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GASTROINTESTINGASTROINTESTINALAL
OBSTRUCTIONOBSTRUCTIONMARIA NAVAL C. RIVAS, M.D.MARIA NAVAL C. RIVAS, M.D.
DEPARTMENT OF PEDIATRICSDEPARTMENT OF PEDIATRICS
THE MEDICAL CITYTHE MEDICAL CITY
AnatomyAnatomy
EsophagusEsophagusStomachStomachSmall intestinesSmall intestines
DuodenumDuodenumJejenumJejenumIleumIleum
Large IntestinesLarge IntestinesCecumCecumAscending, Ascending, Transverse and Transverse and Descending colonDescending colonSigmoid colonSigmoid colon
RectumRectum
DefinitionDefinition
Blockage of the esophagus, Blockage of the esophagus, stomach, small or large intestines stomach, small or large intestines
Prevents food and fluids from Prevents food and fluids from passing throughpassing through
PathophysiologyPathophysiology
accumulation of food, gas and gastric/intestinal secretions
gastric / bowel distention
decreased intestinal absorption and increased secretion of fluid and
electrolytes
fluid and electrolyte imbalance
Symptoms / SignsSymptoms / Signs
abdominal pain abdominal pain abdominal distentionabdominal distention nausea nausea vomiting : bilious vs. non-biliousvomiting : bilious vs. non-bilious symptoms of malabsorptionsymptoms of malabsorption
MECHANICAL OBSTRUCTIONMECHANICAL OBSTRUCTION
Esophageal AtresiaEsophageal Atresia most common congenital anomaly most common congenital anomaly 1: 4,000 neonates1: 4,000 neonates 90% assoc with tracheoesophageal fistula90% assoc with tracheoesophageal fistula 50% assoc with VATER/VACTERL50% assoc with VATER/VACTERL s/sx : frothing/bubbling of mouth and noses/sx : frothing/bubbling of mouth and nose
coughingcoughing
respiratory distressrespiratory distress
MECHANICAL OBSTRUCTIONMECHANICAL OBSTRUCTION
Diagnosis : Diagnosis : inability to pass nasogastric or orogastric inability to pass nasogastric or orogastric
tubetube early signs of respiratory distressearly signs of respiratory distress absence of gas in the stomachabsence of gas in the stomach
Treatment:Treatment: managing airwaymanaging airway preventing aspirationpreventing aspiration surgical interventionsurgical intervention
MECHANICAL OBSTRUCTIONMECHANICAL OBSTRUCTION
Gastric ObstructionGastric Obstruction Hypertrophic Pyloric StenosisHypertrophic Pyloric Stenosis Congenital Gastric Outlet Congenital Gastric Outlet
ObstructionObstruction Gastric DuplicationGastric Duplication Gastric VolvulusGastric Volvulus
MECHANICAL OBSTRUCTIONMECHANICAL OBSTRUCTION
Intestinal ObstructionIntestinal Obstruction Duodenal ObstructionDuodenal Obstruction Jejunal and Ileal Atresia ObstructionJejunal and Ileal Atresia Obstruction MalrotationMalrotation Intestinal DuplicationIntestinal Duplication Meckel’s DiverticulumMeckel’s Diverticulum AdhesionsAdhesions Intussusception Intussusception
HYPERTROPHIC PYLORICHYPERTROPHIC PYLORIC STENOSISSTENOSIS
Incidence : 3 / 1000 infantsIncidence : 3 / 1000 infants whites > blacks > Asianswhites > blacks > Asians male 4x > femalesmale 4x > females associated with other congenital defects associated with other congenital defects
e.g. tracheo-esophageal fistulae.g. tracheo-esophageal fistula etiology : unknownetiology : unknown
HYPERTROPHIC PYLORICHYPERTROPHIC PYLORIC STENOSISSTENOSIS
abdominal pain abdominal pain abdominal distentionabdominal distention nausea nausea vomitingvomiting
biliousbilious non-bilious non-bilious
others: jaundiceothers: jaundice
sx of malabsorptionsx of malabsorption
occ peristaltic wavesocc peristaltic waves
HYPERTROPHIC PYLORICHYPERTROPHIC PYLORIC STENOSISSTENOSIS
DiagnosisDiagnosis palpable pyloric masspalpable pyloric mass
firm, movable, approx 2 cm length. firm, movable, approx 2 cm length. olive-shapedolive-shaped
located above and to the right of the located above and to the right of the umbilicus (midepigastrium)umbilicus (midepigastrium)
UltrasonographyUltrasonography TreatmentTreatment
Ramstedt pyloromyotomyRamstedt pyloromyotomy Correction of fluid imbalanceCorrection of fluid imbalance
MECHANICAL OBSTRUCTIONMECHANICAL OBSTRUCTION
Gastric ObstructionGastric Obstruction Hypertrophic Pyloric StenosisHypertrophic Pyloric Stenosis Congenital Gastric Outlet Congenital Gastric Outlet
ObstructionObstruction Gastric DuplicationGastric Duplication Gastric VolvulusGastric Volvulus
MECHANICAL OBSTRUCTIONMECHANICAL OBSTRUCTION
