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NEONATAL INTESTINAL OBSTRUCTION

NEONATAL INTESTINAL OBSTRUCTION. DR ENIVWENAE OGHENEKARO. OUTLINE. INTRODUCTION EMBYOLOGY CAUSES OF NEONATAL INTESTINAL OBSTRUCTION PATHOGENESIS CLINICAL MANIFESTATION INVESTIGATIONS TREATMENT FOLLOW – UP CONCLUSION. INTRODUCTION.

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NEONATAL INTESTINAL OBSTRUCTION

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  1. NEONATAL INTESTINAL OBSTRUCTION DR ENIVWENAE OGHENEKARO

  2. OUTLINE • INTRODUCTION • EMBYOLOGY • CAUSES OF NEONATAL INTESTINAL OBSTRUCTION • PATHOGENESIS • CLINICAL MANIFESTATION • INVESTIGATIONS • TREATMENT • FOLLOW – UP • CONCLUSION

  3. INTRODUCTION • A neonate is a baby (newborn) within the first 28 days of life. • Intestinal obstruction is stoppage of the onward (craniocaudal) passage of intestinal contents. • Neonatal intestinal obstruction is the commonest neonatal surgical emergency. • It can be life threatening and requires prompt recognition and intervention.

  4. INTRODUCTION • Delicate physiological adjustment to extra-uterine life. • High risk for surgery and anaesthsia • Improvements in surgery, anaesthesia, neonatal intensive care facilities and parenteral nutrition has improved outcome • Still a challenge in the developing countries

  5. INTRODUCTION • Delicate physiological adjustment to extra-uterine life. • Congenital anomaly may be associated with intrauterine growth restriction and preterm delivery. • Adaptive mechanisms further impaired in preterm, LBW, and SGA neonates

  6. INTRODUCTION

  7. INTRODUCTION • Problems in the neonate compounded by surgical pathology • Hypothermia • Hypoglycaemia • Susceptibility to infection • Jaundice • Respiratory embarrassment • Vitamin K deficiency bleeding

  8. Relevant Embryology • 3rd week of development: formation of the gut tube from the yolk sac

  9. Relevant Embryology • End of 4th week of development: formation of the gut tube from the yolk sac

  10. Relevant Embryology • 5th week of development: formation of the gut tube from the yolk sac

  11. Relevant Embryology • 6th week of development: formation of the gut

  12. Relevant Embryology • Duodenum: solid stage (5th/6th week), Recanalization (11th week)

  13. Relevant Embryology • Development of the pancreas (4th/5th week)

  14. Relevant Embryology • Development of the pancreas (4th/5th week)

  15. Relevant Embryology

  16. Relevant Embryology • 6th – 10th week of gut development: Physiologic herniation

  17. Relevant Embryology • 10th – 12th week of gut development: Return of the midgut

  18. Relevant Embryology • Hindgut development

  19. Relevant Embryology • Innervation: Migration of neural crest cells; 5th – 12th week

  20. Relevant Embryology • Blood supply

  21. Aetiology of Neonatal Intestinal obstruction • Acquired • Congenital

  22. Aetiology of Neonatal Intestinal obstruction • Acquired • Medical • Dyselectrolytaemia • Hypothyroidism • Hypothermia • Sepsis • Necrotizing enterocolitis • Surgical • Complicated Necrotizing enterocolitis • Intussusception

  23. Aetiology of Neonatal Intestinal obstruction – Congenital • DUODENAL • Atresia • Stenosis • Annular pancreas • Malrotation • JEJUNOILEAL • Atresia • Meconium Ileus • Malrotation • Vitelineanormalies • Congenital bands • Obstructed inguinal hernias • COLORECTAL • Hirschsprung’s disease • Anorectal malformation • Meconium plug • OTHERS • Intra-abdominal masses , abdominal wall defects, intestinal duplications, small left colon syndrome

  24. Aetiology of Neonatal Intestinal obstruction – Congenital • Common Causes: • Anorectal malformation • Hirschsprung’s disease • Duodenal atresia • Jejunoileal atresia • Malrotation with midgut volvulus • Obstructed inguinal hernia

  25. PATHOPHYSIOLOGY OBSTRUCTION PROXIMAL ACCUM DISTENSION INCREASE PERISTALSIS NO INTERVENTION WANES (ILEUS)

  26. PATHOPHYSIOLOGY STASIS BACTERIAL PROLIFERATION TRANSLOCATION / TRANSMIGRATION CIRCULATION PERITONITIS SEPTICEMIA

  27. PATHOPHYSIOLOGY DISTENSION VILLOUS ATROPHY ABSORPTION SECRETION VOMITING E/U IMBALANCE

  28. PATHOPHYSIOLOGY INTRALUMINAL PRESSURE ABOVE VASCULAR PRESSURE ISCHAEMIA NECROSIS PERFORATION GENERALIZED PERITONITIS

  29. PATHOPHYSIOLOGY • Constipation • Bowel distal to obstruction - peristalsis eventually stops after expelling contents

  30. PATHOPHYSIOLOGY • Duodenal Atresia • Incidence: 1:5000 – 10000 • Male > Female • Failure of recanalization during the embryonic period • Classification: Types I, II & III

