INTESTINAL OBSTRUCTION ( P aediatrics )

1. INTESTINAL OBSTRUCTION(Paediatrics) Presenter: Dr. Ashith shetty Moderator: Dr. Narayan Bhat

2. Definition: Interference with the normal aboral transit of intestinal contents. Classification: 1) Depending on nature of obstruction • dynamic • adynamic 2) Depending on severity of obstruction • Acute • chronic

3. 3) Depending on the cause of obstruction • In the lumen of the gut -round worms -foreign body • In the wall -growth, stricture, intussusception, atresia, stenosis.

4. Outside the wall -adhesions -bands -hernia -volvulus 4) Depending on blood supply • simple • strangulation

5. 5) Depending on site of obstruciton • Proximal small bowel • Distal small bowel • Large bowel

6. Causes in Paediatric age group • New born - duodenal atresia, jejunoileal atresia, malrotation, meconioum ileus, volvulus neonatorum. • Neonates - congenital hypertrophic pyloric stenosis, malrotation.

7. Causes cont…. • Infants - intussusception, obstructed hernia, congenital bands. • Older children - appendicular complications, meckels complications, worm infestations, primary peritonitis.

8. Pathophysiology Proximal to obstruction Bowel distends Collection of fluid Accumulation of gases

9. Intestinal obstruction Increase peristalisis Obstruction not relieved Peristalisis ceases

10. Defective absorption, decreased fluid intake, loss of fluid by vomiting, sequestration of fluid into bowel lumen leads to severe dehydration, fluid and electrolyte imbalance. • Closed loop obstruction, where both ends are closed as seen in obstructed hernia, torsion, volvulus and high risk of developing strangulation, necrosis and perforation.

11. Factors causing systemic problems • Dilatation of bowel • Decreased absorption across mucosa • Increase secretion into lumen • Intramural inflammation and Hypoxia • Increased intraluminal pressure • Venous congestion and increased pressure • Disrupted mucosal barrier, bacterial translocation

12. Changes in the site of obstruction Impaired venous return Congestion Edema of bowel wall Jeoparidizes the arterial supply Gangrene

13. Gangrene Perforation Bacteria and toxins migrate to peritoneum Peritonitis

14. Clinical features • Pain abdomen : Colicky nature, later continuous and severe if perforation occurs. • Vomiting : Early in jejunal obstruction and late in ileal obstruction, colon. Bilous in upper small bowel obstruction. Faeculant in distal small bowel and colonic obstruction.

15. Abdominal distension : Central distension in small bowel and flanks in large bowel. • Constipation : Early in large bowel. • Signs of dehydration : dry skin, dry tongue, shrunken eyes, feeble pulse, low urine output. • Abdominal findings: -Visible peristalisis -Tympanic note

16. - Rebound tenderness and Rigidity. • On Auscultation: Borborygmi. • Per Rectal: If small bowel is involved & rectum is empty. • Signs of strangulation: -Tachycardia -Hypotension - Rebound tenderness -Rigidity and guarding.

17. To look out for • If obstruction present, at what level? • Is strangulation present? • Is dehydration present? • What is the cause? • What is the treatment for individual case?

18. Duodenal atresia • Commonest site of atresia. • Obstruction manifests in usually 48-72 hrs. • Defective fusion of foregut and midgut with defective recanalization. • Types: 1) complete atresia 2) fibrous cord 3) incomplete or partial obstruction • Duodenal atresia may be pre-ampullary or post ampullary.

19. Clinical features: Bilous / non-bilous vomiting Dehydration Distension Jaundice • Aspiration via nasogastric tube of more than 20ml of gastric contents suggests intestinal obstruction, normal aspiration is less than 5ml.

20. Investigations : • Plain X-ray shows double bubble sign(air filled stomach and duodenal bulb). • In cases where there is no distal air, diagnosis is secured. • Upper GI contrast study

22. Treatment : • Surgical by-pass of duodenal obstruction as either side to side or proximal transverse to distal longitudinal(diamond shaped) duodeno-duodenostomy.

23. Jejuno-ileal atresia • Common site is proximal jejunum, second being distal ileum. • Often associated with malrotation, volvulus. • Maternal polyhydraminos also associated. • The spectrum of gross pathological findings include simple stenosis, complete interruption of intestinal lumen with or with out fibrous cord attached to distal bowel, missing segment of the bowel, or multiple atresia.

25. Types : • Atresia type -1 : caused by membrane or web formed by mucoa and submucosa. • Atresia type-2 : blind end joins by fibrous cord. • Atresia type-3a : disconnected blind ends, atresia ends blindly both proximally and distally. • Atresia type-3b : apple peel or christmas tree deformity. Proximal jejunalatresia near ligament of treitz, absence of superior mesentric artery beyond the origin of middle colic branch, significant loss of intestinal length and large mesentric defect. • Atresia type-4 : multiple atresia.

26. Clinical features : In proximal atresia abdominal distension is less frequent and bilous emesis is usually present, distension more prominent in distal obstruction. Usually develops from the first day of life. Jaundice. Dehydartion. Fever.

