1. Intestinal Obstruction in Children Nopporn Sritippo MD. Department of Surgery Sawanpracharak Hospital

2. Intestinal perforation 3. Intestinal obstruction Proximal or Distal Complications or not Complete or Partial Diagnosis conclusion 4. Cardinal symptoms of Intestinal obstruction Abdominal pain Vomiting Obstipation Abdominal distension 5. What diseases have been commonly caused intestinal obstruction in children.? 6. Intestinal Obstruction in Children at Sawanpracharak Hospital 1. Hirschsprungs disease 2. Anorectal malformations 3. Intussusception 4. Duodenal obstruction 5. Band adhesion 7. 6. Esophageal atresia with TE fistula 7. Jejuno-ileal atresia 8. Necrotizing enterocolitis 9. Obstructed IIH 10. Pyloric stenosis Intestinal Obstruction in Children at Sawanpracharak Hospital 8. Esophageal atresia with TE fistula Pyloric stenosis Duodenal atresia Jejunal atresia 9. Intussusception Hirschsprungs disease Necrotizing enterocolitis Obstructed IIH 10. How do you know which children presented clinical intestinal obstruction.? 11. History Physical examination Investigation Management 4 Nobles Truth 12. History 1. Maternal polyhydramnios 2. Down syndrome 3. Hypersalivation 4. Vomiting 5. Obstipation 13. Maternal polyhydramnios Associated with Esophageal atresia Duodenal obstruction Jejunal obstruction 14. Down syndrome Associated with Hirschsprungs disease Anorectal malformation Duodenal obstruction 15. Hypersalivation Suspected Esophageal atresia 16. Bilious gastric aspirates : an obstruction distal to the ampulla of Vater 17. History Bilious gastric aspirates or emesis suggests an obstructiondistal to the ampulla of Vater As a rule, consider any infant or child with bilious vomiting to have an intestinal obstruction until proven otherwise 18. Down syndrome with constipation 19. History 6. Abdominal distension 7. Pain 8. Mucous whitish stool 9. Smaller caliber of stool 10. Abnormal passing stool site 20. Mucous whitish stool suggests intestinal atresia 21. Anal stenosis Small caliber of stool 22. Recto-urethral fistula , High type of anorectal malformations Abnormal passing stool site 23. History 11. Hernia 12. Previous abdominal surgery 13. Foreign body ingestion 14. Passing stool with intestinal parasite 24. Hernia may be caused the intestinal obstruction 25. Abdominal surgical scar suggests adhesion bands caused intestinal obstruction 26. Foreign body ingestion Coin ingestion Clip ingestion 27. Physical examination The importance of a through physical examination Inspection and palpation of the abdomen and perineum 28. Physical examination 1. Signs of shock 2. Signs of peritonitis 3. Signs of malnutrition 4. Characteristic of Down syndrome 5. Hypersalivationwith inability to pass nasogastrictube 29. Signs of shock Dropped blood pressure Rapidly pulse Changed consciousness Poor skin perfusion , cyanosis Respiratory distress 30. Signs of peritonitis Periumbilical erythema Marked abdominal distension Generalized abdominal guarding and rigidity Intestinal obstruction In children 31. Periumbilical erythema 32. Marked abdominal distension 33. Malnutrition 34. Down syndrome with constipation and abdominal distension 35. Hypersalivation 36. Hypersalivation with inability to pass nasogastric tube suggested esophageal atresia 37. Physical examination 6. Bilious vomitus or not 7. Visible bowel loop 8. Characteristics of abdominal distension 9. Hernia 10. Abdominal surgical scar 38. Visible bowel loop 39. Characteristics of abdominal distension suggests the level of intestinal obstruction 40. Physical examination 11. Imperforate anus or abnormal anal opening 12. Thermometer cant be passed into the rectum Intestinal obstruction In children 41. Imperforate anus is one of the most common cause of intestinal obstruction 42. Rectal atresia - Hegars dilator cant be passed into the rectum 43. Investigation 1. Prenatal ultrasonography 2. Acute abdomen series 3. Invertogram 4. Upper GI Study 5. Barium enema Intestinal obstruction In children 44. Ultrasonography 45. Acute abdomen series 46. Upper GI Study 47. Barium enema 48. Management 1. Early consideration 2. Surgical treatment 3. Non-surgical treatment 49. Successful management of intestinal obstruction in children depends upon both timely diagnosis and prompt therapy 50. NPO NG tube decompression Rectal tube with NSS irrigation ( suspected Hirschsprungs disease) corrected respiratory distress , hypotension , dehydration , metabolic acidosis , septicemia 51. 