neonatal biliary emesis- a problem based approach

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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Double Bubble Appearance

Corkscrew Appearance


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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- 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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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- AXR

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Pneumatosis Intestinalis

Portal Venous Gas


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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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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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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Workup

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AXR: Dilated Bowel Loops

Barium Enema: Swan Neck

Appearance


Workup

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ganglion cells in

myenteric plexus

Suction rectal bx

Noblet Rectal Mucosal Suction Biopsy Gun


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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Colostomy

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Swenson’s

Rectosigmoidectomy

Soave’s Transabdominal

Endorectal Pullthrough

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Duhamel’s Retrorectal

Pullthrough P

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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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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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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 Ascites

Central bowel loops

Amorphous calcification

Multiple focal calcifications

Dilated bowel loops

Neonatal Bilious Vomiting - Algorithm

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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


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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


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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


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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

TAKE HOME MESSAGE

“YELLOW COLOR VOMITUS IS THE RED SIGNAL OF INTESTINAL OBSTRUCTION UNLESS PROVED OTHERWISE”

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neonatal biliary emesis- a problem based approach

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