Gastrointestinal SystemSpots and Xrays..

Dr.Vinayak V. Kodur2nd Yr DM Neonatology Resident

L.T.M.M.C.Sion.

Identify the condition...

Epulis• A rare tumor of the newborn• A/k/a granular cell tumor or congenital gingival

granular cell tumor.• CE has a female predilection with 8:1 ratio. • Epulis is most frequently located on the anterior

maxillary alveolar ridge and usually occurs as a single mass although 10% cases occur as multiple.

• CE clinically appears as a pedunculated protuberant mass, which may interfere with respiration or feeding.

• In cases with large lesions mechanical oral and nasal obstruction can impair fetal deglutition and neonatal respiratory efforts resulting in polyhydramnios prenatally or respiratory impairment postnatally.

• The recommended treatment is prompt surgical resection.

Treatment please...

Tongue Tie

• Type 1 : the attachment of the frenulum to the tip of the tongue, usually in front of the alveolar ridge in the lower lip sulcus.

• Type 2 : two to four mm behind the tongue tip and attaches on or just behind the alveolar ridge.

• Type 3 : the attachment to the mid-tongue and the middle of the floor of the mouth and is usually tighter and less elastic.

• Type 4 : essentially against the base of the tongue, and is thick, shiny and very inelastic.

• Types 1 and 2, considered “classical” tongue-tie, are the most common and obvious tongue-ties, and probably account for 75% of incidence.

• Types 3 and 4 are less common, and since they are more difficult to visualize are the most likely to go untreated.

• Frenotomy is the treatment.

Discuss The Treatment

Cleft Lip and Palate

• Feeding• Pre-Surgerical Infant Orthopedics (PSIO):

Naso-Alveolar Molding (NAM) done to decrease the distance between the ends of cleft lip so that reconstruction becomes easy. Usually done at 1-2months of age.

• Cleft lip repair done at 3-6 months of age.• Cleft Palate at 9-12 months of age.

Diagnosis Please

EA with TEF

• Note the coiled catheter in the airfilled blind pouch in the upper mediastinum and the excessive amount of gas in the abdomen.

• Lack of abdominal gas would, therefore, suggest the diagnosis of an esophageal atresia with a blind pouch; whereas air in the stomach and abdomen indicates communication between the trachea and esophagus, suggesting the diagnosis of tracheoesophageal fistula.

Identify and Indication of use?

A Replogle tube

• Used to continuously drain saliva from the upper oesophageal pouch and is positioned 0.5cm above the end of the oesophageal pouch.

• To prevent aspiration pneumonia.• It is a double-lumen tube• The Replogle tube is placed in the upper oesophageal

pouch and connected to continuous low pressure suction of -15 to -35 cmH20 (equal to -11 to -25 mmHg) to aspirate saliva and prevent aspiration.

Diagnosis Please...

• The respiratory distress in esophageal atresia is caused by aspiration usually of stomach acid through the lower pouch into the airways.

• This x-ray shows the results of putting radiopaque dye into the gastrostomy, the dye has been refluxed up the lower esophageal pouch into the airways.

Diagnosis please..

• Baby presented with nonbilious vomiting at 12 hours of life.

• Baby has not passed meconium yet.• Xray done is like….

Normal Abdominal Gas Pattern

• In a healthy neonate, air is usually seen in the stomach within minutes of birth.

• 3-6 hours, most of the small bowel usually contains gas.

• After 8-9 hours, most of the large bowel should be seen in healthy neonates.

• 12-24 hours gas appears in rectum.

Characteristics..

• Most of the babies will have gas in rectum by 24 hrs of life if there is any doubt then cross-table lateral xray is the investigation of choice.

• Gasless abdomen in older neonate means1. Baby is obtunded so much that he can not even

swallow the air.2. Discontinuity of abdomen3. Baby is in sever sepsis or severely ill.

Characteristics

• Remember small bowel in newborn has thin wall and loops lie in close proximity to each other and thick walled loops or widely separated loops are abnormal.

• Colonic haustrations are difficult to visualize on xray and become persistent only after 6 months of age so its difficult to say which part of the bowel is dilated on an xray in a newborn.

Atresia..• Most common cause of obstruction in newborn is

atresia.• How to establish the level of obstruction??• Duodenum is located in right upper quadrant of the

abdomen, so if only stomach and loop of intestine is dilated in the right upper quadrant then duodenal atresia is likely.

• Jejunum is left upper part of abdomen.• Ileum is predominantly occupying the right lower

part quadrant.

Atresia• Many dilated loops, large in diameter and occupying

mainly the right side of spine = ileal artresia.• Dilated loops confined to upper part of abdomen and

particularly left = Jejunal atresia.• But these rules may give you diagnosis in only 70%

cases.• USG and intra-operative findings may surprise you.• Most common site of small intestinal atresia??• Ileal (50%) > Jejunal (30%) > Duodenal (20%)

Jejunal Atresia

Midgut Volvulus

Midgut Volvulus

• Plain rediographs rarely help• Contrast films: Corkscrew sign “the spiral

appearance of the distal duodenum and proximal jejunum”.

• USG : Whirlpool sign also known as the whirl sign, is seen when structures twist on itself.– The abdomen bowel rotates around its mesentery

creating whirls.

Diagnosis Please..

