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Pediatric Small-Bowel Obstruction Treatment & Management

  • Author: Jaime Shalkow, MD, FACS; Chief Editor: Carmen Cuffari, MD  more...
 
Updated: Dec 11, 2015
 

Approach Considerations

General principles in the medical treatment of small-bowel obstruction include the following:

  • Stabilize the patient and monitor ABCs
  • Replace fluids with diligent intravenous (IV) resuscitation, using isotonic sodium chloride solution or lactated Ringer solution
  • Early bowel decompression with an NG tube decreases the chance of bowel necrosis and perforation
  • Administer broad-spectrum antibiotics when necrosis or perforation is suspected

Patients who do not respond to nonoperative treatment within 12-24 hours require surgical treatment.

Consultations

Consult with a pediatric or general surgeon, depending on availability.

Diet

Administer nothing by mouth (NPO).

Monitoring

Patients with partial small-bowel obstructions can be nonoperatively treated with adequate fluid resuscitation and nasoenteric suctioning. However, close follow-up observation is mandatory for these patients after discharge.

Instruct parents that they must take their child immediately to an emergency department if the child's symptoms (eg, vomiting, pain) recur.

Intussusception

Stabilize the patient's ABCs and replace large fluid losses. Administer NPO to the child and place an NG tube to decompress the obstruction from above. The use of antibiotics is appropriate for management of bacterial translocation.

Barium, water, or air enema reduction is appropriate after surgical consultation if symptom duration is less than 24 hours and if the patient has no signs of peritonitis. Pneumatic reduction seems to be more effective and safer,[82] and it could be considered an optimal first-line treatment.[83] Enemas successfully reduce 80-95% of all intussusceptions, with better success rates in short-duration intussusceptions. Although the classic teaching is to admit any child with an intussusception that is successfully reduced with an enema for observation, in the thought that most recurrences occur during the first 24 hours, Whitehouse et al recently showed that recurrence rates do not differ between children observed as inpatients and those discharged home after successful hydrostatic reduction, suggesting it might be safe, in controlled circumstances, to discharge patients from the emergency department.[84, 85, 86]

Children whose symptoms persist longer than 24 hours, or have signs of peritonitis, should not be considered candidates for enema reduction. The risk of surgery is higher when the lapse between the onset of symptoms and the first attempt of conservative management is longer. Stabilize these children and immediately transport them to the operating room because untreated intussusception is almost always fatal. The recurrence rate is higher after radiographic than after surgical reduction. Surgery is also indicated for patients whose intussusception cannot be reduced after 2 enema attempts. See the image below.

Surgical photograph of an 8-month-old patient with Surgical photograph of an 8-month-old patient with ileocolic intussusception.

Patients with postoperative intussusceptions require surgery for correction. In most cases, the intussusception can be reduced manually and strangulation is uncommon.

Adhesive Small-Bowel Obstruction

Only about 6-7% of children with adhesive small-bowel obstruction require immediate laparotomy. Approximately one half of these patients respond to medical treatment, which includes NPO, IV fluids, NG decompression, and antibiotics to suppress bacterial translocation and help prolong the viability of ischemic bowel. However, children younger than 1 year tend to respond poorly to conservative management. No single agent or treatment has proven effective in preventing adhesion formation after a laparotomy.

The use of water-soluble contrast via NG tube may decrease the need for surgery in some patients. Water-soluble contrast media (Gastrografin) cause redistribution of intravascular and extracellular fluid into the intestinal lumen because of their hyperosmolarity. As a result, these media decrease intestinal wall edema and act as a direct stimulant to intestinal peristalsis.[87]

Incarcerated Hernia

Stabilize the patient's ABCs and focus on replacing the large fluid losses. Nonoperative reduction of a nonstrangulated hernia is possible in approximately 95-98% of cases. Facilitate the reduction by sedating the patient and placing the patient in a mild Trendelenburg position. Gentle traction on the hernia and the contents of the sac usually suffices to reduce the volume and rapidly retract the contents of the sac into the abdominal cavity. After nonoperative hernia reduction, elective repair may be accomplished 24-48 hours after the edema subsides.

The only contraindication to nonoperative reduction is a long-standing incarceration with evidence of peritoneal irritation.

Antibiotic therapy is usually unwarranted, but critically ill infants with perforation and peritonitis require coverage for aerobic gram-negative organisms and anaerobic infections.

