Surgical Problems in the Newborn

Question 1

Surgical problems in the neonate are mainly due to two factors. Name these factors

Answer 1

Prematurity

Congenital abnormality

Question 2

What is the most common surgical problem found in premature babies?

Answer 2

Necrotising enterocolitis

Baby’s gut hasn’t formed properly

Question 3

What is necrotising enterocolitis?

Answer 3

Tissues in the intestine become inflamed and start to die, leading to a perforation developing, which allows the contents of the intestine to leak into the abdomen

Question 4

List symptoms of NEC

Answer 4

Poor feeding
Vomiting bile
Abdominal distension
Blood in stool

Question 5

List features of NEC on imaging

Answer 5

Air on both sides of bowel
Gas under diaphragm
Mottled appearance
Pneumoperitoneum
Portal venous gas

Question 6

State the 3 main ways the bowel can become obstructed

Answer 6

External pressure
Something in lumen
Something in wall

Question 7

What is meconium ileus?

Answer 7

A neonatal bowel obstruction of the distal ileum due to abnormally thick and impacted meconium

Question 8

List symptoms of meconium ileus

Answer 8

Absolute constipation by 48 hours
Bile-stained vomiting
Abdominal distension.

Question 9

How is meconium ileus diagnosed?

Answer 9

Plain radiograph

Water soluble contrast given rectally

Question 10

How does meconium ileus appear on XRAY?

Answer 10

Dilated bowel loops proximal to impaction
Tangled bowel distal to impaction
Soap bubble appearance
Absence of meconium in lumen

Question 11

What is meconium? Within what time frame after birth does a baby usually pass meconium?

Answer 11

First faeces of newborn infant; black tar

First 24 hours

Question 12

What is Hirschsprung’s disease?

Answer 12

A congenital disorder of the colon in which certain nerve cells, known as ganglion cells, are absent, causing chronic constipation and faeces impaction

Question 13

What chronic condition typically presents with meconium ileus in 30% of cases?

Answer 13

Cystic fibrosis

Question 14

What is jejunal atresia?

Answer 14

Congenital anomaly characterised by obliteration of the lumen of the jejunum leading to a high obstruction

Question 15

List symptoms of jejunal atresia

Answer 15

Abdominal distension
Bilious vomiting but good appetite
Mild constipation (may be some faeces)

Question 16

How is jejunal atresia diagnosed?

Answer 16

Plain radiograph

Water soluble lower GI contrast

Question 17

How does jejunal atresia appear on XRAY?

Answer 17

Triple bubble appearance (duodenum = two bubbles)
Fewer dilated small bowel loops (‘ladder’)
No gas in rectum

Question 18

State the main neonatal cause of obstruction caused by external pressure of the bowel

Answer 18

Hernia

Question 19

List clinical signs of obstructive hernias

Answer 19

Absence of groin crease on affected side

Mass in scrotum (due to peritoneal lining not closing)

Question 20

If an XRAY of a pelvic hernia was taken, how would the appearance compare to a higher obstruction?

Answer 20

Dilated bowel loops (‘ladder’ effect)

More loops as lower obstruction

Question 21

List management options for hernia

Answer 21

Manual reduction

Emergency surgery if obstruction

Question 22

What is bile? What is a normal colour of bile?

Answer 22

Breakdown product of billirubin in the liver, stored in the gallbladder and secreted into the jejunum
Usually mossy green, like fairy liquid

Question 23

What condition must be excluded first when a child presents with green bilious vomiting?

Answer 23

Malrotation

Question 24

What is malrotation?

Answer 24

A congenital anatomical anomaly that results from an abnormal rotation of the gut as it returns to the abdominal cavity during embryogenesis

Question 25

What other condition does malrotation predispose the neonate to?

Answer 25

Volvulus

Question 26

What is midgut volvulus?

Answer 26

Twisting of entire midgut along the axis of superior mesenteric artery
Leads to proximal bowel obstruction and ischaemia

Question 27

List investigations of choice in malrotation and volvulus

Answer 27

Upper GI contrast study

Plain radiography

Question 28

How is malrotation and volvulus managed?

Answer 28

Emergency surgery and correction

Question 29

How does malrotation and volvulus appear on imaging?

Answer 29

Double bubble of duodenal obstruction
Loss of C shape of duodenum
Multiple dilated bowel loops

Question 30

What is the longest fixed point in the belly? What is the significance of this?

Answer 30

Duodojejunal flexure to caecum

Along line, all blood supply to midgut comes from SMA

Question 31

How does the axis of the superior mesenteric artery change in malrotation?

Answer 31

DJ flexure is lying low and caecum is lying high due to twisting