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378 Neonatal Intestinal Obstruction

Once a diagnosis is suspected, contrast studies may help
in assessing the rest of the bowel and/or be therapeutic. Such
investigation is paramount for the demonstration of the anatomy in
ARM after a colostomy has been performed and to assess the length
and level in HD (see Figure 61.5). A water-soluble contrast enema
will help to clear the thick meconium in meconium ileus.
Further radiological studies have to be requested to assess
associated abnormalities such as those included in the acronym
VACTERL (vertebral, anorectal, cardiac, tracheo-oesophageal, renal,
and limb).
Blood tests are needed to facilitate and modulate resuscitation.
Depending on the severity of the condition and its delayed presentation,
blood products might be needed for the surgery.
Management
Preoperative Treatment
All conditions need fluid resuscitation and nasogastric decompres-
sion. Broad-spectrum antibiotics should be started prophylactically. Figure 61.4: Contrast enema study showing microcolon.
Condition-Specific Management
Duodenal atresia
Evaluate for trisomy 21. Because duodenal atresia is considered a
midline defect, an evaluation for associated anomalies should include
echocardiography, head and renal ultrasonography, and vertebral
skeletal radiography.
Jejunoileal atresia
Intraoperatively distal atresias can be identified by flushing the distal
intestinal lumen with warm saline to confirm intestinal continuity
down to the level of the rectum.
Meconium ileus
The traditional gastrografin enema has been replaced with a water-
soluble contrast enema, which is equally effective in loosening the
meconium impaction. The enema fluid must be refluxed into the
terminal ileum.
N-acetylcysteine may be administered by NGT to further loosen
the meconium.
Hyperosmolar enemas may increase the risk of hypovolaemic
shock and injury to the intestine with perforation. The risk of
perforation is reportedly 3–10%.
Meconium plug syndrome
A gentle rectal washout with temperate normal saline might alleviate
the obstruction immediately. A rectal suction biopsy and or a contrast Figure 61.5: Contrast enema in Hirschsprung’s disease showing diseased
narrow bowel, transition zone, and dilated normal bowel.
enema should rule out HD.
Full-thickness rectal muscle biopsy is recommended where there
is no frozen section or histochemical assay available
Hirschsprung’s disease
Initial rectal washout will alleviate the obstruction. Rectal suction
biopsy or full thickness biopsy will confirm the diagnosis. A contrast
enema will show the level of disease.
Imperforate anus
An 18-hour plus AXR, which is the time required for swallowed air to
reach the level of obstruction, will help to show the level of abnormality.
Operative Therapy
Duodenal atresia
A diamond-shaped or side-to-side duodenoduodenostomy is an easy
procedure to bypass the obstruction.
Malrotation with volvulus Figure 61.6: Contrast study showing malrotation with volvulus.
Malrotation with midgut volvulus (Figure 61.6) is a true surgical
emergency in the newborn. Delay in operation may result in cata-
strophic loss of the bowel and death.