Necrotizing Enterocolitis

Treatment for NEC is initially medical with broad-spectrum antibiotics and cessation of enteral feeds. However, medical treatment may fail to improve the patients' condition or severe complications supervene and require surgical consultation. Roughly 30-50% of these neonates require surgery.

In the extremely low ̶ birth-weight infant, it is difficult to determine if free air in the abdominal cavity is due to a spontaneous perforation or NEC.

A vast array of surgical options have been described. Peritoneal drainage seems useful to decompress the abdominal compartment syndrome, improving cardiorespiratory status. However, randomized controlled trials have failed to demonstrate any survival or mortality differences between laparotomy and drainage groups, as well as long-term need for parenteral nutrition.[39] However, 50% of infants in the peritoneal drainage groups were spared from further surgical intervention, and time to attain full enteral feeds in infants less than or equal to 1000 g was prolonged in this group.[88]

Infants with advance NEC often require cardiopulmonary support, rendering them too unstable to be transferred to the operating room for surgical treatment. Transfer of patients from NICU to the OR presents the risk of physiological changes including hypothermia and clinical deterioration en route, as well as dislodgment of vital tubes or theater availability. Operating on babies at the NICU also poses constrains related to lighting, ergonomics, and equipment.[39]

NEC management involves cessation of enteral feeds; gastric decompression on low, continuous suction with a sump-type tube; fluid management to correct hypovolemia; parenteral nutrition with a centrally located IV catheter once fluid resuscitation is complete; and antibiotic therapy.

Direct antimicrobial therapy is aimed at enteric bacteria (eg, Escherichia coli, Klebsiella species, Enterococcus species, anaerobic colonic flora [Clostridia species]).

Serial abdominal examinations should be performed, preferably by the same examiner.

Obtain radiographs of the abdomen, including cross-table lateral films, every 6-8 hours for the first 48 hours. Obtain blood, urine, sputum, and CSF cultures, if indicated.

Strong evidence shows breastfeeding to be a protective measure against NEC.[89] A large Cochrane review supports the use of probiotics, especially in infants weighing more than 1000 g. This is slowly gaining popularity among neonatologists; however, more research is necessary to change this practice.[66, 90, 91]

Small studies have recently suggested that the use of pentoxifylline in adjunct with antibiotics for preterm babies with NEC and sepsis may decrease mortality without any adverse effects.[92]

Meconium Disease

Treatment of meconium ileus requires evacuating the meconium. Nonsurgical methods relieve the obstructions of more than 50% of patients.

The therapy of choice for uncomplicated meconium ileus is nonoperative hyperosmolar enema (Gastrografin or Omnipaque), with enterotomy and irrigation reserved for enema failures. Dilute Gastrografin with N -acetylcysteine may also be administered using an NG tube from above to help loosen the meconium. Distal intestinal obstruction syndrome may be treated in the same way.

Complicated cases (meconium peritonitis, meconium pseudocyst, perforation, intestinal atresia) require exploration and bowel resection with primary anastomosis or stoma creation.

Meconium plug syndrome is usually relieved with rectal stimulation (suppositories, washouts, or contrast enemas).

Next

Surgical Therapy

Intussusception

Intussusception can be reduced by radiographic means in 80-95% of patients. Surgical reduction is indicated when symptoms have been present for more than 24 hours, in the presence of shock that cannot be corrected, when a lead point has been identified, when necrosis or perforation are present, or if the intussusception is irreducible by radiographic means. (See the image below.) The procedure can be performed safely via laparotomy or laparoscopy. Patients operated on laparoscopically have shorter hospital length of stay and a mildly higher incidence of recurrence, although this is not statistically significant.[93]

Necrotic bowel after surgical reduction of an intu Necrotic bowel after surgical reduction of an intussusception.

Incarcerated hernia

After reducing the hernia, elective repair is possible 24-48 hours after the edema subsides. For patients whose hernias cannot be reduced and for patients with strangulation, immediate surgery is mandatory to prevent the incarceration from progressing to perforation and frank peritonitis.

Malrotation of the bowel with midgut volvulus

Preserving intestinal viability requires rapid diagnosis and surgery for malrotation with midgut volvulus. Initiate NG suction and IV hydration when entertaining the possibility of midgut volvulus. If abdominal plain radiographic findings confirm the diagnosis, defer contrast studies and take the child directly to the operating room.

