Intestinal obstruction in neonatal/pediatric surgery

doi:10.1053/j.sempedsurg.2003.08.005

Seminars in Pediatric Surgery

Volume 12, Issue 4, November 2003, Pages 241-253

https://doi.org/10.1053/j.sempedsurg.2003.08.005 Get rights and content

Abstract

Intestinal obstruction in the newborn infant and older child may be due to a variety of conditions, including atresia and stenosis, annular pancreas, malrotation, duplication cyst, meconium ileus, meconium plug syndrome and neonatal small left colon syndrome, Hirschsprung’s disease, neoplasia, trauma, and other rarer causes. The mode of presentation can be acute or more chronic with systemic upset due to shock. Neonates, more so than older children, with unrecognized intestinal obstruction deteriorate rapidly, show an increase of associated morbidity and mortality and appropriate surgical treatment becomes more hazardous. Early diagnosis depends largely on the prompt detection of obstructive manifestations by the clinician and the subsequent accurate interpretation of radiographic findings and other investigations, leading to definitive treatment, which should always be preceded by appropriate resuscitation/preparation of the infant/child. Management of intestinal obstruction will almost always be surgical, apart from some notable exceptions and all are discussed in more detail. With the advent of pediatric and neonatal intensive care and multidisciplinary care, the morbidity and mortality of cases of intestinal obstruction reported in current series is generally extremely low and mainly determined by the coexistence of other major congenital anomalies (eg, cardiac), delays in diagnosis and treatment or coexisting medical conditions. Newer treatments and future developments may reduce the residual mortality in such cases as ultrashort-bowel syndrome.

Section snippets

Presentation/general management of intestinal obstruction

The mode of presentation can be acute, with obvious features of obstruction (vomiting, which will invariably become bile-stained); pain (usually colicky), with or without features of peritonism and perforation; and severe systemic upset due to shock. The presentation can also be more subtle and chronic in cases of incomplete or recurring/resolving bouts of obstruction.

Neonates, more so than older children, with unrecognized intestinal obstruction deteriorate rapidly, show an increase in

Gastrointestinal tract obstruction anatomy/pathogenesis/etiology/treatment

There are many ways to classify intestinal obstruction, perhaps the most widely used being the classical way, describing the origin of the obstruction: extrinsic, mural, or intraluminal. Another mnemonic, which attempts to classify according to etiology appears in Fig 1.

Obstructions at each anatomical region will be described in more detail from stomach to the anorectum.

Conclusions/the future

With the advent of pediatric and neonatal intensive care and multidisciplinary care the morbidity and mortality of cases of intestinal obstruction reported in current series is generally extremely low and mainly determined by the coexistence of other major congenital anomalies (eg, cardiac), delays in diagnosis and treatment or coexisting medical conditions73 (Table 1).

Future therapies for patients with gastrointestinal disease secondary to cystic fibrosis include lung transplantation,

