Common Surgical Problems in the Neonate

Question 1

What are the most common surgical problems in a neonate?

Answer 1

• Meconium Ileus
• Malrotation
• Jejunal Atresia
• Inguinal Hernia
• Necrotising Enterocolitis

Question 2

Why do newborn babies get sick?

Answer 2

• premature babies

- Babies born with a congenital “something”

Question 3

How can prematurity cause problems in the bowel?

Answer 3

• bowel wall not sturdy enough to be used at preterm age

=> often perforate and release gas

Question 4

HOw can a bowel perforation due to prematurity be identified on a neonatal abdominal XRay?

Answer 4

• outlined liver (due to gas around it)
• Bubbles of gas in pelvis (bowel herniation)
• Portal gas in biliary tree
• train track bowel wall => gas on both sides

Question 5

What condition in neonates is characterised by perforation on XRay?

Answer 5

Necrotising Enterocolitis

Question 6

How are babies with Necrotising Enterocolitis fed?

Answer 6

• Special feeds (mother’s milk is best)

- can use NG or IV feeds

Question 7

How does an obstruction in newborns occur and how is it identified?

Answer 7

• due to congenital abnormality

- problem with feeding normally identified

Question 8

Where can a blockage occur in neonates?

Answer 8

• in the lumen
• in wall of bowel
• outside of bowel

Question 9

A baby is keen to feed, yet by 48 hours shows signs of bilious vomiting and is bringing their feed back up.
They have yet to pass their first bowel movement and their abdomen is distended.
What is the most likely diagnosis?

Answer 9

Meconium Ileus (intralumenal cause)
- if not yet passed first bowel movement, then it may be stuck in ileum

Question 10

What investigations should be considered if there is suspicion of meconium ileus?

Answer 10

• FLuroscopy (contrast used with XRay)

- Lower GI contrast given (=> inserted upwards via rectum)

Question 11

What can be seen on fluroscopy in Meconium Ileus

Answer 11

• Large bowel (colon) may appear small as it has never been filled
• Large dilated small bowel loops
• Some small contracted bowel
• Patchy appearance of ileum

Question 12

How is a baby’s tummy described on examination if they have meconium ileus?

Answer 12

• “doughy” on palpation due to distension

Question 13

What condition is meconium ileus commonly associated with?

Answer 13

• Cystic fibrosis (due to increased secretions)

- 1/3 of babies will present with this and not respiratory problems

Question 14

How can a fluoroscopy be useful in meconium ileus?

Answer 14

• Contrast fluid can be useful in lubricating bowel to allow meconium to move

Question 15

What treatment is used for meconium ileus if fluroscopy is NOT successful at moving the meconium?

Answer 15

• Surgery

- Temporary Stoma

Question 16

Name another intralumenal cause of obstruction

Answer 16

constipation

Question 17

What causes of obstruction are found in the bowel wall?

Answer 17

• Atresia (usually in small bowel)

=> congenital dead end

Question 18

How does bowel atresia present after birth?

Answer 18

• 6 hours after birth a baby starts vomiting green.
• Full abdomen
• No bowel movements passed

Question 19

How does bowel atresia usually appear on XRay?

Answer 19

• distended bowel

- Not many loops of bowel as obstruction is normally high (hence why vomiting starts after 6 hrs or so)

Question 20

Why would fluoroscopy be useful in investigating for atresia?

Answer 20

checks for meconium in parts of bowel

Question 21

How is bowel atresia treated?

Answer 21

2 dead ends joined together

Question 22

Give an example of a condition that could cause bowel obstruction from outside of the wall?

Answer 22

• Hernia (compresses bowel as squeezed into tighter space)

- Malrotation (twisting of bowel on mesentery)

Question 23

How may an inguinal hernia be identified

Answer 23

• swelling in inguinal area

- asymmetrical groin creases

Question 24

How can a bowel herniation be identified on Xray?

Answer 24

• gas in wrong place (e.g. in pelvis)

- laddering of loops may be seen on top of each other

Question 25

What part of herniation can cause bowel ischaemia?

Answer 25

Tight pressure in scrotum with testes

- as have descended in inguinal canal

Question 26

XRays are not required for a diagnosis of a hernia. TRUE/FALSE?

Answer 26

TRUE

Question 27

When do children with malrotation usually present?

Answer 27

within 1st month

but can be older

Question 28

How is malrotation usually investigated?

Answer 28

Upper GI contrast study

Fluoroscopy

Question 29

How does malrotation appear on XRay?

Answer 29

• stomach distended
• Duodenal-Jejunal flexure is low and medial (rather than high and lateral behind stomach)
• Usually Ileo-caecum -> DJ flexure is largest diameter in abdomen
• Decreasing this diameter allows the mesentery to twist upon itself and cut off blood supply

Question 30

What blood vessel is compromised if the mesentery twists on itself during a case of malrotation?

Answer 30

Superior Mesenteric Artery (SMA)

Question 31

How is malrotation surgically treated?

Answer 31

• Division of Ladd’s bands (fibrous stalks of peritoneal tissue that attach caecum to the retroperitoneum)

Question 32

What diagnosis should be excluded first in a sick newborn?

Answer 32

Malrotation (as bowel may become ischaemic => baby wont survive)