Abnormalities In Small Bowel

dr. Iqbal Pahlevi, SpB, SpBA

•Congenital• Atresia small bowel• Omphalomesenteric

duct persisten• Meckel’s Diverticulum• Umbilical Fistula

• Omphalocele• Gastroschizis• Malrotation

•Acquired• Stenosis Pyloric• Intussussception

Embryology

INTESTINAL ATRESIA & INTESTINAL ATRESIA & STENOSISSTENOSIS

DUODENUM, Yeyunum, Ileum

incidence rates range from 1:2,500 to 1:40,000 live births

Maternal polyhydramnios is also a common ultrasonographic finding observed in 20–75% of cases with duodenal atresia, mainly in the second half of pregnancy.

In all cases of combined polyhydramnios and “double bubble” sign, a detailed evaluation for other associated anomalies, especially cardiac anomalies, should be undertaken.

Amniocentesis for chromosomal analysis is helpful for counseling.

• Patophysiology• Duodenal maldevelopment occurs secondary to either inadequate endodermal

proliferation (gut elongation outpaces proliferation) or failure of the epithelial solid cord to recanalize (failure of vacuolization).

• Clinical Presentation• vomiting within hours of birth most often bilious, • has a scaphoid abdomen. • Passing meconium within the first 24 hours of life is not usually altered.

• X-ray :X-ray : double bubble atresia duodenum 3-6 bubble atresia jejenum > 6 bubble atresia ileum

Atresia Duodenum

Atresia jejenum atresia ileum

Meckel’s Diverticulum

Meckel’s Diverticulum

• Most common congenital abnormality of the gastrointestinal tract

• antimesenteric border of the ileum • Often contain heterotropic tissue-

gastric, occasionally pancreatic• Vast majority of Meckel’s diverticuli are

clinically silent

Umbilical fistula

• Persistence of entire vitelline duct → canal between umbilicus and ileum.

• Fetal discharge may be found at the umbilicus.

Omphalocele

• Defect is covered by a surrounding membrane (peritoneum and amnion)

• Umbilical cord inserts into the sac• Typically contain bowel and/or liver,

stomach and spleen

Gastroschizis

• Ischemic compromise due to compression of mesenteric blood vessels when defect is small

• Serositis and serosal peel result from amniotic fluid exposure

• Ischemic changes and atresia are late events related to mesenteric constriction

Umbilical cord beside the defect

Comparison

OMPHALOCELE

• 1:4,000 to 10,000

• Covering sac present

• Cord onto sac

• Herniated bowel normal

• Failure of migration and fusion of folds wk 3 to 5

• Anomalies 45 to 55 %

GASTROSCHISIS

• 1:20,000 to 30,000

• Covering sac absent

• Cord onto abdominal wall

• Bowel edematous, matted

• Failure of return of midgut to abdomen by wk 10

• Anomalies 10 to 15%

Malrotation

• Normal delivery• 1st week : sign of obstruction (+)• If volvulus occured• Risk of necrotic• Operations in 6 hours

• Derotation • Excision of the Ladd band• verticalisation

Pyloric Stenosis

• The pylorus becomes abnormally thickened and manifests as obstruction to gastric emptying.

• Infants with IHPS (Infantile Hypertrophic Pyloric Stenosis) are clinically normal at birth, and subsequently develop nonbilious forceful (“projectile”) vomiting during the first few weeks of postnatal life.

• Gastric outlet obstruction leads to emaciation and, if left untreated, may result in death

Clinical Presentation

• Recent onset of forceful nonbilious vomiting, typically described as “projectile.” Frequency of vomiting is initially intermittent, but will progress to follow all feedings.

• Seen gastric wave before vomit• Palpable “oliv mass” can be detect in empty gastric

• Emesis may become blood tinged with protracted vomiting, likely related to gastritis.

• Since the child is unable to achieve adequate nutrition, he or she exhibits a voracious appetite

INTUSSUSCEPTION

PART OF THE INTESTINE FOLDS ON ITSELF LIKE A TELESCOPE

CAUSES

90% Idiopathic

Unsure but it is believed that a virus may be the cause.( Anomalies with peristalsis)

10% Pathologic

A polyp, tumour or other mass (divertikel’s Meckel) within the intestinal tract is caught by the normal contractions, creating a “lead point” which pushes along causing the intussusception

SYMPTOMS

Pain in intussusception is colicky, severe, and intermittent crying, pulling up legs, pale

Vomiting

Stools like “red currant jelly”

TYPES of INTUSSUSCEPTION

IleoIleal Small bowel/small bowel.

May spontaneously resolve

Straight to surgery

Child with up to 5 at same time.

Ileo Cecal Small bowel/ Large bowel

Radiology Intervention

Air Enema to reduce by “pushing it back”

TYPES of INTUSSUSCEPTION

Colocolic Large bowel/large bowel

Usually the elderly

No Radiology intervention

Straight to surgery

Diagnose

• Clinical Presentation• Workup

• Complete blood count leukocytosis• Plain abdominal radiography reveals signs that

suggest intussusception in only 60% of cases. Plain radiograph findings may be normal early in the course of intussusception

• Ultrasonography Hallmarks of ultrasonography include the target and pseudokidney signs

Initial Management

• intravenous crystalloid resuscitation is begun (10 mL/kg x 2, plus 1.5 x maintenance fluid).

• A Foley catheter is placed to evaluate fluid resuscitation. • A nasogastric tube is placed. • Broad-spectrum intravenous antibiotics are administered. • Body temperature must be preserved in the operating room