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The term encompasses all abnormalities caused by rotational errors during embryonic development of the midgut. The majority of intestinal malrotation (60–80%) presents in the neonatal period as an acute surgical emergency secondary to midgut volvulus [2,3]. Failure in recognition, or management of this diagnosis may lead to significant sequelae including short gut syndrome, intra-abdominal sepsis and/or death [1].
Intestinal malrotation is a rare congenital abnormality occurring in 0.2–1% of the population. Adult presentations comprise only 0.2–0.5% of all cases leading to diagnostic challenges and worse outcomes in adults. We present a rare case of chronic/intermittent midgut volvulus with unique anatomic findings in an adult with intestinal malrotation.
An 18-year-old Caucasian male presented to a community hospital with abdominal pain, nausea, and vomiting. He underwent a CT scan demonstrating concern for small bowel volvulus and subsequently underwent a negative exploratory laparotomy. He was discharged post-operatively with no identified etiology for his presentation. He subsequently had multiple presentations to the ED with recurrent symptoms, review of imaging led to concern for duodenal volvulus resulting in transfer to a tertiary hepatobiliary centre. Repeat CT scan two weeks following initial presentation was consistent with intestinal malrotation with midgut volvulus. Bloodwork was unremarkable and physical exam demonstrated normal vital signs with a tender epigastrium. He underwent an exploratory laparotomy with Ladd's procedure. Intra-operative findings included a midgut volvulus and uniquely positioned Ladd's bands to the transverse colon. Post-operatively he tolerated oral intake and was discharged with three-month follow-up.
Adults with intestinal malrotation suffer from delays in diagnosis and management. In contrast to the neonatal population, adults often present with vague, or chronic symptoms, which obscures the diagnosis.
The increased morbidity and mortality observed in adults with intestinal malrotation highlights the need for surgeons to appreciate the challenges associated with this diagnosis in the adult population to ensure early recognition and management.
Not movin’: Pediatric bowel obstruction
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There are many causes of pediatric bowel obstruction, and imaging plays an important role in the detection and management. Plain radiography is the initial imaging study of choice in many cases and has several advantages, including helping to determine the level of obstruction, detection of free air, and widespread availability. However, other imaging modalities may be used as first-line choices. In patients with suspected intussusception or pyloric stenosis, ultrasound is indicated. In patients in whom malrotation is a concern, an upper gastrointestinal series should be performed to assist in making this diagnosis. Computed tomography, while excellent at detecting abdominal pathology, is often used as a follow-up study when initial imaging (plain radiography or ultrasound) is either equivocal or suggests complex abdominal pathology.
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To explore the surgical treatment and predictors of intestinal necrosis in children with intestinal obstruction through analyzing blood biochemical indicators, and to establish a predictive model and evaluate its predictive accuracy, sensitivity and specificity.
The data of children with intestinal obstruction hospitalized in Jiangxi Provincial Children's Hospital from January 2014 to June 2019 were retrospectively analyzed.
Thirty-six substances in the blood of children with successful conservative management and those requiring surgical treatment were significantly different. The model composed of 7 variables, including age, white blood cell count, creatine kinase, troponin I, myoglobin, C-reactive protein and fibrinogen, can be used to predict the unsuccessful conservative management in children with intestinal obstruction, whom need further operation. The average prediction accuracy was 83.50%, the false positive rate was 16.67% (32/192), AUROC is 0.9160 (95% CI, 0.8930–0.9390), and the sensitivity and specificity were 83.20% and 92.70% respectively. A prediction model based on the white blood cell count, creatine kinase, troponin I and myoglobin could predict the occurrence of intestinal necrosis. The average prediction accuracy was 73.70%, false positive rate was 4.49% (15/334), AUROC was 0.7390 (95% CI, 0.6820–0.7960), and the sensitivity and specificity were 71.70% and 64.70%, respectively.
Combination of age, white blood cell count, creatine kinase, troponin I, myoglobin, C-reactive protein and fibrinogen can be used to predict whether the children with intestinal obstruction need surgical treatment or not. Leukocyte count, creatine kinase, troponin I and myoglobin are closely related to the condition of children with intestinal obstruction and can be used to predict whether intestinal necrosis occurs.
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Small left colon syndrome with imperforate anus, a rare coincidence
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A case report of High type imperforate anus with recto-urethral fistula was found to be associated during colostomy with left micro-colon. The mother of the child was insulin dependent diabetic. Such babies are more prone to VACTERL anomalies. Small left colon syndrome has never been reported to coincide with imperforate anus, though the two can occur in babies born of diabetic mothers as a separate entity.
Feeding Outcomes in Neonates With Trisomy 21 and Duodenal Atresia
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Diagnosis is typically made on prenatal imaging (i.e., double bubble noted on ultrasound) or immediately after birth due to feeding intolerance. It is commonly repaired early in life via duodenoduodenostomy.3 These patients can have feeding difficulties in the early, postoperative period.
Duodenal atresia (DA), a common cause of congenital duodenal obstruction, is associated with trisomy 21. The postoperative feeding issues are not well described in this population. We hypothesize that the combination of DA and trisomy 21 is associated with the need for postoperative enteral feeding access.
A retrospective cohort of patients between 2010 and 2017 with the diagnosis of DA or duodenal stenosis was identified. Relevant prenatal and postnatal clinical data were abstracted. Univariate analyses were performed.
Forty-three patients were identified. Nineteen patients (44%) were diagnosed with trisomy 21. Eight patients (25% with trisomy 21) had gastrostomy placed at the time of DA repair. In the remaining patients (n = 35), 40% ultimately had a gastrostomy button placed. The indications for placement included poor oral skills (n = 8), aspiration (n = 5), and failure to thrive (n = 1). All these patients had trisomy 21, resulting in 82.4% of trisomy 21 patients having a gastrostomy. There was a significant association between trisomy 21 and placement of a gastrostomy button both during index admission (P = 0.003) and lifetime (P < 0.001). All trisomy 21 patients with congenital heart disease (n = 9) had a gastrostomy placed versus only five of eight trisomy 21 patients (62.5%) without structural heart disease (P = 0.006).
Our data suggest that a correlation exists between trisomy 21, structural congenital heart anomalies, DA, and the eventual need for gastrostomy. These data should inform operative planning for this patient population.
Should we look for Hirschsprung disease in all children with meconium plug syndrome?
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Meconium plug syndrome (MPS) is a benign cause of obstruction in neonates that typically presents with abdominal distension, emesis, and failure to pass meconium within the first 24–48 hours of life. Differential diagnosis includes intestinal atresia/stenosis, malrotation, volvulus, Hirschsprung disease (HD), meconium ileus, anorectal malformation, small left colon syndrome and more [1–3]. The transient large bowel obstruction is relieved by the passage of meconium plugs, which often occurs after rectal stimulation or with a diagnostic and therapeutic contrast enema.
Meconium plug syndrome (MPS) is associated with Hirschsprung disease (HD) in 13–38% of cases. This study sought to assess institutional variation in utilization of rectal biopsy in children with MPS and the likelihood of diagnosing HD in this population.
Patients with MPS on contrast enema in the first 30 days of life from the Pediatric Health Information System database in 2016–2017 were included. Institutional rates of rectal biopsies performed during the initial admission were calculated and then used to predict institutional rates of early HD diagnoses using Poisson regression.
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The incidence of HD is increased in children with MPS. There is significant hospital variability in the utilization of early rectal biopsy, and opportunity exists to standardize practice.
Type of Study: Study of Diagnostic test
Level of Evidence: Level III

