Surgical Neonatal Vomiting

Август 10, 2022

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Surgical Neonatal Vomiting

Содержание

2. Interactive Case studies Summary of specific surgical conditions
3. What is a neonate? What is preterm? What is term?
4. Definitions Neonate – premature and term babies less that 44 weeks post-conceptional age Premature neonate Term
5. History and Symptoms
6. History and Symptoms Gestation Weight Antenatal history Colour of vomit Frequency of vomit Bowel opening Saliva?
7. Physical Findings
8. Physical findings Observations Erythema and bruising Distended Scaphoid abdomen Mass Anus – site, size and patency
9. Investigations Plain AXR/CXR Upper/Lower GI contrast Abdominal USS
10. Case 1 Term neonate 1 day old Vomiting Relevant points in history Relevant examination findings Differential
12. Oesophageal atresia and tracheo-oesophageal fistula 1 in 3500 liveborn births Antenatal Polyhydramnios, absent stomach, associated anomalies
13. Classification Type A: 8%, Type B: 1%, Type C: 86%, Type D 1%, Type E: 4%
14. Repair Right thoracotomy (usually) 4th or 5th intercoastal space Extrapleural approach +/- division of azygous vein
18. Duodenal Atresia 1 in 5000 Antenatal diagnosis – ‘double bubble’ Associated with Trisomy 21 - 30%,
20. Malrotation +/- volvulus
21. Malrotation 1 in 6000 present in babies 0.5% of autopsies show degree of malrotation Abnormal duodenal
22. Malrotation + volvulus SURGICAL EMERGENCY Bilious vomiting in neonate Upper GI contrast to diagnose Emergency laparotomy
24. Jejunal/Ileal atresia Stenosis – 11% Type 1 – 23% Type 2 – 10% Type 3 –
25. Jejunal/ileal atresia 1 in 5000 births Aetiology – antenatal vascular compromise May have short bowel Resection
26. Meconium Ileus CF – 1 in 2500 births ~16% of babies with CF Inspissated sticky meconium
27. Microcolon in Meconium ileus
28. Hirschsprung Disease
29. Hirschsprung Disease 1 in 5000 births M:F 4:1 Associated with Trisomy 21 Delayed passage of meconium
30. Hirschsprung Disease Aganglionosis of bowel Variable failure of neural crest cell migration Rectosigmoid – 75% Long
31. Anorectal malformation
32. Anorectal malformation 1 in 4000 births Management depends on level of ARM Primary anoplasty for low
33. Case 2 3 week old term baby Relevant points in history Relevant examination findings Differential diagnosis
34. Infantile Hypertrophic Pyloric Stenosis 1-4:1000, M:F 4:1 Overgrowth of pyloric muscle Gastric outlet obstruction Increasing non-bilious
35. Pyloric stenosis
36. Infantile Hypertrophic Pyloric Stenosis Diagnosis – palpable mass on ‘test feed’ USS Pyloric length >16mm Single
37. Inguinal hernia
38. Inguinal hernia Usually can reduce If truly incacerated – emergency exploration Otherwise if premature baby or
39. Case 3 Preterm neonate – bilious vomiting Born 27 weeks gestation Weight 1 kg 1 week
43. Necrotising Enterocolitis 90% in preterm 10% in term babies ~5% of all babies admitted to Neonatal
44. Necrotising Enterocolitis Surgery indicated for: Worsening clinical condition despite maximal supportive therapy Perforation Laparotomy Assess extent
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Interactive
Case studies
Summary of specific surgical conditions

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What is a neonate?
What is preterm?
What is term?

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Definitions
Neonate – premature and term babies less that 44 weeks post-conceptional

age
Premature neonate <37 weeks post-conceptional age
Term neonate 37-40 weeks post-conceptional age
Post term >40 weeks post-conceptional age

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History and Symptoms

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History and Symptoms
Gestation
Weight
Antenatal history
Colour of vomit
Frequency of vomit
Bowel opening
Saliva?
Associated co-morbidities

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Physical Findings

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Physical findings
Observations
Erythema and bruising
Distended
Scaphoid abdomen
Mass
Anus – site, size and patency
Tenderness
External

genitalia – normal? Palpable testes?
Inguinal hernia

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Investigations
Plain AXR/CXR
Upper/Lower GI contrast
Abdominal USS

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Case 1
Term neonate
1 day old
Vomiting
Relevant points in history
Relevant examination findings
Differential diagnosis

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Oesophageal atresia and tracheo-oesophageal fistula
1 in 3500 liveborn births
Antenatal
Polyhydramnios, absent stomach,

associated anomalies
Salivation, cyanosis on feeding
Inability to pass NGT
Associated anomalies:
Vertebral – butterfly vertebra, rib anomalies
Anorectal
Cardiac – Tetralogy of Fallot, AVSD, ASD, VSD etc
Tracheo-oesophageal fistula
Esophageal atresia
Renal – dyeplasia, agenesis and other defects
Limb – radial ray defects

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Classification
Type A: 8%, Type B: 1%, Type C: 86%, Type D

1%, Type E: 4%

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Repair
Right thoracotomy (usually)
4th or 5th intercoastal space
Extrapleural approach
+/- division of azygous

vein
Identification of TOF
Transfixion and division
Identification of upper pouch
End to end full thickness anastomosis
Transanastomotic tube
+/- post op contrast study

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Duodenal Atresia
1 in 5000
Antenatal diagnosis – ‘double bubble’
Associated with Trisomy 21

- 30%, malrotation
Milky or bilious vomiting depending on level of obstruction in relation to bile duct
85% obstruction distal to bile duct
Side to side duodenoduodenostomy

