Neonatal Bilious Vomiting- Part2
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The document outlines a problem-oriented approach to diagnosing and managing neonatal bilious vomiting, emphasizing the differential diagnoses and treatment options available. Key causes include meconium ileus, Hirschsprung’s disease, and duodenal atresia, with specific management strategies for each condition. An algorithm for diagnosis and treatment based on clinical presentations and imaging findings is also provided, underscoring the urgency of addressing bilious vomiting as a potential sign of intestinal obstruction.
Neonatal Bilious Vomiting- Part2
- 1. NEONATAL BILIOUS VOMITING- Part 2 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. HIRSCHSPRUNG’S DISEASE Craniocaudal migration of ganglion cells of the bowel begins at 12th wk of gestation Arrest of this migration produces an aganglionic segment of bowel-absence of Aurbach’s & Meissener’s plexus This aganglionic segment of bowel unable to relax & peristaltic wave stops proximally- functional obstruction Incidence 1 in 5000 Male:Female 4:1
- 6. HIRSCHSPRUNG’S DISEASE Mutations in RET proto-oncogene are commonly associated with Hirschsprung’s disease Not passed/ delayed passage of meconium Abdominal distension Bilious vomiting Fever & diarrhea suggest Toxic megacolon
- 8. HIRSCHSPRUNG’S DISEASE Workup AXR: Dilated Bowel Loops Barium Enema: Swan Neck Appearance
- 9. HIRSCHSPRUNG’S DISEASE Workup Absence of ganglion cells in myenteric plexus Suction rectal bx Noblet Rectal Mucosal Suction Biopsy Gun
- 10. HIRSCHSPRUNG’S DISEASE Management Empty bowel with saline enema (30 to 50 ml) daily If can successfully decompress the bowel- continue rectal washouts for 45 days If unable to decompress the bowel- do Rt transverse colostomy or Levelling colostomy
- 12. HIRSCHSPRUNG’S DISEASE Swenson’s Rectosigmoidectomy Soave’s Transabdominal Endorectal Pullthrough
- 15. HIRSCHSPRUNG’S DISEASE De La Torre’s Transanal Endorectal Pullthrough
- 16. MECONIUM ILEUS Uncomplicated cases show impacted meconium in terminal ileum- inspissated tar like meconium Accounts for 9 to 10% of all neonatal intestinal obstructions Present in 8 to 10% of cystic fibrosis patients at birth Complicated cases include volvulus,perforation and peritonitis with sepsis
- 17. MECONIUM ILEUS Signs depend on degree of obstruction and complications Significant abdominal distension may develop during neonatal period General status progressively deteriorates with incipient sepsis in cases of perforation In perforation, the scrotum or labia may have greenish discoloration due to patent processus vaginalis
- 18. MECONIUM ILEUS
- 19. MECONIUM ILEUS- Imaging Studies Disparate sized bowel loops Soap bubble appearance- Neuhauser’s sign
- 20. MECONIUM ILEUS- Management 60 to 70% of simple Meconium ileus can be successfully treated with Gastrograffin enema Other 30% need operative management Goal of surgery is to remove the abnormal meconium from GIT & maintain adequate length of bowel Surgery consists of resection& anastomosis of involved segment and/or roux-en-y ileostomy
- 22. MECONIUM ILEUS- Management Paul Mikulicz Double Barrel Ileostomy Bishop-Koop’s Distal chimney Ileostomy Santulli’s Proximal chimney Ileostomy
- 23. MECONIUM PLUG A long plug of mucus and sticky meconium in rectum & distal colon results low intestinal obstruction Due to immaturity of colonic & rectal expulsive mechanism Often associated with neonatal Hirschsprung’s disease Rectal exam/rectal wash results in expulsion of the plug and relief of intestinal obstruction
- 24. MECONIUM PLUG
- 25. MECONIUM PERITONITIS Intrauterine perforation of intestineleakage of meconium into peritoneal cavity reaction of peritoneum to this leaked meconium Due to intrauterine vascular compromise of intestine ischemia&perforation as early as 4th month of intrauterine life Different pathological typesMeconium pseudocyst, generalised adhesive peritonitis,meconium ascites & infected meconium peritonitis
- 26. MECONIUM PERITONITIS Often associated with cystic fibrosis & Prognosis is poor Bilious vomiting, failure to pass meconium and abdominal distension Abdominal wall edema, erythema and free fluid in peritoneal cavity AXR multiple air fluid levels and peritoneal calcifications Surgical treatment releasing of adhesions, removal of devitalised tissues, closure of perforation, intestinal resection& anastomosis
- 27. MECONIUM PERITONITIS Meconium Ascites Central bowel loops Amorphous calcification Multiple focal calcifications Dilated bowel loops
- 28. Neonatal Bilious Vomiting - Algorithm
- 29. Neonatal Bilious Vomiting Sl N o History Physical Plain XRay Contrast studies Diagnosis Treatment 1 Bilious vomiting Not passed meconium Maternal hydramnios Upper abdominal distension VGP Down’s syndrome Double Bubble appearan ce Barium meal : Duodenal obstructio n Duodenal Atresia Or Annular Pancreas Kimura’s Diamond Shaped Duodeno duodenosto my 2 Bilious Vomiting Infrequent passage of small amount of meconium Upper abdominal distension Double Bubble Appearanc e Paucity of gas in distal bowel Barium meal: Absence of C loop Duodenum Cork screw appearanc e Malrotatio n Midgut volvulus Ladd’s Procedure Derotation Resection Anastomosi s
- 30. Neonatal Bilious Vomiting Sl N o History Physical Plain XRay Contrast studies Diagnosis Treatment 3 Bilious vomiting Not passed meconium Abdominal distension Empty rectum Triple bubble appearanc e Multiple air fluid levels Barium enema : Micro colon Jejunal atresia Or Ileal atresia Resection& End to back anastomosi s 4 Bilious Vomiting Passing meconium Prematurity& Birth asphyxia Bleeding PR Sick child Septicemia Abdominal distension Signs of Peritonitis Pneumato sis intestinalis Portal venous gas Free peritoneal gas ------------ Necrotisin g enterocoliti s Aggressive medical treatment If it faills Surgical intervention
- 31. Neonatal Bilious Vomiting Sl N o History Physical Plain XRay Contrast studies Diagnosis Treatment 5 Delayed passage of meconium Vomiting Gross abdominal distension P/R:Explosive passage of meconium & flatus Distended bowel loops Barium enema: Swan neck appearanc e Hirschspru ng’s disease Pullthrough operation with or without colostomy 6 Bilious Vomiting Failure to pass meconium Moderate to severe abdominal distension Disparate sized bowel loops Soap bubble appearanc e Barium Enema: Microcolon Meconium ileus Gastrograffi n enema Resection anastomosi s Bishop- koop & Santulli Ileostomy
- 32. Neonatal Bilious Vomiting Sl N o History Physical Plain XRay Contrast studies Diagnosis Treatment 7 Bilious vomiting Failure to pass meconium Moderate to severe abdominal distension P/R: Child passes plug Distended bowel loops -------------- Meconium plug syndrome Rectal washouts 8 Bilious Vomiting Failure to pass meconium Severe abdominal distension Abdominal wall edema & erythema Multiple air fluid levels Peritoneal calcificatio n Free peritoneal gas Barium Enema: Microcolon Meconium peritonitis Release pf adhesions Closure of perforation Resection & Anastomosi s
- 33. TAKE HOME MESSAGE “YELLOW COLOR VOMITUS IS THE RED SIGNAL OF INTESTINAL OBSTRUCTION UNLESS PROVED OTHERWISE”