Intestinal ObstructionIntestinal Obstruction Duodenal ObstructionDuodenal Obstruction Jejunal and Ileal Atresia / ObstructionJejunal and Ileal Atresia / Obstruction MalrotationMalrotation Intestinal DuplicationIntestinal Duplication AdhesionsAdhesions Intussusception Intussusception
abdominal pain abdominal pain abdominal distentionabdominal distention nausea nausea vomitingvomiting
biliousbilious non-bilious non-bilious
others: jaundiceothers: jaundice
sx of malabsorptionsx of malabsorption
DUODENAL OBSTRUCTIONDUODENAL OBSTRUCTION
DUODENAL OBSTRUCTIONDUODENAL OBSTRUCTION
CausesCauses congenital duodenal atresiacongenital duodenal atresia annular pancreasannular pancreas Ladd’s bands of malrotationLadd’s bands of malrotation
CONGENITAL DUODENAL ATRESIACONGENITAL DUODENAL ATRESIA
Etiology : failure to recanalize the duodenal Etiology : failure to recanalize the duodenal lumen after the lumen after the
solid phase of intestinal solid phase of intestinal development during 4development during 4thth to to
55thth week of gestation week of gestation
Incidence : 1 in 10,000 birthsIncidence : 1 in 10,000 births
25-40% of all intestinal atresias25-40% of all intestinal atresias
50% are premature50% are premature
Other associated congenital anomaliesOther associated congenital anomalies Down’s syndromeDown’s syndrome 20-30%20-30% MalrotationMalrotation 20%20% Esophageal atresia 10-20%Esophageal atresia 10-20% congenital heart disease 10-15%congenital heart disease 10-15% anorectal and renal anomalies 5%anorectal and renal anomalies 5%
Diagnosis : “double – bubble sign” on plain Diagnosis : “double – bubble sign” on plain abdominalabdominal
radiographsradiographs
: readily detected by fetal : readily detected by fetal ultasonographyultasonography
: echocardiogram: echocardiogram
: radiography of chest and spine: radiography of chest and spine
Treatment : nasogastric / orogastric Treatment : nasogastric / orogastric decompressiondecompression
intravenous fluidsintravenous fluids
surgery - duodenoduodenostomysurgery - duodenoduodenostomy
ANNULAR PANCREASANNULAR PANCREAS
rare conditionrare condition 22ndnd part of duodenum is surrounded part of duodenum is surrounded
by a ring of pancreatic tissueby a ring of pancreatic tissue complete / incomplete obstructioncomplete / incomplete obstruction Diagnosis: abdominal ultrasound & Diagnosis: abdominal ultrasound &
radiographradiograph Treatment: duodenoduodenostomy Treatment: duodenoduodenostomy
abdominal pain abdominal pain abdominal distentionabdominal distention nausea nausea vomitingvomiting
biliousbilious non-bilious non-bilious
others: jaundiceothers: jaundice
sx of malaborptionsx of malaborption
JEJUNAL AND ILEAL JEJUNAL AND ILEAL OBSTRUCTIONOBSTRUCTION
JEJUNAL AND ILEAL JEJUNAL AND ILEAL OBSTRUCTIONOBSTRUCTION
CausesCauses congenital jejuno-ileal atresiascongenital jejuno-ileal atresias meconium ileusmeconium ileus Hirschsprung diseaseHirschsprung disease
CONGENITAL JEJUNOILEAL CONGENITAL JEJUNOILEAL ATRESIAATRESIA
attributed to intrauterine vascular accidents attributed to intrauterine vascular accidents
leadingleading
to ischemic necrosis of the bowel and to ischemic necrosis of the bowel and resorption resorption
of the affected segmentsof the affected segments associated with prematurity, polyhydramnios, associated with prematurity, polyhydramnios,
monozygotic twins, failure to pass meconiummonozygotic twins, failure to pass meconium
CONGENITAL JEJUNOILEAL ATRESIACONGENITAL JEJUNOILEAL ATRESIA
Diagnosis: prenatal sonograms Diagnosis: prenatal sonograms
air-fluid levels on plain radiographsair-fluid levels on plain radiographs
contrast studies contrast studies
ultrasoundultrasound Treatment: resection of dilated proximal portion of Treatment: resection of dilated proximal portion of
bowelbowel
followed by end to end anastomosisfollowed by end to end anastomosis
CONGENITAL JEJUNOILEAL ATRESIACONGENITAL JEJUNOILEAL ATRESIA TypesTypes
I – mucosal obstruction caused by an I – mucosal obstruction caused by an intraluminal intraluminal membrane with intact bowel membrane with intact bowel wall and mesenterywall and mesentery
II – small diameter solid cord connects the II – small diameter solid cord connects the proximal proximal and distal bowel and distal bowel
IIIA – both ends of bowel end in blind loopsIIIA – both ends of bowel end in blind loops