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Intestinal obstruction in neonatal/pediatric surgery

Abstract

Section snippets

Presentation/general management of intestinal obstruction

Gastrointestinal tract obstruction anatomy/pathogenesis/etiology/treatment

Conclusions/the future

Am J Emerg Med

J Pediatr Surg

J Pediatr Surg

Am J Emerg Med

J Pediatr Surg

J Am Coll Surg

Semin Pediatr Surg

J Pediatr Surg

J Emerg Med

Semin Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

Gastroenterol Clin North Am

Semin Pediatr Surg

J Pediatr Surg

Gastroenterology

Radiol Clin North Am

J Pediatr Surg

Radiographic manifestations of intestinal obstruction in the newborn

JBR-BTR

Cryptosporidium-induced gastric obstruction in a child with congenital HIV infectioncase report and review of the literature

J Pediatr Gastroenterol Nutr

Outcome after surgical repair of junctional epidermolysis bullosa-pyloric atresia syndromea report of 3 cases and review of the literature

Arch Dermatol

Duodenal atresia

Br J Hosp Med

Duodenal atresiaa comparison of three modes of treatment

Eur J Pediatr Surg

Familial apple peel jejunal atresiasurgical, genetic, and radiographic aspects

Pediatrics

Colonic atresia combined with Hirschsprung’s diseasea diagnostic and therapeutic challenge

J Pediatr Surg

Congenital colonic stenosis

South Med J

A case of Meckel’s diverticulum complicated by stenosis of the colon

Am J Gastroenterol

Fibrosing colonopathy in cystic fibrosis

Arch Dis Child

Omphalomesenteric duct malformations

Semin Pediatr Surg

Duplication of the stomach. Case report and review of the literature

Am Surg

Ileal duplication cyst associated with heterotopic pancreasreport of a case and literature review

Acta Pathol Jpn

Intestinal obstruction caused by duplication of the caecum

Eur J Pediatr

Duplication of the rectumreport of four cases and review of the literature

Pediatr Surg Int

Adenocarcinoma within a rectal duplication cystcase report and literature review

Ann R Coll Surg Engl

Metastatic adenocarcinoma arising in a congenital foregut cyst of the esophagusa case report with review of the literature

Am J Clin Oncol

An unusual presentation of intestinal duplication with a literature review

Dig Dis Sci