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Malrotation +/- volvulus

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Malrotation
1 in 6000 present in babies
0.5% of autopsies show degree of

malrotation
Abnormal duodenal loop
Narrow mesentery
Peritoneal band ‘Ladds’ bands from caecum to lateral abdominal wall
Clockwise torsion of entire midgut

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Malrotation + volvulus
SURGICAL EMERGENCY
Bilious vomiting in neonate
Upper GI contrast to

diagnose
Emergency laparotomy to devolve bowel
counterclockwise
Total gut necrosis – life threatening

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Jejunal/Ileal atresia
Stenosis – 11%
Type 1 – 23%
Type 2 – 10%
Type

3 – 35%
Type 4 – 21%

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Jejunal/ileal atresia
1 in 5000 births
Aetiology – antenatal vascular compromise
May have short

bowel
Resection and anastomosis
May be multiple
May require tapering
May be end to end or end to side depending on discrepancy

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Meconium Ileus
CF – 1 in 2500 births
~16% of babies with CF
Inspissated

sticky meconium
Distal small bowel obstruction
May be complicated
Microcolon on contrast enema
may be therapeutic
Contrast enema
Laparotomy and washout of bowel +/- stoma

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Microcolon in Meconium ileus

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Hirschsprung Disease

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Hirschsprung Disease
1 in 5000 births
M:F 4:1
Associated with Trisomy 21
Delayed passage of

meconium >48hours
Abdominal distension
Vomiting – may be bilious
Diagnosis – rectal biopsy
Aganglionosis, thickened nerve trunks, increased acetylcholinesterase

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Hirschsprung Disease
Aganglionosis of bowel
Variable failure of neural crest cell migration
Rectosigmoid –

75%
Long (colonic) segment – 15%
Total colonic – 5-7%
Total interstinal – <5%
Spastic bowel – failure to relax
Requires decompression – rectal washouts
Definitive surgery – pullthrough of ganglionic bowel

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Anorectal malformation

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Anorectal malformation
1 in 4000 births
Management depends on level of ARM
Primary anoplasty

for low
Stoma and delayed reconstruction for high
Recto-urethral fistula most common in boys
Recto-vestibular fistula most common in girls

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Case 2
3 week old term baby
Relevant points in history
Relevant examination findings
Differential

diagnosis

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Infantile Hypertrophic Pyloric Stenosis
1-4:1000, M:F 4:1
Overgrowth of pyloric muscle
Gastric outlet obstruction
Increasing

non-bilious vomiting
Metabolic derangement
Hypochloremic
Hypokalaemic
Metabolic alkalosis
Medical emergency - rehydration

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Pyloric stenosis

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Infantile Hypertrophic Pyloric Stenosis
Diagnosis – palpable mass on ‘test feed’
USS
Pyloric length

>16mm
Single muscle thickness >4mm
Pyloromyotomy
Open – supraumbilical or RUQ
Laparoscopic

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Inguinal hernia

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Inguinal hernia
Usually can reduce
If truly incacerated – emergency exploration
Otherwise if premature

baby or younger than 4 weeks post birth – repair urgent basis

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Case 3
Preterm neonate – bilious vomiting
Born 27 weeks gestation
Weight 1 kg
1

week post birth
Relevant points in history
Relevant examination findings
Differential diagnosis

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Necrotising Enterocolitis
90% in preterm 10% in term babies
~5% of all babies

admitted to Neonatal Unit
Multifactorial pathogenesis
Inflammation and coagulative necrosis
20-40% require surgery
Up to 50% mortality reported in those requiring surgery
Worst outcome extremely low weight preterm babies

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Necrotising Enterocolitis
Surgery indicated for:
Worsening clinical condition despite maximal supportive therapy
Perforation
Laparotomy
Assess extent

of disease - may be total gut necrosis
Resection anastomosis – if appropriate
Resection and stomas
‘Clip and drop’

Surgical Neonatal Vomiting

Содержание

InteractiveCase studiesSummary of specific surgical conditions

What is a neonate?What is preterm?What is term?

DefinitionsNeonate – premature and term babies less that 44 weeks post-conceptional

History and Symptoms

History and SymptomsGestationWeightAntenatal historyColour of vomitFrequency of vomitBowel openingSaliva?Associated co-morbidities

Physical Findings

Physical findingsObservationsErythema and bruising DistendedScaphoid abdomenMassAnus – site, size and patencyTendernessExternal

InvestigationsPlain AXR/CXRUpper/Lower GI contrastAbdominal USS

Case 1Term neonate1 day oldVomitingRelevant points in historyRelevant examination findingsDifferential diagnosis

Oesophageal atresia and tracheo-oesophageal fistula1 in 3500 liveborn birthsAntenatalPolyhydramnios, absent stomach,

ClassificationType A: 8%, Type B: 1%, Type C: 86%, Type D

RepairRight thoracotomy (usually)4th or 5th intercoastal spaceExtrapleural approach+/- division of azygous

Duodenal Atresia1 in 5000Antenatal diagnosis – ‘double bubble’Associated with Trisomy 21

Malrotation +/- volvulus

Malrotation1 in 6000 present in babies0.5% of autopsies show degree of

Malrotation + volvulus SURGICAL EMERGENCYBilious vomiting in neonateUpper GI contrast to

Jejunal/Ileal atresiaStenosis – 11%Type 1 – 23% Type 2 – 10%Type

Jejunal/ileal atresia1 in 5000 birthsAetiology – antenatal vascular compromiseMay have short

Meconium IleusCF – 1 in 2500 births~16% of babies with CFInspissated