A Ladd procedure is the preferred treatment. It includes evisceration and inspection of the mesenteric root, derotation of the volvulus (which has always been reported to occur in a clockwise direction), lysis of Ladd bands with kocherization of the duodenum along the right abdominal gutter, opening of the visceral peritoneum that covers the mesentery, and replacing the small bowel into the right side of the abdomen and the large bowel into the left side (in a position of nonrotation). It also includes an appendectomy (usually an inversion appendectomy), because the cecum and appendix are located in an unusual place. The procedure can also be laparoscopically performed.[94]

Any frankly necrotic bowel should be resected and end-to-end anastomosis performed unless the peritoneal cavity is grossly contaminated or the condition of the patient does not allow it; in such cases, stomas should be created.

Postoperative adhesive small-bowel obstruction

A possible diagnosis of adhesive small-bowel obstruction requires prompt surgical consultation because delay can lead to intestinal necrosis. The most difficult part is to decide if and when the child is to undergo surgery. As a general rule, the presence of fever, tachycardia, leukocytosis, rebound tenderness, or complete obstruction warrants surgical exploration. Patients usually present with a single-point obstruction. The authors recommend entering the abdomen through a fresh extension of the original incision, to avoid damage to the bowel adhered to the old scar.

Adhesiolysis is the treatment of choice. Only the adhesion causing the obstruction needs to be resolved, since extensive unnecessary adhesiolysis increases the risk of serosal tears and bowel perforations, as well as an increased inflammatory response that may produce further adhesive obstruction. Careful sharp dissection of adhesions with gentle handling of the intestine is imperative. This can be achieved laparoscopically or with laparotomy. Some patients require bowel resection because of perforation or necrosis.[95]

Duplication cysts

The treatment for duplications is surgical excision, even in an asymptomatic patient who is incidentally diagnosed. The prevalence of gastric mucosa suggests that the duplications should not be left indefinitely. The procedure may depend on the location of the cyst.

In esophageal duplications, the cyst is excised, and a mucosectomy is performed if the muscular layer shared with the esophagus is left behind. The entire muscular wall can be excised with the cyst, taking care not to penetrate the esophageal mucosa.

Duplications of the small intestine usually require resection and anastomosis. In rectal duplications, only the mucosal lining usually needs to be excised, because the duplication and normal rectum share the muscularis layer. If malignant degeneration is suspected, total excision, including excision of the normal rectum, may be necessary. Infected duplications may require initial drainage, followed by a staged resection. Laparoscopically assisted resection of ileocecal duplications is safe and effective. See the image below.

Surgical photograph of a 3-year-old male patient w Surgical photograph of a 3-year-old male patient with an obstructive, noncommunicating ileal duplication.

Annular pancreas

Surgical management is similar to that of duodenal atresia. Diamond-shaped duodenoduodenostomy is the preferred approach (Kimura procedure).

Necrotizing enterocolitis

Indications for surgery include pneumoperitoneum, fixed dilated bowel loop, abdominal wall discoloration, or children whose conditions deteriorate or show no improvement with conservative therapy. Portal venous air suggests extensive intestinal necrosis but does not indicate that celiotomy is necessary. See the image below.

Plain abdominal film on a premature baby girl with Plain abdominal film on a premature baby girl with necrotizing enterocolitis. Note the air in the biliary tree and the grossly dilated bowel.

The options for surgical management include laparotomy with abdominal decompression, with or without resection of necrosed bowel followed by primary anastomosis or creation of an ostomy, versus peritoneal drainage alone.[50, 39] The surgical team must make the decision of whether a particular patient requires peritoneal drainage or laparotomy. Many surgeons place a peritoneal drain and wait until the patient is stable to take him or her to the operating suite for exploratory laparotomy. However, a meta-analysis showed a higher mortality rate (55%) in patients who underwent peritoneal drainage.[96]

If the perforation is due to full-blown NEC, the bowel may continue to necrose and the patient may suffer later form short-bowel syndrome, which has catastrophic long-term complications. Although some studies have shown a higher mortality rate in patients undergoing surgery at the NICU instead of the operating room, those children were likely more critically ill, which motivated the surgeon to decide not to transfer the patient.

Mesocolic hernia

In symptomatic patients with internal hernias, prompt surgical exploration in order to reduce the hernia and repair the defect is imperative to improve survival. These patients usually have a delayed diagnosis and present as a surgical emergency with acute bowel obstruction and intestinal ischemia.[26]

See the image below.

