Download as PDF, PPTX
Uploaded bySelvaraj Balasubramani
Neonatal biliary emesis- a problem based approach
The document discusses neonatal bilious vomiting, outlining differential diagnoses, workup procedures, and treatment options. Key causes include duodenal atresia, malrotation, necrotizing enterocolitis, Hirschsprung's disease, meconium ileus, and meconium peritonitis. An algorithm for managing neonatal bilious vomiting is presented, emphasizing the importance of prompt assessment and intervention.
More Related Content
Similar to Neonatal biliary emesis- a problem based approach
More from Selvaraj Balasubramani
Neonatal biliary emesis- a problem based approach
- 1. NEONATAL BILIOUS VOMITING APROBLEM ORIENTED APPROACH P I M S
- 2. Neonatal Bilious Vomiting Dr.B.SELVARAJMS;Mch; FICS; ASSOCIATE PROFESSOR IN PEDIATRIC SURGERY PONDICHERRY INSTITUTE OF MEDICAL SCIENCES PONDICHERRY- 605014 INDIA P I M S
- 3. OBJECTIVES To discuss thedifferential diagnosis of biliary emesis in neonates To discuss appropriate workup to confirm the diagnosis To discuss the various treatment options To make you confident in managing a newborn with bilious vomiting P I M S
- 4. A Neonate’s requestto Surgeon “Please exercise the greatest gentleness with my diminutive tissues and try to correct the deformity at first operation; give me blood and proper amount of fluid and electrolytes; add plenty of oxygen to anesthesia, and I will show you that I can tolerate a terrific amount of surgery. You will be surprised at the speed of my recovery,and I shall be grateful to you” P I M S Dr.WILLIS POTTS
- 5. Neonatal Bilious VomitingCauses Meconium Peritonitis Necrotising Enterocolitis Hirschsprung’s Disease Anorectal Malformation Rarely Mesentric Cyst & Intestinal Duplication Incarcerated inguinal hernia P I M S Duodenal atresia/stenosis Annular Pancreas Malrotation&MGV Intestinal Atresia: Jejunal&Ileal Meconium Ileus Meconium Plug
- 6. Neonatal Bilious VomitingCauses •MALROTATION & MGV •MESENTRIC CYST& DUPLICATION CYST •CONGENITAL BANDS LIKE VI DUCT BANDS •MECONIUM ILEUS •MECONIUM PLUG •MECONIUM PERITONITIS EXTRINSIC •DUODENAL ATRESIA/STENOSIS •JEJUNAL/ILEAL ATRESIA •HIRSCHSPRUNG’S DISEASE •NECROTISING ENTEROCOLITIS CAUSES MURAL INTRA LUMINAL
- 7. DUODENAL ATRESIA/STENOSIS Failure ofvacuolisation & recanalisation of solidcord state of duodenum at 7 to 10 wks of intrauterine life Proximal Stomach&Duodenum get dilated and hypertrophied Bilious vomiting in Postampullary type Failure to pass meconium Minimal upper abdominal distension Hydramnios in mother& Down’s syndrome in the child P I M S
- 8. DUODENAL ATRESIA/STENOSIS- Types MembraneType Simple Fenestrated Windsock Anomaly Complete Mural discontinuity with connecting fibrous cord Complete Mural discontinuity without connecting fibrous cord P I M S
- 9.
- 10. Duodenal Atresia/Stenosis Workup AntenatalUSG Abdomen Double Bubble appearance Postnatal AXR Classical Double Bubble Appearance P I M S
- 11.
- 12. Duodenal Atresia- Windsockanomaly P I M S
- 13. Duodenal Atresia- Postop care Dysmotility due to Megaduodenum may require a period of TPN Transanastomotic feeding tube may obviate the need for TPN Graded introduction of enteral feeds as bowel motility recovers Prophylactic antibiotics for 48 hrs P I M S
- 14. ANNULAR PANCREAS A rimof pancreatic tissue encircles 2nd part of duodenum A defect in rotation and fusion of ventral analgae with the dorsal analgae of pancreas Clinical picture and radiological findings are akin to Duodenal Atresia Treatment also same as that of Duodenal Atresia P I M S
- 15.
