NEONATAL BILIOUS VOMITING- PART 1 & 2
Dear Viewers,
Greetings from “Surgical Educator”
Today I have uploaded two videos on “Neonatal bilious Vomiting- Part 1 & 2. In this episode, I talked about various congenital causes for bowel obstruction in neonatal babies that also cause bilious vomiting. Since there are many causes, I have created two videos to cover everything. In Part1, I talked about duodenal atresia, annular pancreas, malrotation, jejunal & ileal atresia and necrotising enterocolitis. In Part2, I talked about Hirschsprung’s disease, meconium ileus, meconium plug, small left colon syndrome and meconium peritonitis. I request you to watch both videos together and I hope you will enjoy them. You can watch all my surgical teaching video casts in the following links:
Surgicaleducator.blogspot.com
Youtube.com/c/surgicaleducator
Thank you for your support.
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Neonatal Bilious Vomiting- Part2
1. NEONATAL BILIOUS
VOMITING- Part 2
A PROBLEM ORIENTED
APPROACH
Dr.B.Selvaraj MS;Mch; FICS;
Professor of Surgery
Melaka Manipal Medical College
Melaka 75150 Malaysia
2. OBJECTIVES
To discuss the differential diagnosis of
biliary emesis in neonates
To do appropriate workup to confirm the
diagnosis
To select the various treatment options
To make you confident in managing a
newborn with bilious vomiting
5. HIRSCHSPRUNG’S DISEASE
Craniocaudal migration of 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
6. HIRSCHSPRUNG’S DISEASE
Mutations in RET proto-oncogene are commonly
associated with Hirschsprung’s disease
Not passed/ delayed passage of meconium
Abdominal distension
Bilious vomiting
Fever & diarrhea suggest Toxic megacolon
10. HIRSCHSPRUNG’S DISEASE
Management
Empty bowel with 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
16. MECONIUM ILEUS
Uncomplicated cases show 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
17. MECONIUM ILEUS
Signs depend on 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
20. MECONIUM ILEUS- Management
60 to 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
23. MECONIUM PLUG
A long plug 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
25. MECONIUM PERITONITIS
Intrauterine perforation of intestineleakage 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 typesMeconium pseudocyst,
generalised adhesive peritonitis,meconium ascites &
infected meconium peritonitis
26. MECONIUM PERITONITIS
Often associated with 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
29. Neonatal Bilious Vomiting
Sl
N
o
History Physical 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
30. Neonatal Bilious Vomiting
Sl
N
o
History Physical 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
31. Neonatal Bilious Vomiting
Sl
N
o
History Physical 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
32. Neonatal Bilious Vomiting
Sl
N
o
History Physical 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
33. TAKE HOME MESSAGE
“YELLOW COLOR VOMITUS IS THE
RED SIGNAL OF INTESTINAL
OBSTRUCTION UNLESS PROVED
OTHERWISE”