Abnormalities In Small Bowel

dr. Iqbal Pahlevi, SpB, SpBA

 Congenital
Atresia small bowel
Omphalomesenteric
duct persisten
Meckels Diverticulum
Umbilical Fistula

Omphalocele
Gastroschizis
Malrotation

Acquired
Stenosis Pyloric
Intussussception

Embryology

INTESTINAL ATRESIA &

STENOSIS

DUODENUM, Yeyunum, Ileum

incidence rates range from 1:2,500 to 1:40,000 live
births
Maternal polyhydramnios is also a common
ultrasonographic finding observed in 2075% of cases
with duodenal atresia, mainly in the second half of
pregnancy.
In all cases of combined polyhydramnios and double
bubble sign, a detailed evaluation for other associated
anomalies, especially cardiac anomalies, should be
undertaken.
Amniocentesis for chromosomal analysis is helpful for
counseling.

 Patophysiology

Duodenal maldevelopment occurs secondary to either inadequate

endodermal proliferation (gut elongation outpaces proliferation) or
failure of the epithelial solid cord to recanalize (failure of vacuolization).

Clinical Presentation

vomiting within hours of birth most often bilious,

has a scaphoid abdomen.
Passing meconium within the first 24 hours of life is not usually altered.

X-ray : double bubble atresia duodenum

3-6 bubble
atresia jejenum
> 6 bubble
atresia ileum

Atresia Duodenum

Atresia jejenum

atresia ileum

Meckels Diverticulum

Meckels Diverticulum
Most
common
congenital
abnormality
of
the
gastrointestinal tract
antimesenteric border of the
ileum
Often
contain
heterotropic
tissuegastric,
occasionally
pancreatic
Vast
majority
of
Meckels
diverticuli are clinically silent

Umbilical fistula
Persistence of entire vitelline duct canal between
umbilicus
and ileum.

Fetal discharge may be found at the umbilicus.

Omphalocele
Defect is covered by a
surrounding membrane
(peritoneum and amnion)
Umbilical cord inserts into the sac
Typically contain bowel and/or
liver, stomach and spleen

Gastroschizis

Umbilical cord beside the

defect

Ischemic compromise due

to compression of
mesenteric blood vessels
when defect is small
Serositis and serosal peel
result from amniotic fluid
exposure
Ischemic changes and
atresia are late events
related to mesenteric
constriction

Comparison
OMPHALOCELE

GASTROSCHISIS

to 10,000

1:20,000 to 30,000

1:4,000

Covering sac present

Covering sac absent

Cord onto sac

Cord onto abdominal wall

Herniated bowel normal

Bowel edematous, matted

Failure of migration and fusion of

folds wk 3 to 5

Failure of return of midgut to

abdomen by wk 10

Anomalies 45 to 55 %

Anomalies 10 to 15%

Malrotation
Normal delivery
1st week : sign of
obstruction (+)
If volvulus occured
Risk of necrotic
Operations in 6 hours
Derotation
Excision of the Ladd band
verticalisation

Pyloric Stenosis
The
pylorus
becomes
abnormally
thickened and manifests as obstruction to
gastric emptying.
Infants with IHPS (Infantile Hypertrophic
Pyloric Stenosis) are clinically normal at
birth, and subsequently develop nonbilious
forceful (projectile) vomiting during the
first few weeks of postnatal life.
Gastric outlet obstruction leads to
emaciation and, if left untreated, may
result in death

Clinical Presentation
Recent onset of forceful nonbilious vomiting, typically
described as projectile. Frequency of vomiting is
initially intermittent, but will progress to follow all
feedings.
Seen gastric wave before vomit
Palpable oliv mass can be detect in empty gastric

Emesis may become blood tinged with protracted

vomiting, likely related to gastritis.
Since the child is unable to achieve adequate nutrition,
he or she exhibits a voracious appetite

INTUSSUSCEPTION

PART OF THE INTESTINE FOLDS ON ITSELF LIKE A TELESCOPE

CAUSES
90% Idiopathic
Unsure but it is believed that a virus may be the
cause.( Anomalies with peristalsis)

10% Pathologic
A polyp, tumour or other mass (divertikels Meckel)
within the intestinal tract is caught by the normal
contractions, creating a lead point which pushes
along causing the intussusception

SYMPTOMS

Pain in intussusception is colicky,

severe, and intermittent crying,
pulling up legs, pale
Vomiting
Stools like red currant jelly

TYPES of INTUSSUSCEPTION
IleoIleal

Small bowel/small bowel.

May spontaneously resolve

Ileo Cecal

Small bowel/ Large bowel

Radiology Intervention

Straight to surgery
Child with up to 5 at same time.

Air Enema to reduce by pushing it back

TYPES of INTUSSUSCEPTION

Colocolic

Large bowel/large bowel

Usually the elderly

No Radiology intervention
Straight to surgery

Diagnose
Clinical Presentation
Workup
Complete blood count leukocytosis
Plain abdominal radiography reveals
signs that suggest intussusception in
only 60% of cases. Plain radiograph
findings may be normal early in the
course of intussusception
Ultrasonography Hallmarks of
ultrasonography include the target
and pseudokidney signs

Initial Management
intravenous crystalloid resuscitation is begun (10 mL/kg
x 2, plus 1.5 x maintenance fluid).
A Foley catheter is placed to evaluate fluid
resuscitation.
A nasogastric tube is placed.
Broad-spectrum intravenous antibiotics are
administered.
Body temperature must be preserved in the operating
room