neonatal biliary emesis- a problem based approach

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  • 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 Neonates 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

    Hirschsprungs 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

    HIRSCHSPRUNGS 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& Downs 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/StenosisWorkup

    Antenatal USG Abdomen

    Double Bubble appearance

    Postnatal AXR

    Classical Double Bubble Appearance

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  • Kimuras 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 Ladds 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 volvulusBleeding PR,abdominal distension and vomiting

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  • 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

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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- Ladds Procedure

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    Division of Ladds 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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  • HIRSCHSPRUNGS 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 Aurbachs & Meisseners plexus

    This aganglionic segm