Abnormalities In Small Bowel
dr. Erjan Fikri, M Surg, SpB, KBA
• Congenital •Acquired
• Atresia small bowel
• Stenosis Pyloric
• Omphalomesenteric
• Intussussception
duct persisten
• Meckel’s Diverticulum
• Umbilical Fistula
• Omphalocele
• Gastroschizis
• Malrotation
Embryology
INTESTINAL ATRESIA & STENOSIS
DUODENUM, Yeyunum, Ileum
incidence rates range from 1:2,500 to 1:40,000 live births
Maternal polyhydramnios is also a common ultrasonographic finding
observed in 20–75% of cases with duodenal atresia, mainly in the
second half of pregnancy.
In all cases of combined polyhydramnios and “double bubble” sign, a
detailed evaluation for other associated anomalies, especially cardiac
anomalies, should be undertaken.
Amniocentesis for chromosomal analysis is helpful for counseling.
• Patophysiology
• Duodenal maldevelopment occurs secondary to either inadequate endodermal
proliferation (gut elongation outpaces proliferation) or failure of the epithelial solid
cord to recanalize (failure of vacuolization).
• Clinical Presentation
• vomiting within hours of birth most often bilious,
• has a scaphoid abdomen.
• Passing meconium within the first 24 hours of life is not usually altered.
• X-ray : double bubble atresia duodenum
3-6 bubble atresia jejenum
> 6 bubble atresia ileum
Meckel’s Diverticulum
Meckel’s Diverticulum
• Most common congenital abnormality of the
gastrointestinal tract
• antimesenteric border of the ileum
• Often contain heterotropic tissue- gastric, occasionally
pancreatic
• Vast majority of Meckel’s diverticuli are clinically silent
Umbilical fistula
• Persistence of entire vitelline duct → canal between
umbilicus and ileum.
• Fetal discharge may be found at the umbilicus.
Omphalocele
• Defect is covered by a surrounding
membrane (peritoneum and amnion)
• Umbilical cord inserts into the sac
• Typically contain bowel and/or liver,
stomach and spleen
Gastroschizis
• Ischemic compromise due to
compression of mesenteric
blood vessels when defect is
small
• Serositis and serosal peel result
from amniotic fluid exposure
Umbilical cord beside the defect
• Ischemic changes and atresia are
late events related to mesenteric
constriction
Comparison
OMPHALOCELE GASTROSCHISIS
• 1:4,000 to 10,000 • 1:20,000 to 30,000
• Covering sac present • Covering sac absent
• Cord onto sac • Cord onto abdominal wall
• Herniated bowel normal • Bowel edematous, matted
• Failure of migration and fusion of folds wk 3 • Failure of return of midgut to
to 5 abdomen by wk 10
• Anomalies 45 to 55 % • Anomalies 10 to 15%
Malrotation
• Normal delivery
• 1st week : sign of obstruction (+)
• If volvulus occured
• Risk of necrotic
• Operations in 6 hours
• Derotation
• Excision of the Ladd band
• verticalisation
Pyloric Stenosis
• The pylorus becomes abnormally thickened
and manifests as obstruction to gastric
emptying.
• Infants with IHPS (Infantile Hypertrophic
Pyloric Stenosis) are clinically normal at birth,
and subsequently develop nonbilious forceful
(“projectile”) vomiting during the first few
weeks of postnatal life.
• Gastric outlet obstruction leads to emaciation
and, if left untreated, may result in death
Clinical Presentation
• Recent onset of forceful nonbilious vomiting, typically described as
“projectile.” Frequency of vomiting is initially intermittent, but will
progress to follow all feedings.
• Seen gastric wave before vomit
• Palpable “oliv mass” can be detect in empty gastric
• Emesis may become blood tinged with protracted vomiting, likely
related to gastritis.
• Since the child is unable to achieve adequate nutrition, he or she
exhibits a voracious appetite
INTUSSUSCEPTION
PART OF THE INTESTINE FOLDS ON ITSELF LIKE A TELESCOPE
CAUSES
90% Idiopathic
Unsure but it is believed that a virus may be the
cause.( Anomalies with peristalsis)
10% Pathologic
A polyp, tumour or other mass (divertikel’s Meckel)
within the intestinal tract is caught by the normal
contractions, creating a “lead point” which pushes
along causing the intussusception
SYMPTOMS
Pain in intussusception is colicky, severe, and
intermittent crying, pulling up legs, pale
Vomiting
Stools like “red currant jelly”
TYPES of INTUSSUSCEPTION
IleoIleal Small bowel/small bowel. Ileo Cecal Small bowel/ Large bowel
May spontaneously resolve Radiology Intervention
Straight to surgery
Child with up to 5 at same time. Air Enema to reduce by “pushing it back”
TYPES of INTUSSUSCEPTION
Colocolic Large bowel/large bowel
Usually the elderly
No Radiology intervention
Straight to surgery
Diagnose
• Clinical Presentation
• Workup
• Complete blood count leukocytosis
• Plain abdominal radiography reveals signs that suggest intussusception in only
60% of cases. Plain radiograph findings may be normal early in the course of
intussusception
• Ultrasonography Hallmarks of ultrasonography include the target and
pseudokidney signs
Initial Management
• intravenous crystalloid resuscitation is begun (10 mL/kg x 2, plus 1.5 x
maintenance fluid).
• A Foley catheter is placed to evaluate fluid resuscitation.
• A nasogastric tube is placed.
• Broad-spectrum intravenous antibiotics are administered.
• Body temperature must be preserved in the operating room
