Disorders of the
Intestines
Intestinal Obstruction
represents the most frequent GI emergency
requiring surgical intervention during the
neonatal period
INTESTINAL OBSTRUCTION
1 in 1,500 – congenital
Types:
partial or complete
simple or strangulating
Etiology:
intrinsic – intestinal atresia or stenosis
90% affects small intestine
extrinsic – compression of the bowel by vessels
organs (annular pancreas), cysts (duplication)
Abdominal distention
↓ fluid absorption ; fluid secretion ↑
isotonic intravascular depletion → hypokalemia
ischemia Loss of mucosal integrity Bacterial proliferation
Endotoxemia
Bacteremia
sepsis
Clinical presentation
varies with:
cause
level of obstruction
time between the obstructing event and the
patient’s evaluation
Classic TRIAD of symptoms of
obstruction in the neonate
Vomiting
abdominal distention
obstipation
Obstruction high in the intestinal tract:
large-volume, frequent, bilious emesis with
little or no abdominal distention
Pain is intermittent and is usually relieved by
vomiting
Obstruction in the distal small bowel:
moderate or marked abdominal distention
with emesis that is progressively feculent
Diagnosis
History, PE and radiologic findings
In neonates – maternal hx: polyhydramnios
(high intestinal obstruction)
Aspiration of more than 15-20 mL of fluid,
particularly if it is bile stained, is highly indicative
of proximal intestinal obstruction.
Xray
Management:
Correction of fluid disturbance
Nasogastric decompression
Broadspectrum antibiotics
When to operate?
If strangulated
if no medical improvement in 12-24hrs
DUODENAL ATRESIA
2.5-10 per 100,000 live births
results from failed recanalization of the intestinal
lumen during 7th wk gestation
accounts for 25-40% of all intestinal atresias
Increased incidence among premies (50%);
Downs (50%)
Associated with other congenital anomalies:
Congenital heart disease (30%)
malrotation (20-30%)
annular pancreas (30%)
renal anomalies (5-15%)
Esophageal atresia with or without TEF (5-10%)
skeletal malformations (5%)
anorectal anomalies (5%)
CLINICAL MANIFESTATIONS AND
DIAGNOSIS
Hallmark: bilious
vomiting without
abdominal distention
Plain film: presence of a
“double-bubble” sign
UGI with contrast ---
confirms diagnosis and
to rule out volvulus
Treatment:
includes nasogastric or orogastric
decompression
intravenous fluid replacement
Other ancillary procedures:
Echocardiography, renal ultrasound, and
radiology of the chest and spine should be
performed
surgical repair: duodenoduodenostomy.
JEJUNAL AND ILEAL ATRESIA
30% of all neonatal intestinal obstruction
Male = female
sites;:
30 % proximal jejunum
70 % distal jejunum
10 – 15 % proximal ileum
JEJUNAL AND ILEAL ATRESIA
generally attributed to intrauterine vascular
accidents, which result in segmental
infarction and resorption of the fetal
intestine.
JEJUNAL AND ILEAL ATRESIA
Abdominal distention is rarely present at
birth, but it develops rapidly after initiation of
feeds in the 1st 12-24 hrs (progressive
abdominal distention) ( ileal > jejunum )
Bilious vomiting
80% of infants fail to pass meconium in the
1st 24 hr of life
20-30% unconjugated hyperbilirubinemia
JEJUNAL AND ILEAL ATRESIA
Associated anomalies common –
gastroschisis, meconium ileus, malrotation
with and without volvulus, Hirschsprung’
disease
*Microcolon is seen with all ileal atresia
A small “microcolon” suggests disuse and the
presence of obstruction proximal to the ileocecal
valve
JEJUNAL AND ILEAL ATRESIA
Dx : Plain film –multiple
dilated loops of bowel
with air – fluid levels
contrast studies are often
required to localize the
obstruction.