IIIB – extensive mesenteric defect that causes IIIB – extensive mesenteric defect that causes distaldistal
ileum to coil around the ileocolic arteryileum to coil around the ileocolic artery
IV – multiple segments of bowel atresiaIV – multiple segments of bowel atresia
MECONIUM ILEUSMECONIUM ILEUS
last 20-30cm of ileum is collapsed and filled last 20-30cm of ileum is collapsed and filled with with
pale-colored stool, above which is a dilated pale-colored stool, above which is a dilated bowel of varying length obstructed by bowel of varying length obstructed by meconium with thick syrup consitency meconium with thick syrup consitency
80-90% has cystic fibrosis80-90% has cystic fibrosis
MECONIUM ILEUSMECONIUM ILEUS
Diagnosis: plain radiograph shows hazy Diagnosis: plain radiograph shows hazy appearance appearance on the R on the R lower quadrantlower quadrant
Treatment: Gastrografin enemaTreatment: Gastrografin enema
resection of ischemic resection of ischemic bowelbowel
HIRSCHSPRUNG DISEASEHIRSCHSPRUNG DISEASE
Congenital Aganglionic MegacolonCongenital Aganglionic Megacolon absence of ganglion cells in the bowel wall absence of ganglion cells in the bowel wall
beginning inbeginning in
the internal anal sphincter extending variably the internal anal sphincter extending variably to proximal to proximal
intestinesintestines 5% involves terminal ileum5% involves terminal ileum 1 : 5,000 live births1 : 5,000 live births male : female (4:1)male : female (4:1)
HIRSCHSPRUNG DISEASEHIRSCHSPRUNG DISEASE
Clinical ManifestationClinical Manifestation
delayed passage of meconiumdelayed passage of meconium chronic constipationchronic constipation palpable fecal mass in LLQpalpable fecal mass in LLQ empty rectal vaultempty rectal vault
HIRSCHSPRUNG DISEASEHIRSCHSPRUNG DISEASE
DiagnosisDiagnosis rectal manometry and rectal biopsyrectal manometry and rectal biopsy Radiograph : transition zone (funnel-shaped area) Radiograph : transition zone (funnel-shaped area)
between normal dilated proximal colon and a between normal dilated proximal colon and a smaller-caliber obstructed distal colonsmaller-caliber obstructed distal colon
Treatment : surgicalTreatment : surgical
MALROTATIONMALROTATION incomplete rotation of the intestines incomplete rotation of the intestines
during fetal developmentduring fetal development duodenum fixed to the posterior abdominal duodenum fixed to the posterior abdominal
wallwall right & left colon and mesenteric artery root right & left colon and mesenteric artery root
fixed to the posterior abdomenfixed to the posterior abdomen most common type: failure of cecum to most common type: failure of cecum to
move to R lower quadrantmove to R lower quadrant malposition of ligament of Treitz, superior malposition of ligament of Treitz, superior
mesenteric vein located to the left of the mesenteric vein located to the left of the arteryartery
abdominal pain abdominal pain abdominal distentionabdominal distention nausea nausea vomitingvomiting
biliousbilious non-bilious non-bilious
others: jaundiceothers: jaundice
sx of malabsorptionsx of malabsorption
MALROTATIONMALROTATION
MALROTATIONMALROTATION complication: VOLVULUScomplication: VOLVULUS
twisting of the small or large bowel twisting of the small or large bowel around itselfaround itself
acute presentation of bowel obstructionacute presentation of bowel obstruction Diagnosis: ultrasound and Diagnosis: ultrasound and
contrastradiographic contrastradiographic studiesstudies
1.1. duodenal obstructionduodenal obstruction
2.2. thickened bowel loops to the R of spinethickened bowel loops to the R of spine
3.3. free peritoneal fluidfree peritoneal fluid
MALROTATIONMALROTATION TreatmentTreatment
Malrotation : surgical intervention Malrotation : surgical intervention Volvolus : Volvolus : reduce twisted bowelreduce twisted bowel
free duodenum and upper free duodenum and upper jejenum of any jejenum of any
bands / position in R abdominal bands / position in R abdominal cavitycavity
colon is freed from adhesions colon is freed from adhesions and placed in R and placed in R abdomen with cecum in abdomen with cecum in the L lower quadrantthe L lower quadrant
INTUSSUSCEPTIONINTUSSUSCEPTION
portion of alimentary tract is telescoped portion of alimentary tract is telescoped into an adjacent segment most into an adjacent segment most commonly involving ileocolic and commonly involving ileocolic and ileoileocolicileoileocolic
