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References
1.Sorva R, Mäkinen-Kiljunen S, Juntunen-Backman K. Betalactoglobulin secretion in human milk varies widely after cow’s milk ingestion in mothers of infants with cow’s milk allergy. J Allergy Clin Immunol. 1994;93(4):787-792.
2.Vandenplas Y, Brueton M, Dupont C, et al. Guidelines for the diagnosis and management of cow’s milk protein allergy in infants. Arch Dis Child. 2007;92(10):902-908.
Chapter 25
Intestinal Obstruction
Travis J. McKenzie and D. Dean Potter
Key Points
››Pediatric intestinal obstructions are divided into neonatal versus childhood.
››Neonatal intestinal obstructions are divided into proximal versus distal.
››Proximal obstructions require an upper contrast study, lower require lower contrast study.
››Bilious emesis or bilious aspirates in a neonate mandates an evaluation for malrotation.
››Pediatric intestinal obstructions frequently require surgical therapy.
25.1 Introduction
Pediatric intestinal obstructions are divided by age group: neonatal versus childhood. Neonatal obstructions are further divided into proximal versus distal obstructions to help guide further evaluation (Table 25.1). In a newborn, any bilious emesis, bilious aspirates, or a gastric aspirate of 20 mL or more is highly suggestive of intestinal obstruction.Importantly, childhood intestinal obstructions are often a surgical disease. As such, any patient suspected of having intestinal obstruction
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232 T.J. McKenzie and D.D. Potter
TABLE 25.1. Etiology of intestinal obstruction.
Neonatal (Proximal)
Rotational anomalies/malrotation
Duodenal atresia
Duodenal stenosis
Hypertrophic pyloric stenosis
Annular pancreas
Antral atresia
Pyloric atresia
Esophageal atresia
Neonatal (Distal)
Hirschsprung’s disease
Meconium ileus
Jejunoileal atresia and stenosis
Imperforate anus
Colonic atresia or stenosis
Small left colon syndrome
Omphalomesenteric remnant
Milk curd syndrome Childhood
Postoperative adhesions
Adynamic ileus
Intussusception
Incarcerated Hernia
Inflammatory Stricture
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Pseudo-obstruction |
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Alimentary tract duplication |
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should be referred to a medical center with the radiologic and surgical capabilities necessary to care for these patients. This chapter presents some common causes of pediatric intestinal obstruction.
25.2 Neonatal Intestinal Obstruction
(Proximal)
1.Malrotation/Volvulus: Presents with feeding intolerance or bilious emesis to cardiovascular collapse secondary to acute volvulus and intestinal ischemia/infarction. Commonly a well baby that presents to emergency department with bilious emesis. Plain abdominal radiograph is often non-diag- nostic but findings of proximal obstruction (double bubble) with distal intestinal gas mandates evaluation for malrotation (Fig. 25.1). Diagnosis by upper contrast radiography or emergency laparotomy. Treatment is operative.
2.Duodenal Atresia: Presents within hours of birth with repeated bilious or non-bilious emesis without abdominal distention. Double bubble on abdominal radiograph is classic finding. If delayed repair planned, upper contrast study to evaluate for malrotation with midgut volvulus is advised. Treatment is elective surgical repair after resuscitation.
3.Duodenal Stenosis: Double bubble with distal intestinal gas. If distal gas is present, must rapidly evaluate for rotational anomaly. Older children may present with duodenal web and perforated diaphragm. Upper contrast study to evaluate obstruction is useful. Surgical intervention is commonly required.
4.Hypertrophic Pyloric Stenosis: Progressive non-bilious emesis that becomes projectile often followed by hunger. Significant dehydration with hypochloremic, hypokalemic, metabolic alkalosis. Resuscitate with chloride rich fluids. Abdominal exam may reveal mass in the right upper quadrant (olive). Diagnosis by ultrasound. Treatment is pyloromyotomy after fluid resuscitation.