Meconium Ileus• Radiological features:• Microcolon (unused colon)• "Frothy" or "soap-bubble pattern of bowel gas

(air mixed with meconium), often in the right lower quadrant

• Dilated small bowel loops • Small bowel obstruction • Calcification due to meconium peritonitis

Xray

• Distal ileum packed with meconium and larger than microcolon on contrast enema

• Small bowel obstruction with dilated loops of bowel and soap bubble bowel gas pattern in the right lower quadrant

• On barium enema, there is a microcolon.

Baby presented on day of life 15 with bilious vomiting..Mother had lactation failure and baby was fed formula milk with improper dilution. Xray done was showing..

Diagnosis Please..

Inspissated Milk Syndrome• Probably occurs with the use of formula containing

excess long-chain fatty acids which form insoluble soaps resulting in indigestible milk curds.

• Bioavailability of fat, human 90% and formula 65%• How to differentiate it from meconium peritonitis?• Diffuse and scattered calcification outside the bowel

linings = meconium peritonitis• Calcification in a particular area mainly the right iliac

fossa and well within the bowel wall = inspissated milk syndrome.

Diagnosis Please…

• Infant born to diabetic mother.• Had history of delayed passage of meconium

followed by abdominal distension.• Identify the study and pathology..

Small Left Colon Syndrome.

• This condition is commonly seen in infants of diabetic mothers.

• Note the microcolon distal to the splenic flexure.

• Management of this condition is nonoperative, with slow enteral feedings and total parenteral nutrition support until the colon dilates to a more functional size.

Diagnosis please..

Meconium Peritonitis

• Xray shows diffuse calcifications in the peritoneal cavity. This is a classic radiographic sign.

• As the bowel perforation occurs in utero, on rare occasions the meconium tracks down the inguinal canal into the scrotum and areas of calcification may be seen in the scrotum.

Bleeding Per Rectum

Apt Test

• The Apt test diagnoses melena neonatorum caused by ingested maternal blood.

• Fetal hemoglobin in the presence of alkali remains pink and is not denatured. Adult hemoglobin in the presence of alkali denatures and changes to a yellow-brown color.

• What is the procedure of Apt test??

Diagnosis Please..

Pneumoperitoneum

• Cross-table lateral radiograph of an infant with pneumoperitoneum.

• This view may be of value in making the diagnosis when other radiographs are inconclusive.

• There is lucent area below the abdominal wall superior to the gastric air bubble and bowel gas pattern.

Supine and Upright x-ray

• In the flat plate film on the left, the decreased density especially over the liver is due to the presence of free air (free air floats to the top).

• The diagnosis may be easily missed on this film.

• In the upright plate on the right, the pneumoperitoneum, with sub-diaphragmatic air is easily appreciated.

Guess the sign

Football Sign..

• X-ray shows pneumoperitoneum in an infant with perforation of the colon.

• The large central translucent collection of air referred to as the “football sign” with sharp demarcation of the falciform ligament.

Diagnosis Please..

Urachal Anomalies

Patent Urachus

• A completely patent urachus manifests with the passage of urine from the umbilicus.

• Radiopaque contrast material injected into the orifice outlines the urachal tract and fills the bladder.

• Treatment consists of surgical excision of the umbilicus along with the entire urachus down to the bladder.

• Results are typically good.

Describe the X-ray

Describe the X-ray

Poor Prognosis criteria

Diagnosis Please..

Diagnosis Please...

Describe the X-ray

Describe the X-ray

Describe the X-ray

Describe all signs..

NEC

Portal Gas after UVC insertion

• The UVC tip has tracked into the liver and there appears to be faint portal venous gas.

• Air in portal venous branches can be associated with umbilical venous catheter insertion.

• Inconsequential transient portal venous air can be seen immediately after umbilical venous catheter insertion and should not necessarily be attributed to necrotizing enterocolitis.

Diagnosis Please..

Hernia in Newborn• Treatment:• Hydrocele without hernia: differ treatment till

completion of a year as many will reduce on their own.

• Inguinal hernias: – Do not spontaneously heal and must be surgically

repaired because of the ever-present risk of incarceration.

– Generally, a surgical consultation should be made at the time of diagnosis, and repair (on an elective basis) should be performed very soon after the diagnosis is confirmed

Diagnosis Please..

Same patient

Diagnosis Please..

Omphalocele..• Omphaloceles can be quite small in infants and can

resemble a Wharton’s jelly cyst. • The sac may contain a single loop of bowel.• Because of this risk of an omphalocele, the cord

should not be cut or clamped close to its insertion.• An omphalocele is caused by failure of the complete

return of intestines to the abdominal cavity in early fetal life (10 weeks).

• The umbilical cord is incorporated and a sac is present.

Omphalocele

• Extra-abdominal contents are positioned midline. • Intestinal malrotation is a frequent associated finding. • Omphaloceles may occur as isolated findings or can be

associated with other congenital and chromosomal abnormalities.

• It is frequently seen in trisomy 13 and in Beckwith-Wiedemann syndrome.

• The incorporation of umbilical cord differentiates this from gastroschisis

Diagnosis Please..

Gastroschisis..• In gastroschisis there is no covering membrane.• Anterior abdominal wall defect which is usually

paramedian to the right of the umbilical cord insertion.

• Rarely associated with other congenital anomalies. There may be an associated intestinal malrotation and occasionally there are atretic portions of the extra-abdominal bowel.

• The stomach, bowel, and bladder may be outside the abdomen and completely uncovered.

Gastroschisis

• Note that the liver is never outside the abdominal cavity in an infant with gastroschisis.

• Many times the loops of bowel are dilated and thickened, since they lie free in the amniotic fluid.

THANK YOU