incidenceincidence 1-4 in 1,000 live births ( 3mos-6yrs)1-4 in 1,000 live births ( 3mos-6yrs) rare in neonatesrare in neonates 60% younger60% younger than 12 monthsthan 12 months 80% of cases occur before 2480% of cases occur before 24thth month month male:female is 4:1male:female is 4:1
INTUSSUSCEPTIONINTUSSUSCEPTION
EtiologyEtiology most cases unknownmost cases unknown some associated with adenovirussome associated with adenovirus complicates URTI, AGE, otitis media, complicates URTI, AGE, otitis media,
Henoch-Schonlein PurpuraHenoch-Schonlein Purpura theory on swollen Peyer’s patchestheory on swollen Peyer’s patches lead points in 2-8% caseslead points in 2-8% cases
meckel’s diverticulummeckel’s diverticulum intestinal polypintestinal polyp neurofibromaneurofibroma hemangiomahemangioma lymphomalymphoma
INTUSSUSCEPTIONINTUSSUSCEPTION PathologyPathology
intussusceptum invaginates into intussuscipiens dragging mesentery
constriction of mesentery
obstruction of venous return
engorgement of intussusceptum
bloody stools with mucus (currant-jelly stools)
edema and bleeding from mucosa
INTUSSUSCEPTIONINTUSSUSCEPTION Early PhaseEarly Phase
1.1. sudden onset of paroxysmal, colicky painsudden onset of paroxysmal, colicky pain
2.2. accompanied by straining with legs/knees accompanied by straining with legs/knees flexed and loud criesflexed and loud cries
3.3. frequent vomitingfrequent vomiting
4.4. child may play in between paroxysms of painchild may play in between paroxysms of pain Late PhaseLate Phase
1.1. bile-stained vomitusbile-stained vomitus
2.2. little / no flatuslittle / no flatus
3.3. child is progresively weaker and lethargicchild is progresively weaker and lethargic
4.4. fever with shock-like statefever with shock-like state
INTUSSUSCEPTIONINTUSSUSCEPTION
Physical ExaminationPhysical Examination slightly tender sausage-shaped massslightly tender sausage-shaped mass bloody mucous on rectal exambloody mucous on rectal exam abdominal distentionabdominal distention
DiagnosisDiagnosis plain radiograph : density in the area of plain radiograph : density in the area of
intussusceptionintussusception barium enema : coiled-spring signbarium enema : coiled-spring sign abdominal ultrasound : doughnut or target abdominal ultrasound : doughnut or target
appearanceappearance
INTUSSUSCEPTIONINTUSSUSCEPTION
Treatment : Treatment : emergency reduction except if with signs of emergency reduction except if with signs of
shock, peritoneal irritation, intestinal shock, peritoneal irritation, intestinal perforation or pneumatosis intestinalisperforation or pneumatosis intestinalis
radiologic reduction under fluoroscopic or radiologic reduction under fluoroscopic or ultrasonic guidanceultrasonic guidance
PrognosisPrognosis fatal if untreatedfatal if untreated spontaneous reduction during pre-operative spontaneous reduction during pre-operative
preparationpreparation most recover if reduced within 24 hoursmost recover if reduced within 24 hours Increase mortality after 2Increase mortality after 2ndnd day day
INTESTINAL DUPLICATIONINTESTINAL DUPLICATION
well-formed tubular structures firmly well-formed tubular structures firmly attached to the intestine with a common attached to the intestine with a common blood supplyblood supply
lining of duplications resembles GI tractlining of duplications resembles GI tract very rarevery rare cause unknown but attributed to defect in cause unknown but attributed to defect in
recanalization during embryological recanalization during embryological developmentdevelopment
signs of obstructionsigns of obstruction
ADHESIONSADHESIONS
fibrous bands of tissue that are a common fibrous bands of tissue that are a common cause of cause of
post-operative bowel obstructionpost-operative bowel obstruction 2-3% of patients after abdominal surgery2-3% of patients after abdominal surgery majority are single adhesionsmajority are single adhesions symptoms of obstruction manifest anytime symptoms of obstruction manifest anytime
after 2after 2ndnd
postoperative weekpostoperative week Diagnosis: plain and contrast radiographsDiagnosis: plain and contrast radiographs Treatment: nasogastric decompressionTreatment: nasogastric decompression
IV fluid rescucitationIV fluid rescucitation
broad-spectrum antibioticbroad-spectrum antibiotic