4 3,200 Apgar score 10,10 meconium 52. 1 53. One stage Transanal endorectal pullthrough 54. One stage Transanal endorectal pullthrough 55. 1 secretion 56. 4 57. 1 1 .. 58. Infantile hypertrophic pyloric stenosis 59. Pyloromyotomy 60. Pyloromyotomy 61. 5 2 .. 1 62. 1 3 .. 10 UGI study DJ junction located lower than duodenal bulb and to the right of expected position 63. 11 2 1 .. 3-4 64. 10 2 1 65. HN 0320269 SawanpracharakHospital 66. CC:- PI :- G1P1 , Gestational age 36 weeks by date , PROM , normal labour , APGAR score 9,10 PE :- BW = 1,600 gm. hypersalivation with inability to pass Nelaton catheter No.12 - palpated ill-defined mass at left mid abdomen Unusual presentations of Intestinal obstruction in children 67. mass at left mid abdomen 68. Imperforated anus 69. Plain abdomen 70. Dilated stomach Double Bubble sign 71. Problem list 1. Imperforate anus 2. Hypersalivation with inability to pass Nelaton catheter No.12 3. Abdominal mass 4. Preterm , low birth weight Unusual presentations of Intestinal obstruction in children 72. Make Dicision Explore laparotomy Anoplasty Thoracotomy Unusual presentations of Intestinal obstruction in children 73. Dilated stomach 74. marked dilatation of the stomach and first part of the duodenum with atresia of second part of the duodenum distal end of the rectum was seen in pelvic cavity , low type without fistula of anorectal malformations esophageal atresia with tracheoesophageal fistula Operative findings 75. Duodenoduodenostomy Gastrostomy Anoplasty Repair T-E fistula with primary esophageal anastomosis Operative procedures 76. Duodenal atresia Anorectal malformations (low type) Esophageal atresia with tracheoesophageal fistula Unusual presentations of Intestinal obstruction in childrenDiagnosis 77. ..1691 Dr. Frederick Ruysch 5 78. .. 1886 Harald Hirschsprung 79. ..1901 Tittel ganglion cell 80. Histology abscence of ganglion cells in submucosa , circular , circular - longitudinal 81. 1 : 5,000 : 4 : 1* 82. 83. Rectum , rectosigmoid colon 68 75 % Descending colon 10 % Transverse colon 5 % Ascending colon 2 % Total colon , terminal ileum 8% 84. 1. Short segment 2. Ultrashort segment 3. Long segment 4. Total colonic aganglionosis 5. Total colonic aganglionosis with extended ileum 85. Plain abdomen Barium enema Rectal biopsy Rectal suctional biopsy Manometry 86. Plain abdomen Barium enema 87. Barium enema in case of Total colonic aganglionosis with Ileal extension 88. ..1948 Swenson Hirschsprungs disease ganglion cell 89. Swenson procedure 90. 91. 1. Supportive treatment : unison enema , rectal NSS irrigation 2. short segment: One stage transanal endorectal pullthrough, TEP 92. 3. ultrashort segment : Sphincteromyectomy 4. long segment : explore laparotomy one stage transanal endorectal pullthrough 93. 94. 95. One stage Transanal Endorectal Pullthrough 96. Complications of Hirschsprungs Perforation Enterocolitis* Malnutrition Leakage of anastomosis Fecal incontinence 97. 4 3,200 Apgar score 10,10 meconium History 98. 1 History 99. 