  31. PATHOPHYSIOLOGY • Duodenal Atresia • 85% postampullary, 15% preampullary • Vomiting (bilious) form 1st day of life • Maternal polyhydramnios • More than 50% associated anomalies • Down’s syndrome, cardiac defects, GIT, prematurity, etc

  32. PATHOPHYSIOLOGY • Jejunoileal Atresia • Incidence of 1: 5000 • M:F = 1:1 • 10% Associated anomalies • Likely due to a vascular disruption, leading to resorption of affected segment of ischaemic bowel.

  33. PATHOPHYSIOLOGY • Jejunoileal Atresia • Classified as Type I, II, IIIa, IIIb and IV. • Polyhydramnios with proximal bowel segment • May pass meconium

  34. PATHOPHYSIOLOGY • Malrotation Syndrome • Related to problems associated with midgut rotation and fixation • Incidence of 1:6000 • Up to 75% present in the neonatal period

  35. PATHOPHYSIOLOGY • Malrotation Syndrome • Spectrum • Non rotation • Incomplete Rotation • Hyper-rotation • Reversed rotation • Encapsulated small intestines • Internal Hernias (Paraduodenal & Mesocolic) • Ladd’s bands (Extrinsic duodenal obstruction)

  36. PATHOPHYSIOLOGY • Malrotation Syndrome: midgutvolvolus most feared complication

  37. PATHOPHYSIOLOGY • Anorectal Malformation • Absent normal anal opening • Abnormal development of urorectal septum resulting in incomplete separation of cloaca into urogenital & anorectal portions. • Incidence of 2 -2 .5:10,0000 • M:F = 1 – 1.8:1 • Associated anomalies • VACTERL-H

  38. PATHOPHYSIOLOGY • Anorectal Malformation • Associations • V = Vertebral • A = Anorectal • C = Cardiac • T = Tracheo-oesophageal fistula • E = Esophageal • R = Renal • L = Limb • H = Hydrocephalus

  39. CLASSIFICATION OF ANORECTAL MALFORMATIONWingspread

  40. ANORECTAL MALFORMATION – LOW ARM WITH BUCKET HANDLE DEFORMITY

  41. PATHOPHYSIOLOGY • Hirschsprung’s disease • Functional intestinal obstruction caused by the congenital absence of parasympathetic ganglion cells of the ENS in the distal colon. • 1 in 5000 live births • M:F = 4:1 • Asians > Whites > Blacks • Sporadic : Hereditary = 90 : 10

  42. Pathology - Gross

  43. HD Classification • Ultrashort segment HD -----------------<1% • Short segment HD ------------------------70-80% • Long segment HD -------------------------10-25% • Total colonic aganglionosis (TCA) -----3-15% • Total intestinal aganglionosis (TIA)---0.4-4

  44. PATHOPHYSIOLOGY • Hirschsprung’s disease • May present as: • Acute neonatal intestinal Obstruction • Chronic large bowel obstruction • Acute on chronic large bowel obstruction • Hirschsprung’s Associated Enterocolitis (HAEC) • History of delayed passage of meconium • Constipation from birth

  45. PATHOPHYSIOLOGY • Obstructed Inguinal Hernias • Inguinal hernia is present in upto 10 – 30% of preterm and 3- 5% of term babies • Likelihood of obstruction and strangulation is higher in this group compared to older children and adults. • With delayed intervention, bowel loops may herniate into the patent processusvaginalis, get incarcerated in the inguinal canal, may become obstructed and may get strangulated

  46. PATHOPHYSIOLOGY • Obstructed Inguinal Hernia

  47. Clinical Presentation - History • Abdominal pain – inconsolable cry • Refusal of feeds • Vomiting • Failure to pass meconium • Constipation • Abdominal Swelling • Passage of blood in stool • Groin swelling • Absent/ abnormal anal opening • Perineal fistula, or passage of meconium/ flatus in urine?

  48. Clinical Presentation - History • Convulsion • Fever • Difficulty with breathing • Reduced volume/frequency of micturition • Jaundice

  49. Clinical Presentation - History • Family history • Maternal History • Assisted reproduction • Drugs – teratogens, vasoactive drugs, herbal medications • History suggesting polyhydramnios • Routine Ultrasound scan • Delivery • Resuscitation • Other associated anomalies • Treatment so far

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