Surgical photograph of a 1-year-old male patient w Surgical photograph of a 1-year-old male patient who previously underwent a right radical nephrectomy for Wilms tumor. He presented to the emergency department with signs of a mechanical small bowel obstruction. A transition zone is clearly seen at the point where the small bowel is trapped on an internal hernia through a mesenteric gap.

Cecal volvulus

Surgical reduction of the cecal volvulus and pexy to the lateral peritoneal wall is usually required, in addition to fluid resuscitation, bowel decompression, and ABC monitoring.

Jejunoileal atresia and stenosis

Surgical resection of the atretic segment is followed by end-to-end anastomosis. The proximal, dilated bowel may need to be tapered to fit the smaller, distal intestine. Care should be taken to preserve as much intestinal length as possible in order to prevent short-bowel syndrome, mainly in patients with multiple atresias. These have classically been repaired through transverse supraumbilical incision, although single jejunoileal atresias have been successfully approached through a smaller periumbilical incision (as in the one described for hypertrophic pyloric stenosis).[97]

Duodenal atresia and stenosis

The usual treatment for duodenal atresia is a linear or diamond-shaped duodenoduodenostomy (Kimura procedure). Duodenojejunostomy is another option. A duodenal web is much rarer and can be treated with duodenotomy and excision of the web, with or without duodenoplasty.[98]

Meconium ileus

Surgical management by either primary resection and anastomosis or ileostomy is sometimes required.[99]

Meckel diverticulum

Surgical resection of the diverticulum is the proper treatment in symptomatic patients. Some research has shown that minimal access surgery can be safely performed in pediatric and neonatal cases, providing both a diagnostic and therapeutic approach without concerns for safety.[81]

Previous
 
 
Contributor Information and Disclosures
Author

Jaime Shalkow, MD, FACS Director, National Pediatric Cancer Program, National Center for Pediatric and Adolescent Health (CeNSIA); Attending Pediatric Surgical Oncologist, Cancer Center at the American British Cowdray Medical Center

Jaime Shalkow, MD, FACS is a member of the following medical societies: American College of Surgeons, International Society of Paediatric Surgical Oncology, Pacific Association of Pediatric Surgery, Mexican Association of Pediatric Surgery, Mexican Society of Oncology, Mexican Association of Pediatrics

Disclosure: Nothing to disclose.

Coauthor(s)

Adrian Florens, MD, FAAP Neonatologist, KIDZ Medical Services; Clinical Instructor of Pediatrics, Florida International University and Florida Atlantic University

Adrian Florens, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Eduardo Fastag Guttman, MD Medical Assistant Physician, Anesthesiology Integral

Disclosure: Nothing to disclose.

Issac Octavio Vargas Olmos Universidad Anahuac, Mexico

Disclosure: Nothing to disclose.

Chief Editor

Carmen Cuffari, MD Associate Professor, Department of Pediatrics, Division of Gastroenterology/Nutrition, Johns Hopkins University School of Medicine

Carmen Cuffari, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, Royal College of Physicians and Surgeons of Canada

Disclosure: Received honoraria from Prometheus Laboratories for speaking and teaching; Received honoraria from Abbott Nutritionals for speaking and teaching.

Additional Contributors

Joyce Vazquez-Braverman, MD Instructor of ACLS, BLS, and Heartsavers, American Heart Assocation

Joyce Vazquez-Braverman, MD is a member of the following medical societies: American College of Physicians

Disclosure: Nothing to disclose.

Acknowledgements

Jose Asz, MD Professor of Embryology, Assistant Professor of Surgery and Pediatrics, Faculty of Medicine, Universidad Nacional Autonoma de Mexico; Consulting Staff, Department of General Surgery, National Institute of Pediatrics, Mexico

Disclosure: Nothing to disclose.

B UK Li, MD Professor of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Director, Pediatric Fellowships and Gastroenterology Fellowship, Medical Director, Functional Gastrointestinal Disorders and Cyclic Vomiting Program, Medical College of Wisconsin; Attending Gastroenterologist, Children's Hospital of Wisconsin

B UK Li, MD is a member of the following medical societies: Alpha Omega Alpha, American Gastroenterological Association, and North American Society for Pediatric Gastroenterology and Nutrition

Disclosure: Nothing to disclose.

Nicholas A Shorter, MD Professor of Clinical Surgery and Clinical Pediatrics, State University of New York Downstate University; Division Chief, Department of Surgery, Division of Pediatric Surgery, State University of New York Downstate Medical Center

Disclosure: Nothing to disclose.