1 2 1 Barium enema ; dilated proximal half of transverse colon. The remainder colon is normal caliber. Transitional zone cannot be identified. History 100. Intestinal Obstruction in Children 101. Anorectal malformations 102. imperforate anus abdominal distension passing of meconium via urethra or vagina ectopic anus 103. smaller caliber of stool thermometer cant be passed into the rectum peritonitis 104. imperforate anus 105. abdominal distension 106. passing of meconium via urethra or vagina 107. ectopic anus 108. smaller caliber of stool 109. Hegars dilator cant be passed into the rectum 110. Wingspread classification 1984 1. High type 2. Intermediate type 3. Low type 111. Wingspread classification 1984 High type Female Male 1. anorectal agenesis 1. anorectal agenesis -w rectovaginal fistula - w rectoprostatic fistula - wo fistula - wo fistula 2. rectal atresia 2. rectal atresia 112. Wingspread classification 1984 Intermediate type Female Male 1. rectovestibular fistula 1. rectobulbar fistula 2. rectovaginal fistula 2. anal agenesis wo 3. anal agenesis wo fistula fistula 113. Wingspread classification 1984 Low type Female Male 1. anovestibular fistula 1. anocutaneous fistula 2. anocutaneous fistula 2. anal stenosis 3. anal stenosis 114. How could we know who is high , intermediate or low type.? 115. 1. look for fistula male - perineum , urine female - vestibule , vagina 2. If there isnt fistula invertogram must be performed 116. PC I Invertogram PC line - pubic symphysis to sacrococcygeal joint I - line - lower rim of iliac bone = PC line 117. Associated anomalies Down syndrome Hirschsprungs disease esophageal atresia 118. Treatment 1. Low type anal stenosis - anal dilator anovestibularfistula anocutaneousfistula anoplasty anal agenesis (low) 119. Anoplasty 120. Treatment 2. High type - colostomy - posterior sagittal anorectoplasty - abdominoperineal pullthrough 121. Precautions high or intermediate type usually associated with fistula If invertogram showed high or intermediate type , it may be low type EA w ARM.? , HD w ARM.? 122. Intestinal Obstruction in Children 123. 5 2 .. 1 Intestinal obstruction In children 124. Intussusception 125. Intussusception 126. - - Meckel diverticulum - Intestinal polyp - Lymphoma - Intestinal duplication 127. Ileo-colic type * Colo-colic type Ileo-colo-colic type Ileo-ileo-colo-colic type 128. 2 2 vomiting colic currant jelly stool lethargy abdominal distension 129. Dehydration , lethargy , shock Abdomen - soft , sausage - like , Dances sign - abdominal distension PR ; mucous-bloody stool 130. mucous-bloody stool Intussusception 131. Plain abdomen 132. Acute abdomen series 133. Barium enema 134. Unsuccessful barium hydrostatic reduction 135. 1. Hydrostatic reduction - air - barium 2. Surgical treatment - Manual reduction - Resection and end to end anastomosis 136. Premedication for Hydrostatic reduction Dormicum ( 5 mg/ml/ampule) - dose 0.5-0.75 mg/kg/dose , oral 1 hr. before Chloral hydrate - dose 40-60 mg/kg/dose , oral 1 hr. before 137. Manual reduction Surgical incision Currant jelly stool 138. Intestinal Obstruction in Children 139. Small bowel obstruction in children Duodenal obstruction Jejuno-ileal atresia Obstructed IIH Adhesion band 140. Duodenal obstruction 141. Duodenal obstruction Atresia or web Stenosis Malrotation 142. A failure of revacuolization of the lumen of the duodenum at 8-10 weeks gestation Duodenal atresia 143. Duodenal web results from an obstructive band of mucosa that stretches across the duodenal lumen Duodenal atresia 144. Clinical manefestations Bilious or nonbilious vomitus Epigastrium abdominal distension No passing meconium , delayed , whitish , normal Jaundice 145. Maternal polyhydramnios Down syndrome Clinical manefestations Nasogastric aspirates > 20 ml. Double air bubbles Upper GI study Diagnosis 146. Bilious or nonbilious vomiting Upper abdominal distension Double bubbles sign 147. Associated anomalies include Trisomy 21 ( 40% of patients) Anorectal malformations Congenital cardiac disease Duodenal atresia 148. 2 BW 1,900 gm. feed NG tube bile meconium 149. Plain abdomen Double air bubbles* Duodenal atresia 150. Upper GI study Duodenal stenosis 151. 1 3 .. 10 UGI study DJ junction located lower than duodenal bulb and to the right of expected position 152. A child with bilious emesis must be considered to have malrotation with volvulus until proven otherwise Malrotation 153. Plain abdomen Malrotation 154. Malrotationwith bowel gangrene 155. What are the differences between clinical presentation of duodenal atresia and ileal atresia.? 