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Intestinal Conditions in Infants

and Children
Surgery II
SURGERY II
FACILITATOR: Ma. Celine A. Villegas, M.D.

-
DATE: September 5, 2016

Vomiting especially bilious vomiting


OBJECTIVES
- Abdominal Distention
Identify the Signs and Symptoms of Intestinal - No passage or disturbance of meconium
obstruction in neonates and in the older child passage
Identify causes of Intestinal Obstruction Infants and Children
Identify Laboratory and radiologic exams needed Effects of Intestinal Obstruction in Infants and
to diagnose an Intestinal obstruction Children
Describe Emergency Room measures to
resuscitate such patients especially in the Respiratory Distress
Emergency room Aspiration of vomitus
Describe the surgical treatment for the most Peripheral circulatory collapse
common cases of intestinal obstruction in the o Because of the resulting hypovolemia due to
Pediatric Age group the inability to take in fluids
Hypoglycemia---overall metabolic conditions
Acidosis
Infection
Definition of Intestinal Obstruction o Stasis of GI contentoverall proliferation of
intestinal bacteria
- Interference with the normal passage of Hypothermia
intestinal Contents along the bowel lumen ants and Children
Diagnostic Modalities in Intestinal Obstruction
For Diagnosis
o Abdominal x-rays (plain)
o Contrast Studies (UGIS, Barium enema)
Very rarely you request for UGIS
or Barium swallow
Assessment Investigation
o Complete Blood Count
o Serum Electrolytes
o Culture Studies of blood, urine
(occasionally)
For very septic patients
o Blood Gases (rarely)
For patients who require
intubation
Intestinal Obstruction in a Fetus
Cyanotic Patients
Rarely done because it is painful
Clinical Features of Intestinal Obstruction in
for the babies
Infants and Children
1) Prenatal
- Polyhydramnios (in the mother)
2) Postnatal (V-A-N)
Features of Intestinal Obstruction in In

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QUESTION: Why do you have cyanosis in abdominal
distension?
ANSWER: because the diaphragm is displaced
upward due to the abdominal distension, hence,
there will be reduced lung capacity and lower oxygen
perfusion
General Principles of Management
Respiratory Care
o Make sure that the airway is clear
Control of Hypoglycemia
Control of Hypothermia
Control of Acidosis
Maintenance of Blood Volume
Correction of Fluids/Electrolytes
Antibiotics
Parenteral alimentation if needed especially in
post-op period

Nasogastric Tube Insertion in a Neonate


Ke
Take measurement (to know how much is needed to OROGASTRIC TUBE
insert)
o From the nares to the ears then to the
xyphoid process
o It should be secured on the CHEEK and not
on the NOSE because nose will nercrotize
o OGTan NGT can be inserted through the
mouth
o 2016 transcription: sometimes, an orogastric
tube is placed instead of an NGT and it is
much easier to insert

Common Causes of Intestinal Obstruction in


Children
Neonates (<28 days)
Atresia
o Esophagus
o Duodenum
o Jejuno-ileal
o Colon
Malrotation
o Incarcerated Inguinal Hernia
Hirschsprung Disease
Imperforate Anus

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Infants (> 28 days but less than 1 year old) and
older Children
o Intussusception
o Incarcerated Inguinal HerniaMOST
COMMON
o Post-operative adhesions
o Obstruction from Meckels Diverticulum
o Hirschsprungs disease
o

DUODENAL ATRESIA

Embryology

Failure of Recanalization during solid stage of


Duodenal Development
Incidence: 1:20,000 to 40,000 live births

Radiologic- double bubble sign and Duodenal atresia intraoperative


findings

Embr
Clinical Picture of Duodenal Atresia Operative Management of Duodenal Atresia
Bilious Vomiting Depends on the intraoperative findings;
Bile is secreted at the level of the duodenum Principle bypass obstructed segment
Mild Epigastric Distention Duodenoduodenostomy

Radiologic Picture of Duodenal Atresia


Double-bubble finding on X-ray
No distal gas

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Operative Management of Intestinal Atresia
Resection of proximal bulbous bowel and
atrectic segment
o The bulbous bowel wont function
anymore because the muscular layer is
overly stretched.
End-to-end anastomosis--preferably
Enterostomy
Ileostomy if the patient is septic

