Health-Process-Evidence-based Clinical Practice Guidelines Acute Abdomen in Newborns

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Health-Process-Evidence-based Clinical Practice
GuidelinesAcute Abdomen in Newborns
Rommel Q. De Leon, M.D. Maria Cecilia T. Leyson,
M.D.
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• Operational concept of acute abdomen in newborn
• any abdominal condition from various causes
  involving the intra-abdominal organs that
  requires immediate/urgent intervention in newborn
  (1-28 Day of Life)

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• The two general categories of acute abdomen in
  newborn
• Acute Surgical abdomen requiring immediate
  operative intervention
• Acute Non-Surgical Abdomen requiring
  immediate non-operative intervention

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• What are common causes of acute surgical abdomen
  in newborn?
• Non-Trauma
• G.I. Obstruction
• G.I. bleeding
• G.I. Perforation
• Abdominal Wall defects
• Trauma

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• What are the more common causes of acute
  non-surgical abdomen?
• Non-trauma
• Ileus
• Diarrhea

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NEONATAL INTESTINAL OBSTRUCTION
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• What are reliable signs and symptoms (more than
  90 certainty) that a newborn patient has
  intestinal obstruction?
• Patient with imperforate anus
• Patient with perforate anus with
• Abdominal distention
• Persistent vomiting
• Non-passage of meconium within the first 24 hours
  of life or non-passage of stool within 24 hours

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• Types of Intestinal Obstruction
• Mechanical
• no recent history of systemic illness prior to
  the presentation of intestinal obstruction
• Non Mechanical
• recent history of systemic illness prior to the
  presentation of intestinal obstruction

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Causes of mechanical intestinal obstruction

• High Obstruction
• Gastric outlet obstruction 11,000,000 live
  births
• pyloric atresia
• Pyloric stenosis
• Antral web

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• Duodenal obstruction
• Duodenal atresia
• Duodenal stenosis
• Annular pancreas
• Preduodenal portal vein
• Malrotation
• Jejunal obstruction
• Atresia
• Jejunal stenosis

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Causes of mechanical intestinal obstruction

• Low Obstruction
• Distal small bowel
• Ileal atresia
• Meconium ileus
• Uncomplicated
• Complicated

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• Colonic obstruction
• Dysmotility states
• Meconium plug 1500-1,000 live births
• Small left colon syndrome -- rare
• Hirschsprung's disease 14,000 live births
• Colonic atresia
• Anorectal malformations 14,00-8,000

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Reliable S/Sx of High Obstruction

• Localized distention
• Upper abdomen
• Generalized Distention

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Algorithm
patient
DRE
Imperforate anus
Perforate anus
Abdominal Distention
Generalized/ Diffuse
Localized
High Obstruction
Low Obstruction
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• In a newborn patient with suspected neonatal
  intestinal obstruction, what is the most
  cost-effective initial procedure?
• Ans
• High Obstruction
• Plain abdominal film
• Upper GI series

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• Low Obstruction
• Contrast Barium

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• What are reliable signs and symptoms (more than
  90 certainty) that a newborn patient has
  intestinal obstruction that needs operation?
• Signs of peritonitis
• Clinical deterioration
• Unequivocal clinical evidence of obstruction
• Radiographic evidence of obstruction

Mattei, P. Neonatal Intestinal Obstruction.
Surgical Directives Pediatric Surgery.
2003313-316
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TREATMENT GOALS

• Neonatal intestinal obstruction
• Identification of cause
• Relieve the obstruction
• Restore bowel continuity (if stable)

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Gastrointestinal Bleeding in Newborn
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Causes of Upper GI Bleeding

• Hemorrhagic disease of the newborn
• Stress gastritis
• Systemic illness

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Causes of Lower GI Bleeding

• Hemorrhagic disease of the newborn
• Necrotizing enterocolitis
• Presence of systemic illness

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• In a newborn patient with neonatal
  gastrointestinal bleeding, what is the most
  cost-effective initial procedure?
• Vigilant observation/examination

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• TREATMENT GOALS
• Identification of cause
• Control the bleeding

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Treatment of Upper GI Bleeding

• Hemorrhagic disease of the newborn
• Self-limiting
• Give 1mg Vit K
• Swallowed maternal blood
• Stress gastritis
• Nasogastric suctioning
• Lavage
• H2-blockers

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Treatment of Lower GI Bleeding

• Anal fissure
• Stool softners
• Rectal dilatation
• Necrotizing enterocolitis
• Antibiotics
• Bowel rest
• TPN
• Malrotation with volvulus
• Emergency surgery

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Meconium Peritonitis
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Perforation

• Relaible S/Sx
• No reliable signs of perforation
• Abdominal distention is a clue for perforation
• Paraclinical Diagnosis
• Plain abdominal film

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Meconium Peritonitis

• Is a chemical or foreign-body reaction of the
  peritoneum to prenatal perforation of the
  intestinal tract
• The perforation may sealed off before birth or it
  may persists

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ETIOLOGY

• Meconium ileus, vascular compromise
• Atresias or stenosis, intussusception
• Volvulus, congenital bands etc.
• intestinal obstruction
• Intrauterine intestinal perforation