- 16.
- 17.
- 18. Physiological Umbilical Herniain Fetus P I M S
- 19.
- 20.
- 21. MALROTATION Any defect/ deviationof normal midgut rotation leads to Malrotation 60% of Malrotation patients present in neonatal period Most common type of Malrotation is caused by Ladd’s band due to arrest of rotation at 180* Midgut volvulus is due to narrow duodenocolic isthmus P I M S
- 22. MALROTATION Bilious Vomiting Passing scantymeconium Upper abdominal distension In Midgut volvulus Bleeding PR,abdominal distension and vomiting P I M
- 23. MALROTATION- IMAGING STUDIES AXR-“ Double Bubble Appearance” Upper GI Series: In Simple Malrotation Absence of C loop; DJ flexure & jejunal loops on the right side of abdomen In MGV “Corkscrew Appearance” USG with Doppler scan: Reversed position of SMA & SMV P I M S
- 24. MALROTATION- IMAGING STUDIES P I M S DoubleBubble Appearance Corkscrew Appearance
- 25. MALROTATION- IMAGING STUDIES P I M S Absenceof C Loop Jejunum on Rt side Reversed position of SMA & SMV
- 26. MALROTATION- Ladd’s Procedure P I M S Divisionof Ladd’s band Widening of Duodenocolic isthmus
- 27. Malrotation with MidgutVolvulus Derotation of Volvulus If bowel is viable leave it If bowel not viable Resection and EEA If bowel viability is doubtful Second look laparotomy Complication Short bowel syndrome P I M S
- 28. JEJUNAL & ILEALATRESIA Due to mesenteric vascular accident during fetal life Incidence 1 in 3000 livebirths Present within 24hrs with bilious vomiting,not passed meconium & abdominal distension Proximal obstruction earlier & more severe is the bilious vomiting Distal obstruction more severe is the abdominal distension P I M S
- 29. JEJUNAL & ILEALATRESIA Types P I M S
- 30. JEJUNAL & ILEALATRESIA Types P I M S
- 31. JEJUNAL & ILEALATRESIA- AXR P I M S Jejunal Atresia Triple Bubble Appearance ILeal atresia Multiple airfluid levels
- 32. JEJUNAL & ILEALATRESIA P I M S Barium Enema Unused Microcolon
- 33. JEJUNAL ATRESIA- TaperingJejunoplasty End to back Anastomosis P I M S
- 34. Jejunal & IlealAtresia- Operative Techniques P I M S
- 35. NECROTISING ENTEROCOLITIS Disease ofparadoxes- unknown etiology Most likely mechanism vascular compromise to GIT resulting bacterial invasion of portal venous system Common in premature babies Occurs during 1st or 2nd wk of life after starting oral feedings in babies weighing < 1.5 kgs Distal Ileum & Rt colon are commonly involved P I M S
- 36.
- 37. NECROTISING ENTEROCOLITIS Affected bowelDilated with mucosal necrosis and subserosal collection of gas Bilious vomiting,abdominal distension,rectal bleeding and/or diarrhea Abdominal wall edema, erythema and fixed persistent loop of bowel AXR Pneumatosis intestinalis, Gas in portal vein and/or Free air in peritoneal cavity P I M S
- 38.
- 39.
