Jejunoileal Defects ( Congenital Intestinal Stenosis And Atresia )

Question 1

2 types of jejunoileal defects

Answer 1

Stenosis
Atresia
Atresia is divided into 4 types

Question 2

Types of atresia

Answer 2

There 4 types
Type I atresia

− In type I atresias, there is an intraluminal diaphragm (membrane).

− There is no defect in the mesentery.

− The bowel length is normal.

− As in duodenal webs, a windsock effect may be seen secondary to an increase in intraluminal pressure in the proximal dilated bowel causing a prolapse of the web into the distal part of the bowel.

• Type II
− In type II atresia, the affected segments of intestines are separated from each other and the dilated proximal portion has a bulbous blind end connected by a fibrous cord to the blind end of the distal collapsed bowel.

− The mesentery is intact.

− The bowel length is usually normal.

Type IIIa (Fig. 23.3):

− In type IIIa atresia, the affected segments of intestines are separated from each other without a connecting fibrous cord and the dilated proximal portion has a bulbous blind end which is separated from the blind end of the distal collapsed bowel.

collapsed bowel.

− A V-shaped mesenteric defect is present.

− the bowel is variably shortened.

Type IIIb
− Type IIIb atresia is also known as a Christmas tree or apple peel deformity because of the appearance of the bowel as it wraps around a single feeding vessel.

− There is a large defect in the mesentery.

− The bowel length is significantly shortened.

− The distal small bowel receives its blood supply from a single ileocolic or right colic artery.

Type IV

− Type IV involves multiple small-bowel atresias of any combination of types I–III.

− This defect has the appearance of a string of sausages because of the multiple lesions.

intestinal length is considerably shortened.

Question 3

In 90% of cases , Atresia is single or multiple ?

Answer 3

Single

Question 4

Clinical features

Answer 4

History of polyhydramnios during prenatal ultrasonographic evaluation is common .This is more in those with upper jejunal atresia.

• Prematurity (35 %). This is more in those with jejunal atresia.
• Low birth weight (25 –50 %). This is more in those with jejunal atresia.
• Bilious vomiting. The more proximal the obstruction the more is the vomiting.
• Abdominal distension. This is more common in those with distal obstruction (Fig. 23.8).
• Jaundice (30 %). This is secondary to indirect hyperbilirubinemia and it is more in those with ileal atresia.
• Failure to pass meconium in the first day of life. The passage of meconium does not however rule out intestinal atresia.
• Clinically, intestinal loops as well as peristalsis may be visible.

• An excessively dilated proximal bowel segment may undergo torsion, necrosis, and/or perforation.
In these cases, the patient appears septic and dehydrated, and the abdominal wall may be erythematous.

• Clinically, neonates with a proximal atresia develop bilious vomiting within hours, whereas patients with more distal obstruction may take longer to start vomiting.
• A normal or scaphoid like abdomen in a neonate with bilious vomiting is indicative of a proximal obstruction.
• Abdominal distension is more marked in those with distal obstruction.

Question 5

Diagnosis can be made by

Answer 5

Antenatal ultrasound- dilated intestinal segment with polyhydramnios.

Plain abdominal X-ray of a newborn with small-bowel atresia- diffuse bowel distension, with gasless pelvis and air–fluid levels.

The more distal the obstruction, the more is the gaseous distension.

With more proximal atresias, few air–fluid levels are seen with no apparent gas in the lower part of the abdomen.

− The more distal the obstruction, the more air–fluid levels are seen and distal intestine remains gasless.

Contrast Enema - show small unusued colon ( micro colon)

Used to Distinguish large-bowel obstruction from small-bowel obstruction.

Question 6

Treatment of intestinal atresia

Answer 6

Gastric decompression via an orogastric or a nasogastric tube.

− 1 mg of vitamin K is given intramuscularly.

− Broad-spectrum antibiotics are given intravenously.

− Fluid resuscitation.

• Nothing by mouth

Surgery - When the intestinal length is normal, the dilated proximal pouch can be resected, by removing 10–15 cm of dilated bowel proximal to the atresia, to avoid postoperative physiologic obstruction due to lack or abnormal peristalsis (Figs. 23.12 and 23.13).

− If the bowel length is limited, a tapering enteroplasty should be considered rather than resection (Fig. 23.14).

− A single layer, end-to-oblique or end-to-end anastomosis is performed. The mesenteric gap is then approximated with fine absorbable sutures, taking care not to kink the anastomosis or damage the mesenteric vessel

− Control of temperature to avoid hypothermia.