NEONATAL BILIOUS VOMITING
A PROBLEM ORIENTED APPROACH
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Neonatal Bilious Vomiting
Dr.B.SELVARAJ MS;Mch; FICS;
ASSOCIATE PROFESSOR IN PEDIATRIC SURGERY
PONDICHERRY INSTITUTE OF MEDICAL SCIENCES
PONDICHERRY- 605014 INDIA
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OBJECTIVES
To discuss the differential diagnosis of biliary emesis in neonates
To discuss appropriate workup to confirm the diagnosis
To discuss the various treatment options
To make you confident in managing a newborn with bilious vomiting
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A Neonate’s request to Surgeon
“Please exercise the greatest gentleness with my diminutive tissues and try to correct the deformity at first operation; give me blood and proper amount of fluid and electrolytes; add plenty of oxygen to anesthesia, and I will show you that I can tolerate a terrific amount of surgery. You will be surprised at the speed of my recovery,and I shall be grateful to you”
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Dr.WILLIS POTTS
Neonatal Bilious Vomiting���� Causes
Meconium Peritonitis
Necrotising Enterocolitis
Hirschsprung’s Disease
Anorectal Malformation
Rarely Mesentric Cyst & Intestinal Duplication
Incarcerated inguinal hernia
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Duodenal atresia/stenosis
Annular Pancreas
Malrotation&MGV
Intestinal Atresia: Jejunal&Ileal
Meconium Ileus
Meconium Plug
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
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
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DUODENAL ATRESIA/STENOSIS- Types
Membrane Type
�Simple
�Fenestrated
�Windsock Anomaly
Complete Mural discontinuity with connecting fibrous cord
Complete Mural discontinuity without connecting fibrous cord
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DUODENAL ATRESIA/STENOSIS- Types
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Duodenal Atresia/Stenosis�Workup
Antenatal USG Abdomen
Double Bubble appearance
Postnatal AXR
Classical Double Bubble Appearance
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Kimura’s Diamond Shaped
DUODENODUODENOSTOMY
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Duodenal Atresia- Windsock anomaly
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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
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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
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ANNULAR PANCREAS
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PREDUODENAL PORTAL VEIN
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MALROTATION- Embryology
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Physiological Umbilical Hernia in Fetus
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MALROTATION
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MALROTATION- Different Degrees
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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
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MALROTATION
Bilious Vomiting
Passing scanty meconium
Upper abdominal distension
In Midgut volvulus�Bleeding PR,abdominal distension and vomiting
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MALROTATION- IMAGING STUDIES
AXR- “ Double Bubble Appearance”
Upper GI Series:
In Simple Malrotation�Absence 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
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MALROTATION- IMAGING STUDIES
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Double Bubble Appearance
Corkscrew Appearance
MALROTATION- IMAGING STUDIES
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Absence of C Loop
Jejunum on Rt side
Reversed position of
SMA & SMV
MALROTATION- Ladd’s Procedure
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Division of Ladd’s band
Widening of Duodenocolic
isthmus
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
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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
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JEJUNAL & ILEAL ATRESIA���� Types
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JEJUNAL & ILEAL ATRESIA���� Types
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JEJUNAL & ILEAL ATRESIA- AXR
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Jejunal Atresia
Triple Bubble Appearance
ILeal atresia
Multiple airfluid levels
JEJUNAL & ILEAL ATRESIA
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Barium Enema
Unused Microcolon
JEJUNAL ATRESIA- Tapering Jejunoplasty
End to back Anastomosis
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Jejunal & Ileal Atresia- Operative Techniques
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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
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NECROTISING ENTEROCOLITIS
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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
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NECROTISING ENTEROCOLITIS-Staging
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NECROTISING ENTEROCOLITIS
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NECROTISING ENTEROCOLITIS- AXR
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Pneumatosis Intestinalis
Portal Venous Gas
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
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NECROTISING ENTEROCOLITIS
Indications for Surgery
Pneumoperitoneum & signs of peritonitis
Edematous & Erythematous anterior abdominal wall
Fixed persistent loop of bowel
Portal venous gas
Sudden deterioration of baby during medical treatment
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NECROTISING ENTEROCOLITIS Surgery
Operative strategy depends on extend of involvement of bowel
If perforation is small� Direct suture closure or resection & 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
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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
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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
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HIRSCHSPRUNG’S DISEASE Classification
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HIRSCHSPRUNG’S DISEASE
Workup
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AXR: Dilated Bowel Loops
Barium Enema: Swan Neck
Appearance
HIRSCHSPRUNG’S DISEASE
Workup
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ganglion cells in
myenteric plexus
Suction rectal bx
Noblet Rectal Mucosal Suction Biopsy Gun
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
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HIRSCHSPRUNG’S DISEASE
Colostomy
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HIRSCHSPRUNG’S DISEASE
Swenson’s
Rectosigmoidectomy
Soave’s Transabdominal
Endorectal Pullthrough
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HIRSCHSPRUNG’S DISEASE
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HIRSCHSPRUNG’S DISEASE
Duhamel’s Retrorectal
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HIRSCHSPRUNG’S DISEASE
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De La Torre’s Transanal
Endorectal Pullthrough
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
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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
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MECONIUM ILEUS
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MECONIUM ILEUS- Imaging Studies
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Disparate sized bowel
loops
Soap bubble appearance-
Neuhauser’s sign
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
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MECONIUM ILEUS- Management
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MECONIUM ILEUS- Management
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Paul Mikulicz
Double Barrel
Ileostomy
Bishop-Koop’s
Distal chimney
Ileostomy
Santulli’s
Proximal chimney
Ileostomy
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
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MECONIUM PLUG
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MECONIUM PERITONITIS
Intrauterine perforation of intestine�leakage 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 types�Meconium pseudocyst, generalised adhesive peritonitis,meconium ascites & infected meconium peritonitis
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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
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MECONIUM PERITONITIS
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Meconium Ascites
Central bowel loops
Amorphous calcification
Multiple focal calcifications
Dilated bowel loops
Neonatal Bilious Vomiting - Algorithm
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Neonatal Bilious Vomiting
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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 appearance
Barium meal : Duodenal obstruction
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
Neonatal Bilious Vomiting
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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
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Necrotisin
g
enterocoliti
s
Aggressive
medical
treatment
If it faills
Surgical
intervention
Neonatal Bilious Vomiting
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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
Neonatal Bilious Vomiting
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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
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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
TAKE HOME MESSAGE
“YELLOW COLOR VOMITUS IS THE RED SIGNAL OF INTESTINAL OBSTRUCTION UNLESS PROVED OTHERWISE”
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