156. Duodenal atresia Bilious vomitus No passing meconium Mild abdominal distension Ileal atresia Bilious vomitus No passing meconium Marked abdominal distension 157. Duodenal atresia Ileal atresia 158. Duodenal atresia Ileal atresia 159. Duodenal atresia Ileal atresia -Duodenoduodenostomy - Ileal resection and end to end anastomosis 160. A thai newborn , age 4 day CC:- bilious emesis , no passing of meconium PE:- icteric sclera , upper abdominal distension , visible peristalsis was seen HN 0312194 161. HN 0312194 Passing stool 162. HN 0312194 163. HN 0312194 Upper GT study 164. HN 0312194 Multiple atresia of the jejunum and ileum 165. 2 1 silks sign - positive 166. Symptoms and Signs Bulging in the inguinal region scrotum May be reduced spontaneously , manual or cant be reduced 167. silk glove sign ; thickening and silkiness on palpating the spermatic cord as it crosses the pubic tubercle 168. Pathogenesis; patent processus vaginalis 169. the processus vaginalis obliterated after testicular descent had been completed 170. Incidence Male > female 10 : 1 Right : left : bilateral 10 : 6 : 1 171. Management IIH does not resolve spontaneously Elective herniotomy 172. Complications of Inguinal hernia Incarcerated inguinal hernia - 68% of incarcerated hernia < 1 year Gangrenous/Obstructed inguinal hernia 173. 11 CC:- 3-4 3-4 1 .. PI:- 2 174. PE:- T = 36.5C P = 120/min R = 24/min moderate dehydration , drawsiness Abdomen- mild distension , soft , no mass Left groin spontaneous reduction of left incarcerated IIH PR :- liguid yellowish stool with foul smell 175. 3 . 3-4 176. 11 177. - - - - - 178. Operative findings :- - Cloudy yellowish fluid about 20 ml. with fibrin in peritoneal cavity - Generalized dilatation of small bowel and large bowel - Gangrenous distal ileum size 2 cm. in diameter at 5 cm. from IC valve 179. gangrenous distal ileum 180. :- Explore laparotomy with distal gangrenous ileal resection and end to end anastomosis with intraperitoneal left herniotomy and appendectomy 181. 1. 2. 3. N.P.O. 4. Day surgery procedure 182. 9 CC :- , RUQ , RLQ 3 183. PI :- 4 - 3 ... - 1 RLQ 184. PI :- ... 9 RLQ pethidine IV 185. PE :- T=37C P=90/min R=24/min BP=110/70 mmHg Abdomen :- not distend , tenderness around appendectomy scar 186. CBC :- Hct = 38% wbc=5,030cells/mm3 N = 62% L = 33% M = 3% E = 2% platelet = 315,000 Urine exam : - normal Stool exam : - normal 187. Upper GI study - Normal esophagus and stomach - No definite ulcer in the stomach - The duodenal bulb is not deformed. - The C loop is normal. - Normal transit time and appearance of small bowel 188. Barium enema - Normal appearance of rectum and colon - Minimal depression at mucosa of medial aspect of caecum 189. Ultrasound whole abdomen :- - Normal appearance of liver without definite mass lesion , The gallbladder , spleen , and both kidneys are normal. - Mass lesion is not demonstrated. - Normal appearance of the bladder - The uterus is not well demonstrated. - No evidence of fluid in cul de sac. 190. Operative findings :- - Band adhesion was found at ileo-colic junction. - No Meckel diverticulum - Normal liver parenchyma 191. lysis band adhesion .. 192. Intestinal Obstruction in Children 193. Esophageal atresia and tracheoesophageal fistula A foregut malformation resulting from an error in separation of the esophagus from the respiratory tree Hypersalivation and inability to pass a nasogastric tube is diagnostic of esophageal atresia 194. 2 2,800 Apgar score 10,10 secretion meconium 195. 1. Maternal polyhydramnios 2. Hypersalivation 3. Upper abdominal distension 4. Choking , coughing , cyanosis after feeding Problem list 196. 12-14 197. CXR include abdomen 198. 199. - 200. 1. N.P.O. Esophageal atresia 2. aspirated pneumonia 3. hypothermia 4. pneumonia 201. right thoracotomy and repair T-E fistula with primary esophageal anastomosis 202. 