28. Management : Plain X-ray abdomen : Triple bubble appearence in jejunal atresia, multiple air fluid levels in ileal atresia. Barium enema : Shows narrow nicro colon. Treatment : Resection of the proximal dilated and hypertrophied bowel with end to end anastamosis with or without tapering the proximal bowel.

29. Malrotation Describes the spectrum of anatomical abnormalities of incomplete rotation and fixation of the intestine during fetal development. The normal development of human intestine involves two processes : complete rotation of the mid gut and subsequent fixation of the colon and mesentry. Embryology : midgut normally herniates via umbilical ring at about 4th week. By 10th week the intestine returns to the abdominal cavity and rotates around the axis of SMA for 270 degrees in a counter clock direction.

30. Normal

32. Associated anamolies – intestinal atresia, cardaic anamolies, meckels diverticulum, mental retardation. • Errors of rotation – Non rotation, incomplete rotation, reverse rotation and hyper rotation. Clinical features : Vomiting – bilous, non bilous Abdominal pain Diarrhea Irritability Failure to thrive Features of strangulation, perforation, peritonitis may be present.

33. Management : Plain abdominal X-ray Upper GI contrast study USG abdomen Treatment : Ladds procedure : laparotomy through horizontal incision. Clockwise rotated midgut which is congested and cyanotic needs to be untwisted in a counter clockwise manner

34. Viability of the bowel is confirmed Ladds bands are divided The entire duodenum is kocherised and ligament of treitz is divided so that the duodenum becomes straight towards RIF. Acheives wide route of mesentry and places small bowel in the right side of abdomen preventing further volvulus. Complimentary appendicectomy done.

35. Meconium ileus Neonatal manifestations of fibrocystic disease of pancreas characterized by extremely vicid, protein rich, inspissated meconium causing obstrcution of distal ileum. Earliest manifestations of cystic fibrosis occuring in approximately 16% patients with CF. Presents with abdominal distension, bilous vomiting and failure to pass meconium Neonates presents with features of respiratory dysfunction, exocrine pancreatic insufficiency, high salt in test.

36. Management : Plain abdominal radiograph – calcified meconium pellets with multiple air fluid levels appear as soap bubbles. Contrast enema – monitored fluoroscopically will demonstrate a colon of small caliber containing small rabbit pellets of inspissated mucus. USG abdomen

37. Treatment : Non operative – dissolution through enema tried using gastrogaffin or acetyl cystine passed per rectally for irrigation. Acetyl cystine wash through nasogastric tube is also used. Operative – Bishop koop operation, resection of the segment of ileum containing the mass of meconium, distal ileum is brought out as an irrigating and decompressive ileostomy. An anastamosis is created between the end of the proximal segment and the side of distal segment of the bowel.

38. Volvulus neonatorum • Complication of arrested rotation with bands which predispose to midgut volvulus. • These infants undergo masssive resection of bowel if its gangrenous giving rise to short gut syndrome. • If the loop is not gangrenous treated by laparotomy, untwisting of bowel and division of bands.

39. Hirschprung’s disease Congenital familial condition characterized pathologically by absent ganglion cells in auerbach’s and meissner’s plexus Neurogenic abnormality associated with muscular spasm of distal colon and internal anal sphincter resulting in functional obstruction Risk is greater if there is positive family history and in patients with down’s syndrome

40. Types : Ultra short segment HD – only anal canal and terminal rectum is involved Short segment HD – anal canal and rectum completely involved Long segment HD – anal canal, rectum and part of colon Total colonic HD – anal canal, rectum and full length of the colon.

41. Clinical features : Common in males Symptoms appear with in 2 days of birth Abdominal distension Bilous vomiting Failure to pass meconium In elder children poor feeding, chronic abdominal distension and passage of goat pellet like stools.

42. Management : Barium enema Rectal biopsy Plain X-ray abdomen Ano-rectal manometry Treatment : Colostomy done to have normal bowel function initially Swenson’s procedure – aganglionic bowel is removed down to the level of internal sphincters and coloanal anastamosis is performed on the perineum

43. Duhamel procedure – resection of upper part of rectum and part of colon and anastamosis of colon to posterior part of lower rectum • Recto-rectal pull through procedure

45. Complications of intestinal obstruction Peritonitis Hypovolemia Septic shock Renal failure ARDS

46. Investigations • Complete blood picture • Serum electrolytes • Plain X-ray abdomen multiple air fluid levels jejunum shows herring bone pattern due to volvulae conniventes ileum is smooth and character less large bowel is characterized by haustrations • USG abdomen • Contrast X-ray – orally or rectally

47. Treatment • Nasogastric aspiration • NPO • Replacement of fluid and electrolytes • TPR chart • Input/Output chart • Antibiotics

48. Surgery : If bowel is not viable, then resection and anastamosis. Adhesions released Bands divided volvulus untwisted Obstructed hernia reduced Proximal decompression colostomy

49. References 1) D K Gupta, paediatric surgery, Volume-1. 2) J L Grosfeld, James A. O’ Neil, text book of paediatric surgery; 6th edition; volume-2. 3) Ashcraft, Text of paediatric surgery. 4) Sabiston, 18th edition, Volume-2. 5) Schwratz, 8th edition.

50. THANK YOU