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414 Miscellaneous Causes of Intestinal Obstruction

Bezoars are masses of solidified ingested materials (organic The main presenting feature of either sigmoid volvulus or
or inorganic) found in the stomach or small intestines that can ileosigmoid knotting is acute onset of abdominal distention and
cause intestinal obstruction in children. 7,12 They are of many types. pain followed by obstipation. In ileosigmoid knotting, however, the
Trichobezoars are seen in the mentally retarded as well as in abdominal distention may not be remarkable. Vomiting may be also
emotionally disturbed children, typically teenage girls, and usually be present. Investigations include plain abdominal x-ray, which may
consist of swallowed hair or random ingested objects. Phytobezoars show a bent inner-tube sign. The classic features of sigmoid volvulus
are made of vegetable material and usually obstruct the distal ileum, or on plain abdominal films are not as obvious in ileosigmoid knotting.
stomach, especially postvagotomy. Lactobezoars are usually observed Contrast enema studies occasionally can be helpful in doubtful cases.
in premature infants receiving early feeding of undiluted milk. They However, such investigations, as well as small bowel follow-through
can be caused by powdered formulas mixed inappropriately. studies, should be used judiciously because they could precipitate
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Presentation and diagnosis intestinal perforation, especially in ileosigmoid knotting. After the
diagnosis is made, laparotomy should not be delayed once fluid and
Children usually present with vomiting and failure to thrive. An epi-
electrolytes status has been corrected and broad spectrum antibiotics
gastric mass, often in the shape of the stomach, may be palpable on
administered. 16,17 Bowel gangrene is common, and resection with
physical examination. Plain films of the abdomen are often diagnostic,
anastomosis of the bowel should be done in these cases.
but upper gastrointestinal contrast study may be needed in some cases.
Internal Herniation
Management
Bezoars in the stomach may be broken apart by using an Bowel herniation into abnormal or normal peritoneal recesses could
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endoscope. This may be facilitated by introducing pancreatic enzymes. lead to acute intestinal obstruction in children. Herniation could occur
Laparotomy with gastrostomy or enterostomy may be needed to into normal, anatomic duodenal, or caecal recesses, leading to intesti-
remove hairs that cause complete obstruction. Care must be taken to nal obstruction. Postoperative defects in the mesentry can also lead to
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remove the entire bezoar because it can fragment on removal and be herniation of the bowel and subsequent obstruction and strangulation.
lodged more distally, causing further problems. In cases of colonic Other abnormal sites for herniation of the bowel leading to obstruction
obstruction, colostomy may be needed. The underlying disorder include the falciform ligament, if a defect is present, and the foramen
20,21
resulting in bezoar formation, such as a psychological problem, must of Winslow. A high index of suspicion is needed for prompt diag-
be managed appropriately. nosis and subsequent treatment because delay usually leads to bowel
gangrene, which increases the mortality rate.
Parasites Other Causes
Parasites can cause intestinal obstruction, generally in the mid or dis-
External abdominal masses such as intraabdominal tumours, faecal
tal small bowel, but can even occur in the large bowel. In the tropics,
impaction, paralytic ileus, and benign bowel tumours can result in
Ascaris lumbricoides is the most common parasite involved. These
intestinal obstruction in children.
worms usually get entangled in the small intestine, producing a mass
that could lead to intestinal obstruction. Although the majority of Evidence-Based Research
children present with a subacute course, about a quarter present with Articles on adhesive bowel obstruction in children in Africa are scanty.
features of acute intestinal obstruction, including vomiting, abdomi- Prospective studies are few, and available guides have to be based on
nal distention, and constipation. 13–15 Some children may present with retrospective studies, many of which are from the West. Table 69.2
vomiting of the round worms or passage of the worms through the presents a large series involving postoperative bowel obstruction in
rectum. Investigations include plain abdominal x-ray in additional to newborns and infants.
stool examination for evidence of parasites. The plain roentgenogram
Table 69.2: Evidence-based research.
of the abdomen may show a typical “whirlpool” pattern that indicates
Title High incidence of post-operative adhesions in newborns and
intraluminal worms in most cases. Children with subacute intestinal
infants
obstruction usually respond to the administration of an oral antihel-
Authors Young JY, Kim DS, Muratore CS, Kurkchubasche A, Tracy TF
mintic such as piperazine and management of pain using antispasmod- Jr, Luks FI
® 15
ics such as Buscopan . Patients with acute intestinal obstruction
Institution Division of Pediatric Surgery, Brown Medical School,
should be quickly resuscitated by using intravenous fluids and then
Providence, Rhode Island, USA
undergo emergency laparotomy. At laparotomy, the worms should be
Reference J Pediatr Surg 2007; 42:962–965
disimpacted and milked into the distal colon. In cases of bowel gan-
grene, resection and anastomosis of the bowel is done. However, in Problem The incidence of, risk factors for, and need for operative
intervention in postoperative bowel obstruction in children.
the latter situation, note that worms could migrate into the peritoneal
cavity through the anastomosis site. Comparison/ The authors reviewed children who had laparotomy or
Sigmoid Volvulus and Ileosigmoid Knotting control laparoscopy to determine the incidence of small bowel
obstruction due to adhesions. They also compared the
(quality of
Sigmoid volvulus and ileosigmoid knotting are rare in children but evidence) incidence in older children to that in infants and neonates.
can cause intestinal obstruction with lethal consequences. The main Outcome/ Of 2,187 abdominal operations performed in children, 61
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predisposing factor to sigmoid volvulus is a large redundant sigmoid effect (2.8%) had postoperative bowel obstruction, 70.5% of these
colon with a narrow base, which then acts as a fulcrum for the sigmoid requiring reoperation. Postoperative bowel obstruction
colon to twist, usually in a counterclockwise direction. Ileosigmoid was more common in children younger than 1 year of age
compared to older children (P = 0.01). Infants are significantly
knotting involves the twisting of the small bowel and sigmoid mesen- more likely to require operative intervention compared with
teries around each other. The mechanism for ileosigmoid knotting is older children (P = 0.01).
unclear. An excessively mobile small bowel due to an elongated mes- Historical This large series supports previous evidence that
entery, combined with a long sigmoid colon on a narrow mesenteric significance/ nonoperative management of adhesive small bowel
pedicle, along with the ingestion of a bulky diet in the presence an Comments obstruction often fails in infants and younger children. A
laparotomy is often needed when postoperative obstruction
empty small bowel have been suggested as a possible mechanism. 17,18 occurs in this age group, and it should be performed with
minimum delay.