*resection

Duodenoduodenostomynt of

INTESTINAL ATRESIA

Embryology
Vascular accident in Utero
o Volvulus or Intussusception *end-to-end anastomosis
Incidence:1:330 to 1:1,500 live births o
f Duodenal Atresia MALROTATION
Clinical Picture of Intestinal Atresia
*this is the most dangerous
Vomiting
Abdominal Distention Embryology
Non-passage of Meconium Normal Intestinal Rotation
Operative Management of Duodenal Atresia o Usually at the 4th week of life
Diagnosis of Intestinal Atresia o Return of GIT in the abdomen
o From powerpoint: At 4th week AOG, normal
Plain Abdominal X-rays
occurrence of return of fetal GIT from
Dilated loops of Bowel with differential air-
extraembryonic coelom back into the abdomen.
fluid levels
Bowel undergoes rotation and fixation at certain
Barium Enema Microcolonof
parts of posterior abdominal wall
o If the process is incomplete or deviated from
normal, MALROTATION results.

Plain, UGIS, Barium


A

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Cecum remains in the RUQ
Ladds Bands (top-left)
o Between the duodenum and Cecum
o Fix Cecum at RUQ
Extrinsic Duodenal Obstructioncaused by UGIS (small bowel confined at the right)
Ladds bands
o Duodenum is a straight tube instead of a C-loop

Narrow Vascular pedicle can cause bowel to twist on


itself > volvulus
o If there is midgut Volvulus and the patient did not
underwent surgery, there will be necrosis of the
bowel (whole midgut)
From 2016 transcription: you may want to visit this
site for further discussion of the normal intestinal
rotation: http://www.youtube.com/rs44cXvjbMA
Operative Management of Intestinal Atresia
Clinical Picture of Malrotation
Bilious Vomiting
Once Volvulus is present: Malrotation of the intestines showing the duodenal-
o Abdominal Distention jejunal junction is in the right of the spine and most of
o Bloody Stools- If volvulus if Present the small bowel is on the right side of the abdomen
o Decreased or Absent Stools
o Shock if bowels strangulated

Diagnosis of Malrotation
Barium Enema (cecum at right upper )

Red arrow pointing to the Ladds band between the duodenum and
cecum

Operative Management of Malrotation

Ladds Procedure
o Untwisting the bowel

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o Dividing the Ladds bands compressing
the duodenum
o Appendectomy
o Bowel resection if ischemia or necrosis is
present

Clinical Presentation Of Intussusception


Older infants : 8 months 1 year
A healthy chubby child
Male predominance
History of Upper Respiratory Tract Infection
(Diarrhea can also be an early sign of
Intussusception)

Dreaded Complication of Malrotation : VOLVULUS

Signs and Symptoms of Intussusception

Abdominal Colic
Vomiting
Currant Jelly stool---(Kids, itaga po to sa long
term memory. Say it with me Intu Currant Jelly
Repeat 10x)
Abdominal Distention Late
Hypovolomic Shock Very Late
Period of quiscence when peristalsis stops for a time
o Recurs (peristalsis as the GIT tries to propel
the bowel content resulting into currant jelly
stools

*midgut volvulus in malrotation

INTUSSUSCEPTION

Telescoping of a bowel to itself due to persitatltic


activity (invaination of the Intestine on itself)
Proximal portion of the bowel is drawn into the distal
bowel by peristaltic activity

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Ultrasound Examination
o 100% Specific and Sensitive
o Pseudo Kidney sign
Superimposed hypoecohic and hLayers indicative of
edematous walls of intussuscpetion
o Target Sign
2 rings of low echogenicity separated by a
hyperechoic ring

Diagnosis

Physical Exam
o Palpable tubular massat right
hemiabdomen
o Rectal Exam : No stool in the rectum, only
bloody mucus
o Irritable, Lethargic baby Contrast Enema
o Marked abdominal distentionLATE o Coiled Spring Sign
Diagnostic Studies o Diagnostic and Therapeutic
Plain Abdominal X-ray o Contrast material will push the
o Dilated Bowel Loops intussusception and straighten out the
o Airless Right Lower Quadrant GIT
o Indicative of Intestinal Obstruction
o Lateral View:Differential air fluid levels

Contrast Enema

Nonsurgical Treatment Of Intussusception

Reduction of Intestines
o Air (Pneumatic Reduction)90% reduction
rate; most successful
o Saline (Hydrostatic Reduction)
o Barium
Instillation per Rectum can Straighten out Intestine
Reduction Success Rate
o 42-80% Saline/Barium Reduction
o 90% Penumatic Reduction

