Neonatal Intestinal Obstruction

General Surgery
Prof. Kais Al-Wattar

Neonatal Intestinal Obstruction, focus on Jejuno-ilial Atresia and Malrotation

In these 2 lectures this afternoon we are going to focus on 2 main topics under the neonatal surgical
emergencies which include:
1.
2.
3.
4.
5.
6.
7.
8.

Neonatal intestinal obstruction. this lecture

Esophageal atresia and T.E. fistula. next lecture
Perforations (Neonatal gastric perforation, perforation of the common bile duct).
Imperforate Anus.
Neonatal necrotizing enterocolitis (NEC).
Exomphalos (Omphalocele) and Gastroschisis.
Respiratory emergencies.
Menigocele and Myelomeningocele.

Part 1

The neonatal intestinal obstruction

We classify them either according to the relation of the obstructive cause to the wall of the intestine A
physical blockage causing impedance to the passage of the bowel contents results in mechanical obstruction. These causes
are usually divided into those that compress the bowel from outside (extrinsic), those that arise from the wall of the bowel
and obstruct the lumen (intrinsic), and those that arise within the lumen., or to the level of the obstruction in
relation to the mid portion of the jejunum.
General Symptoms: in neonates in the first few weeks of life
-Bilious Vomiting
-Abdominal Distension
-Failure to pass meconium
Radwan showed us the stereotypes of medical students, which was pretty funny, what about medical professors? :P hope
u like it 3:)

A4 | Faris, 3:)

Neonatal Intestinal Obstruction

General Surgery
Prof. Kais Al-Wattar

1.1 THE CAUSES AND CLASSIFICATIONS OF INTESTINAL OBSTRUCTION

The surgical causes of neonatal intestinal obstruction are summarized in table 1

Table 1

A. Surgical classification of intestinal obstruction

Mechanical
Extrinsic
-Malrotation
-Volvulus Neonatorum
-Duplication
-Diaphragmatic Hernia
- Intussusceptions

Intrinsic
-Atresia
-Stenosis

Intraluminal
-Meconium Ileus
-Meconium Plug

Neurogenic
-Hirschsprungs Disease
-Intestinal Neuronal Dysplasia
-Dismosis

Other classifications of intestinal obstruction in neonates are according to the anatomical location of the
obstruction in relation to the mid portion of the jejunum, If the obstruction is higher proximal to the mid
portion of the jejunum its called high anatomical obstruction, when its distal to the mid jejunum we call it low
anatomical obstruction. The causes are summarized in table 2

Table 2

B. Anatomical classification of intestinal obstruction

High anatomic obstruction

-Pyloric atresia*
-Duodenal obstruction:
-Atresia
-Stenosis
-Annular pancreas*
-Ladd's band*
-Preduodenal portal vein*
-Malrotation Volvulus
-Proximal jejunal atresia or stenosis
-Intestinal duplication
-Internal herniation*

Low anatomic obstruction

-Ileal atresia or Stenosis
-colonic atresia or Stenosis
-Meconium ileus*
-Hirschsprung's disease
-Small left colon syndrome
-Meconium plug syndrome large bowel
-Intussusception
-Anorectal malformations, Imperforate anus
-Intestinal duplication
-Internal herniation

A4 | Faris, 3:)

Neonatal Intestinal Obstruction

General Surgery
Prof. Kais Al-Wattar
Notes:
*Some people may include the pyloric atresia, but its not intestinal so you can omit this from the causes of
intestinal obstruction.
* Ladd's band: a band crossing the duodenum, very important note :P
* Preduodenal portal vein: when the portal vein is anteriorly located, it causes pressure and obstruction;
normally its behind the duodenum.
*Annular pancreas: this is the result of failure of complete rotation of the ventral pancreatic bud during

development, so that a ring of pancreatic tissue surrounds the second or third part of the duodenum. It is most
often seen in association with congenital duodenal stenosis or atresia and is therefore more prevalent in children
with Downs syndrome. Duodenal obstruction typically causes vomiting in the neonate.
*Internal hernia, Internal herniation occurs when a portion of the small intestine becomes entrapped in one
of the retroperitoneal fossae or in a congenital mesenteric defect. The following are potential sites of internal
herniation:
the foramen of Winslow;
a hole in the mesentery;
a hole in the transverse mesocolon;
defects in the broad ligament;
congenital or acquired diaphragmatic hernia;
duodenal retroperitoneal fossae left paraduodenal and right duodenojejunal;
caecal/appendiceal retroperitoneal fossae superior, inferior and retrocaecal;
intersigmoid fossa.
Internal herniation in the absence of adhesions is uncommon and a preoperative diagnosis is unusual.
*Meconium ileus: cystic fibrosis is almost always the underlying cause of this condition, meconium is
normally kept fluid by the action of pancreatic enzymes. In meconium ileus the terminal ileum becomes filled
with thick viscid meconium, resulting in progressive intestinal obstruction.
A sterile meconium peritonitis may have occurred in utero.

