions to neonatal
surgical units.
• Success or failure in terms of morbidity or
mortality depends not much on pinpointing the
exact location of lesion but on correctly
diagnosing obstruction as cause of clinical
symptoms and instituting prompt operative
intervention.

27. Causes of intestinal obstruction
Congenital Acquired Functional
Atresia NEC Hirschprung disease
Stenosis Intusucception Meconium plug
syndrome
Meconium ileus Peritoneal
adhesions
Ileus
Anorectal
malformations
Peritonitis
Enteric duplications
Volvulus
Peritoneal bands
Annular pancreas
Cyst and tumors

28. When to suspect Intestinal
obstruction????
1.Antenatally diagnosed intestinal obstruction
a)Antenatal USG showing double bubble
appearance.
b)Dilated bowel loops >15mm in length and
7mm in diameter
c)Whirlpool appearance to bowel and mesentry
may indicate malrotation with volvulus.
d)Polyhydramnios

29. 2)Family history of Hirschprung disease and jejunal
atresia.
3)Gastric aspirate >20 ml at birth.
4)Delayed passage of meconium in term or near
term baby-Hirschprung ,meconium
ileus,meconium plug syndrome,SLCS.
5)Vomiting-
• Neonates with bilious vomiting are supposed to
have intestinal obstruction unless proved
otherwise.
• Onset after birth is delayed the more distal
obstructuion is preceded by progressive
abdominal distension
6)Mass abdomen-Duplication cysts,pouch colon

30. Nature of vomiting and D/D s
Non bile stained with
abdominal distension
Pyloric atresia/stenosis,pre
duodenal variety of duodenal
atresia
Non bilious without abdominal
distension
GER,CDH,prematurity ,sepsis
Bilious vomiting-Surgical causes Malrotation,duodenal stenosis
or atresia,
Proximal jejunal atresia
Bilious vomiting-other causes Intestinal ileus due to
electrolyte imbalance or sepsis

31. Approach to intestinal obstruction

32. Radiological diagnosis
• Obtain AXR- AP and cross table lateral view.
• Erect abdominal view is done in case of non
sick babies.
• A prone cross table lateral view should be
done at >24 hrs after birth for suspected ARM

33. Normal progression of air in intestine:
Stomach First breath
Duodenum Second or third breath
Proximal small bowel 1 hour
Distal small bowel 3 hour
Caecum 6hour
Rectum 18-24 hour

34. Characteristic signs of AXR
Double Bubble appearance Duodenal atresia
Triple bubble appearance Proximal jejunal atresia
Uniformly dilated bowel loops
with multiple air fluid levels
Distal obstruction
Ground glass or soap bubble
appearnce.
NEC,meconium ileus
Speckled calcification Meconium ileus
Mild double bubble with distal
gas with 2nd part of duodenum
to left of spine
Malrotation

39. Contrast enema:if clinical scenario and
AXR suggest distal obstruction
Microcolon Meconium ileus and SLCS
Abnormal caecal position Malrotation
Right sided colonic
breaking
Volvulus
Abnormal rectosigmoid
index
Hirschprung disease

42. Upper GI series:
• Procedure of choice in diagnosing malrotation
1)Abnormally located D-J flexure-to the right of
spine.
2)Proximal jejunum located in right side of
abdomen.
3)Spiral corckscrew course of distal duodenum
and proximal jejunum.

44. Abdominal USG
• Reversal of relation of SMA and SMV in
malrotation.
• Can also diagnose intussusception and free
fluid in peritoneal cavity.

45. Pre operative management
• NPO and head end elevation.
• Insert OG tube and ensure continous
aspiration.
• If drainage is more than 10ml/kg per 12 hr
shift,replace the volume loss with equal
volume of NS.

46. Post operative management:
• IVF at maintenance level from 2nd POD along
with parenteral nutrition.
• Titrate fluids based on RFT ,weight and urine
specific gravity.
• Maintain Ng tube to contious suction and
measure output.Tube to be removed when
drainage is minimal and non bilious.
• After baby has pased stools start feeding with
small volumes and look abdominal distension .

47. References:
• Ashcrafts Pediatric Surgery, George W.
Holcomb, III, MD and Jerry D Murphy-5th
ed.p400-424.
• Avery’s Diseases of Newborn:Christine A
Gleason,Sherin Devaskar,9e.
• The PGI NICU,Handbook of Protocols,4e.
• Nelson Textbook of Pediatrics,20e.

48. THANK YOU