Bowel Obstruction: Infants and Children

1. Bowel Obstruction: Infants and Children • Age specific: • Adhesions, Malrotation, intusception, meckel’s, appendicitis (“febrile obstruction”) • Hx + Physical much closer to adults

3. Presentation Four cardinal signs of intestinal obstruction in neonate • Antenatal polyhydramnios • Bilious vomiting • Delayed passage of meconium (> 24 hrs) • Gastric residual > 30 cc • Cardinal sing in adult • Vomiting • Abdominal pain • Abdominal distension • Obstipation/ constipation

4. Perioperative Management • Fundamental rule: previous losses /maintenance/ongoing needs • Urine output best measure of adequate resuscitation • ?Need for central monitoring if problematic • Recall distribution of various IV solution • Bolus: as per PALS (20 cc/kg) • Titrate to heart rate, urine output BP • ↑ Maintained 25% for each quadrant of abdomen involved • Antibiotics if any viscus opened, cardiac issues, immunosuppresed (newborn) • Steroids: if on previously/deficiency (stress dose physiology) • Nasogastric tube (Decompression) • Keep patient warm

5. Be Aware of Child with Bilious (Green) Vomiting

6. Malrotation • 10th Week of Development rapid growth of intestine which returns to abdominal cavity with rotation • Problems can occur at any of the 3 stages • Duodenal rotation • Elongation and fixation of the mesentery • Rotation of the colon

8. Tracheo-esophageal fistula • Presentation • Maternal polyhydramnios on U/S • Drooling, choking, coughing, cyanosis with feeding  tracheomalacia • No passage of NG tube • VACTERL • (Vertebral, anal, cardiac, tracheal, esophageal, renal, limb) • Work-up • Complete physical exam • CXR, AXR – vertebral / rib anomalies • Echocardiogram – aortic arch L vs. R to plan incision • Renal U/S • CT head in selected patients • Pneumonitis prevention and treatment • Parenteral antibiotics – gentamicin, ampicillin • Sump suction catheter (Replogle) • Treatment surgical repair

9. Meckel’s Diverticulum's • True diverticulum's • Result from persistence vitelline duct and the omphalomesenteric duct. • Incidence 2%, Most of these people remain asymptomatic throughout life. • Role of 2. • Complication: hemorrhage, acute diverticulitis, perforation, and small bowel obstruction or intussusception

10. Intussusception

11. Duodenal Atresia/ Annular Pancreas • Primary problem is one of recanalization of solid duodenum. • Obstruction typically at level of common bile duct and pancreas • Associated anomalies common: almost 50% • Down syndrome 29% • malrotation 19% • congenital heart disease 17% • TEF 7% • Others (renal, respiratory, imperforate anus - roughly 10%)

12. Jejunal & Ileal Atresia • Pathology related to late second trimester vascular accident (Barnard) • Associated anomalies rare • Classification system

13. Imperforated Anus

14. Hirschsprung’s

16. Meconium Ileus

17. NEC

18. Abdominal Wall Defect Omphalocele Gastroschisis

19. Wilms tumor • asymptomatic abdominal mass • Well baby • rapid abdominal enlargement ( pain, fever, and gross hematuria). 2 to hemorrhage • Treatment is surgical resection

20. Neuroblastoma • Neuroblastoma cells are derived from the primitive neural crest • It was found that patients with an increased number of copies of the N-myc gene had a much worse prognosis • Site: adrenal, retroperitoneum, mediastinum & neck. • Treatment: surgery +/-chemotherapy

21. Duplication Cyst

22. Question?