A4 | Faris, 3:)

Neonatal Intestinal Obstruction

General Surgery
Prof. Kais Al-Wattar
C. Functional obstruction
Patients may present with intestinal obstruction, but the cause is not mechanical and this includes:
-Sepsis
-Electrolyte imbalance
-Necrotizing enterocolitis (NEC)
-hypothyroidism
D. Prenatal diagnosis:
Ultrasound More sensitive for diagnosis of high anatomical lesion
-Double-bubble
-Polyhydramnious
-Dilated loops and increased peristalsis in Jejuno-ilial atresia and in midgut volvulus with thickened
intestinal wall
-Intra abdominal calcification and ascitis in meconium peritonitis
E. Postnatal diagnosis:
-Symptoms
-Physical examination (signs)
-Imaging studies

Symptoms typically begin to manifest within the first 24 hours of life.

The clinical presentation depends on the level of the obstruction.
The severity of the obstruction determines the clinical manifestations
Partial Obstruction often initially produce minimal or no findings

A4 | Faris, 3:)

Neonatal Intestinal Obstruction

General Surgery
Prof. Kais Al-Wattar

1.2 THE SYMPTOMS OF INTESTINAL OBSTRUCTION

A. Vomiting:
-Earliest and most consistent symptoms of Neonatal Intestinal Obstruction.
-The onset, character and severity of the vomiting depend on the cause of the obstruction.
-Bilious vomiting is characteristic of the obstruction distal to the ampulla of vater, 95% of the cases.
-With high lesion bilious vomiting has sudden presentation or may be forceful in nature.
-With distal lesion bilious vomiting may be delayed.
-Non bilious vomiting rarely encountered in the neonate with obstruction due to any type of lesion.
B. Failure to pass meconium:
-Failure to pass meconium within the first 24 hours.
-With proximal lesion neonate may pass some meconium, but fail to pass subsequent stool.
-With incomplete obstruction the neonate may pass little amount of meconium.
-In case of imperforate anus meconium may be passed per urethra recto-urethral fistula in the male or per
vagina recto-vaginal fistula in the female.
C. Abdominal distention:
-Common.
-The more the distal the obstruction the more is the severe distention.
D. Abnormal findings in the stool:
-Bleeding per-rectum indicate a possible volvulus, NEC or intussusception.

A4 | Faris, 3:)

Neonatal Intestinal Obstruction

General Surgery
Prof. Kais Al-Wattar

1.3 THE PHYSICAL EXAMINATION (SIGNS)

-Generally the neonate especially in the delayed cases shows features of fluid loss and electrolytes
imbalance.
-Abdominal distension.
-Tenderness and guarding; peritoneal signs are often present in cases of volvulus, NEC, perforation and
ischemia.
-Abdominal wall erythema is also consistent with peritonitis.
-Palpable mass in the right upper quadrant and empty RIF usually in cases of intussusception.
-Examine the anus and the rectum for anomalies, imperforate anus could be missed.

1.4 INVESTIGATIONS
Usually there is disturbance of fluid, electrolytes and acid base balance
Radiological examination:
-All neonates with suspected intestinal obstruction should have plain abdominal X-Ray in supine and erect or
lateral decubitus position, to see the shape of the gas in the intestine and the presence of fluid levels.
Lateral decubitus position
When medical professionals use this term to describe the position of a patient, they first state the part of the body on
which the patient is resting followed by the word "decubitus". For example, the right lateral decubitus would mean that the
patient is lying on his or her right side. Another example is angina decubitus, (chest pain while lying down)
In radiology, this term implies that the patient is lying down with the X-ray being taken parallel to the horizon.
Patient in lateral decubitus position

X-ray with barium enema

-All must have antero-posterior and left side down decubitus X-Rays.
-Radiology is usually difficult to differentiate dilated small bowel from collapsed large bowel before the first
year of age.
A4 | Faris, 3:)

Neonatal Intestinal Obstruction

General Surgery
Prof. Kais Al-Wattar
A. Radiology in high intestinal obstruction
Double bubble
Plain radiographs in pyloric atresia, pyloric stenosis,
duodenal atresia, duodenal stenosis, annular pancreas
and preduodenal portal vein and ladd's band are
characteristic.

