Intestinal Obstruction of Neonates and Infants

1

What signs and symptoms suggest intestinal obstruction in the neonate?

Signs and symptoms vary according to the location of the obstruction. Proximal intestinal obstruction leads to early bilious vomiting, typically with minimal distention. Neonates with distal intestinal obstruction often present after the first day of life with distention and bilious emesis. Bilious emesis in infants and children deserves immediate investigation. An upper gastrointestinal (UGI) contrast study will identify a surgical cause in about one-third of cases. In particular, malrotation with midgut volvulus should always be ruled out as this condition requires prompt surgical intervention.

2

What is the differential diagnosis of intestinal obstruction in neonates?

Rule out proximal and distal anatomical abnormalities—esophageal atresia and anorectal malformation. Perform a rectal examination. Evacuation of stool during rectal examination suggests Hirschsprung disease. Next, obtain a two-view abdominal x-ray. The extent of gaseous distention of the bowel helps differentiate proximal versus distal bowel obstruction.

• Proximal (minimal bowel gas)

  • Duodenal atresia, stenosis (commonly double bubble)

  • Malrotation with midgut volvulus

  • Jejunal atresia (sometimes triple bubble)

• Distal (bowel gas in multiple loops and distention)

  • Ileal atresia

  • Meconium ileus or plug

  • Small left colon syndrome

  • Hirschsprung disease

3

When are contrast studies of the gastrointestinal tract indicated?

Immediate abdominal exploration is indicated if there is peritonitis or pneumoperitoneum. Malrotation with midgut volvulus must be distinguished from other causes of congenital duodenal obstruction (duodenal atresia/stenosis). In malrotation with midgut volvulus, the UGI demonstrates a distended duodenum, failure of the duodenal-jejunal junction to cross the midline, corkscrewing of the distal duodenum, and minimal or no passage of contrast into the jejunum. Duodenal atresia often presents with a double bubble (first bubble stomach and second bubble duodenum) on plain x-ray at the time of birth. A contrast study may be helpful for the diagnosis of duodenal stenosis. Contrast enema is indicated for distal intestinal obstruction.