Pediatric Small-Bowel Obstruction Clinical Presentation
- Author: Jaime Shalkow, MD, FACS; Chief Editor: Carmen Cuffari, MD more...
Obtain a complete medical history, specifically including information on prior malignancies, radiation therapies, and abdominal or pelvic surgeries. A history of repetitive abdominal pain with vomiting indicates a chronic, partial small-bowel obstruction.
Obtain as much history as possible from the child. Younger children are likely to recall recent events, whereas adults remember more remote events. Physicians should seek an accurate chronology of the disorder. Asking when the child was last completely healthy may provide a more accurate assessment of the child's pathophysiology.
Bilious vomiting in the neonate should be considered secondary to a mechanical obstruction until proven otherwise, and every newborn with this symptom warrants emergent surgical evaluation.
Abdominal pain in patients is common. Caregivers may describe an infant or small child with abdominal pain as irritable or inconsolable. Pain from a small-bowel obstruction is usually colicky. It is described as cramplike and episodic, persisting for a few minutes at a time. A child with obstructive pain may be unable to remain immobile on the examining table. Constant pain occurs later in the disease course, when strangulation, perforation, or both have occurred.
Vomiting is a classic symptom of mechanical obstruction. Emesis caused by a proximal obstruction is usually of gastric content or is bilious if the obstruction is distal to the ampulla of Vater. In distal ileal obstructions, vomit is feculent.
Other issues to focus on include the following:
Anorexia - Anorexia is an early and frequent sign
Diarrhea - Diarrhea may occur early in the course of the obstruction
Obstipation - This is a late sign of complete obstruction
Fever - Fever can occur late in the disease process and is associated with bowel strangulation and necrosis
The first goal when evaluating children with abdominal pain is to identify life-threatening conditions that require emergent interventions. Once this has been accomplished, other causes of abdominal pain can often be identified through deliberate evaluation, with careful attention to the clinical features of the illness (such as the child's age and gender, history of trauma, pattern of the pain, related symptoms, physical findings, and selected diagnostic studies).
Children with abdominal pain frequently have fever. Vomiting is frequently reported among children with abdominal pain. Volvulus must always be quickly excluded as the cause of bilious emesis in a neonate. With intussusception, vomiting (initially nonbilious, but becoming bilious as the obstruction progresses) may occur following episodes of pain.
Intussusception usually causes a sudden onset of severe colicky abdominal pain that often causes a child to draw up both legs. Children appear healthy between paroxysms of pain. As the intussusception progresses, the child becomes progressively more irritable and lethargic until shock develops. Vomiting occurs in the early phase of the illness and is bilious in 30% of cases. Early in the course of the disease, stools are normal, but they rapidly become bloody and mucoid within the first 12 hours.
The classic triad described for intussusception, which consists of colicky abdominal pain; a sausage-shaped, palpable abdominal mass; and currant-jelly stools, is actually found in only 20% of cases. Postoperative intussusception occurs within 2-3 weeks after an extensive retroperitoneal dissection (Wilms tumor, pancreatic surgery, or neuroblastoma). It is usually an ileoileal intussusception, and affected patients lack the palpable mass and rectal bleeding. Patients usually present with crampy abdominal pain, anorexia, bilious vomiting, abdominal distension, and irritability.
An incarcerated hernia is usually associated with signs and symptoms of intestinal obstruction (eg, bilious vomiting, abdominal distention, constipation, obstipation). A tender, edematous, slightly discolored to pale mass in the inguinal area may extend down into the scrotum. A swollen, erythematous mass that becomes erythematous to violaceous and is exquisitely tender usually indicates a strangulated hernia. Fever and toxicity suggest frank necrosis of the incarcerated organ and impending or completed perforation.
Patients with mesocolic hernias typically have repeated episodes of colicky abdominal pain and vomiting. These symptoms spontaneously subside when the hernia spontaneously reduces. Patients with incarcerated hernias have continuous pain, abdominal distention, fever, nausea, and vomiting.
Internal hernias are usually asymptomatic and when symptoms occur, they include vague abdominal symptoms such as diffuse pain, discomfort, and vomiting. Only severe cases present symptoms of intestinal obstruction.
Acute midgut volvulus
The hallmark of acute midgut volvulus is the sudden onset of bilious vomiting, which may be projectile vomiting and, on occasion, have a coffee-ground appearance or contain frank blood. History may reveal feeding problems, with transient episodes of bilious vomiting or failure to thrive. Abdominal distention or a palpable mass may not be evident, because the obstruction occurs very proximally in the GI tract. Older children typically describe colicky abdominal pain. Stools are usually absent, but those that do occur yield positive results on guaiac tests. Bright red blood passed through the rectum implies intestinal ischemia.
Postoperative adhesive small-bowel obstructions usually cause a sudden cramplike abdominal pain, followed by anorexia, nausea, and bilious vomiting. Bowel movements typically cease shortly after symptom onset. Clinical manifestations vary according to whether the obstruction is proximal or distal and the stage of the obstruction.
Spontaneous remission of symptoms in patients with adhesive obstructions is reported to be 47-65%, contradicting the common approach with early surgical intervention, which is reported to be 85% in the United States.
Presentation of duplication cysts primarily depends on the type of mucosal lining and on cyst location. At least 16% of small-bowel duplications contain gastric mucosa and may manifest with peptic ulceration and GI hemorrhage. Spheric cystic duplications may enlarge sufficiently to cause obstruction. Always consider duplication cysts in the differential diagnosis of a vomiting infant or child with a palpable, solid abdominal mass and abdominal distention. These cysts may also act as the lead point for an intussusception or form the apex of a volvulus.
