Neonatal Bilious Vomiting- part1
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This document discusses the differential diagnosis, workup, and treatment options for neonatal bilious vomiting, outlining various causes such as duodenal atresia, malrotation, and necrotizing enterocolitis. It provides details on imaging studies, clinical presentations, and management strategies for these conditions. The document aims to enhance the confidence of healthcare professionals in managing newborns with bilious vomiting.
Neonatal Bilious Vomiting- part1
- 1. NEONATAL BILIOUS VOMITING- Part 1 A PROBLEM ORIENTED APPROACH Dr.B.Selvaraj MS;Mch; FICS; Professor of Surgery Melaka Manipal Medical College Melaka 75150 Malaysia
- 2. OBJECTIVES To discuss the differential diagnosis of biliary emesis in neonates To do appropriate workup to confirm the diagnosis To select the various treatment options To make you confident in managing a newborn with bilious vomiting
- 3. Neonatal Bilious Vomiting-Causes Meconium Peritonitis Necrotising Enterocolitis Hirschsprung’s Disease Anorectal Malformation Rarely Mesentric Cyst & Intestinal Duplication Incarcerated inguinal hernia Duodenal atresia/stenosis Annular Pancreas Malrotation&MGV Intestinal Atresia: Jejunal&Ileal Meconium Ileus Meconium Plug
- 4. Neonatal Bilious Vomiting-Causes •MALROTATION & MGV •MESENTRIC CYST& DUPLICATION CYST •CONGENITAL BANDS LIKE VI DUCT BANDS •MECONIUM ILEUS •MECONIUM PLUG •MECONIUM PERITONITIS EXTRINSIC •DUODENAL ATRESIA/STENOSIS •JEJUNAL/ILEAL ATRESIA •HIRSCHSPRUNG’S DISEASE •NECROTISING ENTEROCOLITIS CAUSES MURAL INTRA LUMINAL
- 5. DUODENAL ATRESIA/STENOSIS Failure of vacuolisation & recanalisation of solidcord state of duodenum at 7 to 10 wks of intrauterine life Proximal Stomach & Duodenum get dilated and hypertrophied Bilious vomiting in Postampullary type Failure to pass meconium Minimal upper abdominal distension Hydramnios in mother& Down’s syndrome in the child
- 6. DUODENAL ATRESIA/STENOSIS- Types 1. Membrane Type a. Simple b. Fenestrated c. Windsock Anomaly 2. Complete Mural discontinuity with connecting fibrous cord 3. Complete Mural discontinuity without connecting fibrous cord
- 8. Duodenal Atresia/StenosisWorkup Antenatal USG Abdomen Double Bubble appearance Postnatal AXR Classical Double Bubble Appearance
- 10. Duodenal Atresia- Windsock anomaly
- 11. Duodenal Atresia- Post op care Dysmotility due to Megaduodenum may require a period of TPN Transanastomotic feeding tube may obviate the need for TPN Graded introduction of enteral feeds as bowel motility recovers Prophylactic antibiotics for 48 hrs
- 12. ANNULAR PANCREAS A rim of pancreatic tissue encircles 2nd part of duodenum A defect in rotation and fusion of ventral analgae with the dorsal analgae of pancreas Clinical picture and radiological findings are akin to Duodenal Atresia Treatment also same as that of Duodenal Atresia
- 13. ANNULAR PANCREAS
- 16. Physiological Umbilical Hernia in Fetus
- 17. MALROTATION
- 19. MALROTATION Any defect/ deviation of normal midgut rotation leads to Malrotation 60% of Malrotation patients present in neonatal period Most common type of Malrotation is caused by Ladd’s band due to arrest of rotation at 180* Midgut volvulus is due to narrow duodenocolic isthmus
- 20. MALROTATION Bilious Vomiting Passing scanty meconium Upper abdominal distension In Midgut volvulusBleeding PR,abdominal distension and vomiting
- 21. MALROTATION- IMAGING STUDIES AXR- “ Double Bubble Appearance” Upper GI Series: In Simple MalrotationAbsence of C loop; DJ flexure & jejunal loops on the right side of abdomen In MGV “Corkscrew Appearance” USG with Doppler scan: Reversed position of SMA & SMV
- 22. MALROTATION- IMAGING STUDIES Double Bubble Appearance Corkscrew Appearance
- 23. MALROTATION- IMAGING STUDIES Absence of C Loop Jejunum on Rt side Reversed position of SMA & SMV
- 24. MALROTATION- Ladd’s Procedure Division of Ladd’s band Widening of Duodenocolic isthmus
- 25. Malrotation with Midgut Volvulus Derotation of Volvulus If bowel is viable leave it If bowel not viable Resection and EEA If bowel viability is doubtful Second look laparotomy Complication Short bowel syndrome
- 26. JEJUNAL & ILEAL ATRESIA Due to mesenteric vascular accident during fetal life Incidence 1 in 3000 livebirths Present within 24hrs with bilious vomiting,not passed meconium & abdominal distension Proximal obstruction earlier & more severe is the bilious vomiting Distal obstruction more severe is the abdominal distension
- 27. JEJUNAL & ILEAL ATRESIA Types
- 28. JEJUNAL & ILEAL ATRESIA Types
- 29. JEJUNAL & ILEAL ATRESIA- AXR Jejunal Atresia Triple Bubble Appearance ILeal atresia Multiple airfluid levels
- 30. JEJUNAL & ILEAL ATRESIA Barium Enema Unused Microcolon
- 31. JEJUNAL ATRESIA- Tapering Jejunoplasty End to back Anastomosis
- 32. Jejunal & Ileal Atresia- Operative Techniques
- 33. NECROTISING ENTEROCOLITIS Disease of paradoxes- unknown etiology Most likely mechanism vascular compromise to GIT resulting bacterial invasion of portal venous system Common in premature babies Occurs during 1st or 2nd wk of life after starting oral feedings in babies weighing < 1.5 kgs Distal Ileum & Rt colon are commonly involved
- 35. NECROTISING ENTEROCOLITIS Affected bowel Dilated with mucosal necrosis and subserosal collection of gas Bilious vomiting,abdominal distension,rectal bleeding and/or diarrhea Abdominal wall edema, erythema and fixed persistent loop of bowel AXR Pneumatosis intestinalis, Gas in portal vein and/or Free air in peritoneal cavity
- 38. NECROTISING ENTEROCOLITIS- AXR Pneumatosis Intestinalis Portal Venous Gas— Pneumobilia
- 39. NECROTISING ENTEROCOLITIS Management Start aggressive medical treatment immediately Keep NPO,NGT aspiration & TPN Broadspectrum Antibiotics Physical, radiographic and ultrasonographic evaluation Q6H for 1st 48 hrs in NICU
- 40. NECROTISING ENTEROCOLITIS Indications for Surgery Pneumoperitoneum & signs of peritonitis Edematous & Erythematous anterior abdominal wall Fixed persistent loop of bowel Portal venous gas- Pneumobilia Sudden deterioration of baby during medical treatment
- 41. NECROTISING ENTEROCOLITIS Surgery Operative strategy depends on extend of involvement of bowel If perforation is small Direct suture closure or re section & primary anastomosis is adequate In extensive bowel necrosis Remove all gross gangrenous bowel& do enterostomy In doubtful bowel viability Second look laparotomy In low birth weight infants with poor general condition do just peritoneal drainage