Intestinal Obstruction in the Newborn Clinical Presentation
- Author: James G Glasser, MD, MA, FACS; Chief Editor: Ted Rosenkrantz, MD more...
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).
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.
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.
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.
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.
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.
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. Failure to recognize Hirschsprung’s disease in a timely fashion may eventuate in toxic megacolon and death.
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.
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