*plain lateral decubitus x-ray of a patient with intussusception

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HIRSCHSPRUNG DISEASE
Congenital absence of parasymphathetic innervation
of the intestines- INTESTINAL MOTILITY
DISORDER common in Filipinos
One way for me to describe this to parents is when a
patient has a stroke, the right or left side of the body
wont work because there is absence of connection
to the brain. The same thing happens for patients
with Hirschsprung. There is no connection between a
certain segment of the intestines to the brain thats
why it doesnt function properly. parang ako walang
connection sa iyo kaya di ako nagfufunction
Indications for Nonsurgical Hydrostatic Reduction in (hanudaw)
Intussusception 1:5,000 livebirths
4:1 male:female ratio
Less than 24 hours old symptoms (early cases) Certain amount of heredity
No signs of peritonitis
No marked obstruction Clinical Presentation
Delayed passage of meconium (more than 24 hours
after birth)94% would pass meconium, if not, they
are suspected to have Hirschsprungs
May progress to massive distention
Chronic constipation
Diarrhea from enterocolitis can sometimes result to
distention and dehydration
Intermittent obstruction relieved by suppositories or
insertion of thermometer to stimulate the intestines---
the child will actually poop

*hydrostatic reduction in intussusception Diagnostic Studies


Barium Enema
Surgical Treatment of Intussuscpetion o Coning or transition zone

Milking Action on bowel


Not a pulling action (if pulled can lead to avulsion)
Appendectomy is done after the bowels have
straighten out

*Transition zone/cloning on barium enema (area that is narrowed)

Anorectal manometrynot widely used in the Phils.


Rectal Biopsygold standard
o Absent ganglion cells
Acetylcholinesterase determination

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Clinical Manifestations
Intestinal obstruction
Operative Management no anal opening or abnormal location
Staged operation fistula may be open on the perineal skin
o Severe disease in some males, meconium present in urine or
o Preliminary colostomy then pullthrough through the urethra
(removal of aganglionic portion) procedure
later Types of Imperforate Anus
Single stage operation High Rectal pouch above levator ani
o Transanal pullthrough procedure Low- Rectal pouch below levator ani

High (left), Low (right)

Diagnosis
In males, where is meconium coming from?
o Male, low typemeconium on the perineal
skin

IMPERFORATE ANUS
A perineum without an anal opening---very common
Most anorectal malformations communicate by a
fistulous tract to the urinary or genital systems or
alternatively open to the skin of the perineum---
sometimes parents would note that stool comes out
of the vagina
1:5,000 live births
males>females
rectal/high lesions more in males
anal/low lesions more in females

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o Male, high typemeconium comes from the
urethra

Imperforate anus-male-low type

In females, count number of orificesif the px has 2


orifices, probably she has high imperforate anus. 1
orifice, urine-stool comes out of a single orifice
high. If 3, displaced lang yung where the stool is
coming out, that is a low imperforate anus.
Male, high type

Ultrasound or MRI
o Location of distal rectal pouch
Accurate determination of level of lesion of
imperforate anus will have bearing in management

Operative Management

Low Type
o Definitive treatment in neonatal period
o Anoplasty
High Type
Imperforate anus-female-low type o Definitive treatment at later date
1. Initial colostomy
X-ray 2. PSARP (Posterior Sagittal
o Determine the type of imperforate anus and Anorectoplasty)
to identify any congenital anomalies that are 3. Closure colostomy
present---patients with imperforate anus
occasionally has VACTRL anomaly
V- Vertebra
A- Anus
C- Cardiac
T- Tracheoesophageal fistula
E-Esophageal
R-Renal and Radial
L- Limb
o Invertogram/rice-wangsteen prone cross
table lateral

Transverse loop colostomy for imperforate anus

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PSARP (Posterior Sagittal Anorectoplasty)- definitive correction of
imperforate anus

Pagtatapos
References: 2016 transcription | recordings and
notes |
*use at your own risk
#ageofOBE
#OBEgames
#MEDbeforeyou
#pustahanlalabasangintussusception
#currantjellypamore
#hashtagngmaramiparapangfill
#districtsurgery
#hellomarkcalimbahin

Please dont forget to evaluate your facilitators!


mamimiss niyo to (Lapena, 2016)

Happy birthday Raiko Cecogo and Kristen Campos!

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