Abdominal gastric and duodenal duplications may be confused with pyloric stenosis, because of their similar presentation. Older patients may present with chronic, intermittent vomiting caused by recurring partial obstruction or with an unexplained GI hemorrhage.
Because 20% of patients with rectal duplications have fistulae, drainage of mucous or pus through the anus or a perianal fistula is not uncommon.
Intestinal atresia and stenosis
Intestinal atresia or stenosis can occur anywhere along the GI tract, and the anatomical location of the obstruction determines the clinical presentation. Most newborns present with bilious emesis, a distended upper abdomen, and a scaphoid hypogastrium. Signs of dehydration are not uncommon. Jaundice is present in 32% of these children. A history of polyhydramnios on prenatal ultrasonography (28%), prematurity (35%), or low birth weight (25-50%) can be helpful hints in the diagnosis.
The cardinal symptom of duodenal atresia is vomiting. Because 85% of atresias are postampullary, most patients present with bile-stained vomit in the first 24 hours of life. Most patients exhibit little or no upper abdominal distention because of the high level of the obstruction. Dehydration, weight loss, and obstipation subsequently develop if treatment is delayed.
Newborns with jejunoileal atresia or stenosis present with bilious vomiting and jaundice; these infants may not pass meconium in the first day of life. Bilious vomiting is more common with jejunal atresia. Abdominal distention occurs more often in patients with ileal atresia.
In annular pancreas, the duodenum is often compressed at a point distal to the ampulla of Vater, making bilious vomiting a hallmark symptom. Abdominal distention is typically minimal, because of the proximal location of the obstruction. Patients may not pass meconium, or bowel movements may cease abruptly. A more insidious form of chronic, partial duodenal obstruction may also occur.
The clinical features of NEC are nonspecific and often include lethargy, temperature instability, and abdominal distention. Other common symptoms include bilious vomiting, gross or occult rectal bleeding, abdominal tenderness, redness of the abdominal wall, and the presence of reducing substances in the stool. Discoloration of the abdominal wall is indicative of bowel perforation. Apparently, clinical parameters are not good predictors of NEC outcome.
The presenting symptoms of cecal volvulus include pain, distention, constipation or obstipation, and vomiting.
In patients with meconium ileus, symptoms depend on the level of the obstruction (which is usually the terminal ileum) and may include vomiting (usually bile-stained), failure to pass meconium in the first 48 hours of life, and possible abdominal distention. Patients may also present with generalized peritonitis (meconium peritonitis), a meconium pseudocyst, or obstruction due to an intestinal atresia.
Patients do not develop fever unless the blood supply to the obstructed bowel becomes compromised, which may allow bacterial translocation and subsequent sepsis.
In children who present late in the course of their illness, poor capillary refill, hypotension, and even shock may occur as a result of increasing third spacing of fluid into the bowel lumen.
Abdominal tenderness may be minimal and diffuse or localized and severe. The abdomen may be tympanic to percussion. Patients who develop peritonitis obviously have severe pain and rebound tenderness.
Bowel sounds can be characterized as follows:
Mechanical obstructions produce active, high-pitched, hyperactive bowel sounds with occasional rushes
Peristalsis may be increased in the upper abdomen (above the obstruction; termed "fighting peristalsis") and decreased in the lower abdomen
With time, peristaltic waves and bowel sounds diminish or disappear
During abdominal examinations, look for hernias in the groin, femoral triangle, and obturator foramina. (Careful physical examination is most useful in the diagnosis of an incarcerated hernia.) Perform a pelvic examination to exclude a genitourinary pathology as the cause of the obstruction.
In intussusception, physical examination of the abdomen occasionally reveals a tender, sausage-shaped mass that is variable in size and firmness, with spasms of pain. Because most intussusceptions are ileocolic, patients may present with Dance sign (empty right lower quadrant). See the image below.
The diagnosis of intestinal malrotation should be suspected in any infant who presents with bilious emesis, acute duodenal obstruction, or abdominal tenderness associated with hemodynamic instability. In young premature infants, NEC may be difficult to distinguish from malrotation.
The most common symptom is abdominal pain. Vomiting is also frequently present, but not necessarily bilious; both abdominal pain and vomiting may be intermittent. Other, less common presentations include failure to thrive, solid food intolerance, malabsorption, chronic diarrhea from protein-losing enteropathy, pancreatitis, peritonitis, biliary obstruction, motility disorders, and chylous ascites. Older children and adults with chronic symptoms may have been previously diagnosed with other chronic GI disorders, such as allergy, irritable colon, functional abdominal pain, or cyclic vomiting syndrome.
In patients with a postoperative adhesive small-bowel obstruction, physical examination may reveal abdominal distention and hyperactive high-pitched bowel sounds. Patients usually have a diffuse and poorly localized tenderness that improves with proximal decompression by a suction tube.
Patients with NEC have a wide variation in clinical presentation, from feeding intolerance to shock; however, specific clinical signs that should raise high suspicion include abdominal distention, bluish discoloration of the abdominal wall, and blood in the stool. Refer to the Bell’s staging criteria, which are still widely used to classify the staging of NEC; the criteria provide a clinical and radiographic assessment of the disease. See the image below.
During rectal examination, keep the following in mind:
Check for gross or occult bleeding that suggests strangulation
The absence of stool in the vault may help to confirm a diagnosis of bowel obstruction, although its presence does not eliminate a more proximal obstruction
In proximal obstructions, patients may be able to evacuate preexisting rectal contents
Massive diarrhea after rectal examination of an empty rectal vault is suggestive of colonic aganglionosis (ie, Hirschsprung disease)
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