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• INTESTINAL PERFORATION
• MECONIUM LEAKS INTO PERITONIUM
• PERITONIUM WILL EXHIBIT RAPID
• FIBROBLAST PROLIFERATION
• FIBROBLASTIC ADHESION
• ENVELOPS THE LESION
• PSEUDOCYSTS
• INCREASE VASCULARITY
• FORMATION OF MATURE COLLAGEN
• FOREIGN BODY GRANULOMAS
• CALCIFICATIONDEVELOPS

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Four Pathologic Types

• TYPE I Meconium Pseudocysts
• Perforation not sealed in utero
• Fibrous cysts wall formed from the surrounding
  bowel loops
• Gangrenous segment of the intestine is a major
  part of the cysts
• Rest of the intraperitoneal cavity devoid of
  adhesions
• Calcifications may lined the walls

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Four Pathologic Types

• TYPE II Plastic Generalized Meconium
  Peritonitis
• Wide spread spillage of meconium throughout the
  peritoneum
• Scattered peritoneal calcifications
• Dense fibrous adhesions
• Intestinal obstruction occurs due to adhesions

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Four Pathologic Types

• TYPE III Meconium Ascites
• Perforation occurs shortly before birth
• Meconium-stained ascitic fluids
• Fine stripped calcification may be present

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Four Pathologic Types

• TYPE IV Infected Meconium Peritonitis
• Perforation that did not sealed off before birth
• There is colonization of neonatal gut allows
  bacterial peritonitis
• Air and meconium present in the peritoneal cavity
• The most serious type of meconium peritonitis

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• Clinical Presentation
• 1 in 35,000 live births
• Intestinal obstruction is the most common
  presentation
• Vomiting may be present on the first or 2nd day
  of life
• Plain abdominal x-rays shows intestinal
  obstruction and intraabdominal calcifications

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• INDICATIONS FOR OPERATION
• INTESTINAL OBSTRUCTION
• PERSITENT INTESTINAL LEAKS
• Specific indications
• X-ray evidence of intestinal obstruction and
  intraperitoneal air
• Abdominal mass encysted meconium
• Localized or generalized cellulitis of the
  abdominal wall
• sepsis

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• GOAL OF MANAGEMENT
• Remove all devitalized tissue
• Preservation of adequate length of bowel
• Reestablish bowel continuity

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Abdominal wall defects in newborn
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• GASTROSCHISIS
• Congenital defect of the abdominal wall
• right of the umbilicus
• no sac or membrane covering the midgut
• OMPHALOCOELE
• Congenital defect in which the abdominal viscera
  remain herniated
• covered with sac

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• Etiology
• - failure of the lateral portion of the
  abdominal wall to join its upper and lower
  component
• - failure in the muscular migrating from the
  dorsal myotomes invade the splanchnopleura of
  the embryomic abdominal wall

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• Goals of treatment
• - close defect
• - prevent dehydration and electrolyte imbalance
• - return of bowel function

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• Treatment
• primary abdominal closure
• prevention of dehydration and electrolyte
  imbalanve

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Omphalocele

• congenital defect in which the abdominal viscera
  remain herniated
• covered with sac

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Paraclinical

• X Ray
• AP/L
• Lateral presence of presacral gas

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Paraclinical for GI Bleeding

• Hemorrhagic dse
• Necrotizing Enterocolitis
• Xray
• Clinical with a background of a septic px

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Paraclinical for Perforation

• Xray
• Plain abdomen upright

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• Etiology
• -incomplete fetal growth and fusion of the
  cephalic, lateral and caudal tissue
• - usually present with congenitak gear dye.

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• Treatment goals

• -close defect
• - prevent dehydration and electrolyte imbalance
• return of bowel function

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• Treatment
• primary closure of the defect

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Abdominal Trauma in Newborn
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• 25 of total trauma victims are children
• Blunt abdominal traumamost common

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Abdominal Trauma

• What are reliable signs and symptoms (more than
  90 certainty) that a patient with abdominal
  trauma needs urgent operation?
• Ans
• -hemodynamic instability
• -definite (persistent, progressive) direct
• tenderness with at least guarding
• -abdominal rigidity

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Abdominal Trauma

• Most common causes
• Birth canal trauma
• Vehicular accident

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Abdominal Trauma

• In a newborn patient with suspected blunt
  abdominal trauma, what is the most cost-effective
  initial procedure?
• Ultrasound

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Clinical Questions

• 9. What are reliable symptoms and signs (more
  than 90 certainty) that a patient has perforated
  abdominal viscus that needs urgent operation?
• Ans
• -definite (persistent, progressive) direct
  tenderness with at least guarding
• -abdominal rigidity

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References

• Baucke VL Failure to Pass Meconium Diagnosing
  Neonatal Intestinal Obstruction, American Family
  Physician, vol 60, 1999
• Irish MJ, Pearl Pediatric Surgery for the
  Primary Care of Pediatrician, The Approach to
  Common Abdominal Diagnoses In Infants and
  Children Pediatric Clinics of North America,
  vol 45, 1990
• Jona J Advances in Neonatal Surgery,
  Neonatology Update, Pediatric Clinics of North
  America, vol 95, 1998
• Kimura K Bilious Vomiting in the Newborn, Rapid
  Decision of Intestinal Obstruction American
  Family Physician vol 61, 2001
• Schulman MH Imaging of Neonatal
  Gartrointestinal Obstruction, Radiologic Clinic
  of North America, vol 37, 1999