Jorge H Vargas, MD Professor of Pediatrics and Clinical Professor of Pediatric Gastroenterology, David Geffen School of Medicine, University of California at Los Angeles; Consulting Physician, Department of Pediatrics, University of California at Los Angeles Health System

Jorge H Vargas, MD is a member of the following medical societies: American Liver Foundation, American Society for Gastrointestinal Endoscopy, American Society for Parenteral and Enteral Nutrition, Latin American Society of Pediatric Gastroenterology, Hepatology & Nutrition, and North American Society for Pediatric Gastroenterology and Nutrition

Disclosure: Nothing to disclose.

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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Small-bowel obstruction visible on plain radiograph caused by intussusception in a 5-month-old patient.
Barium enema revealing a coil spring appearance caused by the tracking of barium around the lumen of the edematous intestine in intussusception.
Small-bowel obstruction caused by an incarcerated inguinal hernia in a 2-month-old infant with bilateral inguinal hernias as well as an umbilical hernia.
Radiograph depicting the double-bubble sign characteristic of duodenal atresia.
Upper GI contrast study demonstrating a jejunal atresia with a proximal dilated atretic bowel and lack of passage of contrast into the distal small bowel.
Surgical photograph of the patient in the previous image depicting the proximal dilated atretic jejunum.
Upper GI contrast study showing a malrotation with lack of normal C-shaped duodenum and the small bowel "hanging" on the right side of the abdomen.
Contrast enema with an abnormally located cecum in a patient with malrotation.
Surgical photograph of necrotic bowel in a patient with midgut volvulus.
Necrotic bowel after surgical reduction of an intussusception.
Surgical photograph of a transition zone in an infant with small bowel obstruction.
Incarcerated left inguinal hernia.
Mesocolic hernia.
Surgical image of a laparotomy on a 7-month-old girl with ileocolic intussusception. An edematous and erythematous cecal appendix was found to be acting as a lead point.
Surgical image of a laparotomy on a 2-day-old female patient with congenital small bowel obstruction. A type I jejunal atresia without mesenteric gap and a grossly dilated proximal intestine is seen.
A barium enema on a 1-year-old male patient depicts an ileocolic intussusception.
Clinical photograph of a 5-month-old male patient with characteristic currant-jelly stools due to intussusception.
Plain abdominal film on a 3-day-old newborn depicting the classic double-bubble sign for duodenal atresia.
Contrast-enhanced upper gastrointestinal film showing a duodenal atresia on a 2-day-old newborn.
Surgical photograph of a 3-year-old male patient with an obstructive, noncommunicating ileal duplication.
Plain abdominal film of a 6-year-old male patient with MRCP (mental retardation and cerebral palsy), with organo-axial gastric volvulus. Note the grossly dilated and obstructed stomach. A gastrostomy feeding tube can be seen in place. Surgical staplers from a previous laparoscopic fundoplication are seen near the diaphragmatic crura.
Surgical photograph of an 8-month-old patient with ileocolic intussusception.
Plain abdominal film of a premature baby born at 28 weeks of gestation with necrotizing enterocolitis. Note the "railroad sign" (pneumatosis intestinalis) in the hepatic flexure and soap-bubbles in the descending colon.
Clinical image of a micro-premature baby boy with discoloration on the right lower quadrant of the abdomen, due to intestinal perforation secondary to necrotizing enterocolitis. An umbilical catheter is in place.
Plain abdominal film on a premature baby girl with necrotizing enterocolitis. Note the air in the biliary tree and the grossly dilated bowel.
Surgical photograph of a 1-year-old male patient who previously underwent a right radical nephrectomy for Wilms tumor. He presented to the emergency department with signs of a mechanical small bowel obstruction. A transition zone is clearly seen at the point where the small bowel is trapped on an internal hernia through a mesenteric gap.
Image of intussusception by ultrasound on a 9-month-old male patient.
Surgical photograph of an 8-month-old boy with intussusception. The surgeon's finger is inserted into the intussusceptum, and the intussuscipiens is seen entering the distal bowel. No leading point was identified.
Surgical photograph depicting loops of bowel passing through a mesenteric defect. The bowel segment proximal to the obstruction is dilated, purplish, distended and hypoperistaltic. The bowel distal to the obstruction is decompressed and normal-looking.
Surgical photograph of a newborn with a type III jejunal atresia. Note the dilated proximal bowel pouch, the mesenteric V-shaped defect, and the thin, nondilated distal jejunum.
Surgical photograph of a Meckel diverticulum.
 
 
 
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