Make your own free website on

Case Management Presentation and Discussion and Sharing of Information on Acute Abdomen in the Newborn

Benjamin C. Deveza, M.D.

General Data :

10-day-old female infant

Chief complaint :

bilious vomiting
History of Present Illness

Pre-Natal History

Born to a 27-year-old mother,
G1P1 (1001), full term via NSD without any complications
Physical Examination
Awake, irritable
CR 110 RR 20 T 37
Pink palpebral conjunctiva, anicteric sclerae, supple neck, no CLAD
Symmetrical chest expansion, no retractions, clear breath sounds,
Physical Examination
Adynamic precordium, with regular rate, rhythm
distended, hypoactive bowel sounds, soft,
Pulses full and equal; no edema, cyanosis
Case Discussion
Salient Features
10-day-old female infant
(+) bilious vomiting
(+) abdominal distention
(+) failure to pass meconium

Bilious vomiting

Bilious vomiting

Bilious vomiting

Do I need a Paraclinical Diagnostic procedure?
- Yes. To increase my degree of certainty

Paraclinical Diagnostic Procedures
Paraclinical Diagnostic Procedures
X-ray findings
X-ray findings
Pre-Treatment Diagnosis
Goals of treatment
Resolution of Obstruction
Prevention of complications
Malrotation of the intestines is not usually evident until the intestine becomes twisted (volvulus) or obstructed by Ladd's bands and symptoms are present.
A volvulus is considered a life-threatening problem, because the intestine can die when it is twisted and does not have adequate blood supp
Specific treatment for malrotation and volvulus will be determined by your child's physician based on the following:
the extent of the problem
child's age, overall health, and medical history
expectations for the course of the problem

A volvulus is usually surgically repaired as soon as possible. The intestine is untwisted and checked for damage.
A volvulus occurs clockwise and it is therefore untwisted counterclockwise.
Subsequently, Ladd’s procedure is performed.
The Ladd’s Procedure
- the bands between the cecum and the abdominal wall and between the duodenum and terminal ileum are divided sharply to splay out the superior mesenteric artery and its branches
The Ladd’s Procedure
- the manuever brings the straightened duodenum into the right lower quadrant and the cecum into the left lower quadrant

- appendix is removed to avoid diagnostic errora in later life
Sharing of Information

Intestinal malrotation occurs when the intestine does not twist correctly. Instead, the way in which it twists blocks the intestine.
Sharing of Information
Sometimes, abnormal tissue referred to as Ladd’s bands attaches the cecum to the duodenum (beginning of the small intestine) and may create a blockage in the duodenum.
Sharing of Information
Our intestines are formed while we are fetuses in the womb, during the tenth week of gestation. As the intestines develop, they normally move from the base of the umbilical cord back into the abdominal cavity. As the intestine returns to the abdomen, it makes two rotations and settles into its normal position.
Sharing of Information
When rotation is incomplete and the intestine does not become fixed into that position, this creates intestinal malrotation.
Sharing of Information
The malrotated intestine is prone to twisting in on its own blood supply, blocking the flow. This is called volvulus.
When volvulus involves the entire small bowel, it is referred to as mid-gut volvulus.

Sharing of Information
Many children with intestinal malrotation also have another congenital (present at birth) problems.
These may involve the abdominal wall or the digestive system, the heart, or the liver or spleen.
Sharing of Information
Malrotation of the intestine is usually not evident until the intestine becomes obstructed by Ladd’s bands or twisted.

When the intestine is obstructed by Ladd’s bands or when the blood supply is twisted, symptoms may include:
Sharing of Information

Sharing of Information

- Abdominal x-ray
- Upper GI series
- Barium enema
- Ultrasound

Sharing of Information Treatment
Once volvulus and/or intestinal malrotation is diagnosed, children begin receiving fluids and antibiotics intravenously.
The fluids keep them from becoming dehydrated, and the antibiotics prevent infections.
A nasogastric tube is placed from the nose into the stomach to prevent gas buildup in the stomach.
Sharing of Information Treatment
As soon as possible, surgery is performed to untwist the intestine. If it is not damaged too badly, the intestine’s circulation may be restored after it is untwisted.
If the intestine is healthy, an operation called the Ladd’s procedure is performed to repair the malrotation.
Sharing of Information Treatment
If the surgeon is not sure the intestine will receive an adequate blood supply even after untwisting, they may need to perform another operation.
Sharing of Information Treatment

This is usually performed within 24 to 48 hours of the first operation. If they find a section of intestine that is damaged so badly it can not be saved, that portion is removed.

Sharing of Information Prognosis
The long-term outcome is generally very good when malrotation is surgically corrected before intestinal damage occurs.
Older children also tend to do well.
However, when a large portion of intestine has to be removed because of intestinal injury, the remaining intestine has trouble absorbing nutrients and fluids .
Sharing of Information Prognosis
The child’s regular diet may need to be supplemented or replaced with total parenteral nutrition (TPN).
Sharing of Information Prognosis
TPN is very effective, but if it is given over a long period of time, children are at risk for developing chronic liver disease.
In a case like this, a child may be considered for an intestinal transplant to protect his or her liver.

Cameron,J.L. Current Surgical Therapy 8th Ed; 2004: 663-664
Rhoads, J.E. Textbook of Surgery Principles and Practice 5th Ed; vol 1 :
Schwartz, S.I. Principles of Surgery 8th Ed 2005
McKellar, D.P. Prognosis and Outcomes in Surgical Disease. 1999
Intestinal Malrotation and Volvulus: An Overview.
Digestive and Liver
Malrotation with Midgut Volvulus.

MCQ: Choose the best answer

1. What is the cardinal symptom of intestinal obstruction in the newborn?
a. abdominal distention
b. bilious vomiting
c. tachycardia
d. abdominal pain

2. What structure differentiates the type of intestinal obstruction as to proximal or distal?
a. ileocecal valve
b. cecum
c. ligament of Treitz
d. jejunum

Direction: Write
“A” if 1, 2, and 3 are valid statements.
“B” if only 1 and 3 are valid statements.
“C” if only 2 and 4 are valid statements.
“D” if only 4 is a valid statement.
“E” if all are valid statements.

3. What are the causes of intestinal obstruction with bilious vomiting in the newborn?
1. Duodenal atresia
2. Malrotation with volvulus
3. Jejunoilieal atresia
4. Meconium Ileus

4. What are the components of Ladd’s procedure?
1. lysis of cecal and duodenal bands
2. Broadening the mesentery
3. Appendectomy

4. Colostomy

5. What are the diagnostic procedures that will help in the diagnosis of malrotation and volvulus?
1. CT scan
2. Upper GI series
3. Endoscopy
4. Barium enema



Table of Contents