Rx : medical / surgery
requires resection of the
dilated proximal portion of the
bowel followed by end-to-end
anastomosis
Meckel Diverticulum
most common congenital anomaly of the
GI tract
caused by the incomplete obliteration of
the omphalomesenteric duct during the
7th wk of gestation
Meckel Diverticulum
3-6 cm outpouching of the ileum along the
antimesenteric border 50-75 cm
(approximately 2 feet) from the ileocecal
valve
A cause of about 50% of GI bleeding in
children
acts as the lead point of an intussusception
Meckel Diverticulum
“rule of 2s”
found in approximately 2% of the general
population
are usually located 2 feet proximal to the
ileocecal valve
approximately 2 inches in length
can contain 2 types of ectopic tissue
(pancreatic or gastric)
generally present before the age of 2 yr
found twice as commonly in females.
Meckel Diverticulum
Intermittent painless rectal bleeding
Stools are brick colored or currant jelly
colored
Dx: difficult
The most sensitive study is a Meckel
radionuclide scan, which is performed after
intravenous infusion of technetium-99m
pertechnetate
Rx: diverticulectomy
INTUSSUSCEPTION
occurs when a portion of the alimentary
tract is telescoped into an adjacent
segment
Second most common cause of acute
abdominal pain in children following
appendicitis
most common abdominal emergency in
children younger than 2 yr.
INTUSSUSCEPTION
It is the most common cause of intestinal
obstruction between 5 mo and 3 yr of age
peaking at 5-7 months
INTUSSUSCEPTION
Cause: idiopathic
Increased risk after rotavirus vaccine
90 % proximal to the ileocecal valve –
ileocolonic, ileoileal, colocolonic
Intussusceptum
=proximal portion
Intussuscipiens
=distal portion
INTUSSUSCEPTION
Etiology:
Lymphoid aggregates in the intestinal
submucosa enlarges and project into
the lumen ( viral infections and
gastrointestinal allergy)→ gets
entrapped in the peristalsis and be
propelled distally invaginating into the
bowel wall
INTUSSUSCEPTION – s/s
Sudden onset of
paroxysmal colicky
pain
vomiting
palpable abdominal
mass (sausage
shaped)
presence of rectal
bleeding
Abdominal X-Ray
Conventionally, first-line modality for suspected intussusception
Low sensitivity, high false negative rate
Can be negative in early Intussusception
• Findings:
1. target sign - Created by gas trapped between two layers of
intestinal wall
2. crescent sign - Created by gas surrounding invagination
3. absent liver edge sign (also called absence of the
subhepatic angle)
4. bowel obstruction
INTUSSUSCEPTION
Diagnosis:
Barium enema- “coiled
spring” appearance
INTUSSUSCEPTION
Mx: Hydrostatic reduction
Success rate: 75%
if symptoms (+) >48hrs → decreases success
rate
Contrast enema is diagnostic in 95% of
cases and therapeutic / curative in most
cases
Recurrence rate: 10%
MALROTATION
incomplete rotation of the intestine during fetal
development
involves the intestinal nonrotation or incomplete
rotation around the superior mesenteric artery.
MALROTATION
The 1st and 2nd portions of
the duodenum are in their
normal position, but the
remainder of the
duodenum, jejunum,and
ileum occupy the right side
of the abdomen and the
colon is located on the left
The most common type of
malrotation involves failure
of the cecum to move into
the right lower quadrant
MALROTATION
1 in 500 infants
>50% presents during the 1st month
Predisposes to volvulus
Vomiting – most common symptom
Bile stained
MALROTATION
Dx : Barium enema – cecum localized to
the right or left quadrant
UGI series – duodenum does not
cross midline and the remainder
of small bowel lies to the right of the
midline
U/S – clockwise rotation of the superior
mesenteric vein around the
mesenteric artery ( “ whirlpool” sign )
MALROTATION
Plain film: non-specific
gasless abdomen
Rx: surgery
VOLVULUS
Involves twisting of a bowel segment upon
itself to the point of occluding its lumen
Most frequent site: sigmoid flexure
MECONIUM ILEUS
Occurs as a
complication of cystic
fibrosis
Hyperviscous meconium
The earliest signs of
meconium ileus:
abdominal distention
bilious (green) vomit
non passage of
meconium
Diagnosis: X ray
Treatment: surgery
MECONIUM PERITONITIS
Result of intrauterine intestinal perforation
with leakage of meconium into the fetal
peritoneal cavity
Hirschsprung disease
Congenital aganglionic
megacolon
Absence of ganglion cells of
Auerbach’s and Meissner’s
plexuses
resulting in a constriction of
involved segment with
consequent dilatation of the
proximal bowel
most common cause of lower
intestinal obstruction in neonates
Hirschsprung disease
usually diagnosed in the neonatal period
secondary to:
distended abdomen
failure to pass meconium, and/or
bilious emesis or aspirates with feeding
intolerance.
Hirschsprung disease
30% has positive
family history
10% have Down
syndrome
Diagnosis: clinical
history and PE
Plain film abdomen
Hirschsprung disease
Dx confirmed by rectal suction biopsy
Treatment: colostomy followed by pull-
through operation
Acute Appendicitis
Most common condition requiring intra-
abdominal surgery in children
Peak: 6-12 years
More common among males
Acute Appendicitis
Etiology: obstruction secondary to
inflammatory changes, either blood-borne,
from enteric infections or from mechanical
causes such as parasites, fecaliths
s/s:
Acute abdominal pain, usually begins peri-umbilical
or in the epigastrium then localizing in the RLQ
Vomiting
High grade fever
Pathophysiology
Inflammation of the vermiform appendix
Obstruction at base blocks outflow of mucus
Pressure builds up
Blood vessels are compressed
Perforation and rupture
Acute Appendicitis
Dx: History and PE
CBC
Ultrasound
Rx: appendectomy
antibiotics
INFLAMMATORY BOWEL DISEASE
Refers to 2 chronic intestinal disorders:
1. Crohn’s disease
2. Ulcerative colitis
The most common time of onset of IBD is
during the preadolescent/adolescent era
and young adulthood
Ulcerative Colitis
Inflammatory disease of the large intestine
Spares the upper GIT
Usually begins in the rectum
Ulcerative Colitis
Blood, mucus, and pus in the stool as well
as diarrhea are the typical presentation of
ulcerative colitis
Tenesmus
The clinical course of ulcerative colitis is
marked by remission and relapse
Dx: confirmed by endoscopic and
histologic examination of the colon
REGIONAL ENTERITIS
Crohn’s Disease
involves any region of the alimentary tract
from the mouth to the anus.
Most often affects the small intestine and
parts of the large intestine.
Inflammation that extends deeper into the
layers of the intestinal wall than ulcerative
colitis.
CROHN’S DISEASE ULCERATIVE COLITIS
90% ileum 95% rectum
Age: 12-15 yrs Age: 8-15 yrs
Lesions SEGMENTAL Predilection for
- skipped areas caucasians and Jewish
Transmural (more
descent
extensive) Higher in males
Cobblestone Lesions continuous
appearance diffuse mucosal
Ulceration with disease
areas of mucosal affects large intestine
and submucosal
thickening
NECROTIZING ENTEROCOLITIS
5-10% premies
Pathogenesis:
gastrointestinal ischemia
underdevelopment of GI immune protection
infectious agents
enteral alimentation
NECROTIZING ENTEROCOLITIS
s/s: abdominal distention (90%), feeding
intolerance - vomiting, bloody mucoid
diarrhea, temperature instability,
bradycardia
Diagnosis: X ray
Pneumatosis intestinalis (subserosal air)
Treatment: medical
surgical ( intestinal perforation)
Anne Connell
Pseudomembranous colitis
Antibiotic associated colitis
Etiology: antibiotic intake disrupts the
colonic microflora enhancing
colonization of C. Difficile
Most common with ampicillin and
amoxicillin
Pseudomembranous colitis
s/s occur 4-10 days after intake of
antimicrobials
diarrhea, fever , vomiting, crampy abdominal
pain, abdominal distention
Diagnosis: high index of suspicion
Barium enema is contraindicated ( risk of
perforation)
Dx: endoscopy
Rx: vancomycin
MALABSORPTION SYNDROME
Disturbance in the digestion and
absorption of any dietary substrate across
the intestinal mucosa exists
Four main elements of normal SI absorption:
1. Pancreas secretes digestive enzymes into the
gut lumen------˃ macromolecules
2. Liver secretes bile acids ------ ˃ fats
3. Transverse mucosal folds and villi provide vast
absorptive surface area
4. Brush border enzymes of mucosa -----˃ complex
sugars
*** if one of the above is missing -----˃ Malabsorption
Questions?
THE
END!!!