- 40. NECROTISING ENTEROCOLITIS- AXR P I M S PneumatosisIntestinalis Portal Venous Gas
- 41. NECROTISING ENTEROCOLITIS Management Start aggressivemedical treatment immediately Keep NPO,NGT aspiration & TPN Broadspectrum Antibiotics Physical, radiographic and ultrasonographic evaluation Q6H for 1st 48 hrs in NICU P I M S
- 42. NECROTISING ENTEROCOLITIS Indications forSurgery Pneumoperitoneum & signs of peritonitis Edematous & Erythematous anterior abdominal wall Fixed persistent loop of bowel Portal venous gas Sudden deterioration of baby during medical treatment P I M S
- 43. NECROTISING ENTEROCOLITIS Surgery Operativestrategy depends on extend of involvement of bowel If perforation is small Direct suture closure or resection & primary anastomosis is adequate In extensive bowel necrosis Remove all gross gangrenous bowel& do enterostomy In doubtful bowel viability Second look laparotomy In low birth weight infants with poor general condition do just peritoneal drainage P I M S
- 44. HIRSCHSPRUNG’S DISEASE Craniocaudal migrationof ganglion cells of the bowel begins at 12th wk of gestation Arrest of this migration produces an aganglionic segment of bowel-absence of Aurbach’s & Meissener’s plexus This aganglionic segment of bowel unable to relax & peristaltic wave stops proximally- functional obstruction Incidence 1 in 5000 Male:Female 4:1 P I M S
- 45. HIRSCHSPRUNG’S DISEASE Mutations inRET proto-oncogene are commonly associated with Hirschsprung’s disease Not passed/ delayed passage of meconium Abdominal distension Bilious vomiting Fever & diarrhea suggest Toxic megacolon P I M S
- 46.
- 47. HIRSCHSPRUNG’S DISEASE Workup P I M S AXR: DilatedBowel Loops Barium Enema: Swan Neck Appearance
- 48. HIRSCHSPRUNG’S DISEASE Workup P I M S Absence of ganglioncells in myenteric plexus Suction rectal bx Noblet Rectal Mucosal Suction Biopsy Gun
- 49. HIRSCHSPRUNG’S DISEASE Management Empty bowelwith saline enema (30 to 50 ml) daily If can successfully decompress the bowel- continue rectal washouts for 45 days If unable to decompress the bowel- do Rt transverse colostomy or Levelling colostomy P I M S
- 50.
- 51.
- 52.
- 53.
- 54. HIRSCHSPRUNG’S DISEASE P I M S De LaTorre’s Transanal Endorectal Pullthrough
- 55. MECONIUM ILEUS Uncomplicated casesshow impacted meconium in terminal ileum- inspissated tar like meconium Accounts for 9 to 10% of all neonatal intestinal obstructions Present in 8 to 10% of cystic fibrosis patients at birth Complicated cases include volvulus,perforation and peritonitis with sepsis P I M S
- 56. MECONIUM ILEUS Signs dependon degree of obstruction and complications Significant abdominal distension may develop during neonatal period General status progressively deteriorates with incipient sepsis in cases of perforation In perforation the scrotum or labia may have greenish discoloration due to patent processus vaginalis P I M S
- 57.
- 58. MECONIUM ILEUS- ImagingStudies P I M S Disparate sized bowel loops Soap bubble appearance- Neuhauser’s sign
- 59. MECONIUM ILEUS- Management 60to 70% of simple Meconium ileus can be successfully treated with Gastrograffin enema Other 30% need operative management Goal of surgery is to remove the abnormal meconium from GIT & maintain adequate length of bowel Surgery consists of resection& anastomosis of involved segment and/or roux-en-y ileostomy P I M S
- 60.
- 61. MECONIUM ILEUS- Management P I M S PaulMikulicz Double Barrel Ileostomy Bishop-Koop’s Distal chimney Ileostomy Santulli’s Proximal chimney Ileostomy
- 62. MECONIUM PLUG A longplug of mucus and sticky meconium in rectum & distal colon results low intestinal obstruction Due to immaturity of colonic & rectal expulsive mechanism Often associated with neonatal Hirschsprung’s disease Rectal exam/rectal wash results in expulsion of the plug and relief of intestinal obstruction P I M S
- 63.