203. Infantile Hypertrophic Pyloric Stenosis Gastric outlet obstruction from pyloric stenosis result from hypertrophy of the pylorus and associated with reduced nitric oxide levels in the pylorus muscle tissue IHPS 204. 1 1 .. 9 .. 2 .. 2,900 205. Visible peristalsis 206. Vomiting Peristalsis wave at LUQ Normal passing stool Problem list 207. Plain abdomen Upper GI study 208. 4 : 1 3 209. 210. - N.P.O. - Retained NG tube gastric content - Hyperchloremic metabolic alkalosis - Dehydration 211. Ramstedt pyloromyotomy 212. Ramstedt pyloromyotomy 213. 2 214. 1 preterm with very low birth weight (920 gm.) with pneumonia 4 feed 215. Risk factors after birth Preterm Low Apgar score Infection Hypoxia 216. Clinical staging of NEC* Suspected NEC Definite NEC Advanced NEC NEC* - Necrotizing enterocolitis 217. suspected or definite NEC refuse feeding abdominal distension vomiting bloody stool 218. advanced NEC periumbilical erythema palpable fixed dilated bowel loop 219. Management Suspected or Definite NEC - NPO 1-2 wks - Retained NG tube - Broad spectrum antibiotics - IV Fluid and Parenteral nutrition 220. Indication for Surgery Persistent dilated bowel loop Portal vein gas Perforated bowel 221. HN 316226 Sawanpracharak Hospital 222. 20 CC : - 1 PI : - 1 .. - 4 . .. 1 1 223. PE : T 39.8C P 121 /min R 34/min BP 119/81mmHg : alert , active infant with marked abdominal distension abdomen - superficial vein dilatation - periumbilical erythema with palpated ill-defined mass at mid-abdomen Unusual presentations Intestinal obstruction in children 224. CBC : Hct 35.7% wbc 13,700 cells/mm3 N 69.8% L 18.5% E 0.4% platelet 365,000 Stool exam. : soft , brown , occult blood positive ova & parasite not found , wbc neg , rbc neg Plain abdomen : 225. Problem list Fever Intermittent crying Progressive abdominal distension Vomiting Periumbilical erythema Leukocytosis Positive occult blood in stool 226. Impression : suspected gangrenous enteritis Treatment : - NPO - 5% D/NSS/3 1000 ml - retained NG tube - unison enema 10 ml - cefoxitin (100 MKD) 120 mg IV q 8 hrs - metronidazole (30 MKD) 50 mg IV q 8 hrs 227. Differential diagnosis : - Amoebic colitis with peritonitis - volvulus 228. Repeat stool exam. : Soft , yellow , occult blood-positive , ova&parasite-not found , wbc - neg , rbc - neg 229. Ultrasound whole abdomen : 230. Ultrasound whole abdomen : Suspected dilated bowel loops at mid- abdomen Normal liver , spleen and kidneys 231. 14 hrs later 232. 36 hrs later 233. 36 hrs later 234. Make dicision for operation 235. Operative findings 236. Operative findings 237. Gangrenous jejunum 238. Segmental volvulus of jejunum 239. Broad-base mesenteric root defects (basilar) 240. Counterclockwise detorsion , resection and anastomosis 241. The affected gangrenous volvulus of jejunum 242. Pathological result Small intestine , resection :- - Acute necrotizing enteritis with acute serositis 243. Segmental volvulus of Jejunum Volvulus - clockwise rotation of the bowel causing lymphatic, venous or arterial occlusion. Midgut volvulus Segmental volvulus 244. Midgut volvulus Rotation of the entire bowel from the second portion of the duodenum to the mid transverse colon about the axis of the superior mesenteric artery. 245. superior mesenteric artery 246. Segmental volvulus On rare occasions volvulus involve only the small bowel in a segmental fashion affecting a portion of jejunum, ileum or both. 247. Segmental volvulus Predisposing anatomical defects ;- congenital bands (Meckel diverticulum) acquired adhesive bands abnormal foreshortened mesenteric defect hanging tumors (mesenteric cyst) intraluminal lesions of the small bowel VP shunts 248. Segmental volvulus Clinical manifestations ;- sudden intestinal obstruction - bilious vomiting - abdominal distension - signs of peritonitis variable changes of ischemic bowel - shock - metabolic acidosis 249. Segmental volvulus Management ;- counterclockwise detorsion of the affected segment removing the anatomic cause resection with anastomosis pexing of the bowel may be needed