Plain abdominal radiograph showing

classical double bubble appearance as well
as distal gas shadow.
Double-bubble shadow is associated
with gas in the distal loops in cases of
stenos, most common in duodenal atresia.

Malrotation
In cases of Malrotation, the upper GIT contrast study is
characteristic; it usually shows failure of the duodeno-jejunal
junction to cross to the left of the spine, obstruction of the
duodenum and abnormal right-sided jejunum.

Malrotation; on an image from a

barium enema study, the intestine occupies
an intermediate position between that of
nonrotating and the normal postnatal
position. The cecum and the terminal ileum
are displaced upward and medially.

A4 | Faris, 3:)

Neonatal Intestinal Obstruction

General Surgery
Prof. Kais Al-Wattar
Birds Beak
sign

When there is volvulus, the characteristic

corkscrew* appearance of the small bowel
and the birds beak* sign represent the
passage of the contrast into the volvulized
segment of bowel, barium enema is not very
helpful. Ultrasound also can be helpful in these
cases.

By doing a barium enema

Note the site of twist. This has been called
the Birds Beak sign

Corkscre
w

Midgut volvulus: Image from a

contrast-enhanced upper gastrointestinal
series clearly demonstrates the corkscrew
appearance of the proximal small bowel
(arrows) as it twists around the superior
mesenteric artery.

A4 | Faris, 3:)

Neonatal Intestinal Obstruction

General Surgery
Prof. Kais Al-Wattar
Supine radiograph
With jejunal atresia there will be dilated
proximal loops and multiple air fluid levels, upper
GIT contrast study is not always necessary
Jejunal atresia
Supine radiograph in a neonate with
associated esophageal atresia shows three
dilated loops of bowel.st = stomach.
Upright radiograph
Jejunal atresia
Upright radiograph obtained in a different
patient shows air-fluid levels in the stomach
and the first part of the small bowel. No
distal gas is seen.

B. Radiology in low intestinal obstruction

All cases with suspected low intestinal obstruction required contrast enema given through the anus. Plain XRays will show dilated bowel loops with multiple air fluid levels except in meconium ileus.
Soap bubble
In meconium ileus plain films show distended loops without air
fluid levels and in the classical cases "singleton's sign"
represent distended loops of the small bowel with "soap
bubble" pattern of meconium in the right lower quadrant.

Abdominal scout radiograph shows

marked distention of the small bowel and a
soap bubble appearance in the right side
of the abdomen (arrows), a finding
suggestive of mottled air and feces.

A4 | Faris, 3:)

Neonatal Intestinal Obstruction

General Surgery
Prof. Kais Al-Wattar
A contrast enema should be performed in cases with suspected meconium ileus for diagnostic and
therapeutic purposes; In meconium ileus the Gastrografin enema maybe diagnostic and therapeutic, it will fill
the large bowel and will localize the site of obstruction, second, this material which is oily like material may
dissolve the thick meconium blocking the distal ilium at the ilio-cecal junction and open the obstruction in early
meconium ileus, in complicated meconium ileus its contraindicated to do any contrast enema.
Patients with complicated meconium ileus that results from in utero perforation have different findings ,
plain films should be examined for calcification and free air.
Colonic atresia , micro colon and Hirschsprung's disease the Barium enema will demonstrate the site of
obstruction , in micro colon or small left colon syndrome usually the Barium enema will show normal rectum.
In Hirschsprung's disease the Barium enema will demonstrate the ganglionic loop and the proximally dilated
colon and the transitional zone in 65% of the cases.
Intussusception
A variety of plain films may
indicate a diagnosis of
intussusception but the Ultrasound
study is usually more informative.

Target sign

Ultrasound view of an intussusception.

Figure shows a transverse view. Alternating
hyperechoic and hypoechoic concentric rings are
present within the lumen of a distended loop of
bowel, giving the typical "target" sign.

Longitudinal U.S.

Figure shows a longitudinal view of the

intussusception. Notice that multiple layers
of bowel wall are within the lumen of the
intussusceptions.

A4 | Faris, 3:)

10

Neonatal Intestinal Obstruction

General Surgery
Prof. Kais Al-Wattar

1.5 TREATMENT OF MECHANICAL OBSTRUCTION

A. Preoperative
-N.G. suction, dont give anything orally.
-I.V. fluids.
-Correction of electrolytes and acid base balance.
-Antibiotics.
B. Operative
-Laparotomy and dealing surgically with the underlying cause.
C. Postoperative
-In the Neonatal Intensive Care.

