NEONATAL BILIOUS VOMITING- Part 2 A PROBLEM ORIENTED APPROACH Dr.B.Selvaraj MS;Mch; FICS; Professor of Surgery Melaka Manipal Medical College Melaka 75150 Malaysia
NEONATAL BILIOUS VOMITING- Part 2
A PROBLEM ORIENTED APPROACH
Dr.B.Selvaraj MS;Mch; FICS;Professor of Surgery
Melaka Manipal Medical CollegeMelaka 75150 Malaysia
OBJECTIVESTo discuss the differential diagnosis of biliary emesis in neonates
To do appropriate workup to confirm the diagnosis
To select the various treatment options
To make you confident in managing a newborn with bilious vomiting
Neonatal Bilious Vomiting-Causes
Meconium Peritonitis
Necrotising Enterocolitis
Hirschsprung’s Disease
Anorectal Malformation
Rarely Mesentric Cyst & Intestinal Duplication
Incarcerated inguinal hernia
Duodenal atresia/stenosis
Annular Pancreas
Malrotation&MGV
Intestinal Atresia: Jejunal&Ileal
Meconium Ileus
Meconium Plug
Neonatal Bilious Vomiting-Causes
• MALROTATION & MGV• MESENTRIC CYST& DUPLICATION CYST• CONGENITAL BANDS LIKE VI DUCT BANDS
• MECONIUM ILEUS• MECONIUM PLUG• MECONIUM PERITONITIS
EXTRINSIC
• DUODENAL ATRESIA/STENOSIS• JEJUNAL/ILEAL ATRESIA• HIRSCHSPRUNG’S DISEASE• NECROTISING ENTEROCOLITIS
CAUSES
MURAL
INTRALUMINAL
HIRSCHSPRUNG’S DISEASE
Craniocaudal migration of ganglion cells of the bowel begins at 12th wk of gestationArrest of this migration produces an aganglionic segment of bowel-absence of Aurbach’s & Meissener’s plexusThis aganglionic segment of bowel unable to relax & peristaltic wave stops proximally- functional obstruction
Incidence 1 in 5000
Male:Female 4:1
HIRSCHSPRUNG’S DISEASE
Mutations in RET proto-oncogene are commonly associated with Hirschsprung’s disease
Not passed/ delayed passage of meconium
Abdominal distension
Bilious vomiting
Fever & diarrhea suggest Toxic megacolon
HIRSCHSPRUNG’S DISEASE Classification
HIRSCHSPRUNG’S DISEASE
Workup
AXR: Dilated Bowel Loops
Barium Enema: Swan Neck
Appearance
HIRSCHSPRUNG’S DISEASE
Workup
Absence of ganglion cells in myenteric
plexus
Suction rectal bx
Noblet Rectal Mucosal Suction Biopsy Gun
HIRSCHSPRUNG’S DISEASE Management
Empty bowel with saline enema (30 to 50 ml) daily
If can successfully decompress the bowel- continue rectal washouts for 45 days
If unable to decompress the bowel- do Rt transverse colostomy or Levelling colostomy
HIRSCHSPRUNG’S DISEASE
Colostomy
HIRSCHSPRUNG’S DISEASE
Swenson’s Rectosigmoidectomy
Soave’s Transabdominal
Endorectal Pullthrough
HIRSCHSPRUNG’S DISEASE
HIRSCHSPRUNG’S DISEASE
Duhamel’s Retrorectal Pullthrough
HIRSCHSPRUNG’S DISEASEDe La Torre’s TransanalEndorectal Pullthrough
MECONIUM ILEUS
Uncomplicated cases show impacted meconium in terminal ileum- inspissated tar like meconiumAccounts for 9 to 10% of all neonatal intestinal obstructions
Present in 8 to 10% of cystic fibrosis patients at birth
Complicated cases include volvulus,perforation and peritonitis with sepsis
MECONIUM ILEUS
Signs depend on degree of obstruction and complications
Significant abdominal distension may develop during neonatal periodGeneral status progressively deteriorates with incipient sepsis in cases of perforation In perforation, the scrotum or labia may have greenish discoloration due to patent processus vaginalis
MECONIUM ILEUS
MECONIUM ILEUS- Imaging Studies
Disparate sized bowel loops
Soap bubble appearance-Neuhauser’s sign
MECONIUM ILEUS- Management
60 to 70% of simple Meconium ileus can be successfully treated with Gastrograffin enema
Other 30% need operative management
Goal of surgery is to remove the abnormal meconium from GIT & maintain adequate length of bowel
Surgery consists of resection& anastomosis of involved segment and/or roux-en-y ileostomy
MECONIUM ILEUS- Management
MECONIUM ILEUS- Management
Paul MikuliczDouble Barrel
Ileostomy
Bishop-Koop’sDistal
chimneyIleostomy
