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BILIOUS VOMITING
Resuscitation* History, age of onset and associated symptoms
Abdominal film;
Distention Air-fluid levels Sweat test Groundglass sign
Abdominal film,
doublebubble sign
Abdominal film:
air fluid level
Ultrasound; Upper GI spiral sign - Abnormal location of the superior mesenteric vessels
Abdominal film;
Distention Pneumatosis Air in the aortal vein
Meconium Ileus
Duodenal Atresia
Jejunoileal atresia
Necrotizin g Ileus
Meconium Ileus
Duodenal Atresia
Jejunoileal atresia
Necrotizin g Ileus
Diamond-shaped duodenoduodenostomy
Ladd's procedure
I. Preoperative Management:
Place infant in an incubator for close observation and temperature control
Place nil by mouth Nasogastric or orogastric catheter should be placed for gastric decompression to prevent further vomiting and aspiration
Establishment of an intravenous line should follow for administration of fluid, electrolytes and nutrition
II. Postoperative:
Same as preoperative plus nasogastrotube is inserted until passing of the stool or present of intestinal sound and then start oral feeding
Malrotation
Early volvulus
Late volvulus
Clinical Picture
1. Bilious Vomiting
2. Acute symptoms of:
Intermittent abdominal pain Diarrhoea Constipation Haematochezia
Investigations
1. Plain x-ray abdomen
Double bubble sign
Plain x-ray
Ultrasound
Reversal of the normal superior mesenteric artery (SMA)/superior mesenteric vein (SMV) relationship
Whirlpool sign of malrotation shows whirling bowel and associated mesenteric vasculature
Contrast Study
Malrotation with midgut volvulus and duodenal obstruction. The position of the duodenojejunal junction is abnormal.
Corkscrew appearance
Ladds Procedure
A. B. the
The abdomen is opened The small intestines are seen first and appear to hide colon. The entire intestinal mass is delivered out of the abdomen
C. D.
The intestinal mass is rotated to reduce the volvulus The intestines are re-positioned in the abdomen
Duodenal Atresia
COMPLAINT
Resuscitate untill hemodynamically stable RESUSCITATION early (few hours after birth) bilious vomiting No abdominal distension (may have but uncommon) No passage of meconium (may have in incomplete type) Associated symptom : Down syndrome in 1/3 of patient 20% have congenital heart VACTERL
EXAMINATION
INVESTIGATION
Contrast study: - Gastrographin meal (diagnose the incomple type) Bypass surgery: -duodenodeuodenostomy -duodenojejunostomy
TREATMENT
Preoperative measure
Jejunoileal Atresia
Types
CLINICAL PICTURE
Bilious vomiting Absent bowel sounds No meconium Abdominal distention
INVESTIGATIO NS
1. Plain x-ray Thumb-sized loops of bowel with air-fluid levels 2. Barium enema Define microcolon
TREATMEN T
Preoperative Operative: 1. Resection and primary anastomosis of atretic segments 2. Tapering enteroplasty (limited bowel length)
Meconium Ileus
SIGNS OF INTESTINAL OBSTRUCTI ON Bilious emesis Abdominal distention Palpable loops of small intestine
INVESTIGATION S 1. Plain x-ray distended intestine, absence of airfluid levels, "soap bubble" appearance 2. Contrast enema 3. Investigations of cystic fibrosis
A. Illustration of intestine blocked by meconium. B. Abdominal x-ray of a newborn infant with meconium ileus showing dilated loops of bowel.
TREATMENT
NONOPERATIVE
[Evacuation of meconium] 1. Multiple enemas 2. Dilute Gastrograffin with N-acetylcysteine
OPERATIVE
3. Hyperosmolar solutions
(1% acylcysteine)
Necrotizing Enterocolitis
Clinical Picture
Gastrointestinal
Systemic
Feeding intolerance Abdominal distention Abdominal erythema & tenderness Emesis Occult/gross blood in stool Abdominal mass
Temperature instability
Hypotension Acidosis Glucose instability DIC Positive blood cultures
(pathognomic)
Linear streaking pattern
Bubbly pattern
3. Pneumoperitoneum
Pneumatosis Intestinalis
Note the air visible in the bowel wall. The air dissects the bowel wall giving it a double lined appearance (railroad tracks without the ties)
Pneumoperitoneum
Treatment
1. Preoperative preparations 2. Operative: Resection of necrotic bowel and
enterostomy
Indications:
Absolute indication: pneumoperitoneum Clinical deterioration despite medical management Positive paracentesis Fixed intestinal loop on serial x-rays Erythema of abdominal wall
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