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Intestinal Obstruction in the Newborn Clinical Presentation

  • Author: James G Glasser, MD, MA, FACS; Chief Editor: Ted Rosenkrantz, MD  more...
Updated: Mar 17, 2016

History and Physical Examination

The signs and symptoms of intestinal obstruction in a newborn may be subtle and nonspecific; hence, a detailed history and a thorough physical examination are important.

Bilious gastric aspirates or emesis indicate that the obstruction is distal to the ampulla of Vater. An infant with bilious vomiting should be considered to have malrotation and midgut volvulus until proven otherwise (with upper gastrointestinal (GI) contrast study).[4]

Although bilious emesis is an acknowledged medical emergency, a survey of 175 pediatric and neonatal physicians, nurses, midwives, and parents reported that almost 75% of participants did not properly identify green as the color of bilious emesis; yellow was the color most often selected.[15]

With a bulbous, dilated obstructed loop of intestine, there may be abdominal distention. Peristalsis may be palpable, particularly if the bowel is filled with fluid. Bowel sounds may be absent, normal, or hyperactive. If perfusion of the intestine is compromised, the infant may have tenderness and signs of shock, including pallor, prolonged capillary refill time, and poor perfusion. There may be hematochezia or evidence of thrombocytopenia or coagulopathy.

Infants with distal intestinal obstruction generally present with diffuse abdominal distention and delayed passage of meconium and absent transitional stools. Bowel sounds may be hypoactive or absent if the obstruction is chronic.

Imperforate anus and other anorectal anomalies are readily diagnosed by inspection of the perineum.

Duodenal atresia

Vomiting and upper abdominal fullness are consistent findings with duodenal atresia. An infant with duodenal atresia may present with emesis of gastric contents or with bilious vomiting, depending upon the location of the obstruction with respect to the ampulla of Vater. In 85% of patients with duodenal atresia, the obstruction lies distal to the ampulla, and these patients have bilious vomiting.

The abdomen is usually distended by the dilated stomach and proximal duodenum but becomes scaphoid when the contents of the distended stomach and duodenum are aspirated. Patients with duodenal atresia should be evaluated for trisomy 21 (Down syndrome).

Malrotation with volvulus

The initial presentation of a newborn with volvulus of the midgut is often bilious vomiting. Immediately after acute volvulus of the midgut, the abdomen is soft and scaphoid and may or may not be tender. As blood flow in the superior mesenteric pedicle is compromised, the bowel becomes ischemic and dilates, and the baby’s abdomen becomes increasingly distended and firm. Hypotension and shock may develop from sequestration of fluid within the obstructed bowel. Passage of frank blood per rectum may also occur. Prompt surgical intervention is required.

Jejunal atresia

Infants with Jejunal atresia usually present with bilious vomiting. If the atretic proximal intestine is dilated and bulbous, the baby may also have abdominal distension.

Ileal atresia

With distal obstruction, babies present with more generalized abdominal distention and obstipation; vomiting occurs late, and it is usually feculent. Intestinal duplications may cause obstruction by impingement upon the intestine’s lumen or by volvulus.

Meconium ileus and plug syndrome

Meconium ileus usually presents with abdominal distention and obstipation. Meconium plug syndrome is a relatively benign condition, usually occurring in healthy-appearing term infants. Abdominal distention and failure to pass meconium within the first 24 hours of life are the presenting signs.

Hirschsprung disease

Babies with Hirschsprung’s disease either fail to pass meconium in the first 24 hours of life, or are intolerant of feedings, or develop abdominal distended and refractory constipation after discharge from the nursery. One must be vigilant to carefully follow infants who have delayed passage of meconium.[16] Failure to recognize Hirschsprung’s disease in a timely fashion may eventuate in toxic megacolon and death.[17]

Imperforate anus

Routine inspection of a newborn perineum should include notation of the position and patency of the anus. Anorectal malformations range from anterior displacement of the anal opening to a completely imperforate anus (see the image below). Many infants with imperforate anus have an abnormal sacral progression (seen on pelvic radiographs), as well as a fistula between the rectum and the genitourinary tract, demonstrated by finding meconium in the urine.

Imperforate anus. Imperforate anus.
Contributor Information and Disclosures

James G Glasser, MD, MA, FACS Associate Professor of Surgery and Pediatrics, University of South Alabama College of Medicine; Attending Staff, USA Children's and Women's Hospital

James G Glasser, MD, MA, FACS is a member of the following medical societies: Christian Medical and Dental Associations, American Pediatric Surgical Association

Disclosure: Nothing to disclose.