- 64. MECONIUM PERITONITIS Intrauterine perforationof intestine leakage of meconium into peritoneal cavity reaction of peritoneum to this leaked meconium Due to intrauterine vascular compromise of intestine ischemia&perforation as early as 4th month of intrauterine life Different pathological types Meconium pseudocyst, generalised adhesive peritonitis,meconium ascites & infected meconium peritonitis P I M S
- 65. MECONIUM PERITONITIS Often associatedwith cystic fibrosis & Prognosis is poor Bilious vomiting, failure to pass meconium and abdominal distension Abdominal wall edema, erythema and free fluid in peritoneal cavity AXR multiple air fluid levels and peritoneal calcifications Surgical treatment releasing of adhesions, removal of devitalised tissues, closure of perforation, intestinal resection& anastomosis P I M S
- 66. MECONIUM PERITONITIS P I M S Meconium Ascites Centralbowel loops Amorphous calcification Multiple focal calcifications Dilated bowel loops
- 67. Neonatal Bilious Vomiting- Algorithm P I M S
- 68. Neonatal Bilious Vomiting P I M S Sl N o HistoryPhysical Plain XRay Contrast studies Diagnosis Treatment 1 Bilious vomiting Not passed meconium Maternal hydramnios Upper abdominal distension VGP Down’s syndrome Double Bubble appearan ce Barium meal : Duodenal obstructio n Duodenal Atresia Or Annular Pancreas Kimura’s Diamond Shaped Duodeno duodenosto my 2 Bilious Vomiting Infrequent passage of small amount of meconium Upper abdominal distension Double Bubble Appearanc e Paucity of gas in distal bowel Barium meal: Absence of C loop Duodenum Cork screw appearanc e Malrotatio n Midgut volvulus Ladd’s Procedure Derotation Resection Anastomosi s
- 69. Neonatal Bilious Vomiting P I M S Sl N o HistoryPhysical Plain XRay Contrast studies Diagnosis Treatment 3 Bilious vomiting Not passed meconium Abdominal distension Empty rectum Triple bubble appearanc e Multiple air fluid levels Barium enema : Micro colon Jejunal atresia Or Ileal atresia Resection& End to back anastomosi s 4 Bilious Vomiting Passing meconium Prematurity& Birth asphyxia Bleeding PR Sick child Septicemia Abdominal distension Signs of Peritonitis Pneumato sis intestinalis Portal venous gas Free peritoneal gas ------------ Necrotisin g enterocoliti s Aggressive medical treatment If it faills Surgical intervention
- 70. Neonatal Bilious Vomiting P I M S Sl N o HistoryPhysical Plain XRay Contrast studies Diagnosis Treatment 5 Delayed passage of meconium Vomiting Gross abdominal distension P/R:Explosive passage of meconium & flatus Distended bowel loops Barium enema: Swan neck appearanc e Hirschspru ng’s disease Pullthrough operation with or without colostomy 6 Bilious Vomiting Failure to pass meconium Moderate to severe abdominal distension Disparate sized bowel loops Soap bubble appearanc e Barium Enema: Microcolon Meconium ileus Gastrograffi n enema Resection anastomosi s Bishop- koop & Santulli Ileostomy
- 71. Neonatal Bilious Vomiting P I M S Sl N o HistoryPhysical Plain XRay Contrast studies Diagnosis Treatment 7 Bilious vomiting Failure to pass meconium Moderate to severe abdominal distension P/R: Child passes plug Distended bowel loops -------------- Meconium plug syndrome Rectal washouts 8 Bilious Vomiting Failure to pass meconium Severe abdominal distension Abdominal wall edema & erythema Multiple air fluid levels Peritoneal calcificatio n Free peritoneal gas Barium Enema: Microcolon Meconium peritonitis Release pf adhesions Closure of perforation Resection & Anastomosi s
- 72. TAKE HOME MESSAGE “YELLOWCOLOR VOMITUS IS THE RED SIGNAL OF INTESTINAL OBSTRUCTION UNLESS PROVED OTHERWISE” P I M S