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
Treatment
Goals of treatment
Resolution of Obstruction
Prevention of complications
Treatment
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
Treatment
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
Treatment
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.
Treatment
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
Treatment
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
MALROTATION WITH MIDGUT VOLVULUS
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
Symptoms
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
Symptoms
Sharing of Information
Diagnosis
- 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.
THANK YOU !!!
References
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. eMedline.com
Digestive and Liver Disorders.eMedline.com
Malrotation with Midgut Volvulus. LearningRadiology.com
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
MCR.
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