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FIGURE 25.1.  Abdominal radiograph demonstrating proximal intestinal obstruction with distended stomach and distal intestinal gas (arrow). This mandates evaluation for malrotation.

25.3  Neonatal Intestinal Obstruction (Distal)

1.Hirschsprung’s Disease: Diagnosis frequently made in neonatal period. Failure to pass meconium in first 24 h of life or constipation requiring suppositories or rectal stimulation is suggestive. Baby may have bilious emesis and abdominal distention. Rectal exam reveals a tight anus and explosive diarrhea. Diagnostic studies include plain radiographs, contrast enema, and rectal biopsy. Bilious emesis mandates upper contrast study for malrotation. Treatment

is surgical and depends on the extent of aganglionosis. Baby may present with sepsis secondary to Hirschsprung’s associated enterocolitis. Treat with hydration, intravenous antibiotics including metronidazole and colon irrigations.

2.Meconium Ileus:Associated with Cystic Fibrosis. Neonates are often born with abdominal distention. Uncomplicated form presents with bilious emesis, abdominal distention, and failure to pass stool. Complicated form includes intestinal ischemia/infarction. Plain radiograph shows obstruction with “soap-bubble” or “ground-glass” appearance in the right lower quadrant secondary to inspissated meconium. Contrast enema shows microcolon of disuse. Uncomplicated meconium ileus managed with solubilizing contrast enemas. Need to demonstrate reflux of contrast into dilated loops of bowel. Complicated forms require laparotomy.

3.Jejunoileal Atresia and Stenosis: Patients present early with bilious emesis, abdominal distention, jaundice, or failure to pass meconium. Obstruction may be complete or partial. Plain abdominal radiographs demonstrate many loops of dilated bowel. Contrast enema shows microcolon of disuse. Treatment is surgical repair after resuscitation.

4.Imperforate Anus: Usually present neonatally with abnormal perineal examination. Associated anomalies including vertebral malformations, cardiac anomalies, tracheoesophageal fistula, and genitourinary malformations. Patients should be referred to an appropriate center with pediatric surgical capabilities as early surgical repair may be indicated.

25.4  Childhood Intestinal Obstruction

1.Postoperative Adhesive obstruction: Most common etiology of bowel obstruction. Present with bilious emesis and abdominal distention in the setting of previous surgery. May occur anytime following abdominal operation. Plain

236 T.J. McKenzie and D.D. Potter

abdominal radiographs with dilated bowel loops with airfluid levels.Treat with intravenous hydration, gastrointestinal decompression with replacement of lost GI fluid, and delayed surgery if needed. Surgery early if signs of bowel ischemia/infarction.

2.Adynamic Ileus: Present in a similar fashion to those with mechanical obstruction (bilious emesis, abdominal distention) in the setting of other physiologic stress (pneumonia, postoperative, inflammatory conditions). Differentiating ileus from mechanical obstruction can be difficult. Plain radiographs may not differentiate between the two diagnoses. Contrast-enhanced gastrointestinal series may be necessary.Treatment is conservative/non-operative similar to adhesive obstruction.

3.Intussusception: Invagination of one part of the intestine into another. Most common in 3–12 month olds, but can be found in all ages. Severe colicky abdominal pain that lasts only a few minutes.The child will commonly bring up their legs (in infants). Possible abdominal mass and rectal bleeding (current jelly stools). Ultrasonography is the initial diagnostic modality of choice. Treatment is radiologic reduction. Operative intervention for signs of bowel ischemia/infarction or failed radiologic reduction.

4.Incarcerated Inguinal Hernia: Commonly present during the first year of life, more common in males and premature babies. Patient may have a history of hernia or intermittent inguinal bulge. Incarceration results in pain and irritability with progressive obstructive symptoms including bilious emesis and abdominal distention. Late presentation may include peritonitis. Attempt at manual reduction may be made if the patient is stable and without evidence of intestinal compromise. Repair is operative.

5.Inflammatory stricture: Relatively common complication of necrotizing enterocolitis. Presents with feeding intolerance, abdominal distention or persistent diarrhea.Work-up includes an upper and lower contrast study. Treatment is operative.

References

1.Gingalewski C. Other causes of intestinal obstruction. In: Grosfeld J, ed. Pediatric Surgery. 6th ed. Philadelphia: Mosby; 2006:1358-1368.

2.Akgur FM, Tanyel FC, Buyukpamukcu N, et al. Adhesive small bowel obstruction in children:The place and predictors of success for conservative treatment. J Pediatr Surg. 1991;26:37-41.

3.Andrassy RJ, Mahour GH. Malrotation of the midgut in infants and children. Arch Surg. 1981;116:158.

4.Calder FR, Tan S, Kitteringham L, et al. Patterns of management of intussusception outside tertiary centres. J Pediatr Surg. 2001;36:312.