Santulli’sProximal chimney
Ileostomy
MECONIUM PLUG
A long plug of mucus and sticky meconium in rectum & distal colon results low intestinal obstructionDue to immaturity of colonic & rectal expulsive mechanism
Often associated with neonatal Hirschsprung’s disease
Rectal exam/rectal wash results in expulsion of the plug and relief of intestinal obstruction
MECONIUM PLUG
MECONIUM PERITONITIS
Intrauterine perforation of intestineleakage of meconium into peritoneal cavity reaction of peritoneum to this leaked meconium
Due to intrauterine vascular compromise of intestine ischemia&perforation as early as 4th month of intrauterine life
Different pathological typesMeconium pseudocyst, generalised adhesive peritonitis,meconium ascites & infected meconium peritonitis
MECONIUM PERITONITIS
Often associated with cystic fibrosis & Prognosis is poor
Bilious vomiting, failure to pass meconium and abdominal distension
Abdominal wall edema, erythema and free fluid in peritoneal cavity
AXR multiple air fluid levels and peritoneal calcificationsSurgical treatment releasing of adhesions, removal of devitalised tissues, closure of perforation, intestinal resection& anastomosis
MECONIUM PERITONITIS
Meconium AscitesCentral bowel loops
Amorphous calcification
Multiple focal calcificationsDilated bowel loops
Neonatal Bilious Vomiting - Algorithm
Neonatal Bilious VomitingSl No
History Physical Plain XRay
Contraststudies
Diagnosis Treatment
1
Bilious vomitingNot passed meconiumMaternalhydramnios
Upper abdominal distensionVGPDown’s syndrome
DoubleBubbleappearance
Barium meal :Duodenalobstruction
Duodenal Atresia Or Annular Pancreas
Kimura’sDiamond ShapedDuodenoduodenostomy
2
BiliousVomiting
Infrequent passage of small amount of meconium
Upper abdominal distension
DoubleBubbleAppearance
Paucity of gas in distal bowel
Barium meal:Absence of C loop DuodenumCork screw appearance
Malrotation
Midgut volvulus
Ladd’sProcedure
DerotationResectionAnastomosis
Neonatal Bilious VomitingSl No
History Physical Plain XRay
Contraststudies
Diagnosis Treatment
3
Bilious vomiting
Not passed meconium
Abdominal distension
Empty rectum
Triple bubble appearanceMultiple air fluid levels
Barium enema :Micro colon
Jejunalatresia Or Ileal atresia
Resection& End to back anastomosis
4
BiliousVomiting
Passing meconium
Prematurity&Birth asphyxia
Bleeding PR
Sick child
Septicemia
Abdominal distension
Signs of Peritonitis
Pneumatosis intestinalis
Portal venous gasFree peritoneal gas
------------
Necrotising enterocolitis
Aggressive medical treatment
If it faillsSurgical intervention
Neonatal Bilious VomitingSl No
History Physical Plain XRay
Contraststudies
Diagnosis Treatment
5
Delayed passage of meconium
Vomiting
Gross abdominal distensionP/R:Explosive passage of meconium & flatus
Distended bowel loops
Barium enema:Swan neck appearance
Hirschsprung’s disease
Pullthrough operation with or without colostomy
6
BiliousVomiting
Failure to pass meconium
Moderate to severe abdominal distension
Disparate sized bowel loopsSoap bubble appearance
Barium Enema:Microcolon
Meconium ileus
Gastrograffin enemaResection anastomosisBishop-koop & Santulli Ileostomy
Neonatal Bilious VomitingSl No
History Physical Plain XRay
Contraststudies
Diagnosis Treatment
7
Bilious vomiting
Failure to pass meconium
Moderate to severe abdominal distensionP/R: Child passes plug
Distended bowel loops --------------
Meconium plug syndrome
Rectal washouts
8
BiliousVomiting
Failure to pass meconium
Severe abdominal distension
Abdominal wall edema & erythema
Multiple air fluid levelsPeritoneal calcificationFree peritoneal gas
Barium Enema:Microcolon
Meconium peritonitis
Release pf adhesionsClosure of perforation
Resection & Anastomosis
TAKE HOME MESSAGE
“YELLOW COLOR VOMITUS IS THE RED SIGNAL OF INTESTINAL OBSTRUCTION UNLESS PROVED OTHERWISE”