Shelley C Springer, JD, MD, MSc, MBA, FAAP Professor, University of Medicine and Health Sciences, St Kitts, West Indies; Clinical Instructor, Department of Pediatrics, University of Vermont College of Medicine; Clinical Instructor, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health

Shelley C Springer, JD, MD, MSc, MBA, FAAP is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Chief Editor

Ted Rosenkrantz, MD Professor, Departments of Pediatrics and Obstetrics/Gynecology, Division of Neonatal-Perinatal Medicine, University of Connecticut School of Medicine

Ted Rosenkrantz, MD is a member of the following medical societies: American Academy of Pediatrics, American Pediatric Society, Eastern Society for Pediatric Research, American Medical Association, Connecticut State Medical Society, Society for Pediatric Research

Disclosure: Nothing to disclose.


William T Adamson, MD Division Chief of Pediatric Surgery, Associate Professor of Surgery, University of North Carolina at Chapel Hill School of Medicine; Surgeon-in-Chief, North Carolina Children's Hospital

William T Adamson, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, Society of Laparoendoscopic Surgeons, and Wilderness Medical Society

Disclosure: Nothing to disclose.

David A Clark, MD Chairman, Professor, Department of Pediatrics, Albany Medical College

David A Clark, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Pediatric Society, Christian Medical & Dental Society, Medical Society of the State of New York, New York Academy of Sciences, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Andre Hebra, MD Chief, Division of Pediatric Surgery, Professor of Surgery and Pediatrics, Medical University of South Carolina College of Medicine; Surgeon-in-Chief, Medical University of South Carolina Children's Hospital

Andre Hebra, MD is a member of these medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Children's Oncology Group, Florida Medical Association, International Pediatric Endosurgery Group, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons, South Carolina Medical Association, Southeastern Surgical Congress, and Southern Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

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Esophageal atresia. Intraoperative view of proximal esophageal atresia and distal tracheoesophageal fistula.
Malrotation with volvulus of proximal small intestine coiled around the superior mesenteric vessels.
Duodenal atresia. Note the double-bubble sign and narrowing in the second portion of the duodenum. There is partial obstruction, the duodenum does cross the midline, and there is no twist.
Jejunal atresia. Note the sharp transition between the proximal dilated jejunum and the distal unused intestine at the point of the atresia.
Jejunal atresia. Ischemic compromise of the proximal segment is noted.
Meconium plug. Contrast enema reveals the dilated colon proximal to the meconium plug; the enema may be therapeutic to relieve the obstruction.
Imperforate anus.
A sample algorithm for the diagnosis of neonatal intestinal obstruction.
Pyloric stenosis. Intraoperative view of the hypertrophied pylorus prior to a pyloromyotomy incision.
Intraoperative view showing an intraluminal web, which will be excised; the longitudinal enterotomy will then be closed transversely.
Discontinued intestinal atresia. Intraoperative view of the bulbous obstructed proximal bowel and the diminutive distal intestine.
Meconium ileus. Intraluminal intestinal obstruction from thick, tenaceous meconium.
Colonic atresia. This huge, dilated colon will never function satisfactorily and therefore must be resected.
Midgut volvulus. Intraoperative view of the twisting of the terminal ileum and cecum around the base of the mesentery.
Omphalomesenteric duct (Meckel diverticulum) attached to the umbilicus.
Colon pull-through for Hirschsprung disease.
Midgut volvulus. Necrosis of the midgut is the the most feared complication of malrotation/volvulus.
Incarcerated inguinal hernia. Intestinal obstruction caused by an incarcerated inguinal hernia; the viability of the testicle is also at risk.
Malrotation volvulus. Note the partial duodenal obstruction. The distal duodenum does not cross the midline (over the vertebral column) and the "curly Q" twist.
Gastrografin enema. Note the tiny, unused colon and the dilated (by swallowed air) proximal, obstructed intestine.
Midgut volvulus. The bowel is eviscerated and the entire midgut is twisted counterclockwise, effecting reduction of the volvulus.
The midgut volvulus is reduced.
The peritoneal bands (Ladd bands) tethering the duodenum to the colon are divided, exposing the superior mesenteric vessels.
Complicated meconium ileus. Volvulus of the dilated, meconium-ladened loop of intestine.
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