SUMMARY
A. Intestinal Atresia, seriously guys no need to draw a table!
The commonest cause of neonatal intestinal obstruction.
Caused by: just theories
-Failure of recanalization of the intestine during the development of the GIT.
- Segmental occlusion of blood supply in the intrauterine life, leads to failure of development of that
segment and atresia.
-No clear cause.

Table 3

B. Duodenal Obstruction

Causes:
-Duodenal atresia (the most
common)
-Duodenal duplication
-Annular Pancreas
-Ladds band
-Duodenal Hematoma
(usually following blunt abdominal
trauma)

Diagnosed by:
-Maternal Polyhydromnios
-Bilious vomiting
-Upper abdominal distension
-Associated other anomalies;
congenital heart disease, skeletal
abnormalities and down syndrome
-Later signs of fluid and electrolytes
imbalance and sepsis
-Radiology, double bubble shadow
mostly with duodenal atresia

Treatment:
-Nasogastric suction
-Intravenous fluid
-Correction of electrolytes and acidbase balance
-Treat sepsis
-Surgery (dealing with the
underlying cause)

A4 | Faris, 3:)

11

Neonatal Intestinal Obstruction

General Surgery
Prof. Kais Al-Wattar

Part 2 Focus on Jejuno-Ilial Atresia and Malrotation

2.1 JEJUNO-ILIAL ATRESIA
A. Presentation:
Bile stained vomiting, abdominal distension; the degree of
distention depends on the level of obstruction,
failure to pass meconium; small amounts of mucus or meconium
maybe passed per rectum even in the presence of a complete
atresia and the x-rays usually show multiple air-fluid levels.
B. The various types of Jejuno-ilial atresia include

Type 1
The bowel is continuous, but the
lumen is occluded by a
membrane.

Type2
The lobes of small intestine are
connected by a band, the
proximal lobe is dilated and the
distal lobe is collapsed, and there
is a mesentery between them.
Type 3
When there is no mesentery,
there is a missing segment
between the proximal dilated
lobe and the distal collapsed lobe.
Type 4
Multiple areas of intestinal
atresia of different types,
sometimes called Christmas Tree
type of atresia.

A4 | Faris, 3:)

12

Neonatal Intestinal Obstruction

General Surgery
Prof. Kais Al-Wattar
C. Treatment
-Nasogastric suction.
-Intravenous fluids.
-Electrolytes and Acid-Base balance.
-Antibiotics.
-Surgery; resection of the proximally dilated end and end to end
anastomosis.
-Post Operative care.

2.2 MALROTATION
A. Embryology
Usually there is arrest of the rotation of the cecocolic loop at 180 degrees and the
caecum lie in the hypochondrium in front of and adjacent to the duodenum, there is a
narrow base of the mesentery of the entire gut attached to posterior abdominal wall
along the axis of the superior mesenteric artery.
Ladds band from the cecocolic loop crosses and compresses the second part of the
duodenum causing intermittent obstruction.
B. Clinically
The patient might be asymptomatic and then develop the symptoms when he is older,
family history of a similar condition might be encountered and the child might have other
associated congenital anomalies.
The presenting symptoms might be in the form of:
-Duodenal obstruction.
-Intermittent intestinal obstruction, when the segment rotate intermittently such additions
makes the difference between copy-pasting slides and actual tafree3 3:P.
-As a complication of the condition (Volvulus).
The radiological features which indicate the diagnosis in the uncomplicated case are:
-Plane x-ray showing gasless abdomen.
-Barium meal shows the dilatation of the stomach and the DJ flex :P is normally to the left of the
spine but now its to the right of the spine, which is another feature of Malrotation, the small
bowel is on the right side and the large bowel is on the right side, classical finding 8).
-Barium enema shows arrest at the mid site of the colon.
C. Treatment
-Pre Operative.
-Surgery.

A4 | Faris, 3:)

13

Neonatal Intestinal Obstruction

General Surgery
Prof. Kais Al-Wattar
D. Volvulus Neonatorum
This is the most serious complication of Malrotation, might occur intermittently when the midgut rotate
around the axis of the narrow base of the mesentery twist of the mesentery creating less dramatic symptoms
or when the midgut rotate many times presenting as acute catastrophic event, and in this case it will lead to
acute intestinal obstruction in one or two ways or both.
The poorly attached small bowel undergoes volvulus around the axis of the
universal mesentery which is twisted so that the flow of blood is cut off
Gangrene, resection
producing strangulating obstruction obstruction of both the lumen and the
blood supply of the small bowel.
This causes double obstruction; first we have obstruction of the proximal
lobe of small bowel and obstruction at the level of transverse colon, this twist
will lead to traction of the band compressing the duodenum; as the cecum is
wound tight, the bands attached to it compress and obstruct the second part of
the duodenum.
The ischemia might progress to a severe degree leading to gangrene of
the involved intestine.
Derotation by surgery
The patient in this condition will present either with the intermittent
symptoms of intestinal obstruction or might present with acute intestinal
obstruction and gangrene of the midgut with shock, in such case he/she might
pass bloody stained mucus per rectum.
Treatment of Volvulus Neonatorum:
-Pre-operative preparation.
-Surgery includes (derotation and resection of the gangrenous bowel in the
complicated case); if the child survived he will have short bowel syndrome
and nutrition problems.

This space intentionally left blank

A4 | Faris, 3:)

14

Neonatal Intestinal Obstruction

General Surgery
Prof. Kais Al-Wattar

Part 3

Focus on Duplication and Intraluminal Obstruction

3.1 DUPLICATION OF THE INTESTINE

A. Types of intestinal duplication
Duplication of the alimentary tract maybe Cystic or Tubular and both can be
communicating or non-communicating, and duplications of the small bowel can
carry ectopic gastric mucosa, which will excrete gastric juice leading to digestion
of the wall and perforation or bleeding.
The three cardinal characteristics of duplication are:
-They are firmly attached to a particular part of the gastrointestinal tract.
-They posses a well-developed smooth muscle layer.
-The epithelial lining is representative of some part of the alimentary tract.

Cystic duplication

Tubular duplication

B. Presentation
-Asymptomatic
-Abdominal mass
-Complications, intestinal obstruction, bleeding, perforationetc.
Duplication of the Jejunum usually present as cyst located at the mesenteric
side stretched by the normal jejunum, or may present as tubular duplication
which sometimes communicated with the adjacent intestine.
Large bowel duplication is usually tubular and maybe communicating.
C. Treatment
The treatment of duplication cyst is excision of the whole lesion, usually with the
related normal bowel segment because they have the same blood supply.

A4 | Faris, 3:)

15

Neonatal Intestinal Obstruction

General Surgery
Prof. Kais Al-Wattar

3.2 INTRALUMINAL OBSTRUCTION

A. Meconium ileus
-The commonest form of intraluminal intestinal obstruction in neonates.
-The meconium in the small intestine become thick, tenacious and sticky which impact
and obstructs the lumen of the intestine.
-The clinical presentation is usually low small intestinal obstruction with pronounced
abdominal distension, and in the delayed cases complications might arise.
-There is an association with the fibrocystic disease in the pancreas.
-The abdominal x-rays usually show dilated loops of bowel of varying caliber and usually
without air-fluid levels, remember: the only intestinal obstruction without air-fluid
levels is meconium ileus.
-The appearance of the intestine and the contained meconium in meconium ileus
shows!!
Complications:
-Perforation.
-Gangrene of the lobe involved.
-Volvulus of the segment.
Treatment:
-Prepare the child, explore the abdomen, open the
abdomen and we will see the small bowel, part dilated and
part full of thick meconium; the meconium is rubber like, sticky thick material.
-Gastrografin Enema, it will dissolve the material in the early stage.
-Surgery.
B. Meconium plug
Obstruction of the large bowel or the rectum by thick meconium and
inspessiated milk, presenting as acute large bowel obstruction with a gross
abdominal distension in a child who is born healthy, not like in the meconium
ileus usually born looking ill.
Rectal examination or enema usually relieves the obstruction after passage
of the inspissiated meconium and gush of the intestinal content.
Exclude associated Hirschsprungs Disease or other rectal anomalies, if the child
later on developed constipation we should investigate for Hirschsprungs disease.

THATS ENOUGH!
A4 | Faris, 3:)

16

Neonatal Intestinal Obstruction

General Surgery
Prof. Kais Al-Wattar

Finally I finished the last 5 mints, Took 2 days!

I can only hope it was a good lecture, easy and useful
To Radwan for being awesome, w Yazan for being minor CR :P and to my friends b A4
Laith w 3ibs >> Niroo5 w 8arb baddale... w homeless night, lazm n3edha

3122
:

Written by: Faris AL-Faris, 3:)

A4 | Faris, 3:)

17