(ATLAS OF PEDIATRIC PHYSICAL DIAGNOSIS ) Fifth Edition Basil J. Zitelli, MD Holly W.

Davis, MD In contrast with omphalocele, gastroschisis is a defect of the right lateral abd ominal wall. Although controversy exists as to the distinct etiology, most belie ve this deformity results from a vascular accident that leads to occlusion of th e right umbilical vein with subsequent disruption of the end of the abdominal wa ll and mild evisceration. The defect is usually small in term infants; however, large amounts of bowel may lie in the amniotic cavity. This anomaly occurs early in gestation, and the bowel is left in contact with the amniotic fluid, which p roduces an intense inflammatory response or peel (Fig. 17-126). This peel is belie ved to alter bowel motility in the postoperative period, leading to long delays in the return of bowel function. Recent efforts have focused on earlier delivery in the 32- to 34-week gestational age range in order to diminish these deleteri ous effects on bowel function. In contrast with omphalocele, gastroschisis is generally not associated with oth er congenital anomalies. Only 7% to 10% of patients have associated conditions, the most common of which are intestinal atresias. Ischemia due to in utero volvu lus, malrotation, or incarceration through the narrow defect may lead to vascula r compromise that causes an atresia (Fig. 17-127). The surgical management of these conditions is similar. In both conditions the g oal is the safe primary closure of the defect without creating an abdominal comp artment syndrome that leads to pulmonary embarrassment, renal insufficiency, int estinal ischemia, or necrotizing enterocolitis either due to the size of the def ect or the rigidity of the bowel. Gastroschisis constitutes a surgical emergency because the exposed bowel may become desiccated or injured. Omphaloceles, which have a protective peritoneal covering, may be managed in a more elective manner . A staged closure must be performed in some patients; this may include placemen t of a prosthetic Silastic silo with daily reductions (Fig. 17-128), topical des iccants such as silver sulfasalazine (Silvadene), povidone-iodine (Betadine), or merbromine. Placement of a prosthetic material such as Gore-Tex (W. L. Gore & A ssociates, Flagstaff, Ariz.) or Surgisis (Cook Surgical, Bloomington, Ind.) may provide coverage. These infants have significant postoperative delays in the ret urn of intestinal function and require TPN support for survival. ================================== Avery's Neonatology, 6th Edition MacDonald, Mhairi G.; Seshia, Mary M. K.; Mullett, Martha D. Patients with gastroschisis may demonstrate sluggish motility for up to 8 months , and a protracted course of parenteral nutrition commonly is required. Delayed onset of necrotizing enterocolitis (NEC